Workforce Projections for Emergency Medicine: How Many Emergency Physicians Does the United States Need?

Objective: To mathematically model the supply of and demand for emergency physicians (EPs) under different workforce conditions.
Methods: A computer spreadsheet model was used to project annual EP workforce supply and demand through the year 2035. The mathematical equations used were: supply = number of EPs at the beginning of the year plus annual residency graduates minus annual attrition; demand = 5 full-time equivalent positions/ED X the number of hospital EDs. The demand was empirically varied to account for ED census variation, administrative and teaching responsibilities, and the availability of physician extenders. A variety of possible scenarios were tested. These projections make the assumption that emergency medicine (EM) residency graduates will preferentially fill clinical positions currently filled by EPs without EM board certification.
Results: Under most of the scenarios tested, there will be a large deficit of EM board-certified EPs well into the next century. Even in scenarios involving a decreasing "demand" for EPs (e.g., in the setting of hospital closures or the training of physician extenders), a significant deficit will remain for at least several decades. Conclusions: The number of EM residency positions should not be decreased during any restructuring of the U.S. health care system. EM is likely to remain a specialty in which the supply of board-certified EPs will not meet the demand, even at present levels of EM residency output, for the next several decades.     

The Emergency Medicine Workforce: Shortage Resolving,Future Surplus Expected

IntroductionThe emergency medicine (EM) workforce has been growing at a rapid rate, fueled by a large increase in the number of EM residency programs and growth in the number of Advanced Practice Providers (APPs).ObjectivesTo review current available data on patient volumes and characteristics, the overall physician workforce, the current emergency physician (EP) workforce, and to project emergency physician staffing needs into the future.MethodsData was obtained through review of the current medical literature, reports from certifying organizations and professional societies, Web searches for alternative sources, and published governmental data.ResultsWe conservatively estimate the demand for emergency clinicians to grow by ∼1.8% per year. The actual demand for EPs will likely be lower, considering the higher growth rates seen by APPs, likely offsetting the need for increasing numbers of EPs. We estimate the overall supply of board-certified or board-eligible EPs to increase by at least 4% in the near-term, which includes losses due to attrition. In light of this, we conservatively estimate the supply of board-certified or eligible EPs should exceed demand by at least 2.2% per year. In the intermediate term, it is possible that the supply of board-certified or eligible EPs could exceed demand by 3% or more per year. Using 2.2% growth, we estimate that the number of board-certified or board-eligible EPs should meet the anticipated demand for EPs as early as the start of 2021. Furthermore, extrapolating current trends, we anticipate the EP workforce could be 20–30% oversupplied by 2030.ConclusionsHistorically, there has been a significant shortage of EPs. We project that this shortage may resolve quickly, and there is the potential for a significant oversupply in the future.     

Predictive Validity of the Emergency Physician and Global Job Satisfaction Instruments

Objective: To evaluate the predictive validity of the Emergency Physician Job Satisfaction (EPJS) and Global Job Satisfaction (GJS) instruments.
Methods: Prospective mail survey of 223 Canadian emergency physicians (EPs) using a 42-item questionnaire, including 14 items evaluating their reasons for leaving emergency medicine (EM). Original (1990) EPJS and GJS scores were analyzed using 1-way ANOVA and Scheffe's test comparing the physicians who left EM with those still in their original jobs, and those who had left their original jobs but who stayed in EM. Mean scores on the 14 "reason for leaving" items were compared with scores from an earlier sample of U.S. physicians using a t-test for independent means. Criteria for statistical significance were set at a = 0.05 for all analyses.
Results: The response rate for the primary study questions was 99.1%. Of the respondents, 29.4% had left their original jobs, and 10.4% had left EM altogether. The GJS scores for the physicians who left EM were significantly different from those for the physicians who stayed (p = 0.004). The EPJS scores for the physicians who left EM were not significantly different from those for the physicians who stayed (p = 0.56). There was no significant difference in scores between the Canadian and U.S. physicians' reasons for leaving EM (all p-values > 0.05). Shiftwork scored the highest as a reason to leave EM.
Conclusions: A low GJS score is associated with physicians' leaving EM, but not with changing jobs. The EPJS instrument was not associated with either outcome. Canadian and U.S. EPs place similar levels of importance on potential reasons for leaving EM.     

