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After Years of Calling for More EPs, EM Finds Itself with Too Many

Shaw, Gina

doi: 10.1097/01.EEM.0000754792.29380.36
    Figure
    Figure:
    workforce, jobs, residencies, supply and demand

    There will likely be nearly 10,000 more emergency physicians than there are jobs for them by 2030, according to a new study commissioned by the American College of Emergency Physicians. (Emergency Medicine Physician Workforce Projections for 2030. April 9, 2021; https://bit.ly/3aQb6CZ.)

    “We are now facing for the first time in history a likely oversupply of emergency physicians within the next decade,” said ACEP President Mark Rosenberg, DO, the chair of emergency medicine at St. Joseph's Health in Paterson and Wayne, NJ, in a webinar releasing the findings. (https://bit.ly/2Ra6sbQ.)

    Emergency medicine residency programs and the overall number of residency slots in the specialty have grown significantly. A total of 4565 residents were in 145 emergency medicine programs in 2008, a number that shot up to 7940 residents in 247 programs by 2019, a 74 percent increase. The number of EM residency slots increased by six percent between 2018 and 2019 alone.

    “Emergency medicine is now the second most popular specialty in the country after internal medicine,” said Louis Ling, MD, formerly the senior vice president for hospital-based accreditation at the Accreditation Council for Graduate Medical Education (ACGME), during the webinar, citing the results of the 2021 residency match held in March. “More people matched to emergency medicine than to family medicine or pediatrics. Combining supply data with demand data, we would need to cut about 1000 residency graduates a year, which gives you an idea of the kind of supply we have.”

    Continuing Growth

    The study, conducted by Edward Salsberg, a member of the health policy faculty at the George Washington University School of Public Health and Health Services, projected future supply and demand for emergency physicians based on potential variability in the rapid growth of emergency medicine residencies; projected attrition rates in the specialty; the rise of nonphysician practitioners (NPPs), who made up 23 percent of the workforce billing independently for ED care in 2018; and projected emergency department volume.

    The most likely scenario, the study predicted, is that the number of emergency medicine residents will grow two percent between now and 2030, 98 percent of whom will enter emergency medicine, and the attrition rate will be three percent among current providers, for a projected supply of 59,050 emergency physicians. Visits per physician will remain constant, with 20 percent of those patients seen by NPPs, for a projected demand of 49,637. That would result in a surplus of 9413 emergency physicians.

    Mr. Salsberg's formula can be adjusted to see what might happen if certain variables change. If, for example, the growth in emergency medicine residencies continues and the number of emergency medicine residents increase by four percent while everything else about supply and demand stays the same, it would mean that more than 10,000 emergency physicians will be looking for work in 2030.

    The study was commissioned by a task force of eight specialty organizations, including ACEP, the American Board of Emergency Medicine, the American College of Osteopathic Emergency Physicians, the American Osteopathic Board of Emergency Medicine, the Emergency Medicine Residents' Association, the Council of Residency Directors in Emergency Medicine, the Society for Academic Emergency Medicine, and the Association of Academic Chairs of Emergency Medicine. Representatives from each of those groups presented recommendations during the webinar to help address the incipient workforce crisis:

    • Encouraging or requiring emergency medicine residency training to be extended to four years without increasing the complement of residents.
    • Increasing emergency medicine procedural requirements to be more robust.
    • Increasing resident salaries to decrease incentives for residencies to be established for the purpose of providing low-cost labor.
    • Calling for fewer residents in each new program and existing programs, or even decreasing positions in current programs.
    • Calling for a decrease in or a halt to new emergency medicine residencies.
    • Investigating the legitimacy of for-profit organizations funding training programs, including potential conflicts of interest.
    • Supporting standardized training for NPPs working in the ED.
    • Better identifying competencies of NPPs compared with emergency physicians.
    • Ensuring that the physician-led team model in the ED is endorsed and promoted.
    • Categorizing emergency departments, including metrics for physicians, NPPs, supervision, and outcomes, to set professional standards for overall better practice.

    Catherine Marco, MD, a professor of emergency medicine at Wright State University and the chair of the study task force, declined to comment for this article, saying the peer-reviewed publication based on the workforce study was still in review at press time.

