Twice a year, the Medical Editor in Chief of ACEP Now sits down with the ACEP President to discuss issues relevant to the College and issues important to emergency physicians. I solicited several of these questions from online emergency-physicians’ forums in order to bring the voice of our colleagues directly to the leadership of the College. The accompanying article is an excerpt of the conversation I had with Dr. Aisha Terry.

Dr. Dark: There are a few big topics that I want to get into today. One is going to be about leadership and mentorship. One is going to be about ownership in emergency medicine. And then of course we’re going to circle back around to the boarding crisis. But first, let’s start with leadership and mentorship within ACEP. It’s one of the things that you wish to focus on during your presidency. What are your plans for ACEP’s leadership pipeline?

Dr. Terry: It’s certainly near and dear to my heart in terms of, not just leadership, but the leadership pipeline. Leadership is about supply and demand. There’s never enough of a supply of leaders for the demand. We’re seeing in emergency medicine now more than ever that indeed there is a demand for more leaders. We are facing unprecedented crises in various ways, and we need people on the ground taking care of patients, but also being leaders outside of the clinical setting. My goal for this year, keeping in mind everything that we’re facing in terms of workforce challenges, is to really focus on upstream efforts for pipeline enhancement. The leadership pipeline is about seeking out, recruiting, preparing, and retaining leaders,

It’s important to start upstream, meaning we have to start with our medical students and residents. One of the things that I hope to do this year is develop a leadership-pipeline portfolio for the College. And the way that I plan to go about this is first and foremost taking our story on the road. One of the things that I think we don’t do enough of as emergency physicians is talk about ourselves and how amazing our specialty is in terms of what we do for patients every day. We need to take that story on the road to make sure that our future emergency physicians and medical students are aware of what an amazing specialty emergency medicine is, how we are the quintessential specialty when it comes to health equity, when it comes to the safety net of health care in this country.

We were touted as being heroes during the pandemic. I think we need to ride that story out a little bit more.

Dr. Dark: One thing that our readers want to talk about is the emergency medicine workforce report that came out a couple of years ago. The data were coming from the pre-pandemic phase and I think there’s been a lot of changes to the assumptions that go into making predictions. Do you think that it’s something that ACEP needs to redo in the post-COVID phase when these assumptions may have changed?

Surrounded by her extended family and friends, Dr. Aisha Terry started her term as ACEP President at the 2023 Council Meeting in Philadelphia. (Click to enlarge.)

Dr. Terry: We know that the variables have changed for sure. Workforce is about, again, supply and demand. When that original study was done, it was based on variables that have changed. We’re seeing more residency programs come into the mix, which of course impacts the formula. We also know that the attrition rate for emergency physicians has changed. That original study was based on there being about a three percent attrition rate. We have looked at the data again in 2022, and the attrition rate is now up to about four to 4.5 percent. And some estimate that the attrition rate could be as high as seven percent.

We know that we’re seeing increasing numbers of nurse practitioners and physician assistants practicing in emergency departments alongside physicians. That is another variable that goes into the mix in terms of workforce relative to supply and demand. We actually have talked about taking another look at that workforce data, plugging in the new variables, seeing how it’s going to impact the prediction. Even a year ago, the prediction of the amount of surplus in terms of number of emergency physicians had actually decreased by about 65 percent compared to the original predicted surplus.

Dr. Dark: In recent years we’ve seen several ACEP leaders representative of several minority groups. Just considering recent ACEP presidents, there is representation from women, Asian, and Black communities. What is the College doing moving forward to maintain this kind of focus on diversity and equity efforts, especially considering the national milieu that’s changed over the past year?

Dr. Terry: The College actually made diversity, equity, and inclusion a very specific initiative and priority several years back with the development of a Diversity Task Force. And from that task force’s efforts, we developed a committee around diversity, equity, and inclusion as well as a section within the College so that we have the assurance that there’s perpetuity in terms of this work. It has to be an ongoing commitment to really changing the fabric of the College and the culture of the College relative to a commitment around diversity, equity, and inclusion. One of the key pieces to ensure that we continue to have a diversity of leadership, again, goes back to that pipeline. We have to realize that actually only 39 percent of emergency physicians are women. We also know that about 35 percent of emergency physicians are from minority backgrounds in terms of race and ethnicity. That’s all of the non-Caucasian groups. There’s definitely some room there for us to enhance the pipeline relative to diversity. When we do that, we will see that shift into ongoing diversity at the leadership level within the College.

Dr. Dark: What can you tell the members about leadership and diversity at that level of the ACEP Board?

ACEP’s 53rd President, Dr. Aisha Terry of Washington, DC, began her one-year term in October 2023. (Click to enlarge.)

