Our specialty has been working for decades to create, evolve, and sustain a workforce that meets the growing emergency medicine needs of our country. Over the past two years, eight organizations—American Board of Emergency Medicine, American College of Emergency Physicians, American College of Osteopathic Emergency Physicians, American Osteopathic Board of Emergency Medicine, Association of Academic Chairs of Emergency Medicine, Council of Emergency Medicine Residency Directors, Emergency Medicine Residents’ Association, and Society for Academic Emergency Medicine—came together with the common goal of taking a data-driven, forward-looking approach to studying the emergency medicine workforce. The findings from the Emergency Medicine Physician Workforce: Projections for 2030 research, from which a manuscript is currently under independent peer review, show that for the first time in history we are headed toward an oversupply of emergency physicians in the next decade.

During an April 9, 2021, webinar, the eight stakeholders plus additional thought leaders furthered the process by proposing several ideas for consideration and discussion. We encourage you to watch the webinar and download a PDF of the slides used in the webinar at acep.org/workforce.

In an all-member email sent on April 15, ACEP identified eight key considerations we are committed to addressing. In this article, we, the ACEP Board, want to explain in greater detail what we mean by that.

To start, we firmly believe there is not one ideal, holistic solution to address market-driven industry instability. Shifting health care economics and evolving practice models affect each of you in different ways. Change will take time and precision, yet we must forge ahead as there are no quick fixes for the challenges we face. Furthermore, the implementation of the ideas discussed will require the coordinated involvement of the entire specialty, with each stakeholder playing an integral role in the process.

To that spirit, we are committed to continuing the multi-organizational task force that conducted the study to discuss feedback received from you and your colleagues, establish working groups, and begin advancing solutions. For our part, ACEP has taken steps to schedule needed engagements, is collating feedback, and is already investigating options. We developed toolkits and assisted in generating feedback and solutions from stakeholder groups—including other organizations, state chapters, ACEP sections and committees, and your local practice or programs. Where there is opportunity for meaningful change, ACEP is committed to developing new approaches that the entire emergency medicine community can support and champion.

Eight Key Considerations

• Stop the proliferation of emergency medicine residents and residency programs

We believe the entire emergency medicine community must come together to discuss all reasonable, realistic, and legal means to stem the growth of EM residencies and residency positions. Even though the Accreditation Council for Graduate Medical Education at this time continues to make decisions based exclusively on educational concerns and not workforce variables, all EM stakeholders as well as those in the EM industry—including hospital organizations, for-profit and non-profit physician staffing organizations, and academic healthcare organizations—should take a hard look at workforce projections, along with market and financial drivers of the past decade, and take the prudent steps to protect the integrity of emergency medicine.

ACEP is committed to ensuring those conversations happen and to the development and adoption of a multi-organization policy specific to stopping the expansion of new programs.

• Raise the bar to ensure consistency across emergency medicine residency training

The original number of required procedures for EM residencies was set decades ago. Some research exists, but more is needed to assess validity of the existing standard and what role simulation should play in competency. Based on such objective research, all emergency medicine organizations can work with the Residency Review Committee for Emergency Medicine to set appropriate requirements around such criteria as the number of procedures required on actual patients (versus simulation) and number of direct patient contact interactions (including primary responsibilities in such conditions as trauma, resuscitation, airway, pediatric critical care/trauma, etc.).

Emergency department volume requirements should impact competition for patient procedures and EM residents should have priority for critical care encounters and procedures. These deliberations, and any subsequent changes they lead toward, should help to strengthen the value of the residency-trained, board-certified emergency physician leading the ED team.

Further, the expected presence of core faculty should be required at the primary sites and minimum qualifications should be delineated, as should faculty academic and scholarly requirements. These requirements must ensure the best educational environment to prepare emergency physicians to provide the quality of care our patients deserve, both now and in the evolving future.

There should be consideration of transitioning to a consistent four-year EM residency training model while maintaining the same total complement of residents. More research is needed to determine if there is evidence that this potential move would addresses additional educational needs while also resulting in a decrease in graduates each year.

ACEP is just one stakeholder in this realm, but we are committed to working with key organizations closely to examine and to update the standards and qualifications of new and existing residency programs—while also protecting the residents and medical students who are counting on them.

• Ensure business interests are not superseding the needs of educating the workforce

There are a lot of voices who assert that the root cause of our workforce issue can be traced back to “pop-up” residencies funded by large, equity-backed management groups and the corporate practice of medicine. ACEP is committed to working with key stakeholders to closely examine the legality and ethics of organizations funding residency training programs. No business interests, whether from a not-for-profit organization or a for-profit organization, should supersede the service needs of educating a workforce, while also caring for our communities.

We also acknowledge that resident salaries have remained relatively flat despite increased academic indebtedness. We encourage research to determine if low salaries have contributed to program expansion and/or limited opportunity in emergency medicine for students from less well-off financial backgrounds.

