Note: Watch a video of the complete Workforce Roundtable here.

I recently met with four emergency physicians—Jesse Pines, MD, MBA, FACEP, national director of clinical innovation at US Acute Care Solutions (USACS) and professor of emergency medicine at Drexel University; Viktoria Koskenoja, MD, chair-elect of the Rural Section of ACEP, who practices in the Upper Peninsula of Michigan; James “Jay” B. Mullen III, MD, FACEP, chair of the Democratic Group Practice Section of ACEP, a practicing emergency physician, and CEO of BlueWater Health, which staffs emergency departments and urgent cares throughout New England; and Sudave D. Mendiratta, MD, FACEP, chair and chief of emergency medicine at University of Tennessee/Erlanger, who also serves as the President of the Tennessee Chapter of ACEP—to discuss the recent emergency medicine workforce projections published in Annals of Emergency Medicine.¹ Our conversation spanned just under an hour and pondered the implications of the authors’ estimates for the future emergency medicine workforce and what it means for emergency physicians.

After recently sitting with a medical student mentee over coffee, I know concerns about the future of the EM workforce invade the minds of not just the leadership of ACEP but also practicing physicians, residents, and the brilliant young men and women who want to follow in our footsteps.

In this article, I have limited space to summarize a few of the important themes. What will the emergency medicine workforce look like at the end of the decade? According to the report, experts anticipate more then 67,000 total emergency medicine practitioners, of which emergency physicians would make up 70 percent. Physician assistants (PAs) and nurse practitioners (NPs) would assume 23 percent of the workforce, while other non-emergency-trained physicians would comprise the remainder. In 10 years, this workforce would slightly exceed the demand for emergency services, creating a surplus that threatens the future of the specialty. One of the first questions I posed to the members of roundtable was, what should the future of emergency medicine look like?

Advanced Practice Professionals

“If we’re going to define the perfect world, we’re going to want high-value medicine,” started Dr. Mullen, referencing that board-certified emergency physicians represent the pinnacle of training and experience in emergency care, but for low-acuity care, advanced practice professionals (APPs) such as NPs and PAs would remain valuable to the clinical team.

Dr. Koskenoja pushed back a little on this notion, saying that “it’s kind of like the wild wild West out there,” referring to her practice in rural Michigan. Recalling anecdotes of patient harms from inexperienced NPs and PAs, she reported that “patients are being hurt in these scenarios when there’s someone … just basically taking care of someone alone and that’s not a safe environment.”

The team approach is better, both agreed, with the emergency physician in the lead. So did Dr. Mendiratta, who stated that “the appropriate use of APPs should not be determined by economic factors. It should be determined by the needs of our patients.” Thus, the leadership skills of emergency physicians become critical. Whether that leadership occurs in real time at busier emergency departments or is available to consultation in lower-volume sites, Dr. Mendiratta affirmed that “an emergency physician should be the leader of a collaborative care team.”

Unfortunately, in some places, such as rural Maine, that is not always the case. “Financially strapped rural hospitals that are having trouble staffing their emergency department, they may reach out and start having an independent PA or nurse practitioner work there,” said Dr. Mullen. “And that’s just so wrong for the patients but also so wrong for that practitioner because they’re going to be faced with challenges they are not up to, and that can sometimes be career-ending.”

The appropriate use of APPs should not be determined by economic factors. It should be determined by the needs of our patients.  —Sudave D. Mendiratta, MD, FACEP

At my urban, academic hospital, we do not hire new graduates, instead requiring two years of higher-level experience in emergency departments before bringing non-physicians on board. We do, however, have a yearlong training program where NPs and PAs work side by side with the rest of our academic team, functioning similar to PGY-1 residents as they gain knowledge and experience with emergency medicine.

The inexperience of new graduates of NP and PA programs is one reason ours and other physician groups, such as USACS, offer training programs for APPs. Dr. Pines explained the USACS model during the roundtable: “We do have a standardized program for APPs where they get onboarding, local mentorship, chart reviews.” Dr. Pines described the curious situation where the utilization of clinical management tools was actually followed with greater devotion by APPs than physicians. “The doctors will know the rule and see the rule and then come up with a reason why they’re going to deviate from the rule,” he said. But physicians are well-equipped for deviation from protocols, with medical decision-making skills honed by a minimum of two to three years of additional training before they can enter independent practice.

Residency Training

Our panel then moved the discussion from APPs to the plight of emergency medicine residents, who have seen, over the past two years, contracts offered and revoked and a job landscape that has gone from feast to famine (read more on the current job market). “They compete for a spot, they get a spot, and then they come out, and if we’re having an oversupply and they can’t find a job anywhere close to where they want to be, that is problematic,” said Dr. Mullen of the current hiring crisis facing emergency medicine residents graduating in the middle of a pandemic.

