Night Shift: Saturated

7 Comments

Throughout my soon to be 40-year career in emergency medicine there were three things you could always count on:  taxes, death and rising numbers of patients coming to the emergency department.

It seemed that no matter what we did, we couldn’t keep up with the increased volume. I once knew an emergency department director who was on the building committee charged with planning for the size of his future ED. When asked what kind of volumes they should plan for, he gave a number that he thought was high at the time. Building was delayed and by the time the ED was built the actual annual volume was twice his highest estimate.


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That put the emergency physicians graduating from residencies in an enviable position. Jobs were everywhere, often times with signing bonuses. I even rode that wave with a career in locum tenens practice that took me all over the country, garnered above average compensation, and provided time flexibility that was unheard of in virtually any field in medicine.

A 1997 article reviewing the EM workforce, predicted that the supply of trained emergency physicians would not equal the demand for those trained emergency physicians until 2020. That seemed like a long way off at the time. Some even doubted it would ever happen. But that was last year, when COVID hit the US and ER volumes dropped by 40% to 60%.

For the first time in my lifetime, graduating emergency medicine residents are having a difficult time finding the jobs. Some are even getting contract offers with an hourly rate, but no guaranteed number of hours.


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How did this happen?  And what should be done about it?

First, there are still predictions of an overall shortage of physicians. The American Association of Medical Colleges (AAMC) has continued to project a shortage of physicians between 42,500 to 121,300 by 2030 due to the aging population with increasing medical needs.

In response to projections like this, increased training positions for all specialties have increased, including EM. The number of EM residency programs increased from 82 in 1990 to 239 in 2018.

When I graduated from medical school in 1979 there were only a handful of three years EM residency programs. And I was lucky to lad one of three first year positions at Akron General Medical Center in Akron, Ohio. There were probably only a couple hundred positions total nationwide. The 2019 National Resident Matching Program matched 2,488 first year positions.


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And as the number of training positions has increased, so has the number of board certified emergency physicians. In 1984, there were only 2,852 ABEM certified emergency physicians. But by 2019, there were 41,026 ABEM/AOBEM-certified EPs.

If we achieve some sort of homeostasis at this point we should be good, right?  Every patient coming to the ED will be able to see a board certified emergency physician. That was the goal. The answer is, maybe not. It seems that we might have our foot stuck on the gas pedal. And we are continuing to. Why is this?  And what should be done about it?

To be fair, let me take the first shot at guys like myself. Emergency medicine has always been a fast paced, high acuity specialty best practiced by the smartest adrenaline junkies on the planet.

When most of us started flying these fighter jets of ERs, we thought we would do it for a few decades and hang up the spurs at age 50 or 55 and kick back for well deserved early retirement. But adrenaline is addictive. So too many of us are still hanging around.

After several attempts I was finally ready to retire. But then when COVID hit, travel became restricted and no fun. Retirement meant that I would be “stuck” at home talking to my wife all day and she had plenty to say about that. But the truth is that all the guys like me need to clear out to make way for the next generation.

The target of this pruning project is a little tougher. The truth is that the need for APPs in EM is probably nearly over. When emergency medicine was young we needed all the help we could get. Utilizing “physician extenders” seem to make perfect sense. The thinking was that you didn’t need a board certified emergency physician for minor illnesses and injuries. But that’s not how it has worked out in reality.

APPs started out working in fast track settings under the supervision as needed. But soon fast track became part of the main ED and supervision became perfunctory. Soon the APP became the second physician, only paid less. To be fair, very few problems have occurred with this model. After all, as the ‘Oracle of Emergency Medicine,” Greg Henry, MD once told me, “APPs can do 90% of what I do as well as I can.

They just don’t often know which 10% they don’t.”

This may be the argument of the purist. But ABEM made it clear when they closed the practice track to board certification for experienced family doctors that they believe EM should not be practiced by those without residency training in EM. But then we hypocritically turned to APPs with little or no ED experience other than a few months of ‘on-the-job training.’

Boot Camps sprung up to train APPs  in emergency medicine. Even some PA/NP ‘residencies’ in EM have become part of EM residencies training along with, and sometimes diluting out, the training experience of emergency medicine residents. It’s an admirable effort, but it begs the question. When you have plenty of well trained EM physicians to fill all the available slots should you continue to train “mid-level providers?”