    High-impact strategies, such as reducing the number of residents in programs or decreasing or stopping new programs, would likely have to be voluntary, as with other specialties, said Lewis Nelson, MD, a professor and the chair of emergency medicine at Rutgers New Jersey Medical School and University Hospital, who represented the Association of Academic Chairs of Emergency Medicine in the webinar. “A mandated reduction would probably only result if ACGME requirements were changed to require more resources and faculty-protected time. The ACGME cannot, at this point, withhold approval of a program if the program meets requirements.”

    Other options considered but discarded as infeasible included seeking shutdown of some existing programs by the ACGME's Residency Review Committee and working with the Centers for Medicare and Medicaid Services to deny funding to new programs in nonteaching or for-profit hospitals.

    Fair Warning

    Some say that the writing has been on the wall about a workforce crisis for years. Thomas Cook, MD, the director of the emergency medicine residency program at Prisma Health Richland Hospital at the University of South Carolina School of Medicine, noted in his EMN column that 77 emergency medicine residency programs had achieved ACGME accreditation between 2016 and 2019 alone. (EMN. 2019;41[10]:1; http://bit.ly/2or6kqm.) Large contract groups like US Acute Care Solutions and TeamHealth and large health care organizations such as HCA have been responsible for much of that surge, he said.

    “I saw this coming, and I'm no genius,” Dr. Cook said. “Here in South Carolina, we have about five million people and five emergency medicine residencies graduating 60 doctors a year. We don't have 60 new emergency medicine jobs a year. When I was a resident, I think Florida had two emergency medicine residency programs in Orlando and Jacksonville. Now I think they have more than 20. Two may be too few, but 20 is way too many.”

    ACGME has routinely rejected programs in the past, but Dr. Cook said he thinks the organization is unlikely to flex that muscle against corporate-sponsored residencies today. “They rejected Parkland's emergency medicine residency in Dallas the first time,” he said. “They took residents out of the program at Harborview in Seattle because the program director was not an emergency physician but a neurologist. Historically, they would act aggressively about making sure programs were supported, but now the number of site visits has gone down, and the same level of action is not happening. The ACGME's total operating budget is about $70 million, and they're expected to control a company like HCA, whose profit last year was $3.8 billion?”

    No Quick Fixes

    The American Academy of Emergency Medicine declined to participate in the workforce study because it was not allowed to participate in the selection of the investigator, the questions to be investigated, or the fee provided to the investigator. It released a position statement a few days later saying it has “long been aware that circumstances have been created which have increased the supply of emergency care clinicians beyond the demand,” attributing that to for-profit health care corporations that created “a substantial number of emergency medicine residency programs” and the training and credentialing of nonphysician practitioners to provide ED care.

    AAEM criticized ACGME for decreasing the academic requirements for residency graduation by eliminating a requirement for a scholarly project and a reduction of the protected time afforded to program leadership for developing academic teaching and research for the residency. “We assert that there is a conflict of interest between profit and education when corporations run residency programs,” the statement said. “We contend that these [nonphysician practitioner] training programs have no place in the emergency department in an environment where resident physicians are unable to find employment due to supply-demand mismatch that currently exists and is predicted to continue or worsen.” (AAEM. April 12, 2021; https://bit.ly/32ZbwTb.)

    Robert McNamara, MD, a professor and the chair of emergency medicine at the Lewis Katz School of Medicine at Temple University in Philadelphia and a past president of AAEM, said there aren't any quick fixes. “AAEM has been saying for a long time that we should not let corporations take over our specialty,” he said. “If we hadn't, we wouldn't be in this position now. The corporations have contributed to the oversupply by opening a number of new residencies and have major influence on the demand side by being in control of which practitioner will see the patient.”

    The situation is “a crushing blow” for current residents and recent graduates, Dr. McNamara said, pointing to his own institution. “Four of our graduates really struggled to find jobs this year. Two of them took per diem positions, one took a fellowship when they really wanted a full-time job, and one had to take a position with a group that doesn't mesh with his professional ethics. It has hit everybody.”

    The core issue, he said, is that emergency physicians have lost the ability to control care in their own EDs. “We have not effectively used the existing rules against the corporate ownership of medicine,” he said. “We need a more widespread effort to challenge these practices. It is not just the graduating residents who are at risk. For the corporations, the bigger the workforce, the less you have to pay the doctors, so an oversupply plays right into their hands.

