A variety of solutions needed to address supply/demand issues.
It is hard to believe that just 50 years ago, there were no board-certified emergency physicians. There were just a handful of residencies and it was unclear what the future of emergency medicine would look like. How many emergency physicians would be needed?
Background
A 1994 workforce analysis prepared for the American Society of Anesthesiologists inaccurately projected an anesthesiologist surplus using predictions on the impact of widespread managed care.[1] Panic ensued as reporting of “evidence” in the popular press of a flawed workforce analysis led to a significant reduction in the anesthesia workforce.[2]
Anesthesia residency applications sharply declined from U.S. medical students and international medical graduates filled the unmatched spots. It took anesthesia nearly a decade to recover.
The American College of Emergency Physicians (ACEP) convened a Workforce Task Force in 2018 with AACEM, ABEM, ACOEP, AOBEM, CORD, EMRA and SAEM as some feared the specialty was reaching market saturation. Learning from the experience of anesthesia, the Task Force recognized the need for a comprehensive study based on more than just historical projections. We needed prospective and evidence-based data to guide the future of our specialty. The methodology had to be rigorous to make the most accurate assessment possible.
One component of the workforce study was to survey all of the 2019 graduating EM residents. That survey showed that more than 80% of graduating EM residents had no difficulty finding a job that year.[3] This suggests that although we may be approaching market saturation in the future, we weren’t there in 2019. Other studies demonstrated a growing distribution problem; there were plenty of jobs in rural areas, but emergency physicians were highly concentrated in urban and suburban areas.[4]
COVID’s impact
COVID then introduced a significant confounding variable to the 2020 job market as emergency department volumes decreased nearly 40% nationwide. This greatly accelerated the contraction of the job market as emergency departments struggled to remain financially solvent in the middle of a pandemic. Many emergency departments have still not returned to baseline patient volumes in 2021. At some point, the pandemic will end. This is a singular disturbance distinct from the longer-term workforce issues in our specialty.
In early 2021, the Workforce Task Force completed Phase 1 by concluding its study, drafting a manuscript for publication and presenting their findings during an April multi-organizational Workforce Summit. The long-term trends indicate that current supply is increasing faster than demand. The task force concluded that, if we do nothing to correct our course, we will be headed toward a likely oversupply of emergency physicians by 2030.
I have never known an emergency physician to do nothing. We act, innovate and “MacGyver” solutions every day. This is what we do best. We do need to address the long-term growth and ensure the supply of emergency physicians is matched to the anticipated career workforce opportunities in the future.
The days after the Workforce Summit led to some predictable panic and confusion and misrepresentation of what was actually said. Now it is time to move past that fear and frustration. We need to work together to find solutions and put plans into action.
Strategy
There is a sense of urgency among all emergency medicine organizations, but it is important to understand that there is not one perfect holistic solution. We will likely need to implement a number of different solutions to address both supply and demand. Each of the proposed solutions will take time to implement, but we will get there.
Nothing will stand in our way to support emergency physicians – not corporations or private equity, insurance companies or non-physician practitioners. ACEP and the other Workforce Task Force members stand committed to supporting all emergency physicians – from those working in small groups to big groups, from community groups to academic centers, from medical students to semi-retired emergency physicians. We are one specialty, one team.
The workforce summit was divided into groups discussing potential solutions to either supply or demand. None of the proposed solutions from the summit are final and there may be other new suggestions that are proposed as we move forward.
What’s next?
We will need to understand the measured impact, feasibility and unintended consequences of each of these decisions and engage with stakeholders outside of emergency medicine. We are listening and we will need to make difficult decisions together. This is our starting point and differing opinions are still needed and welcomed.
Phase 2 of the workforce collaborative will focus on the following framework:
- Evaluate residency requirements to ensure consistency and quality across EM residency training. Propose new residency requirements to the ACGME to meet training standards for the future.
- Ensure business interests do not supersede the needs of educating the workforce or providing quality patient care.
- Support emergency physicians to encourage rewarding practice in all communities, including rural environments.
- Ensure appropriate supervised use of NPs and PAs and oppose independent practice to protect the unique role of emergency physicians.
- Expand demand and broaden emergency physician practice to meet evolving community needs for acute unscheduled care.
When anesthesiology later faced another potential surplus, they expanded their practice into pain management and increased demand for their specialty beyond airway management. We recognize that our skills extend beyond the four walls of a hospital and our specialty will continue to evolve to increase demand. We are trained not to panic when things don’t go as expected and tackling workforce issues is no different. We are the calm ones in the room who bring order to chaos. We are inherent problem solvers and we will get through this together.
Our specialty was born out of need and that need is not going away. We are the experts at acute unscheduled care. There will always be a need to staff hospital based EDs with emergency physicians, but with telemedicine and new healthcare delivery models, we will also have new opportunities to define what our practice can be. There will be growing pains as we evolve, but remember how far we have come.
Fifty years ago, we were told that emergency medicine would never be recognized as a specialty. Now we’re one of the leading specialties in the House of Medicine. We have beaten these odds before. We will beat them again.
For the latest updates on workforce efforts, go to https://www.acep.org/workforce.
References:
- Estimation of Physician Work Force Requirements in Anesthesiology. Bethesda, MD: Abt Associates, Inc., 1994:1–53
- Shubert A, Eckhout G, Ngo A et al. Status of the Anesthesia Workforce in 2011:Evolution During the Last Decade and Future Outlook. Anesth Analg2012 Aug;115(2):407-27.
- Quigley L, Salsberg E., Richwein C. New Emergency Medicine Physicians: Who Are They, Where They Are Working and Their Experience in the Job Market; Results of the Survey of Emergency Medicine Residents Who Completed Training in 2019″; a report from the GW Fitzhugh Mullan Institute for Health Workforce Equity to ACEP, February 2020.
- Bennet C., Sullivan A, Ginde A.et al. National Study of the Emergency Medicine Workforce, 2020. Ann Emerg Med. 2020 Dec;76(6):695-708.
