FORUM academic emergency medicine
Manpower Needs in Academic Emergency Medicine One of the value statements of the American College of Emergency Physicians states that, "Quality Emergency Medicine is best practiced by qualified, credentialed emergency physicians."1 To address this value ACEP has established the following goal: "The number of board-certified physicians will be sufficient to meet the manpower needs of the public. ''~ It is the position of ACEP that there is currently a severe shortage of appropriately trained and certified emergency physicians and, moreover, that the shortage will continue well into the next century. We discuss how ACEP arrived at this position and the role of academic emergency medicine in addressing this shortage. For m a n y years, there has been a public debate as to whether there is a physician shortage or surplus. The Graduate Medical Education National Advisory Commission report of 1980 estimated that there would be 630,000 US physicians by 1990, with a surplus of 70,000. 2 This report also identified emergency medicine as a shortage specialty, indicating there would be a need for 14,000 emergency physicians in 1990, with a supply of only 8,000. Schwartz included such factors as increased provision of administrative and research activity by physicians and concluded that there would be a shortage of 7,000 physicians by the year 2,000. ,~ [Gallery ME, Allison EJ Jr, Mitchell JM, Williams R: Manpower needs in academic emergency medicine. Ann Emerg Med July 1990;19: 797-801.]
Michael E Gallery, PhD* Dallas, Texas E Jackson Allison, Jr, MD, MPH, FACEPt Joyce M Mitchell, MD, FACEPt Greenville, North Carolina Robert Williams, MD, FACEP¢ Ann Arbor, Michigan From the American College of Emergency Physicians, Dallas, Texas;* Department of Emergency Medicine, East Carolina University School of Medicine, Greenville, North Carolina;l and the Horace H Rockham School of Graduate Studies, University of Michigan, Ann Arbor.:~ Received for publication April 16, 1990. Accepted for publication April 23, 1990. Address for reprints: Michael E Gallery, PhD, American College of Emergency Physicians, PO Box 619911, Dallas, Texas 75261-9911.
INTRODUCTION The 1980 Graduate Medical Education National Advisory Commission (GMENAC) report reflected the perceptions of a specialty that was still in infancy; in fact, it had only been formally recognized as a specialty for one year. As recently as 20 years ago, emergency medicine was not yet a truly defined specialty. All emergency "rooms" were staffed by a variety of personnel. Advertising "a physician on duty 24 hours" often meant that a resident or a physician from another specialty was moonlighting in the emergency "room." Sometimes the bulk of patient care was provided by poorly supervised nonphysician practitioners, or occasionally, even a senior medical student with physician backup by telephone. At some facilities emergency "room" responsibilities were rotated among the medical staff with hospital privileges. Staffing responsibilities fell to all specialties - one would just as likely receive emergency care from a family physician as a pathologist. As can be deduced, the background and skill of the then "emergency room physician" staff varied dramatically from day to day. The specialty of emergency medicine evolved as public demand for better care grew. As the patient population became more medically aware and educated, it became necessary for those practicing emergency medicine to respond to their patients' questions and expectations. Twenty-one years ago, the American College of Emergency Physicians was formed by a group of physicians interested in promoting quality emergency care. Since then, standards for graduate training have been developed and promulgated, the number of graduate training programs has increased to more than 83, a certifying examination has been developed, and the specialty achieved primary board status in 1989. The demands for emergency services and the requirements for fulfilling those demands are very different in 1990 than they were 20 years ago o r
19:7 Juty 1990
Annals of Emergency Medicine
797/107
MANPOWER NEEDS Gallery et al
even a brief ten years ago when the G M E N A C report was c o m p l e t e d . What, then, is the present status of the supply of and the demand for emergency physicians?
THE PRESENT Supply It is difficult to accurately predict the number of individuals who currently staff emergency departments. Many physicians practice part-time, and others have recently.entered the practice of emergency medicine from other fields. The American Medical Association states in its Physician
Supply and Utilization by Specialty: Trends and Projections that in 1985 there were 12,000 self-declared emergency physicians. 4 During that same year, ACEP had a m e m b e r s h i p of 11,124. In cross-matching these two lists, it was discovered that there were 6,345 names that did not appear on both lists, providing evidence that there were at least 17,469 emergency physicians in 1985. A more accurate projection, however, may be developed from the total number of EDs and current staffing patterns. According to American Hospital Association (AHA) hospital statistics, there were a projected 5,600 hospitals in the United States with EDs in 1988. 5 A recent ACEP study of staffing patterns in EDs indicated that the mean number of full-time equivalents per ED was 4.7. 6 This statistic takes into account EDs that have no full-time coverage and those that have double and triple coverage. Based on these two numbers, there is a need for as many as 26,320 fulltime equivalents in emergency medicine. It is important to distinguish the number of full-time equivalents from the number of physicians needed. As p r e v i o u s l y discussed, there are a number of individuals who practice emergency medicine on a part-time basis. Therefore, the actual number who practice as emergency physicians may exceed 26,320. However, based on the number of hospitals and staffing patterns it is safe to project that a minimum of 26,320 full-time equivalent positions exist or that at least 26,320 i n d i v i d u a l s practice emergency medicine. Not all of these physicians are or will be able to see patients: m a n y e m e r g e n c y physicians, particularly those who are board certified, are involved in ad108/798
ministration of departments, emergency physician groups, emergency medical services, poison control centers, and teaching. Based on data ACEP has collected over an eightyear period from a variety of surveys, the College projects that at least 25% of the emergency physician population engages in nonclinical responsibilities (Figure).
