Transcript: Workforce Report Town Hall
Takeaways:
Supply of EPs may exceed demand by 2030, due largely to scope of practice issues with NPs and PAs
Emergency medicine should evolve beyond the four walls of the ED
It’s important to understand the business of emergency medicine in order to thrive and stay valuable
No quick, overnight solutions, but it’s important for everyone to stay engaged and informed
On May 4, 2021, VACEP held a Town Hall with members to discuss the recent ACEP report, Emergency Medicine Physician Workforce: Projections for 2030. The study reflects evidence-based data showing our specialty is facing – for the first time in history – a likely oversupply of emergency physicians in the next decade.
The study says the projected supply — assuming a 2% growth in residents and that 98% of those residents enter emergency medicine, plus a 3% attrition rate for current practicing emergency physicians — would lead to around 59,000 physicians in 2030. And if the demand of visits per physician is constant, along with 20% rate of patients seen by PAs and NPs, then demand for emergency physicians would be 49,600. That leaves a surplus of about 9,400 physicians.
Below, an abridged transcript of the call, along with questions that were asked during it. You can also listen to the full town hall or watch it online. Get involved and find more resources on our Workforce page.
Cameron Olderog, MD, FACEP
Cameron Olderog, VACEP President: There’s a lot of assumptions made in the model. And the other caveat is that a lot of this data is pre-COVID, so we don't know how that's going to affect things. We think that COVID highlighted some of these problems earlier than they might have otherwise been highlighted.
There's really two sides of the solutions — the supply side and the demand side: the supply being the number of physicians coming out of residencies, and the demand being the number of jobs available for emergency physicians.
We’re looking at a lot of combinations of different approaches. There’s not one thing that's going to find all of these numbers to make it where we don't have a surplus.
Bruce Lo, MD, MBA, FACEP
Bruce Lo, VACEP Past President: There’s a lot of assumptions, like any modeling. It really is about if we did absolutely nothing at all as a specialty and what would likely happen. However, the numbers are the numbers, and there's a certain reality that we may face. With a lot of different variables that go into it, any of those variables can change or be different and can really throw off the model. Like any kind of specialty organization, we have to be looking to the future to evolve for emergency medicine, and it may be that the evolution is beyond the four walls of what we're used to.
Todd Parker, MD, FACEP
Todd Parker, VACEP President-Elect: The big challenge is going to be: What role do emergency physicians play in the delivery of healthcare? We know the value that we provide, and we have to continue to show that value. Emergency physicians cannot be complacent. We've been fortunate for a very long time. I don't think it's a grim forecast, either. I think there's a lot of opportunity out there to really grow our specialty and prove the need for what we do. As we do that, we're going to continue to make ourselves indispensable.
There will be some natural movement out of emergency medicine if there is a bit of an oversupply. There will be some physicians that maybe don't love the field as much and just want to move on to other things. What we really want to do is incentivize the young physicians that are moving up and excited about emergency medicine, and continue to grow our specialty. We need to keep them engaged and excited about the specialty. This isn’t the end, this is actually a beginning, and this is a tremendous opportunity. It’s almost impossible that any specialty isn't going to face some hurdle or road bump that they have to move past and over in order to grow. And if we embrace this, then then we can do that as a specialty.
What is being done about the influence of private equity? Why are EM residencies still expanding?
Parker: One of the challenges we face is that restricting one business ownership model from doing something without restricting another business ownership model, when they all meet the criteria, becomes a very tricky situation.
I work for a health system that started a residency. That residency is getting ready to start our second year. It's been a fantastic addition to our program, and our residents are outstanding, and it has nothing to do with private equity or corporate management. It has to do with the fact that we're a busy hospital, and we're an ideal site for resident training. And it's helped us recruit a lot of really good attendings who are academically focused. It’s really just elevating our entire emergency medicine program. So I think that there's been blaming of the private equity groups on the glut of residents. But that's not really the case — that's part of it.
Lo: The American College of Graduate Medical Education (ACGME) is the overlying body responsible for accrediting residences. And within each of the specialties, they have their own residency review committee (there’s one for emergency medicine). And they set the bar in terms of what is approved or not approved, or the minimum requirements to have an emergency medicine residency.
What we have seen is a lot of for-profit health systems form a lot of new residencies across the country. And a lot of the for-profit health systems are staffed by contract management groups, or what people refer to as CMGs. I believe there is a for-profit hospital coming up in Virginia that will start an emergency medicine residency program next year that will be staffed by a CMG. So it's happening in Virginia. The state of Florida has also encouraged and incentivized opening new residency programs as part of their way to combat some of the doctor shortages, not just in emergency medicine, but across various specialties.