    “[T]his crisis represents an enormous future danger to patients if emergency medicine loses its ability to attract the best and the brightest,” Dr. McNamara said. “We're even more expendable than we were in the past, so that's why academicians, leaders in the field, and other people who have secure jobs have to speak up now. I'm saddened, but I'm still energized.”

    Ms. Shawis a freelance writer with more than 20 years of experience writing about health and medicine. She is also the author of Having Children After Cancer, the only guide for cancer survivors hoping to build their families after a cancer diagnosis. You can find her work atwww.writergina.com.

    Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.
    • jbroderick9:07:09 AMGetting to this point of oversupply of EPs took years, and the solution will take as long. There will be no one solution, but one I have advocated, lived, and recruited EPs to consider are jobs outside the ED. I work for Landmark Health and was hired six years ago as their first EP. We and other value-based group look for docs in primary care and EM that can distinguish sick from not sick and work to treat non-life-threatening conditions in non-ED settings with community partners, including EMS, using shared decision-making principles. EPs have a unique and valuable skill set that shouldn't be considered useful only for the ED. Health care is moving away from hospitals exclusively and more toward the home. Economic forces but also consumer demand are driving this.
    • fjaramd11:51:07 PMIt took a task force of eight organizations (ACEP, ABEM, ACOEP, AOBEM, EMRA, CRDEM, SAEM, AACEM) to come up with 10 recommendations to help address the incipient workforce crisis. The 10 recommendations included increasing resident salaries, calling for fewer residents, calling for a decrease in new residency programs, extending programs to four years, and investigating legitimacy of for-profit organizations funding training programs. It took a task force of eight to come up with a "no-teeth" statement. Who are we "calling," and who would support the idea of raising resident salaries as a deterrent? Let me understand the task force of 8's way of thinking. A hospital that wants to start a program will hike resident salaries as a incentive for them to not start a program. Sounds a bit like an autoimmune disease. "Speak up!" suggests Dr. McNamara, but to who? As independent emergency physicians, we have no voice. The task force of eight sugarcoats the crisis with utopian ideas. Organizations like ACEP and SAEM are quick to collect outrageous fees so that we can add a few extra letters after our name yet they do very little to protect the collective body and the future practice. The ACGME is the number one reason we have a workforce crisis. Every EP organization should be tasking their legal department to challenge ACGME and for-profit organizations funding residency programs. The argument made is that the ACGME cannot withhold approval of a program if the program meets requirement. The problem is that the ACGME sets the requirements. They can raise and lower the bar at will. Uh-oh, another conspiracy theory in the works. However, I am considering opening a residency program in my garage because I think I stand a pretty good chance of getting ACGME approval. Sadly the horse is out of the barn. Programs are continuing to open like weeds, and when American grads realize this and choose a different field, the slots will remain open and they will fill.
    • hrizvimd7:04:42 PM<div>Companies like these are engaged in racketeering and corporate fraud, and some emergency physicians are industry enablers. NPPs replacing attending physicians in numbers and quality of care is an open fraud enabled by the Centers for Medicare and Medicaid Services. Reveal the truth, and serve your neighbors. Those who speak up should be warned about the backlash.</div><div><br></div><div><span><span>Dr McNamara&#160;and Dr Cook should organize a legal confrontation against the industry shills such as the ACGME, DNP programs like the one at Columbia University, the Federation of State Medical Boards, the Federation Credentials Verification Service, the HHS, and the CMS. The financial tool for the fraud is where merit is sabotaged by corporate implants. And HHS operates the databank to obstruct any earnest whistleblower EP.&#160;There is no point in wasting your angst against industry insiders quoted in this report. </span></span><br></div>
    • bmskalispellmt2:31:43 PMEmergency medicine, like other medical fields, has no one to blame but itself. After years of moaning about a shortage of EPs, encouraging the use of NPs and PAs, and accepting the overproduction of osteopathic (and allopathic) EPs, EM finds itself with a dilemma. It's important to note that the &quot;neurologist&quot; Michael Copass, MD, at Harborview in Seattle, was one of the fathers of EM, particulary EMS, in fact, probably the father of modern EMS. It is my understanding that he was obviously ABEM-eligible but chose not to take the tests. Shame on you for disparaging him. How many ABEM-certified EPs were practicing in 1970?