Emergency medicine is at a crossroads. An increase in the number of emergency medicine providers over the past six years has created a scenario that was not considered possible until recently: Supply will exceed demand in the near future.
We understand why this is happening: The rapid growth in the number of medical schools, EM residencies, and advanced practice providers (APPs) is producing more EM providers than the number of available jobs. Many have asked us the same question: What are we going to do? Unfortunately, the answer is not clear, and the solution will likely be a combination of factors, some of which are not currently recognized.
What if you are an EM resident nearing the completion of training? Are you struggling to find the perfect job? How can you shape your thinking to find what will work best to find employment? When I advise residents, I try to boil the decision process down to as few criteria as possible.
I suggest they consider three variables when selecting a job: money, location, and the actual job. We will focus on location: Which geographic areas of the country have more jobs available?
We looked to the “National Study of the Emergency Physician Workforce, 2020” for answers. (Ann Emerg Med. 2020;76:695.) The paper sorted EP jobs into urban and rural. You might think you already know that, but this paper extensively profiles each group and provides crucial information for EPs struggling to find employment.
The Big Picture
Close to 45,000 (92%) of the nearly 49,000 emergency physicians practicing in the United States in 2020 practice in urban locations. A little more than 2700 EPs (6%) practice in large rural locations, and 1100 (2%) practice in small rural locations.
This paper used the U.S. Department of Agriculture Urban Influence Codes to distinguish between these locations:
- Urban: Counties with one or more cities with a population of 50,000 or more and their outlying counties. Eighty-five percent of the U.S. population lives here.
- Large rural: Rural counties with an urban cluster of at least 10,000 people and economically tied adjacent counties. Nine percent of the U.S. population lives here.
- Small rural: Everything else. Six percent of the U.S. population lives here.
Sixty-nine percent of all U.S. EPs are board-certified in emergency medicine, but breaking that down by location reveals interesting numbers: Seventy percent of urban EPs are board-certified, while 56 percent of those in large rural areas and 40 percent in small rural areas have emergency medicine board certification.
There is also an age gap when looking at emergency physicians by location. The median age of an urban EP is 50, and 19 percent are over 65. EPs in large and small rural areas are older, with median ages of 58 and 61 years old, respectively. Thirty-two percent of EPs in large rural areas and 42 percent of EPs in small rural areas are over 65. That means that more than one-third of EPs in rural areas are within a few years of retirement.
The density of EPs with EM board certification in urban areas in 2020 was 11.2 per 100,000. That number for EPs in large and small rural areas was 5.6 and 2.5, respectively. The density of board-certified EPs in urban areas increased from 8.5 per 100,000 in 2008, but it decreased in large and small rural locations. The density of board-certified EPs in large rural areas declined from 5.5 to 4.7 per 100,000 from 2008 to 2020, and that density in small rural areas declined from 2.5 to 2.3 per 100,000.
EP density is increasing in urban locations. EPs working there are younger and more likely to be residency-trained in emergency medicine, and turnover for existing positions is expected to be lower. The continuing influx of APPs into clinical emergency medicine may also decrease the number of EP jobs in these areas.
By contrast, board-certified EP density is decreasing in rural locations despite the steep increase in the number of EM residency programs over the past decade. Because rural EPs are less likely to be residency-trained and board-certified in emergency medicine, turnover is higher and the demand for new residency-trained EPs should increase. In short, jobs will be easier to find there.
Using a series of maps in this study describing EP density across the United States, the authors painted a national picture of underserved counties. States from North Dakota down to Texas show areas with the lowest density of EPs, which translates to regions with a higher number of job opportunities.
Will a much higher percentage of EM residents move into rural practice in the next decade? This is tough to answer. Physicians have spent more than a decade in intellectually stimulating environments, many in highly urbanized areas. They are accustomed to high-quality entertainment, dining, shopping, and access to mass transit and air travel. Most will want to stay in urban areas for their careers. At some point, however, every EP needs to generate adequate income, and this may force many of them to look outside urban locations for employment.
Dr. Adleris a practicing emergency physician at the University of Maryland Medical Center, where he serves as the director of compliance and reimbursement. He is also the vice president of practice improvement at Brault Practice Solutions, where he oversees provider education and group practice analytics. Follow him on Twitter@ercoderguy. Dr. Cookis the program director of the emergency medicine residency at Prisma Health in Columbia, SC. He is also the founder of 3rd Rock Ultrasound (http://emergencyultrasound.com). Friend him atwww.facebook.com/3rdRockUltrasound, follow him on Twitter@3rdRockUS, and read his past columns athttp://bit.ly/EMN-Match.