6
The Emergency Care Workforce

Emergency care is delivered in an inherently challenging environment, often requiring providers to make quick life-and-death decisions based on minimal information. Many who enter the emergency care profession enjoy the challenging work and the high-pressure environment, and take satisfaction in providing care to patients in urgent need. But providers on the front lines of emergency care increasingly express frustration with the deteriorating state of the emergency care system and the health care safety net. They experience the imbalance between demand and capacity described in earlier chapters on a daily basis, and find themselves spending an increasing proportion of their time on such tasks as getting patients admitted to crowded inpatient units; finding specialists willing to come in during the middle of the night; and finding psychiatric centers, skilled nursing facilities, or specialists who are willing to accept referrals. They also face a rigid regulatory environment that can make it difficult to address patients’ needs in the most efficient, effective, and patient-centered manner.

This chapter describes the professionals working in the emergency department (ED) and addresses the unique challenges hospitals face in staffing EDs. A wide range of professionals deliver care in the ED, including physicians from multiple specialties, nurses, physician assistants, emergency medical technicians (EMTs), social workers, pharmacists, and technicians. The chapter begins with an overview of the roles and responsibilities, training, and demographic characteristics of these workers. The rest of the chapter addresses the committee’s concerns with regard to the size, competency, effectiveness, and safety of the ED workforce.



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Hospital-Based Emergency Care: At the Breaking Point 6 The Emergency Care Workforce Emergency care is delivered in an inherently challenging environment, often requiring providers to make quick life-and-death decisions based on minimal information. Many who enter the emergency care profession enjoy the challenging work and the high-pressure environment, and take satisfaction in providing care to patients in urgent need. But providers on the front lines of emergency care increasingly express frustration with the deteriorating state of the emergency care system and the health care safety net. They experience the imbalance between demand and capacity described in earlier chapters on a daily basis, and find themselves spending an increasing proportion of their time on such tasks as getting patients admitted to crowded inpatient units; finding specialists willing to come in during the middle of the night; and finding psychiatric centers, skilled nursing facilities, or specialists who are willing to accept referrals. They also face a rigid regulatory environment that can make it difficult to address patients’ needs in the most efficient, effective, and patient-centered manner. This chapter describes the professionals working in the emergency department (ED) and addresses the unique challenges hospitals face in staffing EDs. A wide range of professionals deliver care in the ED, including physicians from multiple specialties, nurses, physician assistants, emergency medical technicians (EMTs), social workers, pharmacists, and technicians. The chapter begins with an overview of the roles and responsibilities, training, and demographic characteristics of these workers. The rest of the chapter addresses the committee’s concerns with regard to the size, competency, effectiveness, and safety of the ED workforce.

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Hospital-Based Emergency Care: At the Breaking Point PHYSICIANS Several different types of physicians work in the ED extensively. With the exception of many rural hospitals, most hospitals have full-time coverage by emergency physicians, although the training and background of those physicians can vary considerably. Larger hospitals, particularly those designated as trauma centers, also have a host of other types of physicians on staff who can respond in the event a patient needs specialized medical care beyond what emergency physicians are trained to provide. Emergency Physicians Emergency physicians evaluate the presenting problems of patients, make diagnoses, and initiate treatment. They must be prepared for a wide variety of medical emergencies, and for this reason must be well versed in the emergency care aspects of such diverse subjects as anesthesia, cardiology, critical care, environmental illness, neurosciences, obstetrics/gynecology, ophthalmology, pediatrics, psychiatry, resuscitation, toxicology, trauma, disaster management, and wound management. In addition, because they often represent the sole source of primary care for patients whose only access to care is through EDs, they must be expert at delivering care for minor illnesses and injuries, providing care for chronic conditions, and delivering primary and preventive care. Emergency physicians also have specialized responsibilities beyond their scheduled clinical duties. A survey by Moorhead and colleagues (2002) found that physicians spend several hours per week performing unscheduled clinical duties; administrative work, such as ED quality improvement; medical direction of emergency medical services (EMS); supervision of midlevel providers, such as physician assistants (PAs) and nurse practitioners (NPs); teaching; and research. Many ED physicians also must serve on call for the ED (Moorhead et al., 2002). Emergency physician staffing models are quite different from those seen in most other specialties. The Physician Socioeconomic Statistics Survey (AMA, 2003) found that 32 percent of emergency medicine physicians are self-employed, 19.8 percent are independent contractors, and 48.2 percent are employees. Of the employees, 29.6 percent are employed by freestanding centers or group practices and 66.8 percent by hospitals, medical schools, or state and local governments. These figures suggest that approximately 14 percent (29.6 percent of 48.2 percent) of emergency physicians are employed by contract management groups (CMGs), although there are conflicting data on this point. One survey of board-certified emergency physicians estimated only 18 percent to be employed by a multihospital contract company (Plantz et al., 1998). However, this study did not survey physicians who staffed the ED but were not board certified and was limited by its relatively small size (465 responses out of 1,050 surveyed). The

