Each year, ACEP’s Council elects new leaders for the College at its meeting. The Council, which represents all 53 chapters, 40 sections of membership, the Association of Academic Chairs of Emergency Medicine, the Council of Emergency Medicine Residency Directors, the Emergency Medicine Residents’ Association, and the Society for Academic Emergency Medicine, will elect the College’s President-Elect, Council Speaker and Vice Speaker, and four members to the ACEP Board of Directors when it meets in October. Last month, we met the Council officer candidates. Here, we’ll meet the President-Elect and Board candidates.

President-Elect

The President-Elect candidates responded to this prompt:

What is your view of ACEP’s strategy regarding workforce, scope of practice, and College sustainability?

Christopher S. Kang, MD, FACEP, FAWM

Current Professional Positions: attending physician and faculty, core emergency medicine residency, Madigan Army Medical Center, Joint Base Lewis-McChord, Washington; attending physician, Olympia Emergency Services, PLLC, Providence St. Peter Hospital, Olympia, Washington; clinical assistant professor, department of emergency medicine, University of Washington, Seattle; adjunct assistant professor, military and emergency medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland; associate professor, physician assistant program, Baylor University, Waco, Texas

Internships and Residency: emergency medicine residency, Northwestern University, Chicago

Medical Degree: MD, Northwestern University (1996)

Response

ACEP’s current framework of workforce considerations established the necessary initial strategy to mitigate the projected surplus of emergency physicians by 2030 as well as the foundation for our specialty’s evolution and sustained success. As the Board of Directors liaison to the Emergency Physician Assistant/Nurse Practitioner Utilization and Emergency Medicine Workforce Task Forces, I ensured that physicians remain the leaders of the care team and are not to be treated as replaceable by other degrees.

Emergency medicine became a leader in the house of medicine because our founders and the College fought together for their patients and specialty. However, as experienced by other specialties, the emergency medicine workforce could not grow unbridled indefinitely. The COVID-19 pandemic served as a stress test, accelerated this maturation process, and exposed needed changes. We have further lost ground as we have had to stand on the defensive from both outside of and within our ranks. Instead of assigning blame, ACEP stepped up and moved forward with organizations wishing to collaborate on solutions.

Since chairing the 2018 workgroup that recommended the task forces and the inclusion of all emergency care organizations, I have increasingly gained essential awareness of the issues we face every day. Because of my service on both task forces, I now have critical knowledge of past, current, and potential future workforces and the opportunities for continued partnership with the other stakeholder organizations. It is with this unique insight that I helped define the core tenets of the current framework of workforce considerations, including:

• Uphold the incontrovertible expertise and role of emergency physicians as THE leaders of the emergency care team;
• Promote quality-controlled emergency medicine residency training programs—continue to recruit the best and provide them with the contemporary clinical, administrative, operational, advocacy, and leadership skills to succeed;
• Support emergency physicians in whatever setting they are employed—inside and outside the emergency department, rural to urban, emergency medicine to subspecialty, clinical to education to administration, and contractor to employee to partner;
• Transform emergency care to better meet the needs of our patients, communities, and professions—expand and enhance patient access to the full spectrum of specialized acute care provided, coordinated, and led by emergency physicians; and
• Ensure that business interests do not supersede patient care—the needs of patients and the workforce must be reprioritized.

But strategies must adapt over time as transformation is not often rapid or easy. As the emergency medicine workforce will be a principal issue for years to come, we must proactively advance our strategy to sustain the integrity, health, and success of our specialty. These subsequent steps will be challenging as we navigate dynamic market forces and engage stakeholders outside of our profession. As the team leader, we must fulfill several additional inherent responsibilities, including:

• Procure sufficient resources, opportunities to thrive, and healthier, supportive, and more secure environments for us, our team, and our patients;
• Advocate that emergency physicians are equitably employed by groups, hospitals, health care systems, and government agencies and valued by the health care community and the public to include fair reimbursement;
• Challenge the monopolization of health care services by hospital systems as well as insurers; and
• Include those non-physician providers committed to emergency care as members of our team, and engage in their training, hiring and credentialing, onboarding, clinical practice, and continuing education.
• At this next turning point in our history, we have a prodigious opportunity to once again define emergency medicine and forge ahead. To do so, we must reaffirm our common belief in each other, commit to our leadership role and responsibilities, and fight together with our College for our patients and the advancement of our workforce and specialty.