I welcome the disagreements of my PA/NP colleagues. But when we fill a slot with the lowest level provider able to do 90% of the work of a board certified emergency physician and don’t hold them legally accountable to the highest level, especially if it is for financial gain, don’t we run the risk of devaluing our skill, put patients at unneeded risk and tarnish the reputation of the specialty that we have all worked so hard to establish?

The last and possibly the most sensitive targets of my criticism in this matter are residencies themselves. Now that we have reached a saturation point for board certified emergency physicians does it make any sense to continue to accelerate the growth of training programs?

The ACGME continues to approve new residencies in EM even in areas where there is no data for an EM physician shortage. Florida is a prime example. This state saw a 200% increase in EM residency slots while only increasing other specialty training positions by 20%. Many governing bodies have tried to tackle the problem of tying supply to demand. But it seems to me that the ACGME should have a ‘certificate of need’ type of qualification before any new training programs are certified.

Despite all this bad news, there remains a lot of upside to what is happening in our specialty. Rural ERs are still disproportionately staffed with APPs and present an incredible opportunity for graduating EM residents to hone their skills in some of the best places on earth. One of my first jobs was the co-director of the ED in Mansfield, Ohio.

It was a single coverage ED with enough volume to keep you running all night. Yes, we saw gunshot wounds. But we also saw tractor rollover injuries, ski injuries, lots of motor vehicle crashes, and every kind of illness and condition, both adult and pediatric. It was an incredible experience. And the town was absolutely lovely. More EM residencies need to send their residents to train in rural settings.

They might find a world of opportunity awaits them.

And last, I must confess that I’m speaking out of both sides of my mouth. I’m aware of the potential of glutting the market with board certified emergency physicians, but I’m also aware of the myriad of opportunities that are available to emergency physicians outside of the ER. Telemedicine, geriatric medicine, and many other extensions of this great skill of ours beg to be developed.

But the greatest pandemic of all is the opioid epidemic. And I believe that EPs have the critical knowledge, disposition and experience to make the greatest impact on this devastating condition. That’s where I plan to spend the next few decades of my professional life. At least my wife will sigh with great relief.

 

Give This a Read:

“Too Big Too Fast?  Potential Implications of the Rapid Increase in Emergency Medicine Residency Positions”  Concept Paper

Mary R. Haas, MD, Laura R. Hopson, MD, and Brian J. Zink, MD

Society for Academic Emergency Medicine

 

ABOUT THE AUTHOR

FOUNDER / EXECUTIVE EDITOR Dr. Plaster has been an emergency physician for more than thirty years, working exclusively night shifts for the past twenty years in emergency departments across the country. During that period he joined the U.S. Navy and served two tours in Iraq. Dr. Plaster is the founder and executive editor of Emergency Physicians Monthly and the founder of Plaster Publishing.

7 Comments

  1. Jerry Cattelane Jr on

    Mark, I have enjoyed your columns for a long time. As an EM physician coming up on year 20 (and the last 15 plus as nights only), I agree with much of what you have to say here. In my current position, I have little interest in training new PAs or NPs who are only there to undercut me eventually. There are a few of us that actually send them home early as we reap no benefit financially from them being there while we are incurring ALL of the liability.

    In my opinion, we as a practice need to stand firm against the encroachment of APPs. Yes, Dr. Henry might be right about his 90% comment, however, I guarantee you that a seasoned EM physician is FAR more cost effective than an APP when it comes to the urgent care style of patient. Not every 30 year old with a cough that comes into my ER needs a full workup with labs, CXR and CTA chest. Yet, more often than not, that’s what my APPs are doing.

    I am at the age where I am considering locums or concierge practice as I am heading towards age 51 this summer. On the other hand, I am on a schedule that I can maintain for many years to come. We have gotten smarter about our circadian rhythms and it’s paying off with a longer career. The question is whether or not the market will be there for us.

    I salute you sir. Play on.

  2. Nate Herscovitch MD on

    Congratulation Dr Plaster.
    I got ABEM certified in 1982. Worked night shifts exclusively for the past 25 years and finally retired on 1/1/21.
    I enjoyed every minute of my professional life.

  3. William J. McIntyre, MD on

    I just took a new very rural ED job in Kentucky at age 72. There is a market if we are willing to travel to where the need is.

