As the Affordable Care Act (ACA) is further implemented and more people across the United States have health insurance, the demand for physicians is sky rocketing. The LA Times recently reported how the state of California is having trouble meeting the rush of newly insured patients.
These days, demand for emergency medical staff somewhat resembles what I saw in the decade of the 1990s. From 1990-1999, we had a “candidate driven market”. There was a plethora of jobs available for emergency physicians, but while everyone wanted you, not everyone could afford you. (To make matters even more difficult, huge portions of the graduates were determined to get jobs in Colorado because they loved to ski. Never mind that the average salary back then barely topped $60 an hour)! From 2000-2006, this changed to a client driven market, and it became very competitive to get a job, especially in highly-desired lifestyle areas. Since 2006, we have the worst of both worlds: a rural candidate-driven market and an urban client-driven market, both at the same time.
There is a stark contrast between the multitude of job opportunities--with rising salaries!--in the rural areas, and the stiff competition in highly sought-after big-city areas such as SF, LA, Denver, NYC, Atlanta, Chicago, and Seattle to name only a few. Considering that the annual number of patients seen in EDs is rising across the country, and that newly minted doctors are attracted to urban areas, these numbers ring alarm bells for the urban areas.
We need to find a way to bring the rural EDs into the 21st century. New information technologies, such as the Nationwide Health Information Network and the Mobile ER, are bringing new knowledge in emergency medicine out to non-urban areas. Just as hospital departments are becoming further integrated into the Acute Care Continuum and working together, hospitals and medical staff in different geographical locations can now work together in a more coordinated fashion. Increasingly, providers working in rural settings can be linked with their counterparts in urban and academic areas and have that expertise available to them and their patients.
To mitigate the staffing problem, I think it would be helpful to have residency programs all over the country require that each resident do a rotation in a rural area. This would erase some of the myths of rural work, such as that patients pay their bills with livestock, or that rural hospitals provide poor service and have outdated diagnostic equipment. Residents would become acquainted with the advantages of working in rural areas. For example, as medical malpractice lawsuits rise across the nation and threaten the physician/patient relationship, these lawsuits are less common in rural areas. And as Imamu Tomlinson, MD points out, important lessons for the best practices of medicine can be learned outside the city in rural areas. He points to a study by iVantage Health Analytics that estimates there would be $7.2 billion in annual savings in Medicare if the average cost per urban beneficiary were equal to the average cost per rural beneficiary.
Why does Dr. Tomlinson think that the rural areas can increase efficiency? He points out that because rural EDs are often understaffed, it can actually teach physicians to decrease general utilization and not over order tests. In fact, I think the state of overall healthcare for our country might be improved if all residents (not just those in emergency medicine) were required to take a rural rotation. Not only could they learn valuable lessons about medicine, but it will also teach them more about the business of medicine, something I believe needs to be further emphasized in residency programs.
Similarly, I believe that all EM residents should experience what it’s like to practice at different levels of acuity and census, so that they can knowledgeably choose the practices that are best for them. This knowledge will further empower these providers, although it is gratifying to see the improvement already taking place. According to my research, 52% of emergency physicians still leave their jobs in the first two years. But this is in stark contrast to what I saw when I started my career 23 years ago when it was closer to 79%. I’d like to think my 20 years of educating residents on goal setting and navigating the job market has had some effect on this number. But there is no question in my mind that the average graduating resident is getting smarter about the job market. In the early days, the bulk of the moves were a result of taking the wrong job to begin with. These days, it is often a change in priority. I am working with a candidate right now who is working in his dream lifestyle area up in the Pacific Northwest. But due to the expansion of his own family, he has chosen to return to Ohio to get assistance with child care from Mom and Dad.
Another major factor that has led to the emergency physician shortage is the lowered percentage of experienced, boarded physicians in the job market. A significant number have reached retirement age and are either cutting back hours, stepping down the acuity levels or leaving the specialty altogether. Back in the 90s, emergency physicians were known as the most mobile specialty, making an average of 5 to 6 job moves in a career. Since the bubble burst in the housing market, they have become more housebound. Even if they want to make a move, it can be a struggle to sell their homes without taking a big loss, assuming they can sell them at all.
William Gibson, an innovative novelist and “noir prophet” who coined the term “cyberspace”, is quoted as saying, “The future is here, it’s just not evenly distributed.” I find this line particularly relevant to the current landscape of the healthcare workforce. The ACA and looming physician shortage does indeed make it appear that the future is here. And yet, this candidate driven workforce is by no means evenly distributed throughout our country. Improving the distribution of both medical knowledge and medical personnel over the different geographical parts of the country will benefit urban areas, rural areas, and physicians themselves.