Aisha T. Terry, MD, MPH, FACEP

Current Professional Positions: associate professor, emergency medicine and health policy, and senior advisor, emergency medicine health policy fellowship, George Washington University School of Medicine and Health Sciences, Washington, D.C.

Internships and Residency: emergency medicine residency, University of Maryland Medical System department of emergency medicine, Baltimore

Medical Degree: MD, University of North Carolina School of Medicine, Chapel Hill (2003); MPH, Columbia University Mailman School of Public Health (2011)

Response

These challenges offer welcomed disruption and tremendous opportunity to shape a bright future for our specialty and livelihoods. Now is the appointed time for ACEP to do what it was designed to do, unapologetically continue to lead! These issues share the common thread of being critical to the mission of ACEP and are inextricably tied to the value of the emergency physician (EP). Thus, as we together tackle these unprecedented issues, I will lead with visionary strength and make the reaffirmation of our value the fulcrum of the strategy.

Workforce: As Chair of ACEP’s Membership Task Force in 2008–2009, I recall studying Carlos Camargo’s 2005 study which predicted that board-certified EPs would not satisfy workforce needs until the year 2038. Today, it is predicted that there will be a major oversupply of EPs—for the first time ever—by the year 2030. This prediction, coupled with the recent relative paucity of EP employment opportunity due to the impact of the pandemic, threatens the stability of the emergency medicine (EM) workforce, the capacity to provide our patients with access to care, and the ability to successfully recruit future EPs.

As President-Elect, I will prioritize this existential challenge in a manner that optimizes ACEPs real-time relevance to all EPs. My efforts as a second-term Board member align with our strategy to 1) acknowledge the problem and rightful alarm; 2) inform by highlighting the complexities and differentiating fact from myth; 3) address head-on by sharing an action-based, multipronged strategy tied to an aggressive timeline; and 4) engage others to join these efforts in a unified way, which promotes swift progress. Consistent and transparent communication about our efforts and progress made is imperative. We must also highlight Chapter efforts, engage stakeholders in collaborations, and constantly seek feedback from our members.

Finally, we would be wise to acknowledge that a prediction is just that; several unknowns remain. For example, how will COVID-19 impact attrition? How might the role of workforce geographic distribution evolve? How will demand for EM services change? How will the proliferation of the nurse practitioner (NP) and physician assistant (PA) workforce be impacted? The answers to these and other salient questions will undoubtedly impact the future of our workforce and must be considered now.

Scope of Practice: ACEP believes that emergency care should be EP-led and opposes the independent practice of NPs and PAs. As President-Elect, I will lead efforts to attain and embrace data-driven solutions to combat scope-of-practice threats. We must be intentional about marketing our value and emphasizing why EP-led care offers distinct advantage as the gold standard. In doing so, ACEP’s Clinical Emergency Data Registry (CEDR) data (>50 million ED visits from about 30,000 EPs, NPs, and PAs) would be an excellent tool to utilize in answering key questions and illustrating our comparative value. Further, as we pursue the implementation of ED accreditation standards, we must determine and enforce best practices for quality-promoting staffing models relative to scopes of practice among the ED care team.

We must also build upon past and current efforts. Outstanding strides have been made, for example, through the work of ACEPs Advanced Practice Provider Task Force, statements on the importance of title transparency in clinical settings, and our partnership with the American Medical Association (AMA) to dispel the myth that increased NP/PA scope of practice improves access to care.

College Sustainability: My candidate platform includes the creation and optimization of infrastructure that fosters longevity for EP livelihoods and the financial stability of the College. ACEP is well positioned to achieve this goal by building upon its investment in quality and data.

The delivery of high-quality care will continue to be required, measured, and tied to reimbursement. ACEP’s CEDR is a member benefit that promotes quality while fostering EP compensation through federal quality reporting. The registry allows EPs to avoid financial penalties ($300 million in avoided penalties to date) and reap lucrative bonuses (up to $2,000 per EP for 2020).

CEDR is poised to evolve far beyond its current registry function, however. Imagine, for example, if ACEP had a digital platform by which to lead robust EM-focused research, real-time disease surveillance, and ethical data commercialization opportunities through unique EM use cases. Such would minimize the College’s current reliance on member dues and meetings income (both total about 40 percent of revenue), while expanding our digital footprint in health care.