Demand According to Marder et al, "previous studies of future supply and requirements fit into two general categories depending upon the strategy used to project the requirements. These categories are needs-based studies, the best known in the 1980 report of the Graduate Medical Education National Advisory Committee { G M E N A C ) and d e m a n d - b a s e d studies, such as that of the Bureau of Health Professions. ''4 As the authors point out, the needs-based model develops projections based on what a panel of experts believe will be required given a certain assumption about pathology and epidemiology as well as what would be required from a professional standpoint to meet health-care needs. For example, the G M E N A C s t u d y c o n s i d e r e d the number of migraine headaches that would occur among a population and the number of those individuals who would need to be seen by a neurologist. A major limitation of this model is that such needs assessments are highly subjective and difficult to verify. Will those, for instance, who suffer from migraine headaches actually seek out the care of a neurologist? The demand-based model attempts to project future resource requirements based on current use. This model can be limited by the degree to which one considers alternative delivery systems or changes in demand patterns. Consider, for example, if one were living in 1950 and attempting to project the number of persons needed to deliver milk in 1970. If one simply looked at utilization in 1950 and projected it out to 1970 without considering the influence on demand for home delivery placed by the g r o w t h of supermarkets, one would indeed come to an erroneous projection. A n o t h e r problem with demand-based models is that they neglect certain segments of the population that have unmet needs, eg, the poor and the uninAnnals of Emergency Medicine
sured. N o n e t h e l e s s , the d e m a n d based model provides a more accurate, albeit limited, prediction of the future. A review of utilization trends is an i m p o r t a n t e l e m e n t in a d e m a n d based model for projecting manpower needs. With regard to use of the ED, the AHA reported 86,641,305 visits in 1988 (a 3.7% increase from 1987).5 These data are based on actual presentations to the EDs. During a 15year period from 1973 to 1988, the AHA reported that the number of ED v i s i t s grew by 31.6% (from 65,858,734 to 86,641,305). During that period, an annual decline in ED visits was experienced only three times; two of those years (1982 and 1983) were associated with a severe national recession. In the period from 1983 to 1988, the frequency of ED visits grew by 11.8%. 7
THE PROBLEM Future Supply Versus Future Demand As previously indicated, ACEP has taken a position that every patient has a right to be seen by an appropriately trained and appropriately credentialed emergency physician. The current supply of such individuals is limited and, as demonstrated below, the u n d e r s u p p l y m a y get larger. Currently, there are 8,764 emergency physicians certified by the American Board of Emergency Medicine (ABEM). ABEM certification has been available through two modes of eligibility: the practice track and residency training in emergency medicine. In the practice track mode, the physician is eligible to sit for the emergency medicine board examination by completing 7,000 hours and 60 months of practice in emergency medicine, with 24 m o n t h s of cont i n u i n g f u l l - t i m e p r a c t i c e out of those 60 months. As of June 30, 1988, any physician who had not completed the practice requirements had to complete an approved residency in emergency medicine to be eligible to take the board examination. The eventual discontinuation of the practice-eligible route was part of the original application of ABEM to the A m e r i c a n Board of Medical Specialties. The second avenue to eligibility to sit for the emergency medicine board examination is to complete a Resi19:7 July 1990
Physician Specialty Supply 1980, 85 - 87 Active Society Members US Practicing Physicians Certified
• Active Nonsociety Members US Practicing Physicians
Noncertified
Certified
Active Total US Practicing Physicians
Noncertified
Certified
Noncertified
1980
0
10,203
248
2,230
248
1 2 ,4 3 3
1985
1,493
11,187
2,853
3,21 6
4,346
14,403
1986
2,158
11,191
3, 969
3,220
6,1 27
1 4,41 1
1987
2,801
11,400
5,371
3,430
8,1 72
14,830
Estimates of Physician Specialty Supply 1 9 8 7 Active Specialty Supply at Start of Year 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2008 2006 2007 2008 2009 2010
23,000 22,727 22,462 22,206 21,976 21,753 21,537 21,347 21,162 20,983 20,839 20,699 20,563 20,450 20,341 20,264 20,190 20,127 20,067 20,008 19,961 19,915 19,870 19,827
Annual Residency Program Output 430 430 430 450 450 450 470 470 470 500 500 500 520 520 550 550 560 560 560 570 570 570 570 570
