The Emergency Medicine Physician Workforce: Projections for 2030.

STUDY OBJECTIVE: The goals of this study were to determine the current and projected supply in 2030 of contributors to emergency care, including emergency residency-trained and board-certified physicians, other physicians, nurse practitioners, and physician assistants. In addition, this study was designed to determine the current and projected demand for residency-trained, board-certified emergency physicians. METHODS: To forecast future workforce supply and demand, sources of existing data were used, assumptions based on past and potential future trends were determined, and a sensitivity analysis was conducted to determine how the final forecast would be subject to variance in the baseline inputs and assumptions. Methods included: (1) estimates of the baseline workforce supply of physicians, nurse practitioners, and physician assistants; (2) estimates of future changes in the raw numbers of persons entering and leaving that workforce; (3) estimates of the productivity of the workforce; and (4) estimates of the demand for emergency care services. The methodology assumes supply equals demand in the base year and estimates the change between the base year and 2030; it then compares supply and demand in 2030 under different scenarios. RESULTS: The task force consensus was that the most likely future scenario is described by: 2% annual graduate medical education growth, 3% annual emergency physician attrition, 20% encounters seen by a nurse practitioner or physician assistant, and 11% increase in emergency department visits relative to 2018. This scenario would result in a surplus of 7,845 emergency physicians in 2030. CONCLUSION: The specialty of emergency medicine is facing the likely oversupply of emergency physicians in 2030. The factors leading to this include the increasing supply of and changing demand for emergency physicians. An organized, collective approach to a balanced workforce by the specialty of emergency medicine is imperative.

Estimating the size and scope of the academic emergency physician workforce.

BACKGROUND: Academic emergency medicine (EM) is foundational to the EM specialty through the development of new knowledge and clinical training of resident physicians. Despite recent increased attention to the future of the EM workforce, no evaluations have specifically characterized the U.S. academic EM workforce. We sought to estimate the national proportion of emergency physicians (EPs) identified as academic and the proportion of emergency department (ED) visits that take place at academic sites. METHODS: We performed a cross-sectional analysis of EPs and EDs using data from the American Hospital Association, the Centers for Medicare & Medicaid Services, and Doximity's Residency Navigator. EPs were identified as "academic" if they were affiliated with at least one facility determined to be academic, defined as EDs officially designated by the Accreditation Council for Graduate Medical Education (ACGME) as clinical training sites at accredited EM residency programs. Our primary outcomes were to estimate the national proportion of EPs identified as academic and the proportion of ED visits performed at academic sites. RESULTS: Our analytic sample included 26,937 EPs practicing clinically across 4920 EDs and providing care during 130,471,386 ED visits. Among EPs, 11,720 (43.5%) were identified as academic, and among EDs, 635 (12.9%) were identified as academic sites, including 585 adult/general sites, 45 pediatric-specific sites, and 10 sites affiliated with the Department of Veterans Affairs. In 2021, academic EDs provided care for 42,794,106 ED visits or 32.8% of all ED visits nationally. CONCLUSIONS: Approximately four in 10 EPs practice in at least one clinical training site affiliated with an ACGME-accredited EM residency program, and approximately one in three ED visits nationally occur in these academic EDs. We encourage further work using alternative definitions of an academic EPs and EDs, along with longitudinal research to identify trends in the workforce's composition.

Factors associated with emergency physician income.

Objective: Income fairness is important, but there are limited data that describe income equity among emergency physicians. Understanding the magnitude of and factors associated with income differences may be helpful in eliminating disparities. This study analyzed the associations of demographic factors, training, practice setting, and board certification with emergency physician income. Methods: We distributed a survey to professional members of the American College of Emergency Physicians. The survey included questions on annual income, educational background, practice characteristics, gender, age, race, ethnicity, international medical graduate status, type of medical degree (MD vs DO), completion of a subspecialty fellowship, job characteristics, and board certification. Respondents also reported annual income. We used linear regression to determine the respondent characteristics associated with reported annual income. Results: From 45,961 members we received 3407 responses (7.4%); 2350 contained complete data for regression analysis. The mean reported annual income was $315,306 (95% confidence interval [CI], $310,649 to $319,964). The mean age of the respondents was 47.4 years, 37.4% were women, 3.2% were races underrepresented in medicine (Black, American Indian, or Alaskan Native), and 4.8% were Hispanic or Latino. On linear regression, female gender was associated with lower reported annual income; difference -$43,565, 95% CI, -$52,217 to -$34,913. Physician age, degree (MD vs DO), underrepresented racial minority status, and underrepresented ethnic minority status were not associated with annual income. Fellowship training was associated with lower income; Accreditation Council for Graduate Medical Education (ACGME) program difference -$30,048; 95% CI, -$48,183 to -$11,912, non-ACGME-program difference -$27,640, 95% CI, -$40,970 to -$14,257. Working at a for-profit institution was associated with higher income; difference $12,290, 95% CI, $3693 to $20,888. Board certification was associated with higher income; difference, $43,267, 95% CI, $30,767 to $55,767. Conclusions: This study identified income disparities associated with gender, practice setting, fellowship completion, and American Board of Emergency Medicine or American Osteopathic Board of Emergency Medicine certification.

