Indiana’s SB 400, signed into law on May 4, 2023, requires hospitals with emergency departments (EDs) to have a physician on site, on duty, and responsible for the ED at all times.¹ In April 2024, Virginia enacted a similar law (HB 353/SB 392)—with implementation set for July 1, 2025—replacing an established requirement that allowed a physician to be available to the ED on call with a new mandate requiring the physician’s presence in person.²

To many emergency physicians, mandating that all EDs be staffed around the clock by a doctor may seem like a minimum threshold for ensuring the quality and safety of emergency care nationwide, but some hospitals, particularly struggling rural facilities, argue that this standard will be difficult to meet.

Today, some EDs are staffed for part or all of the day by physician assistants (PAs) and nurse practitioners (NPs), and rural EDs are more likely to employ these clinicians practicing independently, without onsite physician supervision or involvement.³ Because ACEP believes that it is crucial for a physician with training and/or experience in emergency medicine to provide or oversee the care in EDs, it supported the Indiana and Virginia chapters’ legislative efforts as a model for other states and a priority for legislative outreach.⁴ ACEP also offers a toolkit for how to pass physician mandates in individual states.

ACEP’s Council voted in September 2024 to collaborate with the American Medical Association (AMA) in advocating for this issue. According to an AMA Newswire release on Nov. 12, AMA concurred that “having a physician on site is the best way to deliver care,” although an AMA Board of Trustees report concluded that some rural and remote facilities may not be able to meet this aspiration.⁵

Other state chapters are interested in pursuing similar mandate laws, according to Todd Parker, MD, FACEP, an emergency physician in Virginia Beach, Va., and immediate past president of the Virginia Chapter of ACEP.

Dr. Parker

“In Virginia, we were ready to go public with a campaign making this a patient safety issue, but in the end that wasn’t necessary,” Dr. Parker said. Currently, there is no hospital in Virginia that doesn’t have a doctor onsite 24/7, he added.

EDs need emergency physicians, first and foremost, because of their training, Dr. Parker said. Emergency physicians get many more hours of supervised clinical training than PAs or NPs, he said. According to a 2020 review of interprofessional variation in education, a board-certified emergency physician has completed at least 5,000 average program clinical contact hours, among other training requirements, compared with 2,000 hours for a PA and 500 for an NP.⁶

Dr. Parker, who also serves as the medical director of the Patient Transfer Center at Riverside Health System, noted that capacity issues have made patient transfers from rural to more comprehensive facilities more difficult, often with extended delays, underscoring the need for a physician to identify critical emergencies and manage them on site for hours, even days, while awaiting transfer.

Dr. Parker asserted that in some cases it is better for the patient to be transferred by EMS directly to a facility that can manage their critical needs, even if that takes an extra hour, than it is to take them to a closer rural ED where they will only be seen by a PA or NP. According to the Emergency Medical Treatment and Labor Act (EMTALA), once they arrive at that rural ED, they can’t leave it until there is an accepting physician at a hospital that has a bed available for that patient.⁷ That could take hours or days, Dr. Parker said.

Viktoria Koskenoja, MD, who practices in the ED at Baraga County Memorial Hospital, L’Anse, Mich., population 1,873, was trained in emergency medicine in urban settings before relocating to Michigan’s Upper Peninsula.

Dr. Koskenoja

“I started seeing egregious mistakes that were made in a department where there was no physician present,” Dr. Koskenoja said. Those mistakes included patients who were transferred unnecessarily to her hospital. If there had been a physician at the department they were transferred from, they wouldn’t have needed to come all this way, she explained.

According to Dr. Koskenoja, who is past chair of ACEP’s Rural Emergency Medicine Section, a line should be drawn requiring a minimal level of training in an ED, no matter the hospital’s size or location.

“In my opinion, that line is medical school and residency training,” Dr. Koskenoja said. “There were two occasions I personally know of where a chest tube was needed for an emergency patient because of a collapsed lung—and it needed to be addressed immediately [but wasn’t]. One time the PA working in that hospital said they just didn’t know how to do that.” She also cited a missed ectopic pregnancy and two cases where time-sensitive ST elevation myocardial infarctions were not diagnosed as examples of insufficient diagnostic skills in rural EDs without physician presence.

What’s Really Going On?

In ACEP Now and elsewhere, there has been an ongoing dialogue about whether there are too many or not enough emergency medicine-trained and board-certified physicians to fill every hospital’s staffing needs, current and future.⁸ In 2019, 20 percent of emergency medicine residents reported some difficulty finding a job in a preferred geographic area or at a salary they anticipated or wanted.⁹

But for rural EDs, it may not be that physicians don’t want to relocate to rural settings, but rather that hospitals are unable to pay the salary needed to attract an EM-certified physician to their rural community.

“A lot of hospitals say they can’t afford a physician, but we know that it is cheaper for their payroll costs to employ an NP or PA,” Dr. Koskenoja said. “It’s hard to know exactly what they can afford versus what they say they can afford. I currently work in an ED that has less than 5,000 visits per year, and it’s exclusively staffed by MDs and DOs. So my hospital is affording it.”

Dr. Koskenoja said that there is a role for PAs and NPs to work in EDs as physician extenders; they are an integral part of the clinical team. But there is a wide difference in training, and that is just a fact, she said.

Stephen Jameson, MD, FACEP, a physician in the ED at Sanford Medical Center, Fargo, N.D., and another past chair of ACEP’s Rural Emergency Medicine Section, said it will be hard to reconcile the gap between a standard for mandated physician presence and what rural hospitals are able to deliver. He studied these while serving on ACEP’s Rural Task Force, starting in 2019.

