A recent study commissioned by the American College of Emergency Physicians (ACEP) identified a likely scenario of a surplus of over 7,000 emergency physicians (EPs) in the United States in 2030. This future scenario was based on an estimated 2% annual graduate medical education (GME) growth, 3% annual EP attrition, 20% of ED encounters seen by a nurse practitioner or physician assistant, and an 11% increase in ED visits relative to 2018. This study raised important questions about the future supply of and demand for emergency physicians, including whether to intervene, what are the likely consequences and moral implications of potential actions, and how to implement potential changes.

The future of the workforce in EM depends on balancing the supply with the demand for emergency physicians. We propose that evaluation of potential actions to balance supply and demand should rely on the ethical principles of beneficence (doing good), nonmaleficence (primum non nocere, or “do no harm”), and justice (fair and equitable treatment).

The Supply of Emergency Physicians

GME in emergency medicine is a 3- or 4-year program. Most federal funding comes from the Centers for Medicare & Medicaid Services (CMS) Medicare GME program, which provided as much as $10.3 billion in 2015. With sustained funding and the continuing popularity of the specialty, the number of EM residency programs has expanded dramatically in recent years. The latest data from the Accreditation Council for Graduate Medical Education (ACGME) in 2020-21 show that EM has a total of 276 accredited residency programs, placing emergency medicine on the latest “top five” list of specialties with the greatest increase in programs (+16 programs) since 2016-2017. CMS recently announced plans to fund an additional $1.8 billion over the next 10 years for additional residency slots, specifically for hospitals serving underserved and rural areas.

Emergency medicine continues to be a popular specialty choice among medical graduates. In fact, post-graduate emergency medicine residency slots increased by 27.5% from 2014 (1,786 slots) to 2018 (2,278), according to a report from the American Board of Emergency Medicine and Accreditation Council for Graduate Medical Education. This rapid growth in EM residency programs poses novel ethical issues, including questions about maintaining the quality of emergency medicine residency training, allocating limited graduate medical education funding equitably, and supporting the work life of emergency medical care professionals. To develop and sustain a highly skilled workforce, medical students and residents must have adequate clinical training opportunities. Data have shown that market forces may not always align with high-quality medical training, and residency expansion does not always mirror the demand for medical specialists. If, for example, a large supply of new emergency physicians significantly exceeds demand, new physicians may confront diminished job prospects and significant salary decreases.

Strategies for striking an optimal balance between the supply of emergency physicians and societal needs for emergency medical care remain uncertain. Some have argued that emergency medicine training requirements should become more rigorous and longer. This is potentially a good solution for enhancing the skills of residency-trained emergency physicians and promoting high-quality patient care. Any changes in training requirements should be directly related to proficiency and quality patient care.

Demand for Emergency Physicians COVID-19’s Effect on Emergency Physician Demand

Initial COVID-19 surges decreased ED volumes and emergency physician staffing in 2020, but these rebounded in 2021. Physicians report greatly increased stress and burnout since the onset of the current pandemic. In a survey by the Physicians Foundation, 58% of physicians often had feelings of burnout versus 40% in 2018, and 37% wanted to retire in the next year., A study of physician interruptions of practice during the pandemic found that these were mostly transient, but that practice interruptions without return for physicians aged 55 and older were significantly greater than for younger physicians. These data suggest that the emergency physician attrition rate of 3% used to calculate emergency physician demand is likely an underestimate due to COVID-19. If that is the case, reductions in the number of emergency medicine residency program graduates could create a future shortage of emergency physicians, with adverse consequences for the accessibility and quality of emergency medical care.

EMTALA and the prudent layperson standard requiring an emergency service to evaluate and treat any condition that patients believe requires immediate unscheduled medical care ensures that there will be continuing demand for emergency physicians. Demand for emergency physicians’ services is reinforced by their commitment to a fundamental moral duty to act for the benefit and welfare of their patients and “respond promptly and expertly, without prejudice or partiality, to the need for emergency medical care,” while being stewards of finite healthcare resources.

Distribution of Emergency Physicians

Rural EDs serve larger proportions of disadvantaged populations. They also face the challenge of a shortage of physicians, especially emergency physicians. Access to care in rural areas is anticipated to worsen, for these reasons:

• While approximately 20% of the US population lives in rural areas, only about 10% of all physicians practice in those areas.
• Physicians practicing in rural EDs are less likely to be EM trained or board certified.
• Over approximately the last decade, this shortage has increased, with the density of emergency physicians per capita in small and large rural areas decreasing.
• Many rural emergency physicians are nearing retirement age.
• Rural hospitals are experiencing a closure crisis due to financial challenges. This crisis pre-dated the COVID-19 pandemic and has subsequently been exacerbated by it.
• Rural hospitals have higher mortality rates for acute conditions.

The challenges facing emergency medical practice in US rural areas pose a significant threat to the moral goal of universal and timely access to quality emergency medical care. While financial incentives are effective in attracting physicians to rural locations, the effects may be transient – once student loans are repaid, physicians tend to return to urban areas. The most consistent factor influencing practice in a rural area is growing up in a rural area.

Factors Influencing Future Demand for Emergency Physicians

Emergency physicians are becoming more involved in a variety of professional activities outside of the direct clinical care of ED patients. The Society for Academic Emergency Medicine (SAEM) website for fellowships now lists 500 available positions in nearly 40 different fellowship programs, and the American Board of Emergency Medicine (ABEM) listed 2,927 ABEM emergency physicians with subspecialty certification in 12 different subspecialties. The National Residency Match Program (NRMP) match data for 2021 showed that ACGME-certified fellowships experienced record high numbers of filled positions.

Despite significant interest in pursuing emergency medicine, the latest 2022 NRMP match illustrated a big drop in the percentage of positions filled, with a 7.0 percent point drop compared to last year. The reasons for this change are uncertain, but may reflect uncertainty relating to future employment opportunities.

Given the number of unanticipated changes that have a significant impact on the healthcare workforce, such as the COVID-19 pandemic, emergency physicians will continue to explore ways to diversify their careers. A study from 2011 demonstrated that 36% of EDs surveyed reported an observation unit in their hospital, with over half of those units staffed by emergency physicians. Urgent care centers have increased in the US from 6100 in 2013 to 9616 in 2019. A recent systematic review of telehealth during the COVID-19 pandemic listed several categories of use in the ED, and the number of descriptive papers regarding emergency physicians using telehealth continues to grow. Tele-emergency allows a specialty-trained EP to provide oversight for another clinician in a remote ED. This practice has been shown to improve the quality of care and health outcomes in rural hospitals. These trends in EP training and in clinical practice arrangements may decrease the number of emergency physicians providing basic ED care, but they may also increase the quality of care and the treatment benefits enjoyed by ED patients.

Conclusions

The future of the EM workforce depends on the supply and distribution of emergency physicians and the demand for emergency medical care. Potential actions to balance these forces should be evaluated using the ethical principles of beneficence (doing good), nonmaleficence (primum non nocere, or “do no harm”), and justice (fair and equitable treatment). Patient access, safety, and the quality of emergency care should be the primary goals of balancing the emergency medicine workforce.

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