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.

Exploring How House Staff Unions Impact the Program Director-Resident Educational Alliance.

ABSTRACT: In 1999, the National Labor Relations Board determined that residents function as employees, thereby allowing them to freely unionize. From 2020 to 2023, house staff (i.e., resident physicians and fellows) unions have significantly increased, and 8 physician training centers, representing nearly 4,000 house staff, have unionized since March 2021. While unions provide residents with an important tool in effecting change in their workplace, their introduction into the educational milieu has the potential to alter the program director (PD)-resident relationship. In this article, the authors use the educational alliance framework to detail 3 factors required to support a quality educational relationship between a resident and their PD. They also elaborate on how the introduction of unions may impact the PD-resident relationship and explore the potential unintended consequences of unionization as it pertains to this relationship. The authors then use 2 social psychology theories, naïve realism and motivated reasoning, to describe common framing dynamics that lead to conflict during collective bargaining processes. They conclude by offering strategies that PDs may use to mitigate tensions that arise in contract negotiations, even without a direct seat at the table. Ultimately, PDs should anticipate continued growth of resident unions and prepare themselves and their programs for the tensions that may arise from this action. The PD role as a neutral third party ought to be preserved, which is possible if all parties set reasonable expectations for the changes in the PD's role and responsibilities under a union. PDs should understand the 3 core aspects of the educational alliance and the importance of establishing credibility with their residents early on to build a strong foundation.

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.

Gender Differences in Emergency Medicine Attending Physician Comments to Residents: A Qualitative Analysis.

Importance: Prior studies have revealed gender differences in the milestone and clinical competency committee assessment of emergency medicine (EM) residents. Objective: To explore gender disparities and the reasons for such disparities in the narrative comments from EM attending physicians to EM residents. Design, Setting, and Participants: This multicenter qualitative analysis examined 10 488 narrative comments among EM faculty and EM residents between 2015 to 2018 in 5 EM training programs in the US. Data were analyzed from 2019 to 2021. Main Outcomes and Measures: Differences in narrative comments by gender and study site. Qualitative analysis included deidentification and iterative coding of the data set using an axial coding approach, with double coding of 20% of the comments at random to assess intercoder reliability (κ, 0.84). The authors reviewed the unmasked coded data set to identify emerging themes. Summary statistics were calculated for the number of narrative comments and their coded themes by gender and study site. χ2 tests were used to determine differences in the proportion of narrative comments by gender of faculty and resident. Results: In this study of 283 EM residents, of whom 113 (40%) identified as women, and 277 EM attending physicians, of whom 95 (34%) identified as women, there were notable gender differences in the content of the narrative comments from faculty to residents. Men faculty, compared with women faculty, were more likely to provide either nonspecific comments (115 of 182 [63.2%] vs 40 of 95 [42.1%]), or no comments (3387 of 10 496 [32.3%] vs 1169 of 4548 [25.7%]; P < .001) to men and women residents. Compared with men residents, more women residents were told that they were performing below level by men and women faculty (36 of 113 [31.9%] vs 43 of 170 [25.3%]), with the most common theme including lack of confidence with procedural skills. Conclusions and Relevance: In this qualitative study of narrative comments provided by EM attending physicians to residents, multiple modifiable contributors to gender disparities in assessment were identified, including the presence, content, and specificity of comments. Among women residents, procedural competency was associated with being conflated with procedural confidence. These findings can inform interventions to improve parity in assessment across graduate medical education.

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.

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.

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.

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.

Program Visits and Residency Interviews.

Interviews and program visits play a major role in the National Resident Matching Program application process. They are a great opportunity for programs to assess applicants and vice versa. Irrespective of all other elements in the application profile, these can make it or break it for an applicant. In this article, we assist applicants in planning their residency interviews and program visits. We elaborate on the keys to success, including planning of the interviews in a proper and timely fashion, searching programs individually, conducting mock interviews, following interview and program visit etiquette, and carefully scheduling and making travel arrangements. We also guide applicants through what to expect and is expected of them during their interview and visit.

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.

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.

The Impact of Anonymity in Emergency Medicine Morbidity and Mortality Conferences: Findings from a National Survey of Resident Physicians.

INTRODUCTION: Although the Accreditation Council for Graduate Medical Education mandates structured case review and discussion as a part of residency training, there remains little guidance on how best to structure these conferences to cultivate a culture of safety, promote learning, and ensure that system-based improvements can be made. We hypothesized that anonymous case discussion was associated with a more effective, and less punitive, morbidity and mortality (M&M) conference. Secondarily, we were interested in determining whether this core structural element was correlated with the culture of safety at an institution. METHODS: We conducted a national survey at 33 emergency medicine residency programs evaluating residents' perceptions of M&M and the culture of safety at their institutions. Data was analyzed using descriptive statistics and bivariate analyses. We summarized Likert scores using mean and 95% confidence intervals. We also performed content analysis of the free-text comments and report on the themes identified. RESULTS: There were 1248 residents at the 33 programs surveyed. Of the 1002 who replied (80.3% response rate), 231 respondents reported anonymous case presentations and 744 reported non-anonymous case presentations. Residents at programs with anonymous case presentations were more likely to report that M&M was non-punitive. There were no other significant differences between anonymous and non-anonymous case presentations on any of the culture of safety domains measured. When these comments were systematically analyzed and coded, we found that the comments related to anonymity were both positive and negative. Among the themes identified were anonymity's impact on punitive response to error, the ability to learn from cases, and professional responsibility. CONCLUSION: Anonymous M&Ms are associated with a perception of a less-punitive M&M and with better ratings in several conference-specific outcomes; however, there appears to be no association between the other Agency for Healthcare Research and Quality culture of safety scores and anonymity in M&M.

Capturing Emergency Department Discharge Quality With the Care Transitions Measure: A Pilot Study.

BACKGROUND: Recent attention has been given to developing measures to capture the quality of ED transitions of care. We examined the utility of a patient-reported measure of transitional care, the Care Transitions Measure-3 (CTM-3), in the ED setting and its association with outcomes of care after ED discharge. METHODS: A telephone survey was conducted of a convenience sample of patients 14 days after discharge from two emergency departments (EDs) in an academic health system. Patients responded to three statements using a four-point agreement scale (strongly disagree, disagree, agree, strongly agree): 1) "The hospital staff took my preferences and those of my family or caregiver into account when deciding what my health care needs would be"; 2) " When I left the ER, I had a good understanding of the things I was responsible for in managing my health"; and 3) "When I left the hospital, I clearly understood the purpose for taking each of my medications." Patients were also queried about outcomes after ED discharge that are known to be related to ED care transitions including medication adherence, completion of recommended follow-up, and return visits to the ED. Multivariable logistic regression was used to determine the association between the CTM-3 score (on a 100-point scale) and outcomes of interest. RESULTS: Among 1,832 patients called, 576 were reached by phone, and 410 consented and completed our survey, representing a 22.4% response rate of patients we attempted to call. A 10-point increase in the CTM-3 score (better care experiences) was associated with a 12% decrease in the odds of having an ED return visit (adjusted odds ratio [AOR] = 0.88, 95% confidence interval [CI] = 0.77-1.00) and a 45% increase in the odds of taking prescribed medications as recommended (AOR = 1.45, 95% CI = 1.12-1.87). There was no association between CTM-3 score and completion of follow-up. CONCLUSIONS: The CTM-3 is associated with outcomes of care after an ED visit, including ED return visits and medication adherence, and may have utility as a patient-reported measure of ED transitions of care.

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.