Dr. Jameson

“In our minds, we felt we should get emergency physicians into every ED,” Dr. Jameson explained. A 27 percent increase in emergency residency program slots in the previous decade seemed like a move in the right direction, he said.

But then a workforce study by Bennett and colleagues showed that although the number of emergency medicine residency programs had increased, most were added to states that already had a lot of them.¹⁰ In contrast, there was an emergency physician “desert” in other, rural parts of the United States.

If you want to fill the gaps, Dr. Jameson said, “first you have to recognize that the trend toward PAs and NPs staffing the smallest EDs, typically working independently, is a reality. The question is what to do with these small volume, critical access and frontier rural hospitals?” Dr. Jameson said. “How far down in volume of patient visits per year can you go and still justify hiring a physician for the ED? And will we ever be able to staff the lowest volume EDs?”

Emergency medicine training has incorporated more rural rotations to give EM residents some exposure to rural medicine and rural life, Dr. Jameson noted. But he wondered if there could be some kind of carve-out in these mandates for very low-volume facilities, an exception to ACEP’s aspirational standard.

Could the affected professional societies come together to define and advocate for training programs to better prepare PAs and NPs for the rural ED, given the reality that many rural hospitals now employ them without direct physician involvement? “We should at least advise that they need more training and help define that training,” Dr. Jameson said. And could telemedicine from urban centers provide more short-term support for the unsupervised clinicians that are already out there?

Family Physicians Want More Respect

The laws in Indiana and Virginia state that EDs should be staffed with a licensed physician, without requiring that physician to be board certified in emergency medicine. Rural hospital advocates point out that many of the physicians now working in rural EDs are family medicine doctors—and they bring invaluable skills to those settings.

Non-emergency-medicine physicians who work in EDs, typically family practice physicians, are actually really good at it,” Dr. Parker said. “I’ve worked with them.”

Dan Doolittle, MD, was trained in family medicine, served in the Air Force, and then, 30 years ago, started practicing emergency medicine exclusively. He deliberately sought out a career in a rural setting.

Dr. Doolittle

“I came to Southern Illinois, where I could buy land and raise my kids on that property,” Dr. Doolittle said. He grew comfortable practicing rural emergency medicine and opted not to be “grandfathered” into board certification when that was offered by the American Board of Emergency Medicine (ABEM) based on hours of clinical practice.

Recruitment of residency-trained emergency physicians to critical access hospitals can be incredibly difficult, Dr. Doolittle said. Many emergency physicians did their residencies in urban programs and are reluctant to move to rural areas to work in rural hospitals. Sometimes these physicians are uncomfortable being the only doctor in the hospital, perhaps in the whole county, during their shift.

“I get that. They’re really smart and trained in trauma medicine. They enjoy the fast pace, and they typically work eight-, 10-, 12-hour shifts in busy EDs,” he said. They have built relationships with their colleagues and hospitals. A rural EM service, by contrast, might ask them to work 24- or 36-hour shifts, which includes time for sleeping, Dr. Doolittle said. “In rural emergency medicine, we sell a whole different product—with a different pace.”

Dr. Doolittle believes that family physicians and other primary care specialties practicing in rural EDs deserve more respect and collegiality from the field. He would like to see ACEP take a position on the legitimacy of primary care doctors running rural EDs. “At least let’s try to work together more collaboratively,” he said.

His company, Integritas Providers of Carbondale, Ill., staffs 12 EDs in rural hospitals in the Midwest. Most of its physicians are experienced non-ABEM physicians from various training backgrounds.

“My wish is that emergency medicine residency programs would focus on offering more rural experiences, training the doctors of the future for a potential rural career, and recruiting medical students from rural communities,” Dr. Doolittle said. But, in the meantime, “we need more doctors tonight.”

Larry Beresford, an Oakland, Calif.-based freelance medical journalist, also writes for The Hospitalist and for EMS World.

References

1. ACEP. New Indiana bill requires hospital EDs to have a physician onsite. Published May 10, 2023. Accessed December 4, 2024.
2. Virginia’s Legislative Information System. House Bill No. 353. Published January 2024. Accessed December 4, 2024.
3. Nelson SC, Hooker RS. Physician assistants and nurse practitioners in rural Washington emergency departments. J Physician Assist Educ. 2016;27(2):56-62.
4. ACEP. Policy Statement. Guidelines regarding the role of physician assistants and nurse practitioners in the emergency department. Approved June 2023. Accessed December 4, 2024.
5. Robeznieks A. Having a physician on site is best way to deliver emergency care. AMA Newswire. Published November 12, 2024. Accessed December 12, 2024.
6. Chekijian SA, Elia TR, Horton JL, et al. A review of interprofessional variation in education: challenges and considerations in the growth of advanced practice providers in emergency medicine. AEM Educ Train. 2020;5(2):310469.
7. U.S. Department of Health and Human Services. Office of Inspector General. The Emergency Medical Treatment and Labor Act (EMTALA). Last updated September 11, 2024. Accessed December 12, 2024.
8. Beresford L. The EM residency program in Corpus Christi resuscitated. ACEP Now. 2024;43(1).
9. Rosenberg M. Workforce of the Future. Report of the EM Physician Taskforce. Published March 9, 2021. Accessed December 3, 2024.
10. Bennett CL, Clay CE, Espinola JA, et al. United States 2020 Emergency Medicine Resident Workforce Analysis. Ann Emerg Med. 2022; 80(1):3-11.