FIGURE. Physician specialty supply,
1980, 1985, 1986, 1987; and estimates of physician specialty supply, 1987-2010. dency Review C o m m i t t e e (RRC)approved residency. Currently there are 83 emergency medicine training programs producing approximately 550 graduates per year. (Several of the 83 programs are newly approved and are not currently producing gradu19:7 July 1990
Annual Alien Specialist Immigration Not Available
Preliminary Adjusted Supply Total 23,430 23,157 22,892 22,656 22,426 22,203 22,007 21,817 21,632 21,483 21,339 21,199 21,083 20,970 20,891 20,814 20,750 20,687 20,627 20,578 20,531 20,485 20,440 20,397
Estimated Annual Attrition, Deaths & Retirement 703 695 687 680 673 686 660 655 649 645 640 636 632 629 627 624 622 621 619 617 616 615 613 612
ates.) As seen in the Table, the ratio of r e s i d e n c y slots for e m e r g e n c y medicine to the number of applications has changed little from 1985 to the present. Although the potential to produce more graduates exists, there is an insufficient number of slots. At present, the only way to become board certified (assuming one has not already been credentialed to take the examination through the Annals of Emergency Medicine
2010
Net Year-end Supply Specialists
Total No. Residents in Clinical Training in Specialty
Estimated Physiciansin Nonclinical Administrative Medicine
22,727 22,462 22,206 21,976 21,753 21,537 21,347 21,162 20,983 20,839 20,699 20,563 20,450 20,341 20,264 20,190 20,127 20,067 20,008 19,961 19,915 19,870 19,827 19,785
1,290 1,290 1,290 1,350 1,35o 1,350 1,410 1,410 1,410 1,500 1,500 1,500 1,560 1,560 1,650 1,650 1,680 1,680 1,680 1,710 1,710 1,710 1,710 1,710
5,682 5,616 5,551 5,494 5,438 5,384 5,337 5,291 5,246 5,210 5,175 5,141 5,113 5,085 5,066 5,047 5,o32 5,017 5,002 4,99o 4,979 4,968 4,957 4,946
"practice-eligible track," which ended in 1988) is to complete an approved residency in emergency medicine. Therefore, the only current way to increase the number of board-certified emergency physicians is to increase output from residency training programs. These increases are largely inhibited by economic factors. In a competitive market, equilibrium between supply and demand is achieved when the value placed on 799/109
MANPOWER NEEDS Gallery et al
the good or service is equal to the resources used in its production. A market not in balance can represent either a long- or short-term problem, and stabilization of the market can o c c u r through a variety of clearing mechanisms. For example, a shortage of emergency physicians could lead to increased prices and escalating physician salaries. The higher salary base would attract greater numbers of physicians to the field of emergency medicine and relieve the shortage. Alternatively, queueing mechanisms could lead to market equilibration. In the event of excessive waiting times in hospital EDs, patients might seek such other sources of treatment as walk-in or after-hours clinics. There are two basic mechanisms of economic shortage with respect to h e a l t h - c a r e m a n p o w e r . First, the quantity demanded of a particular health-care profession exceeds the quality supplied at a given market price. Second, a shortage can occur when there is some restriction in the supply of professionals, such as educational or licensing barriers, s Significant increases in emergency physician incomes, high demand for emergency medicine residency positions, and an increasing number of board-certified emergency physicians suggest a dynamic shortage situation for emergency physicians. With an unrestricted supply of board-certified emergency physicians it would be predicted, from an economic theory, that an equilibrium situation would occur with relative stabilization of emergency physicians' supply and incomes. A s s u m i n g no barriers, the rate of return on emergency medicine education would be such that the number of individuals entering the field would be equal to the demand for such services. How does such a shortage affect the supply of faculty for residency training programs ? In a shortage situation, the rate of return on professional education continues to be high. Wages for e m e r g e n c y physicians would increase, and the supply of new board-certified emergency p h y s i c i a n s w o u l d be r e s t r i c t e d . Those physicians with coveted board-certification status would be highly sought after and well compensated, and c o m p e t i t i o n for emergency medicine residency positions w o u l d c o n t i n u e at a high level. 110/800
TABLE. Emergency medicine residency data
-
-
supply and demand ,for
emergency medicine residency slots* Data
1983
1984
1985
1986
1987
1988
1989
1990
No. of level positions offered 190 409 432 449 424 367 472 562 No. of applicants to residency positions 1,487 2,514 2,710 3,256 3,770 3,424 3,445 4,087 No. of positions filled 189 393 424 439 424 360 412 504 *National Resident Matching Program.