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Hospital-Based Emergency Care: At the Breaking Point American Academy of Emergency Medicine estimates that approximately half of all EDs are staffed by large, national CMGs with majority ownership by non-physicians (Scaletta, 2003). Many of these are small, rural EDs that are unable to attract board certified emergency physicians. Penetration of CMGs is generally lower among large and urban hospitals. A specialty in emergency medicine exists for physicians wishing to practice in the ED. Emergency medicine residency training involves 3–4 years of specialized training after medical school (see Box 6-1). Approximately 62 percent of physicians who identify their primary site of practice as a hospital ED are board certified in emergency medicine. Academic medical centers and large private hospitals in urban areas are much more likely than other types of hospitals to have residency-trained and board-certified emergency medicine physicians (Moorhead et al., 2002). Physicians Not Board Certified in Emergency Medicine Approximately 38 percent of practicing ED physicians are neither board certified nor residency trained in emergency medicine. EDs in suburban and rural locations are more likely to be staffed by emergency physicians that are not residency trained or board certified in emergency medicine than are academic medical centers and large urban hospitals (Moorhead et al., 2002). The majority (84 percent) of these physicians have completed a residency in another specialty, most commonly family practice or internal medicine (Moorhead et al., 2002). The supply of board-certified emergency physicians is not sufficient to staff all ED physician positions, and in the absence of a large-scale expansion of training in the field will not be sufficient for several decades (Holliman et al., 1997). Therefore, physicians from other disciplines (e.g., internal medicine, family practice, pediatrics) are currently filling positions in EDs. Although they lack board certification, these physicians represent an essential component of the ED workforce at many hospitals, especially smaller facilities in suburban and rural settings. Many acquire a high level of competency in emergency care through a combination of postresidency education, directed skills training, and on-the-job experience. Demographics It is difficult to determine precisely how many ED physicians practice in the United States. A 2002 study of the emergency physician workforce in 1999 estimated that approximately 32,000 physicians were working in EDs in 1999, a figure that includes both board-certified and non-board-certified emergency medicine physicians (Moorhead et al., 2002). In a 2004 American Medical Association (AMA) physician survey, however, 25,500 physi-

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Hospital-Based Emergency Care: At the Breaking Point BOX 6-1 The Specialty of Emergency Medicine The specialty of emergency medicine began to organize in the mid-1960s in response to the growing demand by hospitals for full-time emergency room physicians. The American College of Emergency Physicians (ACEP) was founded in 1968 (Danzl and Munger, 2000). In 1970, leaders in emergency medicine established an educational curriculum for residency training, and the first emergency medicine residency program began at the University of Cincinnati. By 1975 there were 23 approved residency programs in the United States. In 1976, a Section on Emergency Medicine was formed at the American Medical Association, and pressure grew for the American Board of Medical Specialties (ABMS) to recognize the specialty. The American Board on Emergency Medicine (ABEM) was established in 1976, but the ABMS did not formally recognize it. The development of the specialty was initially resisted by physicians who believed that training in another discipline, such as internal medicine or family practice, was sufficient to practice emergency medicine (Rosen, 1995). Moreover, emergency medicine represented competition for “adjacent” specialties, such as trauma surgery, cardiology, and primary care. After 3 years of negotiations, however, the ABEM was accepted as a modified-conjoint board, making emergency medicine the twenty-third medical specialty (Rosen, 1995). The ABMS finally granted primary board status to the ABEM in 1989. In 1980, 600 emergency physicians sat for the first certification exam. Emergency medicine developed a critical mass of specialists by allowing experienced practitioners to sit for the certifying exam until 1988, when the “practice track” to board certification was phased out (Marx, 2005). Approximately 20 percent of emergency physicians are board certified as emergency medicine physicians but not residency trained in emergency medicine (Moorhead et al., 2002). Since this “grandfather” track is no longer open, the number of physicians certified through this pathway will decrease over time and eventually disappear. Board certification has also been granted by the American Osteopathic Board of Emergency Medicine (AOBEM) since 1980, and now includes additional certifications in toxicology and sports medicine. In addition to ACEP, another small but growing emergency medicine specialty practice group is the American Academy of Emergency Medicine (AAEM). The cians self-identified themselves as having an emergency medicine specialty (AMA, 2004); this number likely includes some physicians not board certified in emergency medicine but practicing in an ED on a full-time basis. The AMA survey also provided some basic demographic information on those physicians. The composition of practicing self-identified emergency