As President-Elect, I will build upon my experience as Treasurer of the College during the pandemic, one of the toughest financial periods in the history of ACEP. I led our finance team in making tough but necessary decisions, encouraged the implementation of zero-based budgeting, and helped spearhead strategy-focused practices. These efforts contributed to the passage of a 2021–2022 budget that mitigated damage from the 2020 pandemic, resulting in a significantly reduced deficit.

Board of Directors

The Board candidates responded to this prompt:

How do you build confidence that the College prioritizes the interests of our members and our specialty?

L. Anthony Cirillo, MD, FACEP

Current Professional Positions: staff emergency department physician, AdventHealth Dade City and Palm Harbor emergency departments, Florida; director of government affairs, US Acute Care Solutions

Internships and Residency: emergency medicine residency, UMass Medical Center, Worcester, Massachusetts

Medical Degree: MD, University of Vermont College of Medicine, Burlington (1990)

Response

The building of confidence in any relationship is based upon how we listen to, respect, and act both toward each other and in support of each other. In my 30 years of ACEP membership, I have had the opportunity to work with and represent so many great emergency physicians. From my early days as an eager young resident serving on the EMRA Board of Directors to my service now on the ACEP Board of Directors, and in the course of each and every committee, task force, and Board meeting, I have never forgotten that I serve the interests of all ACEP members and the specialty of emergency medicine. ACEP is recognized within the house of medicine and with policy makers in the health care arena as the voice of emergency medicine. The College is respected in this role because we always focus on doing the right thing for our patients and our members. Focusing on the needs of our members and patients is the core of everything we do in ACEP, and we must never lose this foundation.

For this question, I believe one can substitute the word “trust” for “confidence.” I believe that trust in a relationship is built on two things: communication and action. As the College has matured, we have become a multigenerational organization. This maturation has led to some amazing moments, such as a mom or dad emergency physician literally passing the baton of care during shift sign out to a daughter or son. ACEP’s maturation also creates challenges for effective communication with our members. Creating a sense of connection and family is a critical role of ACEP that emphasizes our uniqueness as a specialty. As some in emergency medicine and the health care arena are trying to tear us apart, the College, and by that I mean each member, has been a source of pride and strength for me. But effective communication with a multigenerational group of emergency physicians requires that the College enhance our communication strategies. ACEP’s connection to each and every member, regardless of generation, is vital to our future.

William B. Felegi, DO, FACEP

Current Professional Positions: medial director, Van Buren County Hospital emergency department and Van Buren County Hospital ambulance, Keosauqua, Iowa; EMS medical director, Farmington Ambulance

Internships and Residency: emergency medicine residency, Morristown Memorial Hospital, Morristown, New Jersey

Medical Degree: DO, University of New England College of Osteopathic Medicine, Biddeford, Maine (1989)

Response

ACEP does not have unlimited resources. Action plans cost money, resources, and time.

• Establish priorities based on the needs of our patients, members, and residents. These are proactive priorities. This is the essential basis of why we are emergency physicians and makes our specialty unique—fair balanced billing, prudent layperson, fair reimbursement, protecting EMTALA, etc. Reactive priorities are issues that arise as a part of another’s agenda, whether it’s the government, politicians, national mega-CMGs or private equity, hospitals, other physician groups, or providers. Examples include COVID and the lack of personal protective equipment, PAs wanting to change their name to physician associates, etc.—not always anticipated. Reactive priorities often are compounded by special interest groups that have more than adequate financial resources and political influence. ACEP needs to have a better understanding of issues that outside interests (and members) may have so that we can plan in a more proactive way. We can do better.
• Accurate messaging is key for our membership to understand the College’s priorities. ACEP announced an anticipated surplus of residency-trained emergency physicians. One way of reducing residents was to extend EM residencies by one year. The messaging was off track, and some interpreted as, “Let’s punish residents by increasing training length, placing them in deeper debt without a guaranteed job.” Where I know that this was not the intent, it was the message that residents heard and disseminated on social media to create further panic. Unintended consequences of messaging are often overlooked.
• We must clarify some of what I refer to as bipolar behavior in our messaging and priorities. We aspire to have board-certified EPs working in every ED in this country. On the other hand, some want to ensure that all freestanding EDs are staffed similarly. Yet, critical access hospitals are not mandated to have the same requirements. In fact, there is no requirement to have a physician physically present on site 24-7. Some critical access and rural hospitals have tried to increase the quality of care delivered to patients by hiring PAs that have additional training in EM, but some training programs have been ostracized for calling them “residency programs.” If our goal is to have an EM physician–lead team in every ED, then we need to work on ways to make this happen. Do we really know why residents do not want to practice in critical and rural hospitals? Do we need to readjust training for residents to practice in rural areas? Are our assumptions correct? Estimates are 42 percent of the population get its care in rural EDs, yet these EDs only make up 17 percent of all ED visits. Do we abandon our efforts? We need to figure this out or our goal will never be realized, and we will need to readjust priorities.
• ACEP needs to maintain its integrity. Integrity is doing the right thing at the right time for the right reason. We need to base our priorities, interests, and messaging on strengthening our integrity.

