‘The Future of Emergency Medicine is Bright’

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New ACEP president envisions optimistic times ahead for physicians with tech, staffing and initiative enhancements.

Mark Rosenberg, the current ACEP president, recently spoke with EPM Editor-in-Chief Salim Rezaie and Senior Editor Michael Silverman about his vision for the organization.  This is the first part of the interview concerning the fallout of the COVID-19 pandemic, the importance of staffing and technological advancements. The second part of the discussion will be published next month in our March edition.


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SALIM REZAIE:  Mark, thank you so, so much. I know you’re a busy guy. I just found out minutes before we were getting ready to record this that you just had COVID-19 and are recovering from it. So I even more appreciate your time. We know that [the virus] has kind of been front and center in a lot of worlds and there’ve been a lot of people facing difficulties with job safety. With patient volumes down nationally, we’re hearing about a lot of physicians getting furloughed, having difficulty finding jobs, etc. so I wanted to get your thoughts on helping ensure safety going forward.

MARK ROSENBERG: It’s a big issue. It affects not only everybody who’s working in emergency medicine as a physician, but also our young residents and young physicians who are moving up in their career.

We are in a business. We’re in a business to take care of patients. And we’re in a business where we have minimal financial resources other than those which we either get from the hospital or from our patients. And then we run into a problem where that patient volume and that revenue source is drying out or significantly less than we had budgeted for this year. So, what do we do?


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So problem number one is decreased volume. Problem number two is the nonphysician providers are constantly saying they’re cheaper than we are and they can do our job. Then we have increased residency programs. Then we have insurance companies. ACEP is dedicated and determined to focus on each and every aspect of that. The Workforce Study will give us some of the data that we need. And then we really have to go back in and look at how many residency programs we have.

I believe the future of emergency medicine is bright. I believe it will be different. I believe it will be stronger. And I believe that we will be a front and center part of the healthcare solutions to this country.

REZAIE:  Emergency medicine is the backbone of medicine, at least in the United States. If it wasn’t for us, there’d be so many things falling apart. We really are the safety net for everyone.

How can we make sure that APPs can be integrated, but also not sacrifice workspace for the residents that are coming out and for the current physicians that are looking for jobs? And I think this is also a million-dollar question of: How can we work together to ensure that there’s enough space for everyone?


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ROSENBERG:  Each question seems like it’s worth more money if I get the correct answer, like that’s a $10,000 question. To take any one of those pieces in isolation does the whole conversation a disservice. When we look at the workforce and when we look at the job opportunities and we look at rural emergency medicine, and rural is almost every state in the country, has some rural challenges and western Texas is obviously very different than northern Maine, but nonetheless, many similar challenges.

In those rural areas, we have PAs in Maine that have independent practice. We have nurse practitioners in other states that have independent practice. And we have primary care physicians who are working in many of these locations who don’t have access to resources from ACEP. And yet, we at ACEP consider ourselves the gold standard of board-certified residency trained emergency physicians.

ACEP believes strongly that best emergency medicine is completed and delivered by physician-led teams. So now this conversation can go off into three different directions: Can those board-certified emergency physician-led teams that are ideal pick up the pieces in rural America? Can they pick them up in areas that are short-staffed and can we do that with telemedicine?

One thing that has always intrigued me that I saw happening more and more during COVID is physician-led teams doing paramedicine. I have my paramedical personnel out in the field and I’m helping direct them as I typically do when they’re bringing in patients. But now I’m doing it while they’re going out evaluating patients for me. So the ability for us to expand physician-led teams gives us the opportunity to make this future bright. The APPs are cheaper, better quality, more available. We need to embrace all those concerns and make sure that emergency medicine and board-certified emergency physicians lead this digital transformation that we’re going to see in emergency medicine.

REZAIE:  What can we do to ensure that that workforce stays open to so many well-trained physicians that are coming out because this has really been a problem this year more so than any other year?

ROSENBERG:  And I see it. At St. Joseph’s Health, where I practice, we have our resident class and everybody’s looking for a job. Many are afraid they’re going to lose their contract, and everything that you just said. At ACEP, we are putting together several projects that will really start looking or continue to look at a lot of these pieces. But we have the Work Task Force, which I mentioned. We have the Workforce Study. We have another study looking at ownership in emergency medicine, as we get into private equity and that type of thing. None of these can be separated. They are all coming together.

But there are certain things that are important. Job market research and job market development is an opportunity that ACEP has. I mean, we always had our job fair and that type of thing, but to really make this more of an opportunity to bring together vendors and people who can use emergency physicians, maybe even in nontraditional roles.

Maybe there are opportunities there to look at different fellowships and to look at other specialties to train people in digital transformation and paramedical support and telemedicine and telehealth. And the world’s wide open to us. We run our future.

But one thing is for sure, our specialty, which is based on managing unscheduled emergencies and urgencies, is something that will keep us front and center in the public’s eye forever. What do we want to do with it and how is ACEP going to help make that happen?  I think is the dream that we’re all looking for. And I think all of us on this call not only want that to happen, but believe it will.

SILVERMAN:  Leveraging telemedicine is critical and having the laws to allow it to be that easy in the credentialling piece. There’s a lot of moving parts in a healthcare system that’s generally slow to change.

You can’t get a job now no matter where you are. We’re going to have two years of residency classes competing for jobs. And we’ve had a 20 percent decline in volume. So the traditional emergency medicine job is not what it was a year or two ago. And it’s going to be tricky, but we’ll navigate our way through it. There are a lot of people smarter than I am looking at it. But I think it’s certainly interesting.

ROSENBERG:  It is. You can’t write the book before it’s finished. I think we’re going to look back at this time saying: It was scary but look what we have now. And we’re going to say that with a smile on our face. Emergency medicine is not tied to bricks and mortar.