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Hospital-Based Emergency Care: At the Breaking Point AAEM was formed in 1993 as an organization limited to those emergency physicians with ABEM/ABOEM certification or eligibility for such certification. It has a particular focus on issues related to fair business practices (e.g., open books, physician practice ownership, contract negotiations) with respect to contract management companies. Residency training requirements for emergency medicine physicians were established by the Accreditation Council for Graduate Medical Education, and since then, accredited emergency medicine residency programs have been growing at a rapid rate—from 1 in 1970 to 43 in 1980, 81 in 1990, and 132 in 2005. A recent report cites 3,909 new emergency medicine physicians being trained in accredited residency programs (ACEP Research Committee, 2005). In 2003, board-certified emergency physicians and pediatric emergency physicians were available at 63.5 percent and 18.1 percent of emergency departments, respectively (McCaig and Burt, 2005). Emergency medicine has demonstrated a regular increase in the percentage of U.S. medical students entering the specialty, growing from 2 percent in 1987 to 4 percent in 2002. There are now several subspecialties within emergency medicine: pediatric emergency medicine, medical toxicology, sports medicine, and undersea and hyperbaric medicine. There are also a number of nonaccredited fellowships not funded by Medicare’s Graduate Medical Education (GME) funding that emergency medicine physicians may pursue. These include disaster medicine, medical direction of emergency medical services, ultrasound, health services research, and international emergency medicine. A small number of emergency physicians hold Board Certification in Emergency Medicine (BCEM) from the American Board of Physician Specialties. This certification, which requires completion of a residency in some field plus 5 years of clinical practice in emergency medicine, is recognized only in Florida (ABPS, 2005). While residency programs have grown at a rapid pace, academic departments in emergency medicine have progressed more gradually. The Society of Academic Emergency Medicine (SAEM) was formed in 1989 through the merger of the University Association for Emergency Medicine (UAEM) and the Society of Teachers of Emergency Medicine (STEM) to foster the development of academic emergency medicine and promote research in the field. Today there are 64 autonomous departments of emergency medicine at U.S. medical schools and 135 emergency medicine residency programs. medicine physicians is less diverse than that of the general physician population. Eighty-three percent of self-identified emergency physicians are non-Hispanic white, compared with 75 percent of physicians overall. The primary difference, however, appears to be the lower number of Asians in emergency medicine: in 2002, Asians represented 13 percent of all physicians but only

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Hospital-Based Emergency Care: At the Breaking Point FIGURE 6-1 Number of nonfederal emergency medicine physicians in the United States, 1975 to 2002. SOURCE: AMA, 2004. 7 percent of emergency medicine physicians. Additionally, only 20 percent of emergency medicine physicians are women, compared with 25 percent of all physicians. Emergency medicine physicians also tend to be younger than other physicians. Nearly one-quarter were under the age of 35 in 2002, and fully half were under the age of 45; among the overall physician population, 59 percent of physicians were aged 45 and older (AMA, 2004). The number of self-identified emergency physicians in the United States has increased substantially since 1979, when emergency medicine was first recognized as a specialty (see Figure 6-1). Growth in emergency medicine has been much stronger than that in medicine overall. Since 1990, the number of self-identified emergency physicians in the United States has increased from 14,000 to more than 25,500—an increase of 79 percent compared with a 39 percent increase in the number of all physicians. One of the key reasons for the rapid growth in emergency medicine residency programs is that academic medical centers find these programs quite useful for staffing their own EDs. The “fill rate” of emergency medicine residency positions is quite high, reflecting the fact that the field is a popular career choice for U.S. medical students. Physician Payment ED physicians often are not hospital employees and are reimbursed separately from the hospital. Medicare physician payment is based on a resource-based relative value scale (RBRVS). The provider reports to the payer the service’s Current Procedural Terminology (CPT) evaluation/management (E/M) code, which describes the intensity of the physician service