• Support practicing physicians to encourage rewarding practice in all communities

A consistent EM workforce issue is the undersupply of residency-trained, board-certified physicians working in rural and underserved communities. ACEP’s report from the 2019–2020 Rural Emergency Medicine Task Force  affirmed that rural emergency departments represent 53 percent of all hospitals in the United States and 24 percent of total ED patient volume, yet the number of EM residency–trained or EM board–certified physicians working in rural emergency departments has not changed over the past 10 years. ACEP is not saying that graduating residents should see working in a rural emergency departments as their only option. Instead, we invite the entire EM community to look to the objectives proposed and help identify ways that we can better support those who wish to choose a rural practice. One item to note is our commitment to engage further with the federal government or other non-governmental organizations to expand existing or create new rural, Indian Health Service, and public health scholarships to provide debt forgiveness and salary support for service in these areas.

ACEP remains dedicated to working together with those who share our commitment to identify data-driven solutions that promote both patient safety and emergency physician opportunities.

Support for practicing physicians is not limited to rural or urban location. It pertains to the many different employment models emergency physicians choose to practice in. ACEP continues to update and evolve our policies, many as directed by Council, to support all practicing emergency physicians. Most recently, this includes updates to our policies on Emergency Physician Rights and Responsibilities, Emergency Physician Contractual Relationships, and Compensation Arrangements for Emergency Physicians. ACEP policy statements can be found at www.acep.org/patient-care/policy-statements/. Work continues on other key Council resolutions that were approved or referred to the Board last October.

• Ensure appropriate use of nurse practitioners (NPs) and physician assistants (PAs) to protect the unique role of emergency physicians

Emergency medicine is a medical specialty that requires advanced education, training, orientation, credentials, continuing education, and certification. The emergency department is a unique environment with significant challenges of dynamic patient care, limited information about patient present and past illness or injury, and unpredictable patient acuity and volume. It is unacceptable to have an emergency department that is not led and staffed in real time by a board-certified emergency physician with sufficient time to oversee the department and engage with patients.

The differences in training, competencies, and scope of practice among physicians and between physicians and non-physicians must be clearly defined and delineated when it comes to acute, unscheduled care. There remains much debate, even among ourselves, on the establishment of minimum standards for education, training, and competence of EM NPs and EM PAs. However, standards must not be misconstrued as training a non-physician practitioner to replace the physician.

It is unacceptable to have an emergency department that is not led and staffed in real time by a board-certified emergency physician with sufficient time to oversee the department and engage with patients.

ACEP and our chapters continue to advocate strongly at national and state levels against independent practice of NPs and PAs in emergency care. At no point should the role of the emergency physicians be performed by an independently practicing non-physician practitioner.

• Set the standards for emergency medicine so every patient has access to a board-certified emergency physician

Every patient, no matter their zip code, should receive the same high-quality care when they need acute, unscheduled care to improve overall patient outcomes and as a matter of equity. ACEP has developed accreditation programs in ultrasound, geriatric emergency departments, and pain and addiction care emergency departments. We believe the time is right to explore the merit, feasibility, and operationalization of an emergency department accreditation program that categorizes emergency departments. Similar to the American College of Surgeons’ Trauma Centers, there should be a “gold standard” that patients should expect from their emergency department and from those who are providing the care. We believe every patient seeking emergency care should have access to a board-certified emergency physician. We support board-certified emergency physicians as the decisionmakers regarding staffing within emergency departments specific to physicians, NPs, and PAs.

• Broaden the umbrella to expand emergency medicine physician scope of practice

As evidenced by the many sections within ACEP, the skill-defined practice of an emergency physician is already broad. There is opportunity to deploy systemic solutions around what many emergency physicians already do: observation medicine, acute psychiatric emergencies, EMS medicine, and telehealth, among others. It is important to continue research in these and other emergency medicine practices to document improved quality of care and patient outcomes when care is provided and/or led by board-certified emergency physicians. Opportunities exist to create new or evolve current focused-practice designations toward formalizing additional EM subspecialties—disaster medicine, community health (public health), health care administration, informatics, pain management and addiction, telehealth, emergency psychiatry, and others.

Many have been saying for quite some time that the practice of emergency medicine should evolve to widely transcend the traditional “bricks and mortar” of hospital-based emergency departents. Board-certified emergency physicians should be seen as physicians to all patients with acute, undifferentiated illness or injury in any setting. We believe in exploring opportunities for the practice of emergency medicine within ED-based ICUs, free-standing emergency departments, hospital satellite departments, and physician-owned hospitals, particularly in rural areas. Coupled with the evolving physical and digital infrastructure to predict outcomes and ensure follow-up care, the time is right to broaden our practice.

• Expand the reach of emergency medicine to ensure that no community is left behind

With strong diversity of practice among our members, ACEP recognizes the value of collaborative practice models between academic and rural/community sites to support mutual appreciation of different practice challenges and reduce feelings of isolation of among rural emergency physicians. Furthering the development of blended practice models could meet the needs of the emergency physician, the community, and the hospital while enhancing quality and reducing geographic disparities of care.

Conclusion

In sum, these considerations are a starting point to outline pressing issues and potential solutions proposed to date. Very importantly, your perspectives and approaches are critical to these ongoing deliberations. Differing opinions are still needed and welcomed, as it is vital all consequences, whether intended and unintended, are considered in advance. Feedback, via email or on a discussion forum, can be provided at acep.org/workforce.

ACEP remains dedicated to working together with those who share our commitment to identify data-driven solutions that promote both patient safety and emergency physician opportunities.