Saturday, January 12, 2008

Filling the ER Void

Emergency medicine is often glamorized in hit television programs like ER – fast-paced and crowded, where dramatic rescues are the norm. They depict urban teaching hospitals bustling with specially trained emergency physicians and residents. In reality, such glitz and drama is a far cry from many emergency departments throughout the United States. For example, thousands of emergency facilities are in rural settings and staffed by primary care physicians who may see only a handful of patients each day. In both settings, patients can get access to expert care in an emergent medical situation.

Carlos Camargo, MD, DrPH, of the Massachusetts General Hospital Department of Emergency Medicine agrees that in an ideal world, all emergency departments would be staffed with board-certified emergency physicians 24 hours per day, every day of the week. Currently, that is far from the case. His team of researchers at Mass General set out to approximate the number of emergency medicine board-certified doctors needed to staff all 4,828 emergency departments across the U.S.

“We questioned whether staffing every department with residency-trained, board-certified emergency physicians – which some individuals have advocated for decades – was a realistic goal,” explains Camargo. “So we set out to estimate emergency physician workforce needs, taking into account the diversity of hospitals across the country and projections about the future physician supply and demand.”

Camargo’s paper, published December 2008 in the journal Academic Emergency Medicine, quantified the gross shortages of board-certified emergency physicians nationwide. It turns out the number of physicians with board certification in emergency medicine is unlikely to meet the staffing needs of U.S. emergency departments in the foreseeable future, if ever.

Specifically, the researchers analyzed data from the 2005 National Emergency Department Inventories–USA database to determine the number of emergency departments in the country and their patient volumes. Based on the approximately 22,000 board-certified emergency physicians in practice in 2005, and the 1,350 who became newly certified during that same year, the team developed three scenarios for physician supply. The best case scenario, which was intentionally unrealistic, assumed that no board-certified emergency physician died or retired. The worst case assumed an annual attrition rate of 12 percent, while the intermediate scenario assumed 2.5 percent attrition each year; both of these estimates came from the medical literature.

Having at least one board-certified emergency physician present in all U.S. hospital emergency departments at all times would require approximately 40,000 physicians with such training, indicating that only 55 percent of 2005 demand was being met. Under the intermediate-scenario projection, it would not be possible to meet the goal until 2038, and under the worst-case scenario, the goal could never be met. Even under the unrealistic scenario of no board-certified emergency physician ever dying or retiring, 100 percent staffing of all emergency departments with board-certified emergency physicians would not happen for more than a decade.

Armed with these data, Camargo is encouraging leaders in emergency medicine to reevaluate emergency department staffing goals and to work more closely with the thousands of primary care doctors who currently staff emergency departments nationwide.

“The mismatch between the supply and demand for residency-trained, board-certified emergency physicians is a longstanding problem,” Camargo says. “We probably should explore alternatives, such as giving the family physicians who currently staff many U.S. emergency departments extra training in key emergency procedures. Emergency departments might also increase their reliance on nurse practitioners and physicians assistants, who can help emergency physicians of any training background to better handle the continually rising number of patients.”

He adds, “It’s all about providing the best possible emergency care to patients in all types of communities – both large teaching hospitals and small rural facilities. I hope our paper will start a more realistic discussion about how to best provide that care given our current staffing capabilities and financial limits.”

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