Given that there is a great demand for board-certified emergency physicians in the private practice sector, there is little economic incentive for board-certified emergency physicians to enter the academic world. Thus, it becomes very difficult to develop new residency training programs. In fact, over the past three years, medical center applicants that have had accreditation withheld by the RRC/ Emergency Medicine have consistently been cited as being deficient in having an adequate number of appropriately trained and qualified faculty. 9 Thus, emergency medicine is in a classic "Catch 22." There is an insufficient number of residency-trained emergency physicians. The solution would be to produce more emergency medicine residency graduates, but there is an insufficient number of qualified f a c u l t y to produce the needed n u m b e r of residents. The shortage continues to increase. The problem is made worse when one considers attrition rates. The AHA predicts that the average annual attrition rate of physicians is roughly 2% to 3%. Based on the notion that there are currently 26,300 emergency physician full-time equivalents, an attrition of 2.5% would result in a loss of 658 full-time equivalents each year. It is highly unlikely, however, that this attrition rate of 2.5% can be extrapolated accurately to emergency medicine. There are many reasons to believe that it does not. Emergency medicine is a physically demanding specialty that requires long working hours of great intensity. Emergency physicians are constantly facing critical decisions under a great deal of pressure, sometimes w i t h o u t the benefit of complete information about any given Annals of Emergency Medicine
patient. Because emergency physicians c o n s t a n t l y work different shifts, their circadian r h y t h m s are constantly disrupted. The demands of around-the-clock practice make a shorter practice lifetime reasonable to assume and, therefore, a higher attrition rate in emergency medicine is most probable. Given that there are currently only 500 residency graduates per year, this level of output is not sufficient to keep up with current rates of attrition. One might argue that the shortage will be reduced by physicians from other specialties; however, that is the crux of the problem. ACEP has gone on record as saying that the shortage should be made up by appropriatdy trained and appropriately qualified physicians, that is, those residency trained and board certified in emergency medicine. Indeed, were there shortages in other specialties, such as surgery, few would argue that the shortage should be made up from physicians in another specialty, such as internal medicine. This argument is no more acceptable to the specialty of emergency medicine.
PREDICTIONS FOR THE FUTURE The n u m b e r of b o a r d - c e r t i f i e d emergency physicians has increased dramatically since 1980 (Table). However, one cannot use these numbers to predict for the year 2000 because board certification was a new entity in 1980. Looking at residency programs output, attrition, and nonclinical full-time equivalents, the trends from 1987 to 2010 show a decline in the number of emergency physicians. One can predict that there will be even be fewer emergency physicians to m e e t an increasing d e m a n d in 2000. Demand may also increase be19:7 July 1990
cause of such other factors as access to health care of medically underinsured patients and persons with AIDS. Such patients have limited access to other forms of care and may add to the n u m b e r of ED visits. Indeed, the overcrowding s i t u a t i o n is b e c o m i n g a l a r m i n g l y pervasive and is reported across the country. E m e r g e n c y m e d i c i n e is a recogn i z e d specialty. As w i t h other spec i a l t i e s , e m e r g e n c y m e d i c i n e requires appropriate residency training to adequately develop the skills and knowledge necessary to practice effectively. S o l u t i o n s m u s t focus o n ways to expand and promote quality graduate medical education as a remedy for the current and future shortage of duly qualified emergency physicians. G i v e n that c u r r e n t product i o n of the r e s i d e n c y graduates is woefully inadequate, a t t e n t i o n m u s t be placed on exploring ways to increase the a m o u n t of residency training funds for existing residency training programs and for the creation of n e w programs. In an era of cost cont a i n m e n t , at both federal and local levels, i n c r e a s e d f u n d i n g for resi-
19:7 July 1990
d e n c y t r a i n i n g slots in e m e r g e n c y medicine will be a difficult task. Medical students should c o n t i n u e to be apprised of e m e r g e n c y medicine as a viable career choice. Active efforts should be u n d e r t a k e n to support the development of n e w residencies by m e a n s of faculty and program development. Alternative creative sources of f u n d i n g r e s i d e n c y positions should be identified and promoted. What are the implications of these c o n c l u s i o n s r e l a t i v e to m a n p o w e r needs of academic emergency medicine? Clearly, s t r a t e g i e s m u s t be identified for increasing the n u m b e r of faculty. A t t e n t i o n m u s t focus o n ways to make academia more attractive to b o a r d - c e r t i f i e d e m e r g e n c y physicians. Such strategies might include the offering of f i n a n c i a l a n d other incentives. U n l e s s and u n t i l the p r o b l e m of a d e q u a t e f a c u l t y is addressed, t h e problem of an inadequate n u m b e r of residency training positions will cont i n u e to be an i m p o r t a n t negative issue for a c a d e m i c e m e r g e n c y m e d i cine.
Annals of Emergency Medicine
REFERENCES
1. Long Range Plan, 1988 89. Dallas, American College of EmergencyPhysicians, 1988.
2. Summary Report of the Graduate Medical Education National Advisory Committee to the Secretary, Department of Health and Human Services. Vol I. Washington,DC, DHSS Publica-
tions, 1980, {HRA)81-651. 3. Schwartz WB, Newhouse JP, Bennet BW, et al: The changing geographic distribution of board-certified physicians. N E1~g] J Med 1980; 303:1032-1038. 4. Marder WD, Keltke PR, Silberger AB, et al: Physician Supply and Utilization by Specialty: Trends and Projections. Chicago, American
Medical Association, 1988. 5. Hospital Statistics. 1988 Edition. Chicago, American Hospital Association, 1988. 6. Staffing Patterns of Emergency Departments
(unpublished manuscript). Dallas, American College of EmergencyPhysicians, 1989. 7. Hospital Statistics. Chicago, American Hospital Assc~ciation,1973-1988 editions.
8. FeldsteinPJ: Health Care Economics, Edition 3. New York, John Wiley & Sons, 1988, p 350-351. 9. Analysis of deficiencies cited by the Residency Review Committee for EmergencyMedicine (Unpublishedmemo to the RRC/EM). February 1989.