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Hospital-Based Emergency Care: At the Breaking Point given. Over 80 percent of ED care falls under the five emergency care CPT E/M codes (ACEP, 2004). The codes are converted by the Centers for Medicare and Medicaid Services (CMS) into relative value units (RVUs) and modified by area factors. There are three RVU categories: physician work, practice expense, and professional liability. Each of these RVUs is multiplied by a corresponding geographical practice cost index (GPCI). Medicare then pays the physician 80 percent of the charge, and the patient is responsible for the other 20 percent. An anomaly of reimbursement for emergency physicians is that they are sometimes not credited for some of the tasks they perform. In many cases, the emergency physician is the first to read a patient’s electrocardiogram (EKG) or x-ray and use it to make the relevant clinical decisions. Hospital radiologists and cardiologists sometimes read these results and dictate interpretations hours or even days after treatment has been rendered, and then bill for the service. CMS will reimburse only one physician for each interpretation, and payment often goes to whoever rereads the study at a later time rather than to the emergency physician who applies his or her own interpretation to real-time patient care decisions. Medicaid programs use similar systems that have different rates and details (Kaiser Commission on Medicaid and the Uninsured, 2003). In fact, over 70 percent of all ED physician payments for both public and private care are derived from an RBRVS (ACEP, 2004). Uncompensated Care The American College of Emergency Physicians (ACEP) has been active in an effort to increase the practice expense RVU, including a push to count uncompensated care mandated by the 1986 Emergency Medical Treatment and Active Labor Act (EMTALA) toward that RVU. An AMA survey of physicians in 2000 estimated that emergency physicians incurred an annual average of $138,000 in bad debt by providing care mandated by EMTALA (Kane, 2003). Actual foregone income is probably substantially less than this on average, since the $138,000 is based on charges and not actual payments. Nonetheless, a reimbursement rate of 50 percent suggests significant foregone income that has not been remediated through changes in the CMS practice expense RVU. It should be noted that other specialties that provide emergency care also deliver substantial amounts of uncompensated care and face similar economic problems. Reimbursement of on-call physicians is discussed later in this chapter. Contract Management Groups CMGs provide hospitals with ED physicians who work on a contract basis, allowing hospitals to staff their EDs around the clock, and they

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Hospital-Based Emergency Care: At the Breaking Point often provide contract management services, including coding and billing (McNamara, 2006). About 16 percent of emergency physicians are employed by a CMG company. If independent contractors are included, however, this figure rises to close to 40 percent of emergency physicians (AMA, 2004). Contracting with a CMG is an attractive option for some rural hospitals because it guarantees full-time physician coverage of the ED (Williams et al., 2001). The availability of an ED staff also helps attract physicians from other specialties, who are relieved of the need to staff the ED on a rotating basis. CMGs may be an attractive option for physicians as well as they handle many of the business details of practice, such as billing, and provide health and other benefits. These advantages may come at a price, however. In some areas of the country, CMG companies represent such a large share of emergency physician practices that it may be difficult for a physician to practice emergency medicine unless employed by a CMG, which may require physicians to sign noncompete agreements. Moonlighting The pressing need for ED physicians frequently leads hospitals to augment their staffs with emergency medicine residents, known as “moonlighters,” often to cover evening and weekend shifts. While typically emergency medicine residents, these moonlighters may also include nonemergency physicians and residents training in other specialties, who usually have no specific training or qualifications in emergency medicine (Kellermann, 1995). More than half of all emergency residents reported moonlighting in one survey, though not all in EDs (Li et al., 2000); they cited a variety of reasons for doing so, including supplementing their income and enhancing their educational experience. The practice is discouraged by the emergency medicine specialty organizations because it may place both the resident and the patient at risk, especially when there is no experienced backup in the ED (Keim and Chisholm, 2000). In addition to moonlighters, some physicians working in EDs are provided by “locum tenens” firms that supply physicians to hospital EDs to fill staffing gaps on an as-needed basis. Trauma Surgeons The other specialty of particular relevance to emergency care is the surgical subspecialty of trauma/critical care surgery. Trauma is defined as any bodily injury severe enough to pose a threat to life and limb. It requires an organized emergency response that guarantees immediate intervention, including, if needed, the immediate commencement of surgery. Trauma is a major national health problem and remains the leading cause of death for

