Twice a year, ACEP Now speaks to the President of ACEP. This conversation with Christopher S. Kang, MD, FACEP, assesses how his term leading the College has gone so far, and how the profession is weathering the storms of boarding, burnout, and a challenging Match season.

This boarding crisis seems to have exploded this year. Yesterday on shift, I had a patient that’s been in our ER for at least 120 hours. What’s changed over the past six months that you’ve heard about in terms of the boarding crisis?

Dr. Kang: I think there are three aspects to talk about. One is actually what you and I and others of our colleagues see every day, and that is the boarding crisis has not improved, and in some ways, it’s gotten worse. It depends on regionally and individually of each institution, but I think overall most people would say that boarding has not improved. Second of all is, what is the College trying to do about this? In November, we submitted a letter to the White House asking for a summit to bring all stakeholders together to talk about this issue because it’s going to require every part of the healthcare system to address and it’s not going to be an easy fix.

Over the past few months, we’ve been waiting as the new congressional session has begun to see what actions are taken. We provided them with some data and some anecdotes about how things were actually getting worse, specifically for mental health … they were intrigued, but unfortunately offered no other further actions other than to ask for some additional data.

In the meantime, thanks to ACEP staff and leaders, a task force was formed and concluded its work to identify that if we needed to hold our own summit, who would we invite? What would be our overarching objectives and how would we proceed about doing so? And thankfully that task force has completed its report and has outlined what our objectives are financially, operationally, personnel-wise, patient care-wise.

If we don’t hear back from the White House in the next few weeks, there was a letter that was recently circulated in conjunction with our LAC meeting to see how much congressional support we could have to encourage the White House to hold this. And if not, then we will likely move forward to hold our own summit sometime this summer.

Third is the receptiveness of the rest of the health care community. And as we’ve seen, our nursing colleagues, whether it’s violence, burnout, or overall staffing models has also been impacted, as well as some of our other health care professionals.

Let’s get into some of the solutions that I’ve seen proposed around the country. There was this shooting in a school in Tennessee recently, in recent months, and some of the lawmakers there are talking about investing in a system to help EDs recognize where there might be open psychiatric beds earlier on. Do you think that something as simple as that, just making sure that EDs have the ability to identify open psychiatric beds in nearby communities is a solution that would work at all for this crisis?

Dr. Kang: I think that is a key starting point. During the COVID-19 pandemic, as many readers may be aware, regional care coordination, including Washington State, the Los Angeles area, San Antonio, and Michigan, started utilizing these systems to identify available beds including critical care beds as well as ventilators to be able to distribute patients accordingly. That model has continued to be embraced by some parts of the federal government. And just a couple of days ago we had a meeting with American Psychiatric Association and their members and they also identified the need to be able to better understand where those beds are available. There is a precedent that’s set. The catch now becomes, is it private versus public beds? What’s really available? What happens when we’re short adolescent beds or geriatric psych beds? And then is it just a region or does this now look to include neighboring states?

Talking about mental health, we also need to talk about ourselves as physicians as well. We’re back-to-back burnout champions, according to reports from Medscape, which is a dubious honor to have, what are we doing to prevent the three-peat?¹

Dr. Kang: This is not one of those cases to be proud of being number one. In terms of burnout itself, I think we need to identify a couple of different factors. One of them is we need to acknowledge it’s happening. There’s a mantra before, and it’s also associated with ED violence and other hardships that we endure that it’s part of what you do. Some things are not acceptable, as we’ve talked about with ED violence. Part of it is then understanding what are the causes. For everybody, it’s an individual thing.

Sometimes it may be work conditions, sometimes it may be the terms of your employment, sometimes it could be social stressors, and sometimes it could be from a bad outcome or a bad event. So somewhere along the way overall, I think physicians are seeking to have greater autonomy and respect. And the catch with that is that almost every other part of the health care system no longer necessarily provides and affords the same amount of respect that I think we need to be able to provide the right care, but also for our professional sense and our well-being. Somewhere along the way, we’ve been asked to do more and more and more with less and less, including respect and the support from everybody else.

What is ACEP doing to maintain the attractiveness of the profession amid things like salary declines and all these other factors that are being demonstrated by fewer medical students wanting to go into the profession.

Dr. Kang: I want to start with the last part of your statement and that is why would people not want to go into emergency medicine versus why did people want to go into emergency medicine? And I would say that the College right now is identifying and celebrating what makes our specialty so unique and so good for so many.

We still have many physicians who are generally satisfied with the career and the chance and opportunity to serve their patients, as well as communities. And if you still want to be that quintessential doctor who is there for your patients, regardless of their background, regardless of their needs, 24/7, that’s emergency medicine.

Second, what does emergency medicine offer? If you’re still motivated to see patients and then utilize the skillsets to be able to see any acute undifferentiated patient, to be able to identify, prioritize concerns, and then stabilize and/or disposition patients, that skillset can take you many different places.

Whether it may be telehealth, whether it is pre-hospital, whether it’s innovation simulations, whether it’s concierge medicine, wilderness medicine, space medicine, or emergency medicine provides you with a skillset that can help you provide the best patient care and be prepared in almost any scenario. That has not gone away.

The working conditions, the respect from others has declined. And so we know that some medical school deans, as well as advisors, are directing people not to go into emergency medicine. But as rural hospitals close, as health care systems and practices are changing rapidly, sometimes month to month, we’re still there. We’re still the ones that will care for patients, and we still have that overall critical mission.

