Research in JACEP Open, ACEP’s peer-reviewed open access journal, features a map of the United States to show which emergency departments have round-the-clock coverage by a board-certified emergency physician.
Nothing is shocking at first glance, said emergency physician and research co-author Deborah Fletcher, MD, FACEP. Large patches of land, stretching east-to-west from Minnesota to Wyoming and north-to-south from North Dakota to Kansas reveal little or no physician coverage 24/7. Released in the April 25 edition, “Lack of 24/7 Attending Physician Coverage in U.S. Emergency Departments, 2022,” surveyed 5,622 emergency departments, and 4,621 responded to the 24/7 attending physician question.
Fletcher said the researchers were pleasantly surprised by the 82 percent response rate but disappointed to find that one in 13 EDs are without full-time attending coverage.
“When you think one in 13, that sounds bad enough, but then you realize that one in 13 represents nearly 350 EDs in the country without a physician on site at all hours,” Dr. Fletcher said. “This isn’t a turf war. It’s about patient safety, and emergency physicians care deeply about patient safety and care. Patients in in rural areas or ultra rural areas or whatever we want to call them – ultra frontier – should get quality care, too. I’m probably extra passionate about this because of what happened to me at my own hospital.”
Dr. Fletcher was working part time while caring for her children when her physician group was taken over. She was assured that shifts would still be available and nothing would change. One day, her former residency advisor broke the news that her shift would be going to nurse practitioners and physician assistants.
“It’s just business, they told me,” Dr. Fletcher recalled. “I still loved emergency medicine, and I loved the hospital in my community I worked at for 15 years. But I was replaced. That’s when I got more interested in rural emergency medicine and workforce issues. I started picking up shifts in the rural setting and absolutely loved it.”
The JACEP Open research begs the question, she said. If an emergency physician isn’t providing care when a patient presents to the ED with chest pain, what kind of care can they possibly receive? In several states, more than 30 percent lacked 24/7 coverage; the states with the highest percentages were North Dakota (58%), South Dakota (56%), and Montana (46%). Among these 344 EDs, 318 (92%) had annual visit volumes less than 10,000. Most EDs (307 [89%] of 344) were in a critical access hospital (CAH); 248 (72%) were rural, and 6 (2%) were freestanding.
Researchers used data from the National ED Inventory (NEDI)-USA survey, sent annually to the ED director of every nonfederal U.S. emergency department. The 2022 survey (administered in 2023 to all EDs open during 2022) included the question: “Is at least one attending physician (not resident) on duty in the ED 24 h/d?” The NEDI-USA database includes basic ED characteristics such as annual visit volume, critical access hospital (CAH) status, rural location, and freestanding ED status. The authors investigated the association of ED characteristics with a lack of 24/7 attending physician coverage.
The survey hadn’t always included the physician coverage question. Dr. Fletcher worked with co-author Carlos A. Camargo, Jr., MD, DrPH, to get it added.
Now armed with data, advocacy work to solve the coverage issue continues.
ACEP has a firm stance, making it clear that there is no substitute for a licensed, trained, and board-certified emergency physician. ACEP launched a campaign in 2023 to educate patients and policymakers about the importance of physician-led care teams. ACEP’s Policy Statement released in June 2023, “Guidelines Regarding the Role of Physician Assistants and Nurse Practitioners in the Emergency Department” states that non-physician clinicians do not possess the training and expertise in emergency medicine that may only be acquired through successful completion of an ACGME accredited emergency medicine residency training program.
ACEP believes that regardless of where a patient lives, all patients who present to the ED deserve to have access to high quality, patient-centric care delivered by emergency physician-led care teams. Two states recently achieved this goal. In May 2023, Indiana passed a law requiring a physician on site and responsible for the ED. In April 2024, Virginia lawmakers passed similar legislation.
“That’s the gold standard, right?” said emergency physician Leon Adelman, MD, MBA, FACEP, the author of the Emergency Medicine Workforce Newsletter. “If our grandmother is sick or our kids are in a motor vehicle accident, no matter where in the United States, the ideal is to see a board-certified emergency position within a team-based structure where all the elements of the team understand their role in managing acute care.
Adelman, who is married to a nurse practitioner, said scope creep is particularly worrisome when you consider there were fewer emergency physician in rural areas in 2023 versus 2019.
“Given that reality on the ground, what’s the best alternative?” he said. “Is it better to have a family physician rather than a nurse practitioner straight out of an online program?”
How to move forward in a less than perfect situation is where emergency physicians and ACEP members are miles apart when it comes to rural areas.
Some propose a collaboration with physicians trained in something other than emergency medicine. They say it wouldn’t be ideal, but it would be better than relying on those who didn’t complete a physician residency program. Some say broader telemedicine programs could help. Others say telemedicine isn’t a good option at all because it still takes training to implement life-saving measures. Some things can’t be explained over the phone to somebody who has never done it. Many keep a firm grasp on ACEP’s stance that a board certified, residency trained physician should remain the only option.
In 2020, ACEP’s Board of Directors convened the Rural Emergency Care Task Force to assess the landscape and provide recommendations on how to improve rural care. The 20-page document listed several recommendations, including:
- Determine how to better support emergency physicians currently working in rural EDs, acknowledging a spectrum of residency training and board certification status
- Collaborate with hospitals and other health care systems to develop strategies to avoid further rural ED closures, including ongoing support of the Critical Access Hospital (CAH) program.
