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Emergency Medicine in Crisis

What's happening? And what is Premier doing about it?

March 1, 2009

The field of Emergency Medicine is in a crisis…not quite the “meltdown” we hear of on a daily basis pertaining to our financial system, but a crisis nonetheless. And not for the reasons we so often hear these days. Oh, this is not to say there’s not an increasing volume of patients, presenting to a dwindling number of Emergency Departments, who are older in age and present with more significant medical problems…these are all truisms, but they don’t reflect the crisis to which I am referring.

John Lyman, MD Image The crisis to which I refer is in reference to the inadequate pool of physicians who can actually deliver emergency care. There simply aren’t enough of us out there with the desire and training to practice Emergency Medicine. So while the patients keep coming with their increasing medical and social demands, the pool of emergency physicians is not keeping pace. In fact, for reasons soon to be discussed, we very well may be falling behind.

One of the great ironies, of which there are others, is that in fact there probably are enough physicians across this great nation of ours to appropriately attend to the medical needs of the populace. So how is it there are enough physicians, yet we’re in a crisis mode at the same time?

The simplest answer revolves around the concept of misdistribution, i.e. there are enough physicians, but they’re in the wrong places—and not just in the wrong places but in the wrong specialties. So whereas the number of physicians in the U.S. is greater than 900,000, a seemingly adequate number, they are not evenly distributed across the country nor across the specialty spectrum. The urban settings, especially on the coasts, may have a surfeit of physicians, whereas those of us in the Midwest, and especially in the rural settings, have a significant shortage.

Along with this geographic misdistribution exists, as noted, a specialty misdistribution. The number of physicians entering into the primary care specialties decreases each year (as an aside, Emergency Medicine is not considered a primary care specialty by the governmental definitions…even though it’s hard to imagine any specialty more “primary”), whereas the number entering the specialties, especially the procedure-oriented specialties, is on the rise.

Gurney The reasons for these misdistributions are not hard to find. Location, location, location obviously plays a role. But compensation and lifestyle are also major motivators. The average practitioner leaves his or her medical school well over $150,000 in debt. Is there any wonder they are attracted to the higher-paying, procedure-oriented specialties? So the medical student can choose a specialty that pays more, and is more conducive to having a fixed schedule and more time off, in the location of their choosing. I think I’ve just reached a “Well, duh-h-h” interlude.

To make matters a little worse for Emergency Medicine, we evolved into a specialty in which one can very easily practice on a part time basis…which many people do. The 40-hour work week is laughed at by both the old timers and the newcomers…the old timers laugh and think, “I wish I could get my work week below 50 hours, let alone 40,” and the newcomers laugh and think “Anything more than 30 hours is time and a half, baby.”

All this said, it doesn’t behoove Premier to simply accept that there aren’t enough emergency physicians, and that is that. Rather, Premier has taken some innovative steps to make more efficient use of the supply of providers, since the demand for services will be ever increasing.

Premier Class One such innovation has been our Graduate Training Program, under the auspices of Jerry Tassett, MD, and Kas Oganowski, MD. This year-long program enrolls physicians who have their specialty Boards in a specialty other than Emergency Medicine, yet who have an interest and experience in Emergency Medicine. The great hope is that these physicians (3 this year, 10 next year) will be better equipped to practice Emergency Medicine at those sites that so desperately need emergency physicians. This program will directly increase the supply of physicians able to practice Emergency Medicine. See the facing page for the education article that details the current activities of Premier’s Graduate Training Program.

A second approach taken by Premier has been the utilization of physician extenders, i.e. Physician Assistants and Nurse Practitioners. Such extenders, with the requisite training for their extender role in the ED, are found in the majority of Premier’s many sites. Bob Zaayer, PA-C, oversees Premier’s extender program. This program indirectly increases the supply of physicians, by serving as surrogate physicians.

Additionally, we are constantly searching for methodologies that will increase the efficiency of the physicians and extenders. Such searches may lead to process changes/improvements or the use of alternate documentation methods, such as the use of scribes, or the employment of “teams” to move patients through the ED more efficiently.

In conclusion, let me again state that Emergency Medicine is in a national crisis. We have an ever-increasing patient population—which is presenting sicker and therefore with a parallel increase in demand for time and resource utilization—and a workforce that is, at best, barely keeping pace and, at worst, rapidly losing ground. Premier feels the urgency of this crisis, but we are taking steps to address the issues in an appropriate and proactive manner.

Premier surveyed 63 Emergency Medicine physicians (40 practicing and 23 residents). We asked the practicing docs how many hours per week they averaged, we asked the residents how many they plan to average once in practice.

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