Rural Emergency Medicine: Patient Volume and Training Opportunities

Background: A paucity of board-certified Emergency Physicians practice in rural Emergency Departments (EDs). One proposed solution has been to train residents in rural EDs to increase the likelihood that they would continue to practice in rural EDs. Some within academic Emergency Medicine question whether rural hospital EDs can provide adequate patient volume for training an Emergency Medicine (EM) resident. Study Objectives: To compare per-physician patient-volumes in rural vs. urban hospital EDs in Oklahoma (OK) and the proportion of board-certified EM physicians in these two ED settings. Methods: A 21-question survey was distributed to all OK hospital ED directors. Analysis was limited to non-military hospitals with EDs having an annual census > 15,000 patient visits. Comparisons were made between rural and urban EDs. Results: There were 37 hospitals included in the analysis. Urban EDs had a higher proportion of board-certified EM physicians than rural EDs (80% vs. 28%). There were 4359 vs. 4470 patients seen per physician FTE (full-time equivalent) in the rural vs. urban ED settings, respectively (p = 0.84). Conclusions: Patient volumes per physician FTE do not differ in rural vs. urban OK hospital EDs, suggesting that an adequate volume of patients exists in rural EDs to support EM resident education. Proportionately fewer board-certified Emergency Physicians staff rural EDs. Opportunities to increase rural ED-based EM resident training should be explored.     

The Development of International Emergency Medicine: A Role for U.S. Emergency Physicians and Organizations

ABSTRACT
There is a rapidly growing interest in emergency medicine (EM) and emergency out-of-hospital care throughout the world. In most countries, the specialty of EM is either nonexistent or in an early stage of development. Many countries have recognized the need for, and value of, establishing a quality emergency health care system and are striving to create the specialty. These systems do not have to be high tech and expense but can focus on providing appropriate emergency training to physicians and other health care workers. Rather than repeatedly "reinventing the wheel" with the start of each new emergency care system, the preexisting knowledge base of EM can be shared with these countries. Since the United States has an advanced emergency health care system and the longest history of recognizing EM as a distinct medical specialty, lessons learned in the United States may benefit other countries. In order to provide appropriate advice to countries in the early phase of emergency health care development, careful assessment of national resources, governmental structure, population demographics, culture, and health care needs is necessary. This paper lists specific recommendations for EM organizations and physicians seeking to assist the development of the specialty of EM internationally.     

Assessment of Emergency Physician Workforce Needs in the United States, 2005

Objectives: The objective was to estimate emergency physician (EP) workforce needs, taking into account the diversity of U.S. emergency departments (EDs) and various projections of EP supply and demand. Methods: The 2005 National ED Inventory‐USA ( http://www.emnet‐usa.org/ ) provided annual visit volumes for 4,828 U.S. EDs. The authors calculated annual supply based on existing emergency medicine (EM) board‐certified EPs, adding newly board‐certified EPs, and subtracting board‐certified EPs who died or retired. Demand was estimated at each ED by dividing the number of visits by the average EP volume (based on 2.8 patients/hour, 40 hours/week, and 34% nonclinical time). The models assumed that at least 1 EP should be present 24/7 in each ED, which would require at least 5.35 full‐time equivalents (FTEs) per ED. Based on annual EP attrition estimates, results for best‐case, worst‐case, and intermediate scenarios were calculated. Results: In 2005, there were approximately 22,000 EM board‐certified EPs, but 40,030 EPs would be needed to staff all 4,828 EDs (55% of demand met). A total of 2,492 (52%) EDs had a visit volume that required the minimum number (5.35) FTEs, of which 47% were rural. In the unrealistic (no attrition), best‐case scenario, it would take until 2019 to staff all EDs with board‐certified EPs. In the worst‐case scenario (12% attrition), supply would never meet demand. Our intermediate scenario (2.5% attrition) suggested that board‐certified EPs would satisfy workforce needs in 2038. Conclusions: Supply of EM residency‐trained, board‐certified EPs is not likely to meet demand in the near future. Alternative EP staffing arrangements merit further consideration.     