John T. Finnell II, MD, MSc, FACEP

Current Professional Positions: professor of clinical emergency medicine and associate professor of informatics, Indiana University, Indianapolis; investigator and faculty member, division of biomedical informatics, Regenstrief Institute; attending physician, Eskenazi Health, Indianapolis

Internships and Residency: emergency medicine residency, University of California, San Francisco–Fresno

Medical Degree: MD, University of Vermont, Burlington (1991)

Response

I’ve recently learned of an expected death of a dear colleague, which reminds me of a poem called “The Dash” by Linda Ellis. The Dash represents the time we have and what we can accomplish and reflect upon how we spend our Dash. The actions we take, the progress we make, is all about The Dash.

Confidence in our College is built upon our actions and achievements—The Dash. It begins with the ACEP Council, our councillors, and the Board of Directors. What we accomplish at Council sets the stage for what we need to accomplish today, tomorrow, and the rest of the year. While our progress may feel incremental, significant changes can and do happen.

The College can and should do more to promote our achievements. Our members may not fully realize everything that ACEP is doing for our members and our specialty. As a brief summary:

Advocacy in 2018:

• Four emergency medicine–focused bills signed into law
• 30 Congressional letters of support or comment submitted
• 10 regulatory comment letters submitted
• 555 legislative visits conducted by ACEP members and staff
• More than 4,000 members in the ACEP 911 Legislative Grassroots Network respond to advocacy alerts when needed by ACEP by emailing their members of Congress on a particular issue of concern to emergency medicine. This network covers 95 percent of Congressional districts.
• 5,215 donors to NEMPAC, the 4th largest physician specialty PAC
• NEMPAC contributed $2.2 million to House and Senate candidates and party committees in 2018.

Notable Board items in 2021:

• Legislative and Regulatory Priorities for the First Session of the 117th Congress
• National Pandemic Readiness—Ethical Issues
• Definition of Democracy in EM Practice
• Safer Working Conditions for Emergency Care Workers
• Prudent Layperson Model State Legislation
• Artificial Intelligence in Emergency Medicine

As I reflect over the past two and half years, your Board has considered over 400 items of business. The Council resolutions that you create and approve are the work products and achievements for the College. Think about it—over 400 items of business in close to three years. Our memories are short; the COVID-19 pandemic challenged all of us but allowed us to become stronger. We became stronger by working together to produce the ACEP COVID-19 Field Guide. This resource launched April 8, 2020, and one month later had over 100,000 page views, over 150 agencies/websites/links to our site, and has been translated into Japanese, Chinese, Spanish, Hindi, and Urdu with over 230 pages of content—outstanding, and a great example of how the College prioritizes the interest of members and specialty.

So, in the end, what matters most is not the beginning or the end but our Dash. Our achievements. How will we continue to lead and advance the specialty for all emergency physicians?

I’m proud to be an ACEP member and to serve you and the College.