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Hospital-Based Emergency Care: At the Breaking Point all Americans under age 44. In addition, it takes a huge economic toll on society as it accounts for the greatest loss of productive life in the nation. Trauma care requires a systemic approach that mandates coordination of all prehospital and hospital-based services to optimize care and outcomes. Trauma often occurs during off hours, and trauma centers are therefore busier at night and on weekends and holidays. This requires a 24-hour-a-day operational status that is costly in terms of both facility and human resources. Most severe trauma care is directed by trauma surgeons who are general surgeons with a special commitment to the provision, management, and organization of trauma care within their hospital and region. The term “trauma surgeon” usually refers to a person trained in general surgery who has an additional 1 to 2 years of training in trauma surgery and critical care. These surgeons focus their practice and expertise on trauma surgery and care management, surgical critical care, and recently all emergency general and vascular surgery. They generally complete a minimum of 7 years of residency training—a complete 5-year general surgery residency, followed by 2 years of fellowship training in trauma surgery and surgical critical care. The American College of Surgeons estimates that there are currently about 3,000 trauma surgeons practicing in the United States (Personal communication, C. Williams, February 17, 2006). Trauma surgeons tend to focus their practice in specially designated units known as trauma centers. Indeed, a key component of the trauma center designation process is documentation of continuous coverage by trauma surgeons. For level I designation, a trauma surgeon must be available 24 hours a day, 7 days a week. Most level I and some level II trauma centers have trauma surgeons in house 24 hours a day, 7 days a week, who are responsible for all aspects of care of the trauma patient. Trauma care is also provided by emergency physicians, especially in some level II, III, and IV trauma centers. Subspecialists in anesthesia, emergency medicine, orthopedics, neurosurgery, radiology, and, in some states, rehabilitation medicine are required for all level I and II trauma center accreditation. In the last 30 years, the development of trauma centers and trauma systems has been recognized as a key factor in improving outcomes from injuries, especially those involving vehicular crashes. In addition, trauma centers are a critical component of the safety net system and play a vital role in preparations for potential disasters, both natural and man-made, as well as for acts of terrorism. Trauma that is treated at trauma centers and within an established system has the best outcomes, with significantly lower mortality rates than those seen in non–trauma center hospitals (MacKenzie et al., 2006). The development of trauma systems and trauma surgery practice has been largely directed and codified through a series of reports by the

