Common Sense

The New Threat


Issue: July/August 2021

Author: Andy Mayer, MD FAAEM
Editor-in-Chief, Common Sense

Well another Scientific Assembly has concluded in St. Louis. The very fact that it was held at all was a minor miracle with all of the uncertainties and challenges which COVID presented. The discussion and decisions which had to be made to make this meeting happen were significant, but AAEM held a hybrid in-person and virtual meeting and over 400 emergency physicians gathered in St. Louis for the conference. The speakers, as usual, were excellent and seeing old friends and colleagues in real life instead of on Zoom was very gratifying. Certainly, one felt strange standing in a room with a group of people, sitting in an audience, or shaking the hands of old friends. This was all healing and hopeful of a return to more normal times.

The feeling seemed to be to try and move forward and to get past the pandemic and the fact that we all sort of lost a year or more of our lives. I doubt there were few of us who have not been personally touched by COVID with the illness of ourselves, family, friends, or colleagues. There were many COVID-related discussions and talks. One was a touching panel of three physicians describing their own personal experiences with COVID for different perspectives. One was as a critically ill patient, one related the impact of being a family member of a sick COVID patient, and the third was related to the stress of being a bedside physician. Their stories were all moving. It was good to hear these stories but it was even more fulfilling were talks about issues unrelated to COVID, and those about the challenges which our profession faces.

The mood at the meeting also had a component of anger related to the newest of the serious threats to the profession of emergency medicine. The newest threat is the unprecedented and massive expansion of the number of emergency medicine residencies and residents. AAEM has long spoken out about the dangers of the corporate practice of medicine and the threat of the expansion of the numbers and scope of practice of non-physician practitioners (NPPs) but this newest challenge which must be dealt with and soon. This expansion is now the third pillar of danger to emergency medicine possibly more impactful than corporate management groups (CMGs) or NPPs. You might not think that anger is a positive feeling for a meeting environment, but I think it was in fact very healthy. Typically, when I speak to emergency physicians about the issues facing our profession, there is a sense of frustration and apathy. Anger to the point of actually doing something to positively impact our profession would be much better than sitting idly by as the wolves enter and destroy our profession. 

AAEM has naturally attracted the unsettled soul who is willing to raise their fist and scream, “I’m not going to take it anymore!” The percentage of politically active members in any organization is typically very low, but to me is much higher in AAEM than in other organized medicine groups. It is great to see a member who is impassioned about an issue and see them transform into an expert and leader of an effort to combat one of the issues which face us. Dr. Debbie Fletcher from Louisiana is such a person this past year and has quickly risen to prominence in the fight against the expanding practice rights of NPPs. She was our leader in the fight in Louisiana which just successfully defeated the latest bill to give expand practice rights to nurse practitioners in Louisiana. This type of emergency physician is what attracted me to the organization and has kept me involved for all of these years. Let’s face it; we cannot all be Bob McNamara but there is strength in numbers and activism. The fact is that what any organization needs are dues paying members which can be represented by the more active members. The organization needs the financial and moral support so that the organization’s message can be heard. However, we need more champions and defenders of our specialty specifically to deal with the looming workforce crisis.

The rise of new residencies is an issue which none of us can ignore. This drastic rise in the number of graduating residents could well have a profound negative effect on our specialty and lead to a drastic decrease in the quality of incoming residents. I certainly would never have predicted it. When I left residency in 1990, a residency trained emergency physician was a rare bird and I could have worked anywhere I wanted. I chose an independent democratic group as I had the ability to choose. That ability to choose has already drastically decreased over the years with the expansion of CMGs. There are many areas where they are the only game in town. The expansion of NPPs has led to fewer emergency physicians being utilized to staff America’s emergency departments and with expanding practice rights for NPPs this cost cutting reality will only worsen. One main reason NPPs were proposed to be used in emergency departments was due to the workforce “shortage” so that they could see easier cases and work in rural areas where few residency trained physicians wanted to go. It is a fallacy that many NPPs want to work alone or at night in rural emergency departments.