Rami R. Khoury, MD, FACEP

Current Professional Positions: vice president of operations-west, Independent Emergency Physicians-PC; board member, Henry Ford Allegiance Health Specialty Hospital, Jackson, Michigan; staff physician, Henry Ford Allegiance Health and Ascension Providence Southfield/Novi; assistant clinical professor, department of osteopathic medical specialties, Michigan State University College of Osteopathic Medicine, East Lansing; assistant clinical professor, department of emergency medicine, Michigan State University College of Human Medicine

Internships and Residency: emergency medicine residency, St. John Hospital and Medical Center, Detroit

Medical Degree: MD, Wayne State University School of Medicine, Detroit (2001)

Response

As a practicing physician in an equal-partnership democratic group, I know firsthand the challenges that face today’s front-line physicians. And as a leader in my group, I’ve been privileged to help address those challenges, most recently developing solutions to the operational, financial, and wellness challenges that we faced related to the COVID pandemic. Our group is stronger than it has ever been due to our concerted efforts to achieve our unwavering commitment to openness and transparency with our physician partners. We consistently invite and invest in the development of the next generation of leaders within our group. In our group, all partners are invited and encouraged to share their viewpoints. Our group’s vision and focus are representative of the shared vision of the collective.

Today, ACEP members are clear about the issues that are most pivotal to the future of emergency medicine: fair reimbursement for our skill and expertise, a rational approach to EM workforce and scope of practice for non-physician providers of emergency department care, and employment models that are equitable and transparent. Since its founding in 1968, ACEP has been an organization dedicated to serving its members—emergency physicians and physicians-in-training—who for over 50 years worked tirelessly to advance the specialty of emergency medicine. Each fall during ACEP’s Scientific Assembly, councillors representing each of ACEP’s 53 chapters, 40 sections, EMRA, ACOEP, AACEM, CORD, and SAEM gather to elect ACEP’s leaders and to vote on resolutions that frame the agenda for the College. The passed resolutions are then reviewed by the ACEP Board, which subsequently assigns these objectives to one or more of ACEP’s 30 committees or to new ACEP task forces.

Building confidence that the College prioritizes our members’ interests begins with engaging our members in the process—through committee or task force membership, Council involvement, and active participation in ACEP state chapter affairs. Additionally, confidence in ACEP’s dedication is further enhanced through robust communication with members regarding the amazing work that is being done on behalf of emergency physicians and the patients they care for.

Our specialty certainly has its share of challenges. I believe that challenges create opportunities, and when I look at how much our specialty has grown over the past 50 years, I am optimistic that emergency physicians will continue to innovate, adapt, evolve, and lead in delivering the best care possible for our patients—within the emergency department and beyond. As your next ACEP Board member, I commit to ensuring that the interests of our members, our patients, and our specialty will be prioritized above all else.

Heidi C. Knowles, MD, FACEP

Current Professional Positions: associate medical director and emergency medicine residency core faculty at John Peter Smith Hospital, Fort Worth, Texas; assistant professor, department of emergency medicine, TCU and UNTHSC School of Medicine, Fort Worth; ED staff physician, Texas Health Southlake; EMS program medical director, Trinity Valley Community College, Athens, Texas

Internships and Residency: emergency medicine residency, University of Texas Health Science Center at Houston

Medical Degree: MD, University of Texas at Houston Medical School (2003)

Response

Confidence—“the feeling or belief that one can rely on someone or something; firm trust”—is critical to an organization’s members’ interest, involvement, and commitment. Currently, there is a divide amongst emergency medicine physicians, one side committed to ACEP and the other questioning the priorities and loyalties of ACEP. At this time, it is essential that ACEP commit to building confidence in all emergency medicine physicians, not only to retain members but also to gain new ones, so that ACEP can continue to be the voice of EM.

Communicating a clear strategic picture, one that allows members to gain awareness of the historical precedence set by the College, will help members to better understand future goals and strategies implemented by the Board. Strategic planning that occurs at the national level must be clearly communicated to every member. This transparency will go a long way in building confidence that ACEP is prioritizing the interests of its members and our specialty. The challenge lies in determining which method of communication is best to accomplish this goal. Since ACEP’s membership is diverse, this communication must continue to be multimodal—via traditional and electronic methods, with emphasis being placed on identifying the most efficacious means of getting the message across. Video conferencing is another method that can be taken advantage of to allow members the opportunity to hear this information live as well as have interactive discussions/Q&A sessions. Video conferencing allows members to voice their opinions, feel validated, and, importantly, be heard. The COVID pandemic made this modality commonplace, and most of our members are now familiar with its use. ACEP should embrace this opportunity to set up regional meetings with EM physicians for virtual “town hall” discussions across the country. Communicating the hard work that the ACEP staff and Board members are doing on a daily basis will give members an understanding and insight into how these activities affect them and their practice. This will ultimately lead to a confident and loyal member.