801/111
Manpower Needs in Academic Emergency Medicine One of the value statements of the American College of Emergency Physicians states that, "Quality Emergency Medicine is best practiced by qualified, credentialed emergency physicians."1 To address this value ACEP has established the following goal: "The number of board-certified physicians will be sufficient to meet the manpower needs of the public. ''~ It is the position of ACEP that there is currently a severe shortage of appropriately trained and certified emergency physicians and, moreover, that the shortage will continue well into the next century. We discuss how ACEP arrived at this position and the role of academic emergency medicine in addressing this shortage. For m a n y years, there has been a public debate as to whether there is a physician shortage or surplus. The Graduate Medical Education National Advisory Commission report of 1980 estimated that there would be 630,000 US physicians by 1990, with a surplus of 70,000. 2 This report also identified emergency medicine as a shortage specialty, indicating there would be a need for 14,000 emergency physicians in 1990, with a supply of only 8,000. Schwartz included such factors as increased provision of administrative and research activity by physicians and concluded that there would be a shortage of 7,000 physicians by the year 2,000. ,~ [Gallery ME, Allison EJ Jr, Mitchell JM, Williams R: Manpower needs in academic emergency medicine. Ann Emerg Med July 1990;19: 797-801.]
Michael E Gallery, PhD* Dallas, Texas E Jackson Allison, Jr, MD, MPH, FACEPt Joyce M Mitchell, MD, FACEPt Greenville, North Carolina Robert Williams, MD, FACEP¢ Ann Arbor, Michigan From the American College of Emergency Physicians, Dallas, Texas;* Department of Emergency Medicine, East Carolina University School of Medicine, Greenville, North Carolina;l and the Horace H Rockham School of Graduate Studies, University of Michigan, Ann Arbor.:~ Received for publication April 16, 1990. Accepted for publication April 23, 1990. Address for reprints: Michael E Gallery, PhD, American College of Emergency Physicians, PO Box 619911, Dallas, Texas 75261-9911.
INTRODUCTION The 1980 Graduate Medical Education National Advisory Commission (GMENAC) report reflected the perceptions of a specialty that was still in infancy; in fact, it had only been formally recognized as a specialty for one year. As recently as 20 years ago, emergency medicine was not yet a truly defined specialty. All emergency "rooms" were staffed by a variety of personnel. Advertising "a physician on duty 24 hours" often meant that a resident or a physician from another specialty was moonlighting in the emergency "room." Sometimes the bulk of patient care was provided by poorly supervised nonphysician practitioners, or occasionally, even a senior medical student with physician backup by telephone. At some facilities emergency "room" responsibilities were rotated among the medical staff with hospital privileges. Staffing responsibilities fell to all specialties - one would just as likely receive emergency care from a family physician as a pathologist. As can be deduced, the background and skill of the then "emergency room physician" staff varied dramatically from day to day. The specialty of emergency medicine evolved as public demand for better care grew. As the patient population became more medically aware and educated, it became necessary for those practicing emergency medicine to respond to their patients' questions and expectations. Twenty-one years ago, the American College of Emergency Physicians was formed by a group of physicians interested in promoting quality emergency care. Since then, standards for graduate training have been developed and promulgated, the number of graduate training programs has increased to more than 83, a certifying examination has been developed, and the specialty achieved primary board status in 1989. The demands for emergency services and the requirements for fulfilling those demands are very different in 1990 than they were 20 years ago o r
19:7 Juty 1990
Annals of Emergency Medicine
797/107
MANPOWER NEEDS Gallery et al
even a brief ten years ago when the G M E N A C report was c o m p l e t e d . What, then, is the present status of the supply of and the demand for emergency physicians?
THE PRESENT Supply It is difficult to accurately predict the number of individuals who currently staff emergency departments. Many physicians practice part-time, and others have recently.entered the practice of emergency medicine from other fields. The American Medical Association states in its Physician
Supply and Utilization by Specialty: Trends and Projections that in 1985 there were 12,000 self-declared emergency physicians. 4 During that same year, ACEP had a m e m b e r s h i p of 11,124. In cross-matching these two lists, it was discovered that there were 6,345 names that did not appear on both lists, providing evidence that there were at least 17,469 emergency physicians in 1985. A more accurate projection, however, may be developed from the total number of EDs and current staffing patterns. According to American Hospital Association (AHA) hospital statistics, there were a projected 5,600 hospitals in the United States with EDs in 1988. 5 A recent ACEP study of staffing patterns in EDs indicated that the mean number of full-time equivalents per ED was 4.7. 6 This statistic takes into account EDs that have no full-time coverage and those that have double and triple coverage. Based on these two numbers, there is a need for as many as 26,320 fulltime equivalents in emergency medicine. It is important to distinguish the number of full-time equivalents from the number of physicians needed. As p r e v i o u s l y discussed, there are a number of individuals who practice emergency medicine on a part-time basis. Therefore, the actual number who practice as emergency physicians may exceed 26,320. However, based on the number of hospitals and staffing patterns it is safe to project that a minimum of 26,320 full-time equivalent positions exist or that at least 26,320 i n d i v i d u a l s practice emergency medicine. Not all of these physicians are or will be able to see patients: m a n y e m e r g e n c y physicians, particularly those who are board certified, are involved in ad108/798
ministration of departments, emergency physician groups, emergency medical services, poison control centers, and teaching. Based on data ACEP has collected over an eightyear period from a variety of surveys, the College projects that at least 25% of the emergency physician population engages in nonclinical responsibilities (Figure).
