Not Enough EPs: What Now?

The specialty of emergency medicine began with a vision of providing specialized care to the urgently ill and injured, transforming the nation's emergency rooms from afterthoughts often staffed by reluctant attendings into an efficient hospital portal staffed by well-trained physician specialists. Since 1979 when the specialty was finally recognized by the American Board of Medical Specialties, that vision has been pursued with great success. The pace at which physicians are trained, however, has lagged the growing demand, and now a group of researchers with the Emergency Medicine Network (www.emnet-usa.org) report that their statistical projections indicate that it is unlikely that the supply of board certified emergency physicians will meet the demand in the near future — if ever.ImageIn the short term, the specialty may have to compromise, substituting midlevel practitioners or dual-trained primary care physicians to fill in the gaps. The long-term solution requires a system-wide approach that decreases demand for care in EDs by establishing a true system of health care throughout the United States. “We need to build it into the big picture,” said Lewis Goldfrank, MD, the chairman and a professor of emergency medicine at New York University School of Medicine and a pioneer of the specialty. “As a specialty, we should not always plead for ourselves. We need to plead for society as a whole, and solve the problems with something like the National Health Service Corps that meets the need of the society. If we don't plead for universal health care, no one will. We see how poorly people get care.” It's true that it may prove impossible to train enough emergency physicians to meet the need, Dr. Goldfrank said, but he added that might not be the best answer anyway. A system-wide approach will change the picture and the need. “We analyzed a few different scenarios,” said Adit Ginde, MD, MPH, an assistant professor of emergency medicine at the University of Colorado Denver School of Medicine and an author of two reports on the topic. In the first study, the researchers sought to predict workforce needs, calculating the annual supply of physicians based on the existing number of board certified physicians, adding newly board certified emergency physicians and subtracting those who retired or left the field for other reasons, including death. (“Assessment of Emergency Physician Workforce Needs in the United States, 2005,” Acad Emerg Med 2008 Oct 17 [Epub ahead of print].) They estimated the need for emergency physicians by dividing the number of visits by average emergency physician volume of 2.8 patients per hour, 40 hours a week with 34 percent nonclinical time. At the time, the number of U.S. EDs was 4,828, with 47 percent rural, and they assumed that at least one emergency physician would be present 24 hours a day, requiring at least 5.35 full-time equivalent EPs per department.Figure: Dr. Lewis GoldfrankFigure: Dr. Adit GindeThey concluded that while there were approximately 2,492 emergency physicians in 2005, 40,030 would be needed to staff all the EDs; 2,492 emergency departments had a visit volume that required the 5.35 full-time equivalent physicians. Assuming that no emergency physicians died or retired, the researchers said it would take until 2019 to fill all slots in emergency departments with board certified emergency physicians. Assuming 12 percent attribution per year, that goal would never be met, and assuming 2.5 percent annual attrition, it would take until 2038 to staff all of the nation's emergency departments with residency trained, board certified physicians. (Use your own parameters in their calculator at www.emnet-usa.org/nedi/workforce.html.) In the second study, the investigators used the 2008 American Medical Association Physician Masterfile to count all physicians who designated emergency medicine as a primary or secondary specialty. (“National Study of the Emergency Physician Workforce, 2008.” Ann Emerg Med 2009 Apr 22. [Epub ahead of print].) They determined there were 39,061 emergency physicians practicing, 57 percent of whom were board certified in the specialty and 69 percent who were board certified or had received some emergency medicine training. Most of those who had graduated in the past five years were emergency medicine trained or board certified. Those trained in family medicine accounted for 31 percent and in internal medicine for 23 percent. Rural physicians were less likely than their urban counterparts to have emergency medicine training. The greatest densities of emergency physicians in the population were in New England and large cities. The lowest densities were in the West, South, and Central areas of the country and in rural environments. Physicians who do not have emergency medicine training or board certification continue to provide important services in the nation's emergency departments, the researchers concluded. Demand for emergency physicians will not only continue, but shortages are likely to increase in rural areas. One way to increase the supply is to increase training, but that is fraught with barriers, said Dr. Ginde. “Every year, new residency programs do open, but still it does not make as big an impact on the overall problem as it could.” For one thing, new emergency physicians prefer to practice in urban areas with larger emergency departments. “Even if we could increase the sheer number of emergency physicians, it would not solve that problem,” he said. “The issue is, do we have enough trained emergency physicians?” asked Peter Rosen, MD, a senior lecturer in medicine at Harvard Medical School and an attending in emergency medicine at Beth Israel Deaconess Hospital. “Probably not. But the answer is not to increase class sizes and turn out more residency trained emergency physicians because these people are going to go to communities that already have enough of these physicians. It's not going to disseminate them to the community. “I think the answer is a combination of staff,” he said. “Let the training program catch up with the need. It won't solve the problems for the rural emergency departments and specialty emergency departments.” One answer might be a trainee from a joint family medicine-emergency medicine program, he said. “It will be interesting to see if some of these people who have joint training will do a joint practice. That's a model that has worked in Canada.” States in which practice management groups have taken over many community EDs have seen hospitals that could afford well-trained emergency physicians but are not hiring them, he said. “They are happy to hire the physicians not specially trained in emergency medicine because they are cheaper.” “We always dreamed that one day a patient could go into any emergency department in the country and be treated by a trained, board certified emergency physician,” said Dr. Rosen. “That may not be possible or desirable. If you can get the community hospitals that see 15,000 patients or so staffed with trained emergency physicians, that may be an achievable goal and one