Michael Lozano Jr., MD, MSHI, FACEP

Current Professional Positions: attending physician, Envision Physician Services, Fayetteville Emergency Medical Associates, P.C., Fort Lauderdale, Florida; attending physician, TeamHealth, InPhyNet Contracting Services, LLC, Tampa, Florida; medical director, fire and rescue department, Board of County Commissioners, Hillsborough County, Tampa

Internships and Residency: emergency medicine residency, Albert Einstein College of Medicine of Yeshiva University, Bronx Municipal Hospital Center, Bronx, New York

Medical Degree:  MD, Mount Sinai School of Medicine, New York, New York (1987)

Response

The objective reality is that ACEP does indeed prioritize both our members’ interests and specialty. College publications, policy statements, and advocacy efforts all provide support for that statement in both words and deeds. The challenge is in properly and effectively communicating this reality to our rank-and-file membership. Without that connection to membership, confidence wanes and the weeds of misinformation will flourish. To combat this, we need to be purposeful in framing our communications to always be viewed through the lens of member interest. Additionally, we can educate the membership on our governance structure and provide additional degrees of transparency in our governance processes.

A casual review of the June issue of ACEP Now is representative of how the breadth of our practice is supported by ACEP. There are articles on clinical issues such as the management of pulmonary embolism, marine envenomation, and urticaria. COVID-19 vaccination challenges are discussed alongside the global health aspects of vaccine sharing. Professional development is promoted through conferences (ED Directors Academy, Scientific Assembly, and Leadership & Advocacy) and didactic materials (Critical Decision in EM, and PEERcert+). All are relevant and relatable to physicians practicing emergency medicine. Similarly, when visiting the newly updated ACEP website, one sees categories of content that resonate on a professional or personal level. Additionally, the myriad committees and sections available for participation reflect the priorities of our membership.

The content and services are indicative of the big umbrella that is emergency medicine and which is represented by ACEP. Although some of our efforts, like advocacy, raise all boats, we should make it a point to indicate the personal benefits of membership and not just when we want people to renew. We should include terms such as “member benefit” and prominently illustrate the savings due to membership at the point of purchase for all our products.

Messaging is but one aspect of restoring confidence. Actions speak louder than words, and to that end, we should actively reach out to the membership to determine their preferred mode of communication. We are a multigenerational organization, and our members have individual preferences for connection with us. In tandem we should embark on an educational journey to better inform on the governing structure of ACEP. I would hazard to guess that many members are not clear on the role of Council and how it connects with the Board. There is probably a larger number of members that are unaware of the staff at the ACEP offices (both) and the great and varied work that they do on our behalf. Finally, I would advocate for greater transparency. Let us take advantage of the pandemic and continue to open Board meetings and Council electronically to the general membership. Transparency goes a long way in restoring confidence.

ACEP is an organization that represents the interests of emergency physicians and their patients. In doing so, there are multiple touch points across the career range of membership. Promoting confidence, and in turn commitment, can be achieved through effective communication, education, and transparency.

Henry Z. Pitzele, MD, FACEP

Current Professional Positions: attending physician, Jesse Brown VA Medical Center and Advocate Illinois Masonic Medical Center, Chicago; attending physician, Mesa View Regional Medical Center, Mesquite, Nevada

Internships and Residency: emergency medicine residency, University of Illinois at Chicago

Medical Degree: MD, University of Illinois at Chicago College of Medicine (2000)

Response

So much of what we do as organizational leaders is based in symbolism; what we say in public matters, and what we do in public matters even more. Every day, hundreds of people within ACEP spend countless person-hours working for the betterment of our specialty—unfortunately, this fact does not always permeate down to the members who are busy scanning heads and admitting chest pain. We need to do significantly better with messaging so that the tremendous and significant value which ACEP generates for the specialty (and for front-line docs) is conveyed to the people whose hard-earned money and time make up the foundation of our organization.