Demand According to Marder et al, "previous studies of future supply and requirements fit into two general categories depending upon the strategy used to project the requirements. These categories are needs-based studies, the best known in the 1980 report of the Graduate Medical Education National Advisory Committee { G M E N A C ) and d e m a n d - b a s e d studies, such as that of the Bureau of Health Professions. ''4 As the authors point out, the needs-based model develops projections based on what a panel of experts believe will be required given a certain assumption about pathology and epidemiology as well as what would be required from a professional standpoint to meet health-care needs. For example, the G M E N A C s t u d y c o n s i d e r e d the number of migraine headaches that would occur among a population and the number of those individuals who would need to be seen by a neurologist. A major limitation of this model is that such needs assessments are highly subjective and difficult to verify. Will those, for instance, who suffer from migraine headaches actually seek out the care of a neurologist? The demand-based model attempts to project future resource requirements based on current use. This model can be limited by the degree to which one considers alternative delivery systems or changes in demand patterns. Consider, for example, if one were living in 1950 and attempting to project the number of persons needed to deliver milk in 1970. If one simply looked at utilization in 1950 and projected it out to 1970 without considering the influence on demand for home delivery placed by the g r o w t h of supermarkets, one would indeed come to an erroneous projection. A n o t h e r problem with demand-based models is that they neglect certain segments of the population that have unmet needs, eg, the poor and the uninAnnals of Emergency Medicine
sured. N o n e t h e l e s s , the d e m a n d based model provides a more accurate, albeit limited, prediction of the future. A review of utilization trends is an i m p o r t a n t e l e m e n t in a d e m a n d based model for projecting manpower needs. With regard to use of the ED, the AHA reported 86,641,305 visits in 1988 (a 3.7% increase from 1987).5 These data are based on actual presentations to the EDs. During a 15year period from 1973 to 1988, the AHA reported that the number of ED v i s i t s grew by 31.6% (from 65,858,734 to 86,641,305). During that period, an annual decline in ED visits was experienced only three times; two of those years (1982 and 1983) were associated with a severe national recession. In the period from 1983 to 1988, the frequency of ED visits grew by 11.8%. 7
THE PROBLEM Future Supply Versus Future Demand As previously indicated, ACEP has taken a position that every patient has a right to be seen by an appropriately trained and appropriately credentialed emergency physician. The current supply of such individuals is limited and, as demonstrated below, the u n d e r s u p p l y m a y get larger. Currently, there are 8,764 emergency physicians certified by the American Board of Emergency Medicine (ABEM). ABEM certification has been available through two modes of eligibility: the practice track and residency training in emergency medicine. In the practice track mode, the physician is eligible to sit for the emergency medicine board examination by completing 7,000 hours and 60 months of practice in emergency medicine, with 24 m o n t h s of cont i n u i n g f u l l - t i m e p r a c t i c e out of those 60 months. As of June 30, 1988, any physician who had not completed the practice requirements had to complete an approved residency in emergency medicine to be eligible to take the board examination. The eventual discontinuation of the practice-eligible route was part of the original application of ABEM to the A m e r i c a n Board of Medical Specialties. The second avenue to eligibility to sit for the emergency medicine board examination is to complete a Resi19:7 July 1990
Physician Specialty Supply 1980, 85 - 87 Active Society Members US Practicing Physicians Certified
• Active Nonsociety Members US Practicing Physicians
Noncertified
Certified
Active Total US Practicing Physicians
Noncertified
Certified
Noncertified
1980
0
10,203
248
2,230
248
1 2 ,4 3 3
1985
1,493
11,187
2,853
3,21 6
4,346
14,403
1986
2,158
11,191
3, 969
3,220
6,1 27
1 4,41 1
1987
2,801
11,400
5,371
3,430
8,1 72
14,830
Estimates of Physician Specialty Supply 1 9 8 7 Active Specialty Supply at Start of Year 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2008 2006 2007 2008 2009 2010
23,000 22,727 22,462 22,206 21,976 21,753 21,537 21,347 21,162 20,983 20,839 20,699 20,563 20,450 20,341 20,264 20,190 20,127 20,067 20,008 19,961 19,915 19,870 19,827
Annual Residency Program Output 430 430 430 450 450 450 470 470 470 500 500 500 520 520 550 550 560 560 560 570 570 570 570 570