  4. Sarah Carrier on

    Dr Plaster I’ve followed your opinion pieces for many years. The idea that EM boarded docs are ever going to come out here to the Rural areas remains a fantasy of a few hospital administrators around here. They mostly realize that they will have to “settle “ for some of us IM , FM ,and sometimes Surgery boarded docs who have been doing shifts full time in our rural ED’s for years. We are comparable to the immigrants who fill many jobs in other fields, paid less but doing the same work.

    ACEP needs to look at enlisting some preceptors in the rural areas if they ever want their Diplomates to see the benefits of this type of practice. Oh ,but then they might have to recognize that we DO know how to practice Emergency Medicine.

  5. Judith Tharp on

    I’m in total agreement that the unopposed crowding out of fully trained EM physicians by partially trained and limited experience (most of the time) “physician extenders” no longer serves our interests nor the patients’ interests. Part of that is because we have zero control (it’s all corporate now in most cases). Corporations really only care about profits, so it’s in their interests to saddle every qualified EM MD/DO with as many APPs as possible to increase profits. And it isn’t just because they cost less/hour wage, but because they have learned that there will be more expensive testing ordered by APPs, often unnecessary, but racking up charges. Also there’s the question of basic competence. I had to got to ER 2 years ago because of a big and deep laceration on my leg. A NP did the eval, left the room, then an MA came in and opened a laceration tray, wearing ordinary blue exam gloves, proceeded to open the tray and take out the syringes, cups, instruments laying them on the sterile drape on the Mayo stand, apparently oblivious to the fact that she had made the whole tray and contents nonsterile. The NP came back, and ?I guess because the laceration was so large, decided not to suture it, but to apply a dressing and refer me to a Wound Care Center (!) based in the hospital. I was really nonplussed, took me 6 days to get in to the Wound Care Center, and the outcome was OK, but it took a lot longer to heal than if she had even done a crude closure with 3-0 nylon and a 1/4″ Penrose drain. I later did suggest to the supervising ER doctor (who wasn’t that easy to find) that he observe his MA’s apparent lack of understanding of sterile technique. I realized I had better not extend my complaint my disappointment that no attempt was going to be made to suture the wound, because his hostile response to my bringing up the MA’s improper technique told me that I was lucky to get out of there with a dressing and a tetanus booster. Enough of my personal story. The other issue is that the Corporation who employs the Board Certified Emergency Physicians is only too happy to allow them to assume liability for the work of “collaborating” APPs. In reality, it is impossible in a busy ER to truly supervise and adequately review the work of APPs especially if more than one. But if something goes deadly wrong the EM physician may find him/herself swinging slowly, slowly in the wind. I say all this from the perspective of having spent 30 years full time in busy ERs, retiring to Occ Med in 2006.

  6. Iris Ford DO on

    Dr Plaster, I read your column “Saturated”, with interest. I do have a bone to pick on the idea of “using physician extenders made sense”. It has always been the brain child of corporate medicine in order to make them more money. At least 25 years ago, our group was told there would be one less doctor in the ED and 2NP’s instead, holding down the fast track. The hospital administrator blankly stared at me when I objected, then eventually off-loaded 2 doctor positions, along with “research articles” showing patients were happier with NP care than with physician care. When we were spun off as an independent group, there were still no changes to the line up, although there was no difficulty attracting EM boarded physicians. It has always been about the money and changing the title to “provider” to keep patients in the dark. From the beginning of the new model, our group was told we must sign all the charts and have no input unless it was requested, at which time we “must teach” our likely replacement. This whole sham has been forced on us by people who need us to make more money for them. I wonder if your bravery with this article is influenced by retirement? Ed docs have been fired for saying your sentiments out loud.

  7. Iris Ford DO on

    Dr. Plaster, I read your column “Saturated “ with interest. Your point that at one time APPs were “needed” is not true. The idea of replacing EM trained physicians with NPs or PAs was always the brainchild of corporate medicine to funnel more money upward. Our ED 28 years ago was easily staffed with physicians boarded in EM, yet the hospital administration decreed we would be displaced until the new model was reached. When we were spun of from hospital employment to a group, the model didn’t change, to continue reimbursement for management in the style to which they desired, no doubt. It’s true I’ve found myself stretched so thin to be tearfully grateful for anyone in the trenches, but I fondly remember the good old days when there was another doctor beside me. To maintain employment, I am required to sign charts of others, with the only explanation that it is required for billing. Turns out, it’s required for higher billing. Patients are the unwitting victims of this scheme. They have no idea they were not seen by a doctor, since we are all “providers” and the bill reflects the lie.

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