There’s definitely a growing number of residencies at for-profit facilities. And there are concerns about that. But it's the ACGME that really sets the bar in terms of approving or not approving and because they are the only accrediting body, they have a monopoly of sorts. Anybody that passes that bar needs to be accredited, otherwise it could be in violation of antitrust laws. And so the question is: Should that bar be raised? And organizations like ACEP will be working with the ACGME in terms of setting what that bar should look like. Raising that bar would potentially slow or stop potential new residency programs from opening.
Parker: At Virginia ACEP, I've never seen one instance where I felt like anyone was bringing a corporate conflict of interest into the decision-making process. One of the challenges is that, if we are going to speak out and try to advocate against rules that would prohibit some of these CMGs from doing certain things, it would be very hard to not impose the same restrictions on the democratic groups in the state. Because they're really both business models of groups of physicians that contract with the hospital and employ their physicians with partners. They really are sort of the same entity.
What I tell people is that, right now, in terms of at least influencing legislation and rules and the practice of emergency medicine in the state of Virginia, from a Virginia ACEP standpoint, [private equity has] very little influence. And for us to go after them would be almost inappropriate, at least based on the way things are right now.
“The healthcare system expects emergency physicians to be able to do it all. And if there’s a problem in the hospital, they come to the ER to solve it. And that will continue. ”
Do you expect emergency medicine to be more competitive for osteopathic physicians?
Lo: It’ll be interesting to see what happens from a med student applicant pool to emergency medicine residencies. One theory from the anesthesia world: Back in the ‘90s, when they were facing essentially a similar situation, a lot of medical students actually chose not to go into anesthesia. Will emergency medicine have a similar type of fate? I think it's to be seen; there's a lot of moving pieces. Obviously, there is chatter on social media among the medical students about the future of emergency medicine as a career. We want to be able to encourage the brightest and the best to still go into emergency medicine. We still need good emergency physicians, regardless of what the workforce report shows.
We want to make sure we're not discouraging any kind of medical students to go into the specialty. And with the number of medical students graduating and the number of residency positions available in the U.S., as well as international medical graduates and osteopathic students and so forth, there will be no shortage of students that want to enter the field. Whether osteopathic students are more likely to enter emergency medicine, time will tell.
What are your thoughts on the impact on emergency physician salaries?
Olderog: When you see supply exceed demand, the idea is that it’s always going to drive down reimbursement and what physicians are being paid. I think the problem is that it’s not always clear cut. The market corrects itself in some ways. Medical students may choose not to go into emergency medicine if it’s not going to be worth their time, and they may choose a different specialty. That is a big concern for early career physicians, particularly.
Lo: It depends on multiple factors. In rural areas, there's still a lack of board-certified emergency physicians and there’s openings for jobs in those areas. Now, that may not be where a lot of people want to work, but there's definitely still a demand that exists for those emergency physicians. It also will depend on your job employment type. So if you work in a private group and you're an owner, you'll have control in terms of how you set the structure and your reimbursement. If you're employed, that may come into effect, especially if you work in a highly desirable location where a lot of people want to work. However, basic economic principles do apply to some extent. It'll be interesting to see what happens in the short, medium, and long term. And what history has told us is that it can be very unpredictable.
Parker: For any physician, it doesn't matter what business model you're working in, I think understanding where and how you get paid, and where that money is going, and how that money is generated is important. And making yourself as economically valuable to your employer or your group is always going to help you out in the long run.
I have conversations with physicians who have an impression that there are gobs of money coming in for provider fees that are being siphoned off by various organizations and emergency physicians are being paid pittances on that. And I can promise you, as a former partner in a group, I will say that that is not the case. The margins are pretty lean. You have to work hard to pay competitive salaries — to not just your employees, but even your partners. And so, understanding the economics of it, understanding the importance of generating revenue through proper charting, and making sure that you're doing the things necessary to sort of “earn your paycheck,” if you will, is important.
Olderog: You look at the business world, and the person who always comes out ahead is the entrepreneur who expands first and gets into new businesses. And so where can we use our unique skill set to really shine? We’re hearing really innovative ideas like getting out into communities and using our skills to solve problems. And that's really where you also can balance some of that income concern. That’s where we can come up with some different opportunities to have a bigger share of healthcare delivery.
How are scope of practice issues, particularly with NPs, impacting the workforce projections?