FIGURE. Physician specialty supply,
1980, 1985, 1986, 1987; and estimates of physician specialty supply, 1987-2010. dency Review C o m m i t t e e (RRC)approved residency. Currently there are 83 emergency medicine training programs producing approximately 550 graduates per year. (Several of the 83 programs are newly approved and are not currently producing gradu19:7 July 1990
Annual Alien Specialist Immigration Not Available
Preliminary Adjusted Supply Total 23,430 23,157 22,892 22,656 22,426 22,203 22,007 21,817 21,632 21,483 21,339 21,199 21,083 20,970 20,891 20,814 20,750 20,687 20,627 20,578 20,531 20,485 20,440 20,397
Estimated Annual Attrition, Deaths & Retirement 703 695 687 680 673 686 660 655 649 645 640 636 632 629 627 624 622 621 619 617 616 615 613 612
ates.) As seen in the Table, the ratio of r e s i d e n c y slots for e m e r g e n c y medicine to the number of applications has changed little from 1985 to the present. Although the potential to produce more graduates exists, there is an insufficient number of slots. At present, the only way to become board certified (assuming one has not already been credentialed to take the examination through the Annals of Emergency Medicine
2010
Net Year-end Supply Specialists
Total No. Residents in Clinical Training in Specialty
Estimated Physiciansin Nonclinical Administrative Medicine
22,727 22,462 22,206 21,976 21,753 21,537 21,347 21,162 20,983 20,839 20,699 20,563 20,450 20,341 20,264 20,190 20,127 20,067 20,008 19,961 19,915 19,870 19,827 19,785
1,290 1,290 1,290 1,350 1,35o 1,350 1,410 1,410 1,410 1,500 1,500 1,500 1,560 1,560 1,650 1,650 1,680 1,680 1,680 1,710 1,710 1,710 1,710 1,710
5,682 5,616 5,551 5,494 5,438 5,384 5,337 5,291 5,246 5,210 5,175 5,141 5,113 5,085 5,066 5,047 5,o32 5,017 5,002 4,99o 4,979 4,968 4,957 4,946
"practice-eligible track," which ended in 1988) is to complete an approved residency in emergency medicine. Therefore, the only current way to increase the number of board-certified emergency physicians is to increase output from residency training programs. These increases are largely inhibited by economic factors. In a competitive market, equilibrium between supply and demand is achieved when the value placed on 799/109
MANPOWER NEEDS Gallery et al
the good or service is equal to the resources used in its production. A market not in balance can represent either a long- or short-term problem, and stabilization of the market can o c c u r through a variety of clearing mechanisms. For example, a shortage of emergency physicians could lead to increased prices and escalating physician salaries. The higher salary base would attract greater numbers of physicians to the field of emergency medicine and relieve the shortage. Alternatively, queueing mechanisms could lead to market equilibration. In the event of excessive waiting times in hospital EDs, patients might seek such other sources of treatment as walk-in or after-hours clinics. There are two basic mechanisms of economic shortage with respect to h e a l t h - c a r e m a n p o w e r . First, the quantity demanded of a particular health-care profession exceeds the quality supplied at a given market price. Second, a shortage can occur when there is some restriction in the supply of professionals, such as educational or licensing barriers, s Significant increases in emergency physician incomes, high demand for emergency medicine residency positions, and an increasing number of board-certified emergency physicians suggest a dynamic shortage situation for emergency physicians. With an unrestricted supply of board-certified emergency physicians it would be predicted, from an economic theory, that an equilibrium situation would occur with relative stabilization of emergency physicians' supply and incomes. A s s u m i n g no barriers, the rate of return on emergency medicine education would be such that the number of individuals entering the field would be equal to the demand for such services. How does such a shortage affect the supply of faculty for residency training programs ? In a shortage situation, the rate of return on professional education continues to be high. Wages for e m e r g e n c y physicians would increase, and the supply of new board-certified emergency p h y s i c i a n s w o u l d be r e s t r i c t e d . Those physicians with coveted board-certification status would be highly sought after and well compensated, and c o m p e t i t i o n for emergency medicine residency positions w o u l d c o n t i n u e at a high level. 110/800
TABLE. Emergency medicine residency data
-
-
supply and demand ,for
emergency medicine residency slots* Data
1983
1984
1985
1986
1987
1988
1989
1990
No. of level positions offered 190 409 432 449 424 367 472 562 No. of applicants to residency positions 1,487 2,514 2,710 3,256 3,770 3,424 3,445 4,087 No. of positions filled 189 393 424 439 424 360 412 504 *National Resident Matching Program.
