Since publication of the multi-organization workforce report led by the American College of Emergency Physicians (ACEP), graduating emergency medicine residents have feared an empty job market.¹ Additionally, practicing physicians have considered the loss of job security and relatively high income they potentially took for granted amidst decades of rising emergency department (ED) visit volumes, increasing patient acuity, and prior physician shortages. With an assumed three percent annual emergency-physician attrition rate, the report forecasted a potential oversupply of 7,845 emergency physicians by 2030 after also taking into account emergency services and graduate medical education growth.¹ However, less attention was drawn to the report’s sensitivity analysis showing that if attrition was just one percent higher than assumed, then the estimated surplus would be a more modest 2,486 emergency physicians.

In the pre-COVID-19 era, clinical practice slowly evolved to accommodate fewer night shifts and offer other opportunities for extended practice. But the Great Resignation during COVID-19 has drawn more attention to emergency physician attrition, prompting us to pause and re-evaluate the workforce conversation. Here, we provide a brief overview of our recently published findings that emergency physician annual attrition from the workforce between 2013 and 2019 was collectively greater than estimated in the recent workforce report, with important implications for workforce supply and demand in coming years.²

The Attrition Analysis

Every year, the Centers for Medicare and Medicaid Services (CMS) release reliable national data on the clinical care practices of physicians. We used this dataset to look at clinicians providing emergency services to greater than 50 Medicare beneficiaries in at least one of the study years between 2013 and 2019.

Rural Inequities

Since publication of the workforce report, many have cited concerns about the concurrent physician surplus projections alongside known geographic disparities—namely, the lack of residency-trained or board-certified emergency physicians in rural communities. The CMS data were ideal to investigate this. We identified that emergency physicians comprised 71.2 percent of the emergency-clinician urban workforce in 2013 and 51.3 percent of the rural workforce. For every study year, the number of rural emergency physicians leaving the workforce was always greater than the number of rural emergency physicians entering the workforce the following year.

Supply and Demand at the State Level

Recognizing that physician credentialing, perception of medical malpractice costs, environment, and efforts to recruit emergency physicians are often realized at the state level, we also looked at clinician supply and demand at this more granular level, as efforts to overcome inequities are more complicated than a binary division between rural and urban areas. For each state, we determined clinician densities per 100,000 population in 2013 and 2019, followed by the percent net change, reflecting how much the density increased or decreased from 2013 to 2019. The three jurisdictions in 2013 with the highest emergency physician density per 100,000 population were Washington D.C. (23.0), Michigan (16.5), and Rhode Island (16.4), while the three states with the lowest emergency physician density were South Dakota (6.0), Nebraska (6.9), and Montana (7.0).

By 2019, the three states with the highest percent net change in emergency physicians were Montana (+49.8), South Dakota (+36.7), and Vermont (+29.6). These three states all exhibited relatively low 2013 emergency physician densities and therefore the high net change seemed to be a reassuring finding, as emergency physicians migrated to the states where there was a perceived need for their services.

However, three states in the lowest quintile for 2013 emergency physician density also had negative percent net change by 2019. Idaho (-3.2), Arkansas (-2.6), and Nevada (-0.8) display concerning needs to further increase emergency physician density without positive change occurring over the study years. Separately, we identified clinician-dense states in which another mismatch of supply and demand occurred. Despite already being in the highest quintile of 2013 emergency physician density, states such as Rhode Island (+25.8), Pennsylvania (+19.2), and Michigan (+18.5) all still saw substantial increases in emergency physician density by 2019.

Implications

These findings are salient given worsening inequities in access to emergency physicians, specifically in rural designations. We anticipate persistence of the supply-and-demand mismatch unless substantial efforts are made to address emergency physician recruitment and retention issues. Additionally, these findings are particularly important considering the recent 2022 Match. Despite an increase in emergency medicine residency positions over the last several years, the number of medical school graduates matching into emergency medicine has plateaued. Data from the 2022 cycle even suggests that the entering pipeline may be diminishing, as the number of emergency medicine residency applicants decreased 17 percent (the largest decrease among all specialties) and the number of unfilled residency positions rose from 14 to 219 compared to the 2021 application season.3 It is therefore possible that the combination of increased attrition and decreased entry may reduce the magnitude of the expected 2030 surplus. Two key questions result:

1. Will inflow to the emergency medicine workforce continue to stagnate or even decline?
2. Will outflow from the emergency medicine workforce continue to increase? At minimum, if more recent attrition numbers mirror the years before COVID-19, the actual surplus may pale in comparison to prior expectations.

Looking Ahead

Amidst the Great Resignation, the emergency medicine community must preserve our workforce by ensuring a supportive work environment, redesigning care to accommodate shifts in the workforce, and developing approaches for periodic real-time future surveillance. This is all to avoid today’s feared surplus from turning into a shortage that leaves patients without quality emergency care in a few short decades.

Dr. Gettel (@camerongettel) is an assistant professor of emergency medicine at the Yale School of Medicine.

Dr. Courtney (@dmark123w10) is a professor and executive vice chair of emergency medicine at the UT Southwestern Medical Center.

Dr. Venkatesh (@arjunvenkatesh) is an associate professor of emergency medicine at the Yale School of Medicine.

References

1. Marco CA, Courtney DM, Ling LJ, et al. The emergency medicine physician workforce: projections for 2030. Ann Emerg Med. 2021;78(6):726-737.
2. Gettel CJ, Courtney DM, Janke AT, et al. The 2013-2019 emergency medicine workforce: clinician entry and attrition across the US geography. Ann Emerg Med. 2022.80(3):260-271.
3. Association of American Medical Colleges. ERAS Statistics [online data repository]. Available at: https://www.aamc.org/data-reports/interactive-data/eras-statistics-data. Accessed May 7, 2022.

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