And once we realize that and when we look at our bricks and mortar, it’s very dysfunctional. The emergency departments with long wait times and some of the number of hoops we have to jump over to get things done is really dysfunctional. I think as soon as we separate ourselves from the bricks and mortar, we in emergency medicine are going to make that access much more reasonable and appropriate.

Everybody needs to buy a good pair of sunglasses because it’s going to get brighter and brighter and the sun’s going to shine. And we’re all going to be locked up so long that we don’t realize that we can see in the bright light. But by the end of 2021, make sure you’re wearing your shades — it’s going to be very sunny out there.

1 Comment

  1. Robert D. Booth on

    Dr. Rosenberg,

    I read your most recent interview in EP Monthly with great interest. You and I can agree that emergency medicine has changed in ways that none of us expected during the current pandemic. Who would have thought the ED volumes would drop to such a degree as to lead to layoffs and furloughs of EM physicians, PAs, and NPs. I have no doubt that these trends will turn around in time.

    There are a few points you made in your article that I would like to address. You state that the #2 problem in emergency medicine is the utilization of APPs, “the non-physician providers are constantly saying they’re cheaper than we are, and they can do our job.”

    You go on to state, “When we look at the workforce and when we look at the job opportunities and we look at rural emergency medicine, and rural is almost every state in the country, has some rural challenges and western Texas is obviously very different than northern Maine, but nonetheless, many similar challenges.

    In those rural areas, we have PAs in Maine that have independent practice. We have nurse practitioners in other states that have independent practice. And we have primary care physicians who are working in many of these locations who don’t have access to resources from ACEP. And yet, we at ACEP consider ourselves the gold standard of board-certified residency trained emergency physicians.”

    This is the statement that deserves unpacking. I am a solo emergency medicine PA covering multiple rural critical access emergency departments in northern Maine. PA’s in Maine do not have “independent practice”. We have a system of graduated autonomy that is based on practice setting and years of experience of the PA. The final determination of the level of autonomy is at the practice level between the PA and the MD/DO. This allows for greater utilization of the highly skilled PA workforce. This makes far more sense than a “one size fits all” model created by the state.

    NP’s are the only “APP” that have successfully achieved fully independent practice in 28 states. ACEP is doing itself a disservice by refusing to recognize the difference in training and the mission behind the PA and the NP. There is a remarkable difference and the persistent use of the term “APP” or “Mid-level” is simply lazy.

    I began my medical career as a Navy Corpsman, then 10 years as a Paramedic and finally I achieved my goal which was to become a PA. After completion of PA school, I elected to do a 12-month emergency medicine PA residency program. Fast forward to today, I have been practicing as a PA for 15 years, I have over 30,000 practice hours in the ER and have treated more than 80,000 patients.

    I have worked in just about every ER setting, from large urban academic ERs to small critical access ERs. I have seen the misuse and abuse of the PA and I have had the pleasure to work in areas where the MD and the PA were truly a respectful and collegial team.

    In your interview you seem to attack the notion of PAs and even non-ACEP trained physicians covering these rural critical access ERs in areas like northern Maine and west Texas. I am disturbed by this. Is there evidence that a disservice has been done? You have presented yourself as the “gold-standard” of emergency care. This may be true, but it does not mean that safe and excellent emergency care cannot be provided by non-ACEP trained providers. There is no data to support this insinuation.

    What are these areas to do when ACEP trained MD’s do not want to live in these very rural areas, much less work there at what they can afford to pay? An ACEP trained MD has loans to repay and vastly most choose to work in large urban ER’s where they are paid much higher and have far greater back up and support.

    When I speak to physicians at the larger regional hospital here in Maine where we transfer our sicker patients and those who need any specialist, they have frequently thanked me for being out here. They have said to me “I don’t want to go out there, you don’t have much support or backup.” So, who is going to come out here? If the ACEP MD is not, then who? Rural America still accounts for tens of millions of people who are sick, getting sicker and have the fewest resources.

    I was excited to see you mention the power of telehealth. Let me tell you, I believe that I have seen the future of the ACEP MD, and it is telehealth. At one of the remote facilities I cover, we have an ED telehealth relationship with Dartmouth. It is an incredible and awesome service. In the trauma bay we have a full telehealth set up with monitor and microphones and a large red button on the wall. If I have a patient I need to consult on, all I must do is hit the button and I have an ACEP MD in the room with me. It may be a trauma, it may be a complicated septic patient, whatever it is, they are there like an angel on my shoulder. At that point I become their hands and together we deliver the best medical care possible in these austere and rural settings.

    If ACEP wants to remain relevant in rural America, this is how you do it. The PAs are on the front line because there is no physical way for there to be enough ACEP MDs to cover the need in rural America. But through “force multiplication” with systems like what Dartmouth is doing, ACEP can expand its abilities to be available and provide that guidance in the areas where they are most needed. ACEP MDs are not needed in large urban ER’s where you have 5 MDs on at a time. They are needed out here where you have 1 MD for 100 square miles.

    I would like to thank you for taking the time to read this and I apologize if I strayed at times. But I felt compelled to respond. I ask ACEP to stop fostering the attitude that PAs are a problem, we do not want your job. But we do want the right and respect to walk beside you.

    I will close with this personal story. On the first day of my PA EM residency program, I introduced myself to my attending, a retired Army Colonel; “Hi my name is Rob I am one of the new PA residents.” His only response was “I don’t care if you are a PA, I will hold you to the same standard I hold my residents. There is only one standard of care in medicine and if you can’t handle that, get the hell out of my ER.” That statement shaped my career.

    Respectfully,

    Robert D. Booth, MSPAS, EMPA-C, CAQ-EM

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