Dr. Terry: My fellow Board members are amazing. We are a group of 15 individuals who are incredibly passionate about our specialty, about our College, committed, and we work incredibly hard around the robust agenda that ACEP has. I have the pleasure of working with a Board of Directors who are talented, diverse, from various backgrounds, from various types of professional settings, ranging from academics to private practice to locums to military. And so we have talent ranging from IT [information technology] background to health policy to rural practice, and it’s just a delight to be surrounded by such a diverse group of talent who’s very passionate about the work. Personally, I would love for the College and really the specialty to get to know us better as a Board of Directors. We are clinicians, we take care of patients, and we also love the boardroom. The main thing I think people need to know is that when we go into that boardroom, when we put on the ACEP hat, when we’re representing you as a College, you are the focus, you are the priority.

Dr. Dark: Let me switch gears a little bit. I wanted to talk about ownership in emergency medicine, and I think you mentioned that when you guys are in that boardroom, you’re there to work on behalf of the members. A lot of questions that I’m going to be throwing at you next are actually from emergency physicians. And one of the biggest things I think that is of interest to current practicing docs is how does ACEP plan to combat the corporate practice of medicine now, especially after ACEP has its own policies and procedures about this?

Dr. Terry: The corporate practice of medicine has certainly been on our minds a lot, and we are working to not just have a statement around the corporate practice of medicine, but also to live it out through our actions. When you talk about the corporate practice of medicine, that’s one category, but then in some ways there’s overlap with consolidation, in terms of talking about consolidation of physician groups, and consolidation even of insurers, and then how that folds into, potentially, the corporate practice of medicine. There’s a lot of nuance to it. I think it’s important that we educate each other around the differences between corporate medicine and consolidation.

Dr. Dark: I think consolidation is a very important concept to remember because we have seen insurance companies consolidating, getting bigger, and getting more leverage. On the flip side, we’ve seen physician groups consolidating, getting bigger, and trying to get more leverage. You’re saying we need to have a little nuance between consolidation and corporate practice. Can you explain that?

Dr. Terry: Corporate practice of medicine really speaks to more of the contractual relationships in terms of how the business is put together and run. Whereas consolidation speaks to the combining or merging of one entity with another. At the end of the day, the corporate practice of medicine should never come at the expense of the patient. It should never result in payment being put over patients. Unfortunately, what we see often is that it comes at the expense of the patient in terms of their outcomes, but it also tends to come at the expense of the emergency physician in terms of how it impacts the workplace environment. ACEP’s focus is around making sure that emergency physicians feel safe in their workplace, that they feel supported in their workplace, that they feel that they’re having fair working conditions in order that they can continue to take care of patients in a way that results in improved [patient] outcomes. Unfortunately, when we have mergers and acquisitions resulting in consolidation there’s a lot of trimming in order to create efficiencies. But that trimming cannot come at the expense of quality care for our patients. It cannot come at the expense of poor working conditions for emergency physicians. ACEP is demanding better for emergency physicians.

Dr. Dark: Physicians feel that as efficiencies are created, when certain organizations come in, that people feel like staffing is no longer adequate. How can ACEP ensure that physician staffing is adequate to the volume of patients that are showing up in each department across this country?

Dr. Terry: ACEP is looking to improve the workplace environment for the emergency physician by making sure that we tie adequate staffing to patient outcomes and even quality measures. ACEP is launching an accreditation program in 2024, which will really include several areas of focus. One area is around staffing—ensuring that emergency departments have a standard to follow when it comes to making sure that there are enough people on the ground taking care of patients and linking that to quality outcomes.

Dr. Dark: I think it also goes to say: Do we have enough nurses? Where I work, do we have enough psych techs? Do we have enough ER techs? How can ACEP play a part in making sure that happens as well?

Dr. Terry: One of the key pieces is that ACEP cannot function in a bubble, so it’s really important that we continue to nurture relationships with other organizations. ACEP and the Emergency Nurses Association as well as the American Nurses Association intermingle and collaborate all the time. We talk extensively about how we can work together to improve issues such as workforce shortages relative to nursing and techs. The beautiful thing about ACEP is that we do have a pretty large sphere of influence. We’ve had conversations of late with the American Hospital Association and America’s Essential Hospitals to talk about how we can, together, ensure that the environment and the emergency department is adequate in terms of providing quality care based on staffing.

Dr. Dark: I want to talk a little bit about the boarding crisis that we’ve been experiencing for many years now, that seems to have only worsened recently. What’s your plan to address psychiatric boarding?

Dr. Terry: ACEP will continue to fight the boarding crisis. We had a summit around boarding a few months ago in Washington, DC where ACEP pulled together a large group of stakeholders. We sat down, we spent about seven hours or so talking about what is going on with boarding, why are we seeing an increase at an exponential rate? What’s different today than a decade ago relative to the boarding crisis, and what are the solutions? How can we address this epidemic that is resulting in, literally, people dying in waiting rooms across the country, resulting in people staying in the emergency department and languishing for months in the emergency department because there’s nowhere for them to be admitted to or transferred to? Psychiatric patients are particularly marginalized.