that is good to see come true. Communities have to realize the financial and intellectual support a physician needs.”Figure: Dr. Peter ViccellioFigure: Dr. Jerome HoffmanDr. Ginde agreed, noting that many emergency departments are still staffed by family practitioners or internists. “If they did not staff those emergency departments, there would be no board certified emergency physician to staff them,” he said. “The question is how, while these physicians are staffing the emergency departments, do we understand their needs and move toward the goal of providing as high quality emergency care as we can.” One solution might be to find ways to recruit new graduates to rural areas, Dr. Ginde said, perhaps loan repayment. Another might be to expose residents to the rural environment, he said. These solutions might recruit people in the short term, he said, but retaining them and making their lives and practices enjoyable is another. Even if physicians stayed in the rural area only two or three years, it would help bridge the gaps, he said. Physician assistants or nurse practitioners with skills in emergency care might provide another source of care, he said, but family physicians are another option. “What is the preference as far as having the emergency departments staffed with family physicians who have decades of experience vs. an advanced practice nurse?” Dr. Ginde said hospitals and emergency physicians need to understand their needs, and provide continuing medical education that is emergency medicine-specific. “They are practicing in emergency departments, and without them, there would be no one.” If you look at it from that aspect, you are not competing with residency trained, board certified emergency physicians,” he said. “There is a great need for trained emergency physicians, but we must deal with reality in the intermediate term.” Joint programs may provide an answer, he said, but “there are many issues to be hammered out. If jointly trained physicians were willing to go into rural areas, that would provide a solution. Of course, Dr. Ginde said, the shortage of primary care physicians overall will require other solutions, among them increased medical school enrollment, better funding, and expansion of graduate medical education that is being pursued by the Association of American Medical Colleges. As health care reform looms, he said, the need for more physicians could become crucial. The Massachusetts situation in which newly insured patients are having difficulty finding a medical home demonstrates the crisis now facing the country. “This is all driven by assumptions,” said Peter Viccellio, MD, the vice chairman and a clinical professor of emergency medicine at the State University of New York Stony Brook School of Medicine. “When I first came to Stonybrook, most of the emergency departments [in the area] had no emergency physicians at all. Now they almost all have residency trained physicians, and the places aren't hiring them unless they are residency trained.” The rural problem exists for every specialty area, he said, even those with a surplus. “You don't get people going to rural areas. It's not a marketplace-driven thing. The markets don't respond to rural needs by increasing payments, at least enough to get people to work there,” he said. The question, Dr. Viccellio said, is “What is the point of their study? What is the social or political aim?” Dr. Ginde said papers such as these and others from EmNET can help inform policymakers and specialty leaders, but Dr. Viccellio said just calling attention to the problem isn't enough. He said academic hospitals have a history of matching the size of the residency programs to the volume of patients seen in their facilities. “For years, there has been a residency cap, but the patients have continued to increase. Emergency departments have hired physician assistants and nurse practitioners to replace the resident physicians.” He pointed out that resident hours are now capped, concurrently reducing the workforce. Residency slots have not kept pace with the need, and the internal hospital debate is related to the hospital's needs. Does society need more family practice residents or emergency medicine residents? The question is answered as it relates to each hospital's internal mission. They may match the needs of academic hospitals but not society as a whole, Dr. Viccellio said. At the same time, he said, burgeoning advances in areas such as stem cells could alleviate problems such as diabetes. “Nanobots could clean the vascular tree. We have the potential for dramatic changes out there. You have no idea what your needs will be because the changes will be so dramatic.” Many positions for emergency medicine will not be filled by people trained in emergency medicine, said Jerome Hoffman, MD, a professor of emergency medicine at the University of California Los Angeles. “That's a bad thing. What do you do about it?” Decreasing the number of emergency departments and concentrating care in departments with sufficient trained emergency physicians is one possibility. “Still another is to say that because you can't have enough specialists trained, you just call other specialists. To me, that does not make sense,” Dr. Hoffman said, but “you could divide up the cases so that those with less training don't see the big emergencies.” Urgent care facilities operating adjacent to emergency departments often function that way, but Dr. Hoffman said that method is problematic. “That's not how emergency patients come,” he said. “They don't come to the emergency department with diagnoses. They come in with complaints. It's easy to take care of someone who is obviously sick. What's hard is finding needles in a haystack.” Dr. Goldfrank said the answer rests with b`ig-picture thinking. “People need a medical home and a health care system that can stop things that expand cost,” he said, but regionalization that improves quality in existing departments and provides better access to primary care closer to home could be an answer. Dr. Hoffman agreed. “I can't give you the big answer,” he said, but “the whole health care system is in tremendous turmoil with enormous economic challenges. If we don't fix those, we won't be able to answer the question. It's at the heart of why we are so dependent on emergency medicine. If we had better primary care, we might be less dependent on emergency care. That would go a long way toward fixing this problem.” In the interim, he sees no easy solutions. “None of these questions can be taken out of context. It is clear that if we want a rational health care system, one of the first steps is a single-payer plan that takes the massive insurance profits out of the equation. It is unethical that we allow this wasteful profit-based system to control something as fundamental as health care. I really believe that we are not going to solve the issue of how many emergency doctors there are in Pascagoula, Mississippi, without addressing the fact that the system is not viable, and it's breaking our whole economy.”

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