- Further study small, low volume rural EDs, based on annual patient census and location, to better address specifics unique to rural care delivery.
- Encourage EM residencies to incorporate rural EM practice into their clinical curricula, working with ACGME and its Review Committee-Emergency Medicine (RC-EM) to reduce accreditation barriers program directors cite as currently limiting rural training opportunities.
Dr. Camargo and Dr. Fletcher, co-authors of the JACEP Open research along with Krislyn M. Boggs, MPH; Ashley F. Sullivan, MS, MPH; Janice A. Espinola, MPH; and Maeve Swanton, remain active members of the ACEP Rural EM Section. Frederick Carlton, MD, FACEP, an emergency physician at a regional hospital in Corinth, Mississippi, and current Rural EM Section Chair, said you would have a hard time finding a board-certified emergency physician who doesn’t think ACEP and ACEP state chapters should continue to advocate for the gold standard – a physician-led team and an emergency medicine trained physician in every ED 24/7.
He said states like Indiana and Virginia have done something all ACEP chapters should continue striving to achieve. But there’s a reality that should be recognized, he said.
“This isn’t something that can be fixed in a year or two,” Dr. Carlton said. “It might not be possible to totally solve it, but there are some things we can do that will dramatically improve it. Maybe it’s trying to work with state legislatures to provide funding to encourage board certified emergency physicians to work in these critical access rural hospitals. It’s unpopular to say in certain circles, but maybe we look at more collaboration with family physicians who want to work in these areas. Maybe we increase rural exposure in residency rotations. We have doctors who come from rural areas. But when they go to the city for residency, it’s hard to get them back.”
Anthony Gerard, MD, FACEP, an emergency physician and EM Rural Section member, said emergency physicians and family physicians are worlds apart when it comes to skillset right out of residency. He should know. Dr. Gerard trained in family medicine but practices at an ED in rural Pennsylvania. Despite the difference, he said the gap between family physician and PA or NA is exponentially wider. Rather than expect a PA or NP to learn on the job providing critical care, he said family physicians could be a better option and suggests ACEP collaborate more closely with the American Academy of Family Physicians to fill some of the gaps in frontier locations.
“I don’t think ACEP should change the gold standard for emergency medicine,” he said. “This (JACEP Open) study is important, but it points out something Dr. Carmargo published about and spoke about at conferences and in our meetings 10 years ago. We can’t continue to leave these patients out in the desert without the best possible care. We have to do something.”
Dr. Adelman and Dr. Fletcher point out that a closer look at the research suggests state advocacy is a path forward.
Louisiana, Mississippi, and Alabama are next to each other. Between 20 and 29 percent of EDs in Mississippi don’t have physician coverage 24/7, but that’s not the case in Louisiana or Alabama. The same goes for Nevada and New Mexico. Nevada reports zero EDs with a lack of coverage, while neighbor Utah is at least 10 percent. New Mexico is sandwiched between Texas and Arizona but reports full, 24/7 attending coverage.
In Louisiana, Dr. Fletcher said physicians have been working with lawmakers for more than five years on various scope of practice bills, pushing back on encroachment by NPs and PAs. Meanwhile, she said Mississippi allows telemedicine as a substitute for physician coverage.
“It’s not the same,” she said. “A physician must be on site for that to count. It’s just disappointing, and it means other states might see that and think this is a work around for them. That’s why the laws in Indiana and Virginia are so important. Fighting these battles takes a lot of time and effort. That’s why the laws in Indiana and Virginia were such a big victory.”
The new law in Virgina wasn’t represented as scope of practice legislative effort, said emergency physician Todd Parker, MD, FACEP, Virginia ACEP Past President and current board member. And that’s part of the reason it passed.
Dr. Parker said Virginia ACEP did two things that helped. First, they gathered information on all the EDs in the state and realized that there wasn’t a single ED in the state that didn’t already have 24/7 physician coverage. It wasn’t necessarily emergency physician coverage, but it was physician coverage around the clock. Second, the chapter invested money to commission a poll from a respected pollster and asked Virginians, “If your loved one had to go to the ER, who would you want treating them?” Out of thousands of responses, the results were overwhelmingly in favor of physician coverage.
That provided some important data. But it still took some luck, he said.
They found a law passed 50 years earlier that stated all EDs had to have a physician on call 24/7.
“We never sold it as a scope of practice bill,” Dr. Parker said. “When we were testifying for this, we never said anything about scope. We were just fixing an outdated law that no longer makes sense. We pointed out that with the volumes and complexity and all the things we see in the ED these days, you no longer need a physician on call. You need a physician physically present in the ER.”
Having 24/7 coverage is completely necessary, Dr. Parker said, because the distance between hospitals and specialists makes transfer a challenge. He might have to manage a critically ill patient for hours before they can be moved. You need an emergency physician for those challenges, he said.
“You could make an argument that rural hospitals need emergency physician coverage more than anybody else,” he said. “Who would you want for you or your family member? And this is the question we asked the legislator. If you or a family member is traveling across western or southwestern Virginia, get into a bad car accident, or have some sort of medical emergency, don’t you want to know that if you go to the ER that a physician is going to be taking care of you?”
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