One of the things I also want to address is the increase in the number of residency programs, and there is no doubt when you look at the numbers, the rapid explosion of the number of programs being started. We need to have a conversation about some programs, existing programs, still expanding.

If I’m a young person, early 20s, and I’m thinking of pursuing something that puts me in an emergency department, why would I pick a pathway that takes me four to eight years when I could be doing something fairly similar in a pathway that might be two to three years long?

Dr. Kang: I think part of it is do you want to be the leader? Do you want to, be the best educated, to be the best trained to be able to have those and take advantage of those opportunities, whether it’s working in different environments part-time, whether or not your career may transition somewhere else? The physician should still be the leader of the emergency care team and emergency medicine residencies provide that training.

You may be touching upon a scope of practice and where, hey, maybe I can find a different profession that would allow me to work in certain environments but not take as long and that we know are rapidly growing. In the end, do you want to be working for somebody or do you want to be leading the team? And I would argue that again, emergency physicians are the best educated, best trained, and best qualified to lead the teams in almost any variety of acute care settings.

Let’s talk a little bit about diversity within the workforce itself. So, you’re the first Asian American president that ACEP has had and in the fall, Dr. Aisha Terry is going to become the first black president for the American College of Emergency Physicians, but the leadership of the College and sort of the overall numbers within emergency medicine, in general, tend to not be reflective of the overall population, the diversity in this country. So what is ACEP’s commitment to diversity, equity, and inclusion, especially considering the recent backlash we’ve seen in places like Texas and Florida?

Dr. Kang: It comes to three things. One is what is our overall mission, both as emergency medicine physicians, but also as ACEP. And that is to be able to best take care of our patients. And so giving those voices to those who may be the minority, who may be overlooked. So when we talk about reproductive rights, when we talk about transgender rights, when we talk about other things, how can we better care for those patients?

We have to understand and recognize them and try to make sure that we can provide the best care possible. When you mentioned that, does the College reflect its leadership, reflect its membership? Well, it may or may not reflect its membership in terms of the population. We know that it falls short and over the last several years, we’ve started to have those conversations.

In terms of personal actions, I think one of the things that I’m proudest of is always looking at the diversity of any of our members when we look at committees, objectives, task forces, and even the leadership track. And if you look at our committee chairs that I had a hand in nominating and/or confirming there’s a greater diversity of ethnicity, as well as gender, practice settings, and age.

And so when we talk about diversity, it’s incredibly important that we need to start somewhere, but diversity should be diversity. And so when we talk about ethnicity or race, when we talk about gender, let’s also talk about practice backgrounds, where they are in their careers, geography, part-time/full-time, other specialties, and what they may represent, geriatrics, or psych, or critical care.

I think our leadership track is better reflective of our membership, especially when you start to take a look at our committees and sections. Can we do better at the chapter and national level? Yes, but as I said before, this needs to be a commitment that is permanent, that is long-lasting, and so such a journey is going to require just a little bit of time, patience, commitment, and dedication.

I got a notice recently that my dues were going up, and I bet a bunch of people see that and they’re freaking out a little bit. Why are we raising the dues? (Clarification: ACEP dues were raised $60 for regular members; no other membership category dues were increased.)

Dr. Kang: This was a difficult decision that was a subject of discussion for the Board for the last three to four months. This was not done readily or easily, but at times it was identifying how do we continue to best serve our members. And we hope we’ve demonstrated that with a change a little bit in the focus, our strategic plan, and some of the results that members may or may not have seen overtly or subtly.

ACEP has not increased its national dues for nearly 10 years. So if you take into account that inflation has increased by maybe nearly 25 to 30 percent, if you’ve seen that inflation increased eight percent last year, and you want us to continue to advocate for you at the state level, the federal level, our clinical policies, our representations and liaisons with other organizations, we believe that we needed to raise the dues here to continue to fund those avenues, those projects, and those opportunities to better serve the individual physicians and their practices and their careers.

To emergency physicians who are not currently members of ACEP, what’s your pitch to them as to why they should become ACEP members?

Dr. Kang: I would encourage every emergency physician to get more involved. I hope ACEP is the one that earns the trust and provides and shows its value. When we talk about why you should join ACEP, I think some of it is for what people acknowledge, but may not necessarily give due credit to, the clinical policies that help you fight to better take care of your patients. The clinical policies that aren’t adopted because of advocacy—such as the one-hour sepsis bundle. When we talk about how you can improve your workplace, not only the ability to have food and drink at work, but also security, or making sure that you are respected and can find additional resources, whether it’s EMRs, scribes, practices that will help improve how you can deliver quality care to your patients.

Legislatively, who else can advocate on your behalf to make sure that you are respected and that you are the leader of the emergency care team? Every single emergency physician sees that whether it’s because of our efforts with the RUC and the AMA, whether it’s making sure that the battles of the scope of practice are being fought to better safeguard your role as the leaders of the health care team and the successes we’ve seen in multiple states thanks to our members at the chapter level, whether it’s in your institution, whether it’s training in the workforce …ACEP does many, many things. I hope people will take a step back and say, if ACEP wasn’t doing what it was doing, where would you be and where would your practice be now? And I hope that somewhere along the way, they will see that what they get back is multiples of those dues.

Dr. Dark (@REALCEDRICDARK) is associate professor at Baylor College of Medicine and medical editor in chief of ACEP Now.