The AAMC Standardized Video Interview: Lessons Learned From the Residency Selection Process.

Calls to change the residency selection process have increased in recent years, with many focusing on the need for holistic review and alternatives to academic metrics. One aspect of applicant performance to consider in holistic review is proficiency in behavioral competencies. The Association of American Medical Colleges (AAMC) developed the AAMC Standardized Video Interview (SVI), an online, asynchronous video interview that assesses applicants' knowledge of professionalism and their interpersonal and communication skills. The AAMC worked with the emergency medicine community to pilot the SVI. Data from 4 years of research (Electronic Residency Application Service [ERAS] 2017-2020 cycles) show the SVI is a reliable, valid assessment of these behavioral competencies. It provides information not available in the ERAS application packet, and it does not disadvantage individuals or groups. Yet despite the SVI's psychometric properties, the AAMC elected not to renew or expand the pilot in residency selection.In this Invited Commentary, the authors share lessons learned from the AAMC SVI project about introducing a new tool for use in residency selection. They recommend that future projects endeavoring to find ways to support holistic review engage all stakeholders from the start; communicate the value of the new tool early and often; make direct comparisons with existing tools; give new tools time and space to succeed; strike a balance between early adopters and broad participation; help stakeholders understand the limitations of what a tool can do; and set clear expectations about both stakeholder input and pricing. They encourage the medical education community to learn from the SVI project and to consider future partnerships with the AAMC or other specialty organizations to develop new tools and approaches that prioritize the community's needs. Finding solutions to the challenges facing residency selection should be a priority for all stakeholders.

A Critical Disconnect: Residency Selection Factors Lack Correlation With Intern Performance.

BACKGROUND: Emergency medicine (EM) residency programs want to employ a selection process that will rank best possible applicants for admission into the specialty. OBJECTIVE: We tested if application data are associated with resident performance using EM milestone assessments. We hypothesized that a weak correlation would exist between some selection factors and milestone outcomes. METHODS: Utilizing data from 5 collaborating residency programs, a secondary analysis was performed on residents trained from 2013 to 2018. Factors in the model were gender, underrepresented in medicine status, United States Medical Licensing Examination Step 1 and 2 Clinical Knowledge (CK), Alpha Omega Alpha (AOA), grades (EM, medicine, surgery, pediatrics), advanced degree, Standardized Letter of Evaluation global assessment, rank list position, and controls for year assessed and program. The primary outcomes were milestone level achieved in the core competencies. Multivariate linear regression models were fitted for each of the 23 competencies with comparisons made between each model's results. RESULTS: For the most part, academic performance in medical school (Step 1, 2 CK, grades, AOA) was not associated with residency clinical performance on milestones. Isolated correlations were found between specific milestones (eg, higher surgical grade increased wound care score), but most had no correlation with residency performance. CONCLUSIONS: Our study did not find consistent, meaningful correlations between the most common selection factors and milestones at any point in training. This may indicate our current selection process cannot consistently identify the medical students who are most likely to be high performers as residents.

Changes to the ACGME Common Program Requirements and Their Potential Impact on Emergency Medicine Core Faculty Protected Time.

The Accreditation Council for Graduate Medical Education (ACGME), which regulates residency and fellowship training in the United States, recently revised the minimum standards for all training programs. These standards are codified and published as the Common Program Requirements. Recent specific revisions, particularly removing the requirement ensuring protected time for core faculty, are poised to have a substantial impact on emergency medicine training programs. A group of representatives and relevant stakeholders from national emergency medicine (EM) organizations was convened to assess the potential effects of these changes on core faculty and the training of emergency physicians. We reviewed the literature and results of surveys conducted by EM organizations to examine the role of core faculty protected time. Faculty nonclinical activities contribute greatly to the academic missions of EM training programs. Protected time and reduced clinical hours allow core faculty to engage in education and research, which are two of the three core pillars of academic EM. Loss of core faculty protected time is expected to have detrimental impacts on training programs and on EM generally. We provide consensus recommendations regarding EM core faculty clinical work hour limitations to maintain protected time for educational activities and scholarship and preserve the quality of academic EM.

Brugada syndrome presenting as an "acute myocardial infarction".