Resident Service Hours in Emergency Medicine

Objective: The number of hours worked by residents in all specialties has become a controversial issue. Residents often are expected to competently conduct patient care activities and to take educational advantage of clinical experiences in spite of frequent fatigue and sleep deprivation. This survey of residency directors was designed to assess the scheduled clinical time for emergency medicine (EM) residents. Methods: A 13-question survey dealing with time commitments of EM residents was sent to the residency directors of all accredited EM residency programs in the United States in the fall of 1991. Residency directors were asked to indicate the number of shifts, hours, and days off per week; and the number of night shifts and weekend days off per month for each postgraduate year of residency training (PGY1-PGY4). Directors also were asked whether shifts were scheduled randomly or predictably with progression from days to nights with time off after nights. Results: Seventy of 71 (98.6% response rate) residency directors responded. Residents were scheduled for an average of 49.1 hours per week. Scheduled hours decreased from an average of 51.9 at the PGY1 level to an average of 44.5 at the PGY4 level. A similar progression with year of training was noted for scheduled night shifts/ month, days off/week, and weekend days off/month. A PGY1 trainee averaged 7.0 night shifts/month, 1.9 days off/week, and 3.0 weekend days off/month; while a PGY4 trainee averaged 5.3, 2.4, and 3.2, respectively. Only 40% of the directors reported predictable scheduling progressing from days to nights. Conclusion: Emergency medicine resident schedules, as reported by residency directors, fall well within current specialty-specific requirements and compare favorably with the reported numbers for other specialties. However, because large ranges in scheduling parameters were reported, the data may be of value to residency directors, residents, and prospective residents. Most programs did not report a predictable schedule progression of shifts.     

Bioterrorism Training in U.S. Emergency Medicine Residencies: Has It Changed since 9/11?

Objectives: To assess the change in prevalence of bioterrorism training among emergency medicine (EM) residencies from 1998 to 2005, to characterize current training, and to identify characteristics of programs that have implemented more intensive training methods.
Methods: This was a national cross sectional survey of the 133 U.S. EM residencies participating in the 2005 National Resident Matching Program; comparison with a baseline survey from 1998 was performed. Types of training provided were assessed, and programs using experiential methods were identified.
Results: Of 112 programs (84.2%) responding, 98% reported formal training in bioterrorism, increased from 53% (40/76) responding in 1998. In 2005, most programs with bioterrorism training (65%) used at least three methods of instruction, mostly lectures (95%) and disaster drills (80%). Fewer programs used experiential methods such as field exercises or bioterrorism-specific rotations (35% and 13%, respectively). Compared with other programs, residency programs with more complex, experiential methods were more likely to teach bioterrorism-related topics at least twice a year (83% vs. 59%; p = 0.018), to teach at least three topics (60% vs. 40%; p = 0.02), and to report funding for bioterrorism research and education (74% vs. 45%; p = 0.007). Experiential and nonexperiential programs were similar in program type (university or nonuniversity), length of program, number of residents, geographic location, and urban or rural setting.
Conclusions: Training of EM residents in bioterrorism preparedness has increased markedly since 1998. However, training is often of low intensity, relying mainly on nonexperiential instruction such as lectures. Although current recommendations are that training in bioterrorism include experiential learning experiences, the authors found the rate of these experiences to be low.     