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Hospital-Based Emergency Care: At the Breaking Point American College of Surgeons and its Committee on Trauma, including, most recently, the so-called “Gold Book,” The Optimal Care of the Injured Patient (Committee on Trauma, ACS, 1998). Currently, hospitals face a decline in the numbers of trauma surgeons due to large amounts of uncompensated care, high levels of medical malpractice risk, and the burden placed by trauma practice on family life. A key factor is the low number of general surgeon trainees electing to go into trauma surgery. Today the majority of fellowships in trauma and surgical critical care are not filled. A national shortage of these specialists will become critical as trauma surgeons now in their late fifties and sixties retire. Furthermore, the trauma capacity in certain cities and regions has declined as trauma centers have closed because of high costs and high levels of uncompensated care. Specialists Who Provide On-Call Emergency and Trauma Care Services Hospitals that offer specialist services for inpatients, such as neurosurgery and vascular surgery, must make the same services available to patients who present at the ED (Glabman, 2005). ED physicians rely on and consult these specialists for a range of services—clinical consultation, surgical follow-up, inpatient care, and postdischarge care (Macasaet and Zun, 2005). The limited availability of certain specialists, however, is a well-documented problem that is concerning for both consumers and emergency care providers. Over the past several years, hospitals have found it increasingly difficult to secure specialists for their ED patients. In a 2004 survey by ACEP, two-thirds of ED medical directors reported shortages of on-call specialists at their hospitals (ACEP, 2004). An update to this survey found that the situation is growing worse. In 2005, 73 percent of EDs reported problems with on-call coverage, in contrast to 67 percent the year before (ACEP, 2006). Numerous other studies and surveys have investigated the shortage of on-call specialists, finding that the problem extends across many different specialties and all regions of the country and that it appears to be worsening (Green et al., 2005; O’Malley et al., 2005). Consider the experience of a patient in San Antonio in his twenties who came to the ED with a vascular injury to his leg artery, the result of a gunshot wound. The vascular circulation needed to be repaired within 6 hours or the patient would risk losing his leg. When the patient arrived at the hospital, ED staff attempted to contact the specialist on call, but he was in surgery and could not respond. Another on-call surgeon was also unavailable because he was performing surgery. The ED staff ultimately decided to transfer the patient hundreds of miles away to a hospital with the expertise to treat him. By the time the patient arrived, however, too much time had elapsed for his leg to be saved (Glabman, 2005). EMTALA

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Hospital-Based Emergency Care: At the Breaking Point currently requires hospitals to have contingency plans for such situations, but unfortunately many do not. The experience of this patient in San Antonio is not uncommon, yet it is remarkable. One would expect the city to have adequate specialty resources to care for a patient with such an injury. Another reason why the shortage of on-call specialists is remarkable is because it affects all patients, regardless of income or insurance status; insured patients are at the same risk as uninsured patients of not having a specialist available when needed. Surveys of hospital administrators, ED staff, and specialists indicate that there are at least five underlying factors affecting the availability of emergency and trauma care specialists: (1) the supply of specialists, (2) compensation for providing emergency services, (3) quality-of-life issues, (4) liability concerns, and (5) relaxed EMTALA requirements for on-call panels (Yoo et al., 2001; California Healthcare Association, 2003; Taheri and Butz, 2004; Green et al., 2005; Salsberg, 2005). Each of these factors is discussed in turn below. Supply of Specialists Hospital by-laws often require physicians to take ED call for a certain period of time (e.g., 15 years) in exchange for admitting privileges. Historically, this arrangement worked well; it allowed hospitals to fill their on-call panel and gave young specialists an opportunity to build up their practices. But with the movement of specialists to large, multispecialty groups, younger physicians no longer need to rely on ED call to supply patients. Hospitals have less leverage to tie admitting privileges to ED call, and many groups discourage their members from taking ED call (Taheri and Butz, 2004). The availability of on-call specialists is also dependent upon the local supply of specialists. If there are many specialists in the market, they may be more likely to serve on emergency call panels to draw new patients into their practices, assuming that some of these patients are insured. On the other hand, if there are shortages of certain specialists in a market, those specialists will likely be able to fill their practices without taking call. Indeed, in many areas of the country there is a shortage of certain specialists needed to cover the ED (GAO, 2003a). One reason is that medical school enrollment has not kept pace with the growing population. Neurosurgery is a good example of this point. Despite substantial increases in the U.S. population and in the number of trauma visits, there were fewer practicing neurosurgeons in 2002 (3,050) than there were 12 years earlier. There are far fewer neurosurgeons in the United States than the number of EDs (4,900) (Couldwell et al., 2003). The specialty attributes this decline largely to medical liability problems (discussed below). The shortage of available on-call specialists is a serious and complex