Brugada syndrome is believed to be the cause of up to 50% of sudden cardiac death (SCD) cases due to ventricular dysrhythmias in young healthy individuals with no structural heart disease. This syndrome was first reported in 1992 and is rarely seen in the Emergency Department (ED). Given the life-threatening nature of Brugada syndrome, we hope to increase awareness in Emergency Medicine practitioners. We report the case of a 22-year-old man who was referred to the ED with a history of intermittent palpitations, near-syncope and electrocardiogram findings of RSR' and ST elevation in V1-V2 characteristic of Brugada syndrome. It is crucial that emergency physicians search for this diagnosis, as an implantable cardioverter-defibrillator is the only recognized life-saving intervention, and the risk of SCD is high if the diagnosis is missed.

The AAMC Standardized Video Interview: Reactions and Use by Residency Programs During the 2018 Application Cycle.

PURPOSE: To evaluate how emergency medicine residency programs perceived and used Association of American Medical Colleges (AAMC) Standardized Video Interview (SVI) total scores and videos during the Electronic Residency Application Service 2018 cycle. METHOD: Study 1 (November 2017) used a program director survey to evaluate user reactions to the SVI following the first year of operational use. Study 2 (January 2018) analyzed program usage of SVI video responses using data collected through the AAMC Program Director's Workstation. RESULTS: Results from the survey (125/175 programs; 71% response rate) and video usage analysis suggested programs viewed videos out of curiosity and to understand the range of SVI total scores. Programs were more likely to view videos for attendees of U.S. MD-granting medical schools and applicants with higher United States Medical Licensing Examination Step 1 scores, but there were no differences by gender or race/ethnicity. More than half of programs that did not use SVI total scores in their selection processes were unsure of how to incorporate them (36/58; 62%) and wanted additional research on utility (33/58; 57%). More than half of programs indicated being at least somewhat likely to use SVI total scores (55/97; 57%) and videos (52/99; 53%) in the future. CONCLUSIONS: Program reactions on the utility and ease of use of SVI total scores were mixed. Survey results indicate programs used the SVI cautiously in their selection processes, consistent with AAMC recommendations. Future user surveys will help the AAMC gauge improvements in user acceptance and familiarity with the SVI.

Applicant Reactions to the AAMC Standardized Video Interview During the 2018 Application Cycle.

PURPOSE: This study examined applicant reactions to the Association of American Medical Colleges Standardized Video Interview (SVI) during its first year of operational use in emergency medicine (EM) residency program selection to identify strategies to improve applicants' SVI experience and attitudes. METHOD: Individuals who self-classified as EM applicants applying in the Electronic Residency Application Service 2018 cycle and who completed the SVI in summer 2017 were invited to participate in 2 surveys. Survey 1, which focused on procedural issues, was administered immediately after SVI completion. Survey 2, which focused on applicants' SVI experience, was administered in fall 2017, after SVI scores were released. RESULTS: The response rates for surveys 1 and 2 were 82.3% (2,906/3,532) and 58.7% (2,074/3,532), respectively. Applicant reactions varied by aspect of the SVI studied and their SVI total scores. Most applicants were satisfied with most procedural aspects of the SVI, but most applicants were not satisfied with the SVI overall or with their total SVI scores. About 20% to 30% of applicants had neutral opinions about most aspects of the SVI. Negative reactions to the SVI were stronger for applicants who scored lower on the SVI. CONCLUSIONS: Applicants had generally negative reactions to the SVI. Most were skeptical of its ability to assess the target competencies and its potential to add value to the selection process. Applicant acceptance and appreciation of the SVI will be critical to the SVI's acceptance by the graduate medical education community.

Choosing emergency medicine: Influences on medical students' choice of emergency medicine.

BACKGROUND: Relatively little is understood about which factors influence students' choice of specialty and when learners ultimately make this decision. OBJECTIVE: The objective is to understand how experiences of medical students relate to the timing of selection of Emergency Medicine (EM) as a specialty. Of specific interest were factors such as how earlier and more positive specialty exposure may impact the decision-making process of medical students. METHODS: A cross-sectional survey study of EM bound 4th year US medical students (MD and DO) was performed exploring when and why students choose EM as their specialty. An electronic survey was distributed in March 2015 to all medical students who applied to an EM residency at 4 programs representing different geographical regions. Descriptive analyses and multinomial logistic regressions were performed. RESULTS: 793/1372 (58%) responded. Over half had EM experience prior to medical school. When students selected EM varied: 13.9% prior to, 50.4% during, and 35.7% after their M3 year. Early exposure, presence of an EM residency program, previous employment in the ED, experience as a pre-hospital provider, and completion of an M3 EM clerkship were associated with earlier selection. Delayed exposure to EM was associated with later selection of EM. CONCLUSIONS: Early exposure and prior life experiences were associated with choosing EM earlier in medical school. The third year was identified as the most common time for definitively choosing the specialty.