Factors Associated with Workforce Retention Among Emergency Medical Technicians in Montana

Objective. To assess potential factors associated with workforce retention among emergency medical technicians (EMTs). Methods. In 2008, the Montana Department of Public Health and Human Services conducted a telephone survey of a representative sample of licensed EMTs to assess factors associated with workforce retention. Respondents were asked whether they were considering leaving the profession in the next 12 months and the next five years. Respondents considering leaving the profession in the next five years were also asked to indicate why. Results. One thousand eight licensed and practicing EMTs completed the survey (response rate = 53%). Nine percent of the EMTs were considering leaving the profession in the next year, and approximately one in four (24%) were considering leaving the profession in the next five years. EMTs who were 50 years of age or older (odds ratio [OR] 1.78; 95% confidence interval [CI] 1.58–2.01), those who had worked as an EMT ≥ 10 years (OR 1.71; 95% CI 1.12–2.63), and those who were dissatisfied with the profession (OR 2.94; 95% CI 1.84–4.72) were more likely to be considering leaving the profession in the next five years. Among those EMTs who were considering leaving the profession, most indicated that retirement (47%) was the primary reason, while fewer indicated that a career change (16%), personal or family issues (16%), organizational issues (13%), work hours (12%), job stress (11%), or pay/benefits (9%) were a reason for considering leaving the profession. Conclusions. Approximately one in four EMTs in Montana is considering leaving the leaving the profession in the next five years. Effective strategies to address EMT recruitment and retention are needed.     

Survey of Emergency Medical Services Curricula in U.S. Emergency Medicine Residencies

Some areas of EMS instruction are more consistently offered in residency programs than in the past. Formal (structured) preparation for the provision of OLMC has become almost universal, while involvement in quality-related activities and training in the areas of risk management and EMS administration appear to have increased. However, resident involvement in disaster activities has decreased in recent years, and there is still much variability between programs in the extent and scope of EMS teaching. Field experiences still vary widely, for both ground and air services.     

Emergency department care: Cost awareness by health care providers

With the escalation of health care costs during the past decade, it has become increasingly important for the physician to be aware of the cost of various components of health care delivery. The following study was undertaken to ascertain the “cost awareness” of four different groups of health care providers. This was accomplished by having these groups estimate the cost of patient visits to an emergency department. Significant errors were observed in these cost estimations, and error trends were seen to occur that were independent of education and experience.     

The Status of Complementary and Alternative Medicine Education in U.S. Physician Assistant Programs

Background: Many Americans use complementary and alternative medicine (CAM). Medical educators have responded by incorporating CAM education into their curricula. Research has reported on the number and types of CAM therapies included in physician assistant (PA) curricula, but information on the purposes, methods, and practice of CAM education is lacking.

Purpose: This study was designed to identify the content, methods, purpose, and orientation to CAM education in PA curricula.

Methods: An online survey of all accredited physician assistant programs in the United States addressing content, teaching methods, instructor qualifications, and core competencies was administered.

Results: Response rate was 68%: 77% of PA programs included CAM education in their curriculum; 93% stated it was required. The median number of CAM therapies included in the curriculum was 10. Reasons for including CAM were increased use by patients (79%), complementary medicine in the medical literature (66%), and faculty interest or request (62%). For most PA programs, CAM is taught as a component of other courses through lectures and written exams. Core competencies are consistent with recommendations of the PA profession, as well as other professional medical associations.

Conclusions: Most PA programs have incorporated CAM instruction into their curricula. Content is typically limited to those CAM therapies most commonly encountered in medical practice. The means and methods of teaching CAM are largely the same as for traditional medical content. The most common objectives of CAM education are learning to assess for CAM use, educating patients, and recognizing indications and contraindications while respecting patients' health beliefs and choices.     

Geriatric Emergency Medicine and the 2006 Institute of Medicine Reports from the Committee on the Future of Emergency Care in the U.S. Health System

Three recently published Institute of Medicine reports, Hospital-Based Emergency Care: At the Breaking Point, Emergency Medical Services: At the Crossroads, and Emergency Care for Children: Growing Pains, examined the current state of emergency care in the United States. They concluded that the emergency medicine system as a whole is overburdened, underfunded, and highly fragmented. These reports did not specifically discuss the effect the aging population has on emergency care now and in the future and did not discuss special needs of older patients. This report focuses on the emergency care of older patients, with the intent to provide information that will help shape discussions on this issue.