Given that there is a great demand for board-certified emergency physicians in the private practice sector, there is little economic incentive for board-certified emergency physicians to enter the academic world. Thus, it becomes very difficult to develop new residency training programs. In fact, over the past three years, medical center applicants that have had accreditation withheld by the RRC/ Emergency Medicine have consistently been cited as being deficient in having an adequate number of appropriately trained and qualified faculty. 9 Thus, emergency medicine is in a classic "Catch 22." There is an insufficient number of residency-trained emergency physicians. The solution would be to produce more emergency medicine residency graduates, but there is an insufficient number of qualified f a c u l t y to produce the needed n u m b e r of residents. The shortage continues to increase. The problem is made worse when one considers attrition rates. The AHA predicts that the average annual attrition rate of physicians is roughly 2% to 3%. Based on the notion that there are currently 26,300 emergency physician full-time equivalents, an attrition of 2.5% would result in a loss of 658 full-time equivalents each year. It is highly unlikely, however, that this attrition rate of 2.5% can be extrapolated accurately to emergency medicine. There are many reasons to believe that it does not. Emergency medicine is a physically demanding specialty that requires long working hours of great intensity. Emergency physicians are constantly facing critical decisions under a great deal of pressure, sometimes w i t h o u t the benefit of complete information about any given Annals of Emergency Medicine
patient. Because emergency physicians c o n s t a n t l y work different shifts, their circadian r h y t h m s are constantly disrupted. The demands of around-the-clock practice make a shorter practice lifetime reasonable to assume and, therefore, a higher attrition rate in emergency medicine is most probable. Given that there are currently only 500 residency graduates per year, this level of output is not sufficient to keep up with current rates of attrition. One might argue that the shortage will be reduced by physicians from other specialties; however, that is the crux of the problem. ACEP has gone on record as saying that the shortage should be made up by appropriatdy trained and appropriately qualified physicians, that is, those residency trained and board certified in emergency medicine. Indeed, were there shortages in other specialties, such as surgery, few would argue that the shortage should be made up from physicians in another specialty, such as internal medicine. This argument is no more acceptable to the specialty of emergency medicine.
PREDICTIONS FOR THE FUTURE The n u m b e r of b o a r d - c e r t i f i e d emergency physicians has increased dramatically since 1980 (Table). However, one cannot use these numbers to predict for the year 2000 because board certification was a new entity in 1980. Looking at residency programs output, attrition, and nonclinical full-time equivalents, the trends from 1987 to 2010 show a decline in the number of emergency physicians. One can predict that there will be even be fewer emergency physicians to m e e t an increasing d e m a n d in 2000. Demand may also increase be19:7 July 1990
cause of such other factors as access to health care of medically underinsured patients and persons with AIDS. Such patients have limited access to other forms of care and may add to the n u m b e r of ED visits. Indeed, the overcrowding s i t u a t i o n is b e c o m i n g a l a r m i n g l y pervasive and is reported across the country. E m e r g e n c y m e d i c i n e is a recogn i z e d specialty. As w i t h other spec i a l t i e s , e m e r g e n c y m e d i c i n e requires appropriate residency training to adequately develop the skills and knowledge necessary to practice effectively. S o l u t i o n s m u s t focus o n ways to expand and promote quality graduate medical education as a remedy for the current and future shortage of duly qualified emergency physicians. G i v e n that c u r r e n t product i o n of the r e s i d e n c y graduates is woefully inadequate, a t t e n t i o n m u s t be placed on exploring ways to increase the a m o u n t of residency training funds for existing residency training programs and for the creation of n e w programs. In an era of cost cont a i n m e n t , at both federal and local levels, i n c r e a s e d f u n d i n g for resi-
19:7 July 1990
d e n c y t r a i n i n g slots in e m e r g e n c y medicine will be a difficult task. Medical students should c o n t i n u e to be apprised of e m e r g e n c y medicine as a viable career choice. Active efforts should be u n d e r t a k e n to support the development of n e w residencies by m e a n s of faculty and program development. Alternative creative sources of f u n d i n g r e s i d e n c y positions should be identified and promoted. What are the implications of these c o n c l u s i o n s r e l a t i v e to m a n p o w e r needs of academic emergency medicine? Clearly, s t r a t e g i e s m u s t be identified for increasing the n u m b e r of faculty. A t t e n t i o n m u s t focus o n ways to make academia more attractive to b o a r d - c e r t i f i e d e m e r g e n c y physicians. Such strategies might include the offering of f i n a n c i a l a n d other incentives. U n l e s s and u n t i l the p r o b l e m of a d e q u a t e f a c u l t y is addressed, t h e problem of an inadequate n u m b e r of residency training positions will cont i n u e to be an i m p o r t a n t negative issue for a c a d e m i c e m e r g e n c y m e d i cine.
Annals of Emergency Medicine
REFERENCES
1. Long Range Plan, 1988 89. Dallas, American College of EmergencyPhysicians, 1988.
2. Summary Report of the Graduate Medical Education National Advisory Committee to the Secretary, Department of Health and Human Services. Vol I. Washington,DC, DHSS Publica-
tions, 1980, {HRA)81-651. 3. Schwartz WB, Newhouse JP, Bennet BW, et al: The changing geographic distribution of board-certified physicians. N E1~g] J Med 1980; 303:1032-1038. 4. Marder WD, Keltke PR, Silberger AB, et al: Physician Supply and Utilization by Specialty: Trends and Projections. Chicago, American
Medical Association, 1988. 5. Hospital Statistics. 1988 Edition. Chicago, American Hospital Association, 1988. 6. Staffing Patterns of Emergency Departments
(unpublished manuscript). Dallas, American College of EmergencyPhysicians, 1989. 7. Hospital Statistics. Chicago, American Hospital Assc~ciation,1973-1988 editions.
8. FeldsteinPJ: Health Care Economics, Edition 3. New York, John Wiley & Sons, 1988, p 350-351. 9. Analysis of deficiencies cited by the Residency Review Committee for EmergencyMedicine (Unpublishedmemo to the RRC/EM). February 1989.
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