Much of the federal legislative efforts in terms of various bills actually focuses on mental health relative to boarding. And I think that that’s a strategic and also, obviously, ethically appropriate approach to really focus on these marginalized groups that need us to advocate on their behalf. There are a handful of bills currently, right now, being discussed, [such as] increasing resources for emergency departments to ensure that there are adequate warm handoffs, and community resources, and outpatient resources to direct our psychiatric patients to. There are grants focusing on making sure the infrastructure is strong relative to facilities for mental health and for psychiatric patients to go to from the emergency department. ACEP is supporting those bills and those efforts legislatively around ending boarding, particularly for patients with psychiatric illness.

We will also continue to have discussions with the entities who we invited to the boarding summit a few months ago.

It’s one thing to talk amongst ourselves as emergency physicians about the boarding crisis. It’s another thing to talk to the nurses about it. It’s another thing to talk to EMS about it, the hospital administrators about it, the CEOs of hospitals about it, and even patient-advocacy groups about it. And all of those individuals were at the table at our boarding summit.

Dr. Dark: When we look at those groups, there’s one group that particularly needs to be accountable for this. This is the hospitals and the executives of those hospitals. Because when we think about it, a lot of times some people will mistakenly call this emergency-department boarding. It’s not really emergency department boarding, it is inpatient boarding. What can we do as a specialty to hold those individuals in those hospitals accountable for things like short staffing, but also for staff turnover and for boarding itself?

Dr. Terry: You’re absolutely right. I actually prefer to refer to boarding as hospital system overload. It’s a problem that manifests itself in the emergency department, but no doubt about it, it’s a systems problem and the entire hospital system has to take accountability for it. One way that we hold the hospital accountable is to, again, have discussions with the hospitals and with the CEOs, to understand their angle and also so that they can understand why we care so much. Then we must come together to figure out how to align our incentives in a way that moves the needle. I also think that we need to increase the number of emergency physicians who are CEOs of hospitals; our accreditation program seeks to address this issue by creating standards to include boarding and wait times that the hospital would need to adhere to. The accreditation program that we’re rolling out in 2024 will hopefully create the carrot, and some standards that not only apply, certainly to the emergency physician, but to the hospital too.

Dr. Dark: I’m glad to hear that ACEP is pursuing this through its accreditation program. I’m pretty disappointed that CMS got rid of its boarding measure that hospitals had to report on a few years ago, because I think that was one way you could look at one hospital and see who performs better than another. One thing that I do want to touch on: You said hospital system overload, which is an interesting way to phrase it. I feel like that is loosely related to patient dissatisfaction in the hospital, which I feel like blends over into workplace violence. When patients get frustrated, they get tired of being in the ED, they lash out at nurses and eventually lash out at doctors. If there’s anything you wanted to recap about what ACEP’s doing in regard to workplace safety, I would like to hear about that.

Dr. Terry: Workplace safety is also a huge priority for ACEP and we have participated in multiple efforts over the years to try to improve the workplace environment relative to safety. ACEP did a survey a few years back, which found that there are increasing numbers of instances wherein emergency physicians are being assaulted while in the clinical setting in the emergency department. It is increasing, whether it be verbal assault or physical assault. We definitely know that this is a real problem and it’s not isolated in pockets of the country. It is a widespread phenomenon. When we realized that, we decided to be proactive about making sure that our emergency physicians are protected and don’t have to go to work feeling fearful. To that end, I personally have actually given a handful of lectures across the country around workplace violence, ensuring that our colleagues and other specialties and other stakeholders are aware of the problem. I think most people who don’t work in the emergency department might be surprised to know how, every single day, assaults are happening in the emergency department. ACEP has been championing a couple of key federal pieces of legislation around ensuring that there are channels wherein workplace violence can be reported in a way to ensure consequences to follow. There is legislation that would require OSHA implementing guidelines around reporting workplace violence. There’s another piece of legislation called the SAVES Act, which would ensure that there are consequences to assault against health care workers and physicians in the emergency department. It’s bipartisan, but it also has a carve-out to make sure that patients who may not have the capacity to make good decisions are protected. ACEP has been pushing now for well over a year to get that SAVES Act into law. We also know that a lot of the work around workplace violence takes place at the state level. In fact, there are several states across the country who have had pieces of legislation introduced that increase the consequences of assaulting a health care worker from a misdemeanor to a felony and additionally ensuring that there are pieces in place around reporting. One of the things that I’ve heard across the country is that there is this hesitation to report the assault because there’s a sense that nothing will actually be done about it. And so that’s another way that ACEP is really pushing to make sure that emergency physicians know that there’s no stigma.

Michigan actually just had a huge win legislatively around workplace violence wherein it increased the penalties associated with assault of a health care worker. Virginia ACEP recently had a big win around ensuring that there is protection by having law enforcement present onsite in the emergency department 24/7.

Dr. Dark: I’m glad you mentioned a couple of those states by name because you can find our annual ACEP Now Chapter Roundup by visiting www.acep.org/ChapterAdvocacy.

Dr. Terry, thank you very much for joining us today.

Dr. Dark is assistant professor of emergency medicine at Baylor College of Medicine in Houston, on the Board of Directors of Doctors for America, and Medical Editor in Chief of ACEP Now.