Supply and Demand of Board-certified Emergency Physicians by U.S. State, 2005 Ashley F. Sullivan, MS, MPH, Adit A. Ginde, MD, MPH, Janice A. Espinola, MPH, and Carlos A. Camargo Jr, MD, DrPH
Abstract Objectives: The objective was to estimate the emergency medicine (EM) board-certified emergency physician (EP) workforce supply and demand by U.S. state. Methods: The 2005 National Emergency Department Inventories-USA provided annual visit volumes for U.S. emergency departments (EDs). We estimated full-time equivalent (FTE) EP demand at each ED by dividing the actual number of visits by the estimated average EP visit volume (3,548 visits ⁄ year) and then summing FTEs by state. Our model assumed that at least one EP should be present 24 ⁄ 7 in each ED. The number of EM board-certified EPs per state was provided by the American Board of Medical Specialties (American Board of Emergency Medicine, American Board of Pediatrics) and the American Osteopathic Board of Emergency Medicine. We used U.S. Census Bureau civilian population estimates to calculate EP population density by state. Results: The supply of EM board-certified EPs was 58% of required FTEs to staff all EDs nationally and ranged from 10% in South Dakota to 104% in Hawai’i (i.e., there were more EPs than the estimated need). Texas and Florida had the largest absolute shortages of EM board-certified EPs (2,069 and 1,146, respectively). The number of EM board-certified EPs per 100,000 U.S. civilian population ranged from 3.6 in South Dakota to 13.8 in Washington, DC. States with a higher population density of EM boardcertified EPs had higher percent high school graduates and a lower percent rural population and whites. Conclusions: The supply and demand of EM board-certified EPs varies by state. Only one state had an adequate supply of EM board-certified EPs to fully staff its EDs. ACADEMIC EMERGENCY MEDICINE 2009; 16:1014–1018 ª 2009 by the Society for Academic Emergency Medicine Keywords: emergency physicians, board certification, workforce, rural, staffing
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taffing of U.S. emergency departments (EDs) poses numerous challenges because EDs are present in all parts of the country and should be prepared to handle a wide range of conditions 24 hours per day. Several national reports, including the 2002 American College of Emergency Physicians’ workforce study1 and the 2006 Institute of Medicine report, The Future of Emergency Care in the United States,2 recognize that the supply of emergency medicine (EM) boardcertified emergency physicians (EPs) is insufficient to keep up with demand. Even under optimistic supply From the Department of Emergency Medicine, Massachusetts General Hospital (AFS, JAE, CAC), Boston, MA; and the Department of Emergency Medicine, University of Colorado Denver School of Medicine (AAG), Aurora, CO. Received February 17, 2009; revisions received May 9 and May 28, 2009; accepted June 3, 2009. Reprints will not available be available. Address for correspondence: Carlos A. Camargo, MD, DrPH; e-mail:
[email protected]
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ISSN 1069-6563 PII ISSN 1069-6563583
scenarios (e.g., low EP attrition and willingness of all newly board-certified, EM residency-trained EPs to distribute themselves according to national needs) and optimistic demand scenarios (e.g., no increase in ED visit volumes), the shortage of EM board-certified EPs will persist for decades.3 In addition to EM board-certified EPs, EDs are staffed by physicians who are not EM-trained specialists (e.g., family physicians and general internists) and by midlevel providers (e.g., nurse practitioners and physician assistants).4,5 This reality, coupled with national shortages of EM board-certified EPs3 and of physicians in general,6 suggests that the distribution of EM boardcertified EPs varies. We sought to determine whether or not the distribution of EM board-certified EPs varies at the state level. Although a few individual states have assessed their EP workforces,7,8 the distribution of EM board-certified EPs across all U.S. states is unknown. Knowledge of the distribution of EM board-certified EPs will contribute to a better understanding of staffing, training, and education needs within the specialty.
ª 2009 by the Society for Academic Emergency Medicine doi: 10.1111/j.1553-2712.2009.00509.x
ACAD EMERG MED • October 2009, Vol. 16, No. 10
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Our objective was to estimate EP workforce supply and demand by state, taking into account diverse ED visit volumes and state populations. We hypothesized that EM board-certified EPs would be unevenly distributed, with the greatest concentration of EM boardcertified EPs in states with the largest populations. METHODS We used the 2005 National Emergency Department Inventories (NEDI)-USA database (October 20, 2008, data cut) to obtain a comprehensive list of all nonfederal U.S. hospitals with EDs (n = 4,828) and their annual ED visit volumes. We then calculated the total number of EDs and total visit volume for each state and Washington, DC. Methods for derivation of NEDI-USA have been previously described.9 Briefly, NEDI-USA combines data from Verispan Marketing Group’s Hospital Market Profiling Solution Database (Yardley, PA) and the American Hospital Association Annual Survey of Hospitals (Chicago, IL). Emergency Medicine Network staff (Boston, MA) independently collected information on the 5% of EDs that lacked ED visit volume data or reported an ED visit volume increase of >50% or a decrease of >30% between 2001 and 2005. EDs were defined as emergency care facilities open 24 hours per day, 7 days per week. We excluded EDs in U.S. territories and outlying areas (e.g., Puerto Rico, Guam, U.S. Virgin Islands), specialty hospitals (e.g., mental health, orthopedic, or rehabilitation hospitals; but not children’s hospitals), federal hospitals (e.g., Veterans Affairs and Indian Health Service hospitals), and college infirmaries. Such facilities and others (e.g., correctional centers) may lack formal EDs, and they are not necessarily available for use by the general public. We also excluded ‘‘freestanding EDs,’’ which include satellite EDs (where the ED remains closely affiliated with an acute care hospital) and autonomous EDs (which operate independent of an acute care hospital). We estimated demand for EPs based on several assumptions, as previously described.3 Most importantly, we assumed that at least one EP should be present 24 ⁄ 7 in each ED. Moreover, based on the most recently published EP workforce survey,1 a minimum of 5.35 full-time equivalents (FTEs) would be required to staff an ED with single coverage. We also assumed that 3,548 visits will be seen annually by the average EP, based on 2.8 patients per hour10 and working 48 weeks per year for 40 hours per week, of which 34% was spent on nonclinical requirements.1 We then calculated the demand for EPs for each ED from the following formula: Demand = Number of ED visits in 2005 ⁄ 3,548 visits. If demand for a given ED was