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Hospital-Based Emergency Care: At the Breaking Point maldistribution exists, and in fact has worsened since 1997, when 15 percent of emergency physicians practiced in rural areas (Moorhead et al., 1998; Williams et al., 2001). This change may reflect the rapid growth in urban areas with rising numbers of emergency medicine residency training programs rather than a sharp decline in rural communities. Nevertheless, this maldistribution is a problem that must be addressed. The specialty of emergency medicine has focused on strategies for increasing the number of emergency medicine specialists in rural areas, but workforce issues in rural EDs may never be resolved by such efforts alone. The difficulties of recruitment and retention in rural EDs are due to a variety of causes, but are generally assignable to either work-related factors or personal and community characteristics (Pan et al., 1996). There exists a strong correlation between where a physician is raised and the community in which he or she later chooses to practice (Williams et al., 2001). Additionally, the location of residency training is a major factor in the choice of practice location for emergency medicine residency graduates regardless of previous geographic ties (Steele et al., 1998). Rural hospitals that have residency training programs are more successful in recruiting and retaining physicians when they complete their residency (Connor et al., 1994; Cutchin, 1997). The fact that the majority of emergency medicine residency programs are located in urban areas suggests that residency graduates will likely continue to choose to practice in those areas. Graduates also are faced with lower levels of compensation in rural than in urban areas (Bullock et al., 1999). The high debt burden of many emergency medicine residents, coupled with the limited opportunity to earn sufficient income to pay off educational debt in rural settings, is a significant barrier to rural practice. Increased workload in rural areas is another barrier: rural emergency medicine physicians spend 35 percent more time in on-call backup relative to the average for all emergency physicians (Moorhead et al., 2002). Given the fewer resources and consultants typical of rural settings (Sklar et al., 2002), the lack of physicians trained in emergency medicine in these settings is not surprising. One strategy for increasing the emergency care workforce in rural areas would be to increase the number of emergency medicine residency programs in these areas. However, ACGME program requirements enforced by the Residency Review Committee (RRC) make it virtually impossible to gain certification for a “rural” residency program unless it is situated in a large referral hospital. The RRC is equally reluctant to recognize satellite sites at rural hospitals if they are geographically remote from the program’s base hospital, regardless of distance. Changes in such ACGME requirements might increase rural emergency medicine training during residency and ultimately benefit the rural emergency medicine workforce and the quality of care provided in rural settings. Another approach would be to develop programs that would cover the costs of medical education in return for

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Hospital-Based Emergency Care: At the Breaking Point future assignment to a rural area, based on the National Health Service Corps or Public Health Service Commissioned Corps model but specifically targeting emergency medicine. To compensate for manpower shortages, rural EDs have resorted to alternative methods and providers in an effort to maintain minimum levels of staffing. This strategy is evident if one examines the physician characteristics in rural EDs. In one survey of random hospitals across the United States, rural EDs, comprising 25 percent of all EDs, reported an average of 4.74 physicians per institution, 40 percent fewer than the average for all locales (Moorhead et al., 2002). Numbers of FTEs, defined as those working 40 clinical hours per week, were also significantly lower in rural EDs; there were 3.42 FTEs per rural ED—35 percent fewer than average. Rural EDs were noted to have the highest percentage of osteopathic physicians (14 percent) and non-U.S.-trained physicians (14 percent). It is significant that 67 percent of rural emergency medicine physicians are neither residency trained nor board certified in emergency medicine. Of the 33 percent of physicians with emergency medicine credentials, fewer than half are both emergency medicine residency trained and board certified. Only 12 percent of rural respondents in the survey reported requiring any emergency medicine credentials for ED hiring. In summary, rural EDs have lower levels of staffing, and when they are staffed by physicians, these physicians are much less likely to be emergency medicine specialists and more likely to be trained in family practice or other primary care specialties. Although ideally all EDs would be staffed by residency-trained, board-certified emergency physicians, this is highly unlikely to occur in the near to mid term, if ever. Therefore, alternative staffing models must be developed. Clinicians other than physicians—such as PAs, NPs, CNMs, and CNSs—are often used in the staffing of rural EDs (Moorhead et al., 2002). With national efforts to lower costs and the demonstrated success of using nonphysician clinicians in certain prescribed roles, their use in the staffing of rural EDs may increase (Blunt, 1998). At the same time, it should be noted that rural EDs experience problems with recruitment and retention of all clinicians, not just physicians, and for similar reasons (Bullock et al., 1999). Rural ED providers exhibit wide variability in their skill levels and the competence with which they provide emergency care. Care often falls short of established guidelines. In a study of acute stroke care in nonurban EDs, patients were found to have been treated in ways discordant with AHA recommendations. Hypertension was often treated too aggressively, and inappropriate medications were sometimes used. Additionally, it was suggested that nonmotor symptoms of stroke were less likely to be recognized or were treated with less urgency than motor symptoms of stroke (Burgin et al., 2001). Although these data are far from conclusive, results of such studies may explain in part the stigma of decreased competence attributed