Dr. Mark Reiter has been one of AAEM’s leaders in learning the hard facts related to the rapid expansion of emergency medicine residencies and what that might mean for all of us. His upcoming article in the Journal of Emergency Medicine is something which you must carefully read and understand. The implications of what is quickly happening must be appreciated and we need to quickly adopt the best options which are available to our profession. I also suggest you look at “The Emergency Medicine Physician Workforce: Projections for 2030” or simply web search the issue and you can quickly understand the problem. A recent YouTube video called “How Can We Save Emergency Medicine” is also worth viewing. The facts related to this issue are shocking and each of you needs to be well informed about it.

Did you know that the number of emergency medicine residencies from 2012 to 2021 have increased from 153 to 276? The number of new first year residents has increased from 1,785 to 2,969. Predictions reveal that there may be an oversupply of up to 40% of new residency graduates by 2030. Imagine the future, if current predictions for 2030 are correct, and what it will mean. Think of the current idealistic and motivated but unsuspecting biology major currently in college. They will work their way through the difficult process of medical education and finish an emergency medicine residency in 2030. These young and ambitious emergency physicians will have an average of $200,000 in debt and discover that no jobs are available. If they are lucky enough to land one what terms do you think the friendly CMG who started their residency will offer them? The expected workforce surplus will lead to abysmal job security, deteriorated practice rights and no ability for any emergency physician to express any concerns or advocate for their patients. Any troublemakers will simply be shown the door and a joyful and desperate emergency physician will be glad to work for less money, worse hours and sign as many NPP charts as needed. Are future emergency physicians predestined to a life of indentured servitude after being created as a pool of cheap labor by CMGs and large hospital systems?

The truth at the newest “enemy at the gates” has been revealed by Dr. Reiter’s research and has led him to conclude that drastic and immediate action is needed to prevent this disaster. His recommendation is simple but painful. He recommends increasing residency standards by requiring a minimum of 3,600 patients at the primary training site per emergency medicine resident. This approach would increase the quality of medical education, as it would allow more clinical and procedural opportunities for each resident. This would produce a 40% reduction in the total number of new residents. It also leaves room for the rational expansion of emergency medicine residency slots as emergency department volumes increase with time. This method will allow for the supply of emergency medicine residents will meets demand. Otherwise, in ten years who would chose to enter an emergency medicine residency? Will we continue to get the best and brightest of each class or are we to be relegated to a different sort of emergency medicine resident? Will emergency medicine be the specialty for physicians who could not match in more desirable types of specialties? Who do you think would voluntarily chose to enter a specialty with such abysmal job opportunities?

The AAEM Board of Directors at the Scientific Assembly has endorsed this painful but needed adjustment to the number of emergency medicine residency positions. Below is the position statement recently released by AAEM. AAEM will certainly be criticized by CMGs and other groups who have a financial interest in producing cheap labor. All interested emergency medicine organizations need to step up and support this initiative. There is no time if we are to save the quality of future emergency medicine residents and their professional futures. Every emergency physician needs to enter this fight. 

References

1. Reiter M, Wen LS, Allen BW. “The Emergency Medicine Workforce: Profile and Projections.” The Journal of Emergency Medicine, vol. 50, issue 4, April 2016, P690-693. https://doi. org/10.1016/j.jemermed.2015.09.022 
2. Reiter M, Allen BW. “The Emergency Medicine Workforce: Shortage Resolving, Future Surplus Expected.” The Journal of Emergency Medicine, vol. 58, issue 2, February 2020, P198-202. https://doi.org/10.1016/j. jemermed.2020.01.004 
3. Reiter M, Allen BW. “The Emergency Medicine Residency Programs - Achieving a Balanced Workforce.” Submitted for publication. Draft available upon request. 
4. EM Physician Workforce of the Future; Taskforce Report Overview. ACEP.org.  
5. Percentage Change in Number of First Year ACGME Residents and Fellows by Specialty—2020 and 2018 report. AAMC and American Medical Association. National GME Census in GME Track® (Aug. 13, 2020)

 

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