ED work force appears stretched to its limits

The Institute of Medicine (IOM) report outlined three major dynamics — a shortage of primary care physicians, a disconnect between growing ED patient demand and shrinking capacity, and a shortage of on-call specialists — that are converging to create a dire situation for the emergency medicine work force.

"We know we are in an environment where we have severe physician work force shortages across the board in all specialties," says John C. Moorhead, MD, FACEP, former head of the department of emergency Medicine at Oregon Health & Science University, Portland, and a practicing emergency physician. "I've been working with the Association of American Medical Colleges, and they predict a probable shortage of 20% or more that will likely persist for at least 10 years."

Shortage of physicians contributes

With a shortage in primary care physicians, he explains, patients who normally could access such a physician turn to the safety net, which includes EDs. "We feel good that people can come to us, but this contributes to the overall ED crowding issue that's well described in the report," says Moorhead.

The second key point, he continues, is that despite a decrease in the number of EDs in the country, volume continues to increase and looks to continue in the foreseeable future. "As part of the solution, we are going to have to advocate for some additional funding for the work force and graduate medical education, and we believe a good portion should be devoted to emergency care," Moorhead notes.

The third key issue is the shortage of on-call specialists. "What this means to patients is that we can't assure them we'll have access to the services we'd like to provide them," Moorhead declares.

An 'innocuous' report

To a practicing ED manager, these findings are "pretty innocuous," says Gregory Henry, MD, FACEP, risk management consultant with Emergency Physicians Medical Group in Ann Arbor, MI. "The real key issue they have not addressed is who's giving out the care," he says. "You don't hear anything about using PAs [physician assistants] or techs instead of nurses."

The military has used corpsmen (soldiers able to give first aid) effectively and efficiently since World War II, Henry reports. "My own group uses 65,000 hours a year of PA time," he shares. "They can do a huge amount of preliminary screening, diagnosis, and treatment of patients." They check with physicians on certain diagnoses, and the more complicated cases are turned over immediately to the doctor, "but a huge number of cases they handle particularly well," Henry asserts.

Over the years, Henry contends, the PAs have had higher patient satisfaction rates and fewer malpractice suits against them than physicians. "When we do quality reviews on their charts, they actually do better in terms of adequately and accurately completing the charts than the docs do," he says.

One IOM recommendation Henry does agree with involves having Congress take a close look at malpractice liability. "We need to get closer to the British system, where they have one panel of experts that looks at each question," he says. "It's not an argument of paid experts, but of people who actually know what to do."

Regional call panels

One practical solution the IOM does propose involves the establishment of regional call panels — which Moorhead supports.

"We need to take a very calculated and thoughtful approach to what the solutions should be, but on a regional basis," he says. "I think we should encourage ED leaders to think not only in terms their ED, but to take a leadership approach to coordinating a system of care for the region."

Such an approach can help EDs jointly provide direction for patients to those hospitals with the resources that are needed, Moorhead says. "We have a computerized system in Portland that monitors the capability of the different hospitals," he shares. So, for example, if a hospital has a cardiac surgeon available, patients in need of cardiac surgery are sent to that facility.

Coordination across a regional system, he explains would at least allow acute care patients in ambulances to be sent to hospitals where they have the needed resources on a consistent basis.

Managers should act

Moorhead recommends that ED managers take a proactive approach starting today.

"Emergency department directors need to take what's in this report, walk into the hospital administrator's door, and begin a discussion on how we can address these issues in the short and long term," he asserts. "And we need to recruit assistance not only from administration, but from our colleagues in other specialties as well."

A lot of questions need to be raised, adds Henry. "Everyone believes they need more education, more space," he says. "Tell me, who doesn't?" Henry notes that the point is, there are things ED managers must do regardless of current conditions. For example, he notes, the IOM has called for significant congressional allocations for emergency care:

  • an initial infusion of $50 million to help offset the costs of uncompensated emergency and trauma care;
  • $88 million for projects to test ways to promote coordination and regionalization;
  • $37.5 million each year for the next five years to the Emergency Medical Services for Children Program to address deficiencies in pediatric emergency care.

However, that recommended influx of cash may not be forthcoming, Henry says. "Then what are you gonna do?" he challenges.

Still, Henry is optimistic about the future. "The smart guys will always survive. They will figure it out," he says. "But until we are willing to challenge our thought processes, we will have the 'same-old, same-old.'"


For more information on ED staffing strategies, contact:

  • John C. Moorhead, MD, FACEP, Oregon Health & Science University, 3181 S.W. Sam Jackson Park Road, Portland, OR 97239-3098. Phone: (503) 709-6285. E-mail: moorhead@ohsu.edu.