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Hospital-Based Emergency Care: At the Breaking Point to rural emergency physicians (Leap, 2000). Yet the reality is that rural emergency physicians are often called upon to care single-handedly for critically ill and injured patients in a challenging setting typically lacking in manpower, equipment, and access to consultants. The deficit of rural health care providers has complicated the roles these providers must fill. It is typical for rural primary care physicians’ practices to entail management of patients in EDs, outpatient clinics, inpatient wards, and ICUs, as well as additional duties related to health care administration. Additionally, the low patient census in a rural ED may contribute to the difficulty experienced by physicians and midlevel providers in maintaining a high level of proficiency in emergency medicine. Furthermore, certain specialists who provide on-call emergency and trauma services are even scarcer in rural areas. Substantial near-term increases in the capacity to provide advanced emergency and trauma care in rural settings are unlikely. This situation makes effective regional solutions to the transport of patients to definitive emergency and trauma care essential. But effective transport requires effective stabilization, critical care management, and in some cases surgical intervention. The proposed subspecialty in emergency surgery described earlier in this chapter has particular applicability to rural settings, where there are unlikely to be other specialists with the skills to adequately address certain serious emergencies. All patients, regardless of setting, deserve prompt access to high-quality emergency care. Initiatives to improve the quality of emergency care in rural areas have recognized the need to develop strategies for enhancing the knowledge and training and expanding the size of the rural emergency care workforce. Given current workforce shortages in emergency care and economic conditions in the health system, rural EDs are unlikely to have residency-trained, board-certified emergency physicians on a round-the-clock basis. Approaches recommended to address this situation include increased collaboration between emergency medicine and primary care specialties (such as family practice physicians who provide emergency medical care in rural areas) and increased links between academic medical centers and rural hospitals (Williams et al., 2001). Emergency physicians and family practitioners in Minnesota, for example, have developed a course for training teams of health care providers in comprehensive advanced life support that can serve as a model for collaborative training in rural emergency medicine (Carter et al., 2001). The committee supports these efforts, and recommends that states link rural hospitals with academic health centers to enhance opportunities for professional consultation, telemedicine, patient referral and transport, and continuing professional education (6.6).

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Hospital-Based Emergency Care: At the Breaking Point SUMMARY OF RECOMMENDATIONS 6.1: Hospitals, physician organizations, and public health agencies should collaborate to regionalize critical specialty care on-call services. 6.2: Congress should appoint a commission to examine the impact of medical malpractice lawsuits on the declining availability of providers in high-risk emergency and trauma care specialties, and to recommend appropriate state and federal actions to mitigate the adverse impact of these lawsuits and ensure quality of care. 6.3: The American Board of Medical Specialties and its constituent boards should extend eligibility for certification in critical care medicine to all acute care and primary care physicians who complete an accredited critical care fellowship program. 6.4: The Department of Health and Human Services, the Department of Transportation, and the Department of Homeland Security should jointly undertake a detailed assessment of emergency and trauma workforce capacity, trends, and future needs, and develop strategies to meet these needs in the future. 6.5: The Department of Health and Human Services, in partnership with professional organizations, should develop national standards for core competencies applicable to physicians, nurses, and other key emergency and trauma professionals, using a national, evidence-based, multidisciplinary process. 6.6: States should link rural hospitals with academic health centers to enhance opportunities for professional consultation, telemedicine, patient referral and transport, and continuing professional education. REFERENCES AAPA (American Association of Physician Assistants). 2005. 2005 AAPA Physician Assistant Census Report. [Online]. Available: http://www.aapa.org/research/05census-intro.html [accessed June 16, 2006]. ABPS (American Board of Physician Specialties). 2005. Eligibility Requirements. [Online]. Available: http://www.abpsga.org/certification/emergency/eligibility.html [accessed August 10, 2005]. ACEP (American College of Emergency Physicians). 2004. Two-Thirds of Emergency Department Directors Report On-Call Specialty Coverage Problems. [Online]. Available: http://www.acep.org/1,34081,0.html [accessed September 28, 2004].

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