Olderog: At all levels nationwide and statewide, we've been really pushing to make sure that there is a physician-led delivery model for emergency medicine — really, all medicine. The biggest hurdle we have is that in trying to find data that specifically speaks to quality differences of independent practice, there's just not that much out there. Because we all have the anecdotal evidence that with physician-run care, you're not going to miss those big things, you're not going to order as many tests, you're not going to have as many problems as we see.
Parker: This is a state-level issue. In Virginia, we have fought this battle for a number of years specifically with nurse practitioners who are moving towards independent practice. And we had our line in the sand, which was that nurse practitioners are not a substitute for physicians. And I still remember the day that we were walking into typically very reliable legislators’ offices, and the battle was lost. We quickly had to regroup and realize that nurse practitioners were likely going to get some degree of independent practice. And so we actually changed tactics very quickly, and went towards a more collaborative approach. Because we got a seat at the table very quickly, we were able to put in place some of the most restrictive nurse practitioner independent practice rules in the country… essentially creating an equivalency of a number of years of med school and residency required before you could have independent practice as an NP.
As we’re dealing with these types of issues, legislatively, this is where volunteering and showing up matters — responding to those emails that we send out, action alerts to send letters, and phone calls to state legislators. Just showing up in their offices, telling our stories and having those individual stories of why physician-led teams are so important can stop some of this scope-creep.
“It doesn’t matter what business model you’re working in, I think understanding where and how you get paid, and where that money is going, and how that money is generated is important. And making yourself as economically valuable to your employer or your group is always going to help you out in the long run. ”
Lo: Scope of practice is one of the things that requires all of us, not just a couple people, but everybody to kind of move in unison and speak as a singular voice. It doesn’t take much time to actually get involved. When I first came out to White Coats on Call, I was apprehensive and scared and intimidated about going into legislators’ offices. And what you realize after doing it a couple times, it's actually pretty easy. And legislators actually want to hear from us, the experts. Because I'll tell you, the PA and NP lobbyists, that's what they're doing. They're going full force, and we have to do the same.
What are the next steps for Virginia ACEP, and where should we focus our energy on workforce issues?
Olderog: First, the goal is really to listen and hear ideas. There have been a lot of ideas put out there. There are a lot of innovative emergency medicine docs who figure out how to solve problems every day. And so if we can get someone who thinks up a really unique idea, we might be able to run with that and come up with a couple ideas that work together to solve these problems. None of this is going to be done overnight.
Our priorities in Virginia have been scope of practice issues, and I think that will continue to be our focus. There’s some things we can control at the state level and some things we can’t, like residency approval. We can help our members navigate job openings, help our members understand the business of emergency medicine, help our members connect on ideas on how to expand outside of a traditional emergency department. I think those are roles that we as Virginia ACEP will play.
Lo: The solutions aren't going to be easy, turnkey, overnight solutions, but I think it's about staying engaged. I would encourage everybody to stay educated on the topic as much as possible. At the end of the day, it's incumbent upon all of us to get involved, and to advocate, both for ourselves as well as for the specialty. I want our specialty to continue to thrive in the next 10, 20, 50 years. And what we do now is going to have a huge impact going forward. So if anything, this is just the beginning of this journey, kind of this new era that we're facing.
Olderog: We have amazing jobs that I think the majority of us really enjoy. That is why medical students want to come do what we do. We fix it, right? We solve all the problems. And I think that that really is where we're going to go with this. I don't have as big of a gloom-and-doom as I've seen from some other people. I'm early career. I have 20, 30 years left to do this. There are opportunities to really make sure that we can protect our specialty, make sure that physicians lead care, make sure that we have the best and brightest coming to practice in emergency medicine.
It’s going to be the whole community, the whole family of emergency medicine, coming together to solve these problems. And as all that happens, there's still going to be jobs there. I think there’s a lot to be said for the year we have just gone through. There could be a lot of other factors in the next 10 years that we haven't even foreseen that could affect a lot of the way we practice medicine, a lot of the way that healthcare is delivered.
In general, the healthcare system expects emergency physicians to be able to do it all. And if there's a problem in the hospital, they come to the ER to solve it. And that will continue.
“I was apprehensive and scared and intimidated about going to legislators’ offices. And what you realize after doing it a couple times, it’s actually pretty easy. And legislators actually want to hear from us, the experts. Because I’ll tell you, the PA and NP lobbyists, that’s what they’re doing. They’re going full force, and we have to do the same.”