The other thing we can do is to elect leaders within ACEP who have no other interests than the betterment of the specialty and the improvement in the lives of front-line doctors and ED patients. The physicians who hold leadership-level positions within national staffing companies necessarily have to balance the interests of ACEP with the interests of their company—when those two are at odds (for instance, with the business model of oversupplying EM residents to drive down EP compensation in the long-term, or with the tactic of using non-physician practitioners to drive down demand), it is not realistic to think that these leaders would act as strongly to set guardrails for their own companies as leaders who do not have this other set of corporate goals. The best we can hope for is abstention on these issues—and why should we settle for that from our leaders? I am not maligning these individuals—they clearly work hard for EM and bring significant talent to the organization. But it would be unexpected and weird if these highly efficient executives ignored or worked against their company—if they didn’t represent their companies’ interests well, they wouldn’t have risen so highly. It’s not evil; it’s just that their goals aren’t the same as our goals. And although it has seemed for years that electing these leaders to the ACEP Board (and indirectly, to the Presidency) has been a benign and victimless endeavor, the findings of the Workforce Task Force have shown us that unchecked corporate action in this arena has left us hobbled; we must course-correct, and we must do so now.

The membership knows this—they are waiting for us (the Council and the collective ACEP leadership) to show them that nothing is more important to ACEP than the long-term well-being of EPs. I believe in Dr. Schmitz, and I think she’s the right leader for this heavy task; the multifactorial framework approach to Workforce is absolutely the right way to go—I just want to make certain that we give her the utmost support in the “limit corporate interests” plank of that framework, and that starts with an unconflicted Board. The specialty can and will continue to grow and flourish, and this is the most immediate way to show the membership that ACEP is the best way forward.

Joseph R. Twanmoh, MD, MBA, FACEP

Current Professional Positions: president and founder, Queue Management, LLC; UPMC–Hanover Hospital emergency department, Hanover, Pennsylvania

Internships and Residency: emergency medicine residency, Spectrum Health–Butterworth Hospital, Grand Rapids, Michigan

Medical Degree: MD, Rutgers–Robert Wood Johnson Medical School, New Brunswick, New Jersey (1983)

Response

One of the biggest issues that we currently face is our workforce.

We witnessed an unpreceded drop in ED volumes at the onset of COVID-19. As a result, many members experienced a reduction in hours—and compensation. Twenty percent of new EM residency grads were unable to find jobs. ACEP’s recent study, “Emergency Medicine Physician Workforce: Projections for 2030,” projects a surplus of emergency physicians by 2030. Woven into this challenge is the rising use of non-physician providers (NPPs).

NPPs make up roughly 25 percent of the total EM workforce. The increasing use of NPPs has reduced the need for emergency physicians. In addition, there is an increased push at the state level for the independent practice of NPPs. Recently, the American Academy of PAs voted to change the name of the clinicians they represent from physician assistants to physician associates. The motivation for this is not surprising. In many EDs where I have worked, PAs effectively work independently. However, they can be geographically separated from physicians, making communication challenging. In addition, physicians can be maxed out taking care of their own patients and have little bandwidth to see and evaluate the NPP’s patients. No wonder that some in the NPP world are seeking independent practitioner status.

However, to blame NPPs for this problem misses the root cause. NPPs cost about a third of a physician’s salary. Entities that employ physicians and NPPs—hospitals, health systems, contract groups—are financially incentivized to reduce their labor costs and replace physician hours with NPP hours whenever possible. This is true for both for-profit and not-for-profit organizations. However, the use of NPPs isn’t all the result of unbridled greed; many physician-owned contracts would not be financially viable without the use of NPPs. Hospitals would have increased labor costs, leaving less money available for other health initiatives that serve the community. Yet, the potential for abuse clearly exists. Indiscriminate substitution of physician coverage with NPPs serves only the bottom line.

The solution to this problem will be complex and nuanced. NPPs are now woven into the fabric of the EM workforce, and there is no going back. There are many competing interests, and it will be difficult, if not impossible, for ACEP to take a position that will make everyone happy. However, I believe that our North Star on this issue should be what’s in the best interest of our patients. That is where we can all find common ground. Many years ago, ACEP promoted the standard that emergency departments should be staffed by EM-trained physicians, not moonlighting internists or surgeons. Similarly, we need to redefine what a clinically effective, safe, physician-led care team should be. We need to make that definition the standard for emergency departments across the country. We need to develop a model for an ED care team that we’d trust to care for our loved ones, and a model for where we want to work. By placing patients first, we will be true to ourselves, our members, and our specialty.