However, the consensus from the group was that the market for emergency medicine residency programs would sort itself out over time, either by fewer medical students entering a profession that has been rapidly becoming more competitive or by additional residency programs coming online. Those projections did not seem reassuring to my mentee when I informed her of the potential situation in the next two years when she would be submitting applications to the Electronic Residency Application Service.

The conversation of the roundtable quickly focused on a more pressing concern: the pipeline of emergency physicians available to practice in rural environments.

We talk a lot about diversity in medicine, but we don’t talk about diversity of where people come from. —Viktoria Koskenoja, MD

Rural Medicine

“We really have to directly address the rural issue. I think that’s not a 2030 issue,” interjected Dr. Pines. “That’s a today issue.” One idea to begin dealing with this crisis is to offer rotations in rural emergency medicine for today’s current crop of emergency medicine residents.

“One of the main hurdles, honestly, is that to be considered an appropriate elective in a residency training program, there needs to be a board-certified emergency medicine physician there in the ER,” Dr. Koskenoja reminded the group. The Resident Review Committee for Emergency Medicine requires that for emergency medicine blocks, residents’ cases are staffed by a board-certified/board-eligible emergency physician. Thus, we are left with a chicken-and-egg paradox. How do we get more physicians to experience the rural environment if we can’t get experienced emergency physicians to work in rural departments?

The panel brainstormed a possible solution: going even further back into the medical school pipeline to more strongly recruit and support college students from rural areas who might, after graduating medical school and residency, be more inclined to subsequently practice in rural areas. “We talk a lot about diversity in medicine, but we don’t talk about diversity of where people come from,” said Dr. Koskenoja, referring to a lack of medical school and residency candidates from rural backgrounds.

For practicing physicians, competitive salaries and loan forgiveness could serve as other incentives to draw physicians from geographically oversupplied regions to undersupplied regions. The concept of geographic maldistribution for emergency physicians, as well as other key specialists such as obstetrician-gynecologists and surgical subspecialties, was more believable to the roundtable participants than a situation where emergency physicians were oversupplied in every region of the nation.

Rural medicine offers a welcome and different challenge to urban medical centers or traditional community hospitals in the suburbs. According to Dr. Mullen, “once we actually stabilize the staffing [in rural departments], we find that some people really enjoy the challenge of rural medicine.” Dr. Mendiratta, reminiscing about days of old, felt that practicing in a critical access hospital in an extremely small town was “truly a magical experience.”

Understanding reality, Dr. Koskenoja quipped, “Nobody expects to get a liver transplant when they live in a town of 22,000 people, but you should be able to get good primary care and good emergency care anywhere in the country.”

The role of emergency medicine is not necessarily to be in a brick-and-mortar emergency department 24-7. … That’s part of our future. That’s certainly not all of our future.  —Jesse Pines, MD, MBA, FACEP

Beyond Brick and Mortar

Dr. Pines, ever the futurist, explained that “the role of emergency medicine is not necessarily to be in a brick-and-mortar emergency department 24-7. … That’s part of our future. That’s certainly not all of our future.” Other opportunities such as telemedicine, fueled by the need to adapt to COVID-19’s restrictions on in-person contact between physicians and patients, and freestanding emergency medicine, recently pioneered by waves of emergency physician entrepreneurs, promise new practice models for emergency physicians. However, not all are enthusiastic about these approaches. Emergency physician RJ Sontag, MD, during the recent ACEP Leadership & Advocacy Conference, expressed his displeasure as a new graduate to be forced to practice virtual medicine.

We want to be a place where the best minds, the brightest minds, the most energetic medical students are choosing to be in our profession. —Jay Mullen III, MD, FACEP

Our roundtable experts echoed this sentiment. “Sitting in front of a computer screen isn’t something I enjoy doing all day,” said Dr. Koskenoja. Alluding to the sounds, sights, and smells of the emergency department, she presented a contrasting explanation. “We didn’t become radiologists for a reason.” Not every emergency physician will want to do telemedicine; however, some—people at high risk for COVID or with other personal reasons—enjoyed the flexibility that it offered. Dr. Mullen thinks telemedicine offers an excellent opportunity for emergency departments to expand their footprints while keeping patients—for example, nursing home patients—out of the emergency department and in a place that is best suited to treat them. “This could be an opportunity for emergency physicians to help bring the care to the bedside, at least in a virtual way, to keep the patients where they’re going to be the healthiest,” he said.

Our Future

According to Dr. Mullen, “we want to be a place where the best minds, the brightest minds, the most energetic medical students are choosing to be in our profession.” Regardless of whether the projections from the workforce report pan out a decade from now, provided that we maintain the rigorous nature of our training programs, I am confident that emergency medicine will continue to draw the best and brightest.

Reference

1. Marco CA, Courtney DM, Ling LJ, et al. The emergency medicine physician workforce: projections for 2030 [published online ahead of print Aug. 2, 2021]. Ann Emerg Med. 2021:S0196-0644(21)00439-X.