Handoff Practices in Emergency Medicine: Are We Making Progress?

OBJECTIVES: Transitions of care present a risk for communication error and may adversely affect patient care. This study addresses the scope of current handoff practices amongst U.S. emergency medicine (EM) residents. In addition, it evaluates current educational and evaluation practices related to handoffs. Given the ever-increasing emphasis on transitions of care in medicine, we sought to determine if interval changes in resident transition of care education, assessment, and proficiency have occurred. METHODS: This was a cross-sectional survey study guided by the Kern model for medical curriculum development. The Council of Residency Directors Listserv provided access to 175 programs. The survey focused on elucidating current practices of handoffs from emergency physicians (EPs) to EPs, including handoff location and duration, use of any assistive tools, and handoff documentation in the emergency department (ED) patient's medical record. Multiple-choice questions were the primary vehicle for the response process. A four-point Likert-type scale was used in questions regarding perceived satisfaction and competency. Respondents were not required to answer all questions. Responses were compared to results from a similar 2011 study for interval changes. RESULTS: A total of 127 of 175 programs responded to the survey, making the overall response rate 72.6%. Over half of respondents (72 of 125, 57.6%) indicated that their ED uses a standardized handoff protocol, which is a significant increase from 43.2% in 2011 (p = 0.018). Of the programs that do have a standardized system, a majority (72 of 113, 63.7%) of resident physicians use it regularly. Significant increases were noted in the number of programs offering formal training during orientation (73.2% from 59.2%; p = 0.015), decreases in the number of programs offering no training (2.4% from 10.2%; p = 0.013), and no assessment of proficiency (51.5% from 69.8%; p = 0.006). No significant interval changes were noted in handoffs being documented in the patient's medical record (57.4%), the percentage of computer/electronic signouts, or the level of dissatisfaction with handoff tools (54.1%). Less than two-thirds of respondents (80 of 126, 63.5%) indicated that their residents were "competent" or "extremely competent" in delivering and receiving handoffs. CONCLUSIONS: An insufficient level of handoff training is currently mandated or available for EM residents, and their handoff skills appear to be developed mostly informally throughout residency training with varying results. Programs that have created a standardized protocol are not ensuring that the protocol is actually being employed in the clinical arena. Handoff proficiency most often goes unevaluated, although it is improved from 2011.

Impact of Doximity Residency Rankings on Emergency Medicine Applicant Rank Lists.

INTRODUCTION: This study investigates the impact of the Doximity rankings on the rank list choices made by residency applicants in emergency medicine (EM). METHODS: We sent an 11-item survey by email to all students who applied to EM residency programs at four different institutions representing diverse geographical regions. Students were asked questions about their perception of Doximity rankings and how it may have impacted their rank list decisions. RESULTS: Response rate was 58% of 1,372 opened electronic surveys. This study found that a majority of medical students applying to residency in EM were aware of the Doximity rankings prior to submitting rank lists (67%). One-quarter of these applicants changed the number of programs and ranks of those programs when completing their rank list based on the Doximity rankings (26%). Though the absolute number of programs changed on the rank lists was small, the results demonstrate that the EM Doximity rankings impact applicant decision-making in ranking residency programs. CONCLUSION: While applicants do not find the Doximity rankings to be important compared to other factors in the application process, the Doximity rankings result in a small change in residency applicant ranking behavior. This unvalidated ranking, based principally on reputational data rather than objective outcome criteria, thus has the potential to be detrimental to students, programs, and the public. We feel it important for specialties to develop consensus around measurable training outcomes and provide freely accessible metrics for candidate education.

Ready for Discharge? A Survey of Discharge Transition-of-Care Education and Evaluation in Emergency Medicine Residency Programs.

This study aimed to assess current education and practices of emergency medicine (EM) residents as perceived by EM program directors to determine if there are deficits in resident discharge handoff training. This survey study was guided by the Kern model for medical curriculum development. A six-member Council of EM Residency Directors (CORD) Transitions of Care task force of EM physicians performed these steps and constructed a survey. The survey was distributed to program residency directors via the CORD listserve and/or direct contact. There were 119 responses to the survey, which were collected using an online survey tool. Over 71% of the 167 American College of Graduate Medical Education (ACGME) accredited EM residency programs were represented. Of those responding, 42.9% of programs reported formal training regarding discharges during initial orientation and 5.9% reported structured curriculum outside of orientation. A majority (73.9%) of programs reported that EM residents were not routinely evaluated on their discharge proficiency. Despite the ACGME requirements requiring formal handoff curriculum and evaluation, many programs do not provide formal curriculum on the discharge transition of care or evaluate EM residents on their discharge proficiency.