Rural emergency departments strained by physician shortages

The geographical distribution of emergency physicians in the United States, and which health professions are providing emergency department care, are among the workforce issues examined in a new study published this week in the Annals of Emergency Medicine. The report is,  “State of the National Emergency Department Workforce: Who Provides Care Where?” 

“Emergency departments are an especially vital safety net for patients in rural settings,” said M. Kennedy Hall, a UW Medicine emergency physician and assistant professor, Department of Emergency Medicine at the University of Washington School of Medicine in Seattle. He was the lead study author.

“This study shows that there is an opportunity to address emergency medicine workforce challenges and narrow any potential gaps in training for those providing emergency care, Hall said. "Staffing differences between rural and urban communities should factor into optimal care delivery decisions and sound policymaking.”

Of 58,641 emergency medicine clinicians identified by the analysis, 61 percent (35,856) were classified as emergency physicians. Qualified health professionals who work under physician supervision, known as advanced practice providers made up 24.5 percent (14,360). Non-emergency physicians made up 14.3 percent (8,397). Among the advanced practice providers, physician assistants (68.4 percent) and nurse practitioners (31.5 percent) were most common. Among non-emergency physicians, family practice (41.7 percent) and internal medicine (19.9 percent) physicians were most represented.

In rural areas, clinicians are often trained in other specialties and advanced practice providers conduct disproportionately more emergency care, especially where there may not be an emergency physician available, the authors note.

More emergency physicians were mapped to urban counties (63.9 percent) than their rural counterparts (44.8 percent). More than one-quarter of counties (27.1 percent) had no emergency clinicians of any kind and 44.9 percent of counties had no emergency physicians reimbursed by Medicare Part B.

The highest proportion of emergency physicians can be found bi-coastally and in the Mountain Time Zone. The lowest proportions can be found in the southern United States and in the Central Time Zone.

“Our analysis revealed that more than one third of emergency department clinicians are someone other than an emergency physician,” said Hall. “This points to the need for a broader approach to emergency care training. Health systems have unique needs. Hospitals, particularly in rural areas,  will continue to be challenged to harness the provider mix in their regions.”

Hall added that the emergency services workforce is broad-based with a variety of ambulatory care skillsets in addition to emergency medicine experience.

"It is important," he said, "to provide additional emergency medicine specific training when needed, as well as examine standards for advanced practice provideds and non-emergency physicians, especially in locations where access to trained emergency physicians is limited."

The analysis was based on the 2014 Medicare Public Use Files, or MPUF dataset of 932,243 physicians. This group includes 58,641 (6 percent) unique emergency medicine clinicians. The study found at least 20,000 more emergency physicians than the previously published workforce analysis from a decade ago.

Annals of Emergency Medicine is the peer-reviewed scientific journal for the American College of Emergency Physicians, the national medical society representing emergency medicine. For more information, visit www.acep.org.

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