Contemporary estimates of ED workplace requirements have been offered periodically, analyzing available hospital ED positions and workforce.
In 1997, it was estimated that the need for full-time emergency physicians was 20 – 25,000 positions, with a range of anywhere from 15 –30,000 ED jobs available. At that point in time, approximately one-half of the positions (13,000) were held by trained EM physicians, assuming an annual attrition rate of 3% and graduation rate of 900 – 1000 EM residents annually.1
They described a model where the current annual output of EM residents would balance a 30,000 emergency physician cohort if a 3% annual attrition rate was hypothesized, a 22,000 group if a 4% attrition but only a 15,000 ED physician group if 6% attrition was encountered. They projected that the output of EM residents would only equal demand in the year 2030. This approach does not factor in positions held by non-EM board-certified physicians performing these tasks.
The staffing proforma found that the average hospital ED had 4.96 full-time equivalent (FTE) EDPs per site working an average of 40 hours per week and 7.48 EDPs per site, factoring in part-time physicians (PTE) to the staffing mix.2 The ratio of total to full-time physicians was 1.5:1, and the ratio of American Board of Emergency Medicine Certification was 48% in 1998.
Interestingly, most (90%) residency-trained or certified EDPs worked in multiple EDs, in their day-to-day practice. The staffing models employed by hospitals were varied. Physician employees were found in 44% of hospitals, where 49% were staffed by independent contractor physicians in this study. Currently, a similar ratio applies to management-group-based contracted physicians versus hospital employed physicians (60:40).
Mid-level providers are employed in increasing numbers as well. PAs are found in 29% of EDs, where 12% utilized nurse practitioners (NPs), and 6% employed both PA/NPs to supplement physician staffing or provide goal-directed integrated care.
Their overall projection in 1998 was that the emergency medicine workforce needed 37,000 physicians, assuming 7.5 physicians per facility (5.0 FTE/2.5 PTE) or 32,000 total physicians accounting for those working as multiple slots.
A follow-up study was published in 2002 noting first a 5% decline in the number of hospitals in operation from 5329 to 5064.3 There were 7.85 total and 5.29 full-time physicians per institution on average. This physician group worked approximately 40 hours per week clinically as well.
A demographic profile of the EDP finds an average age of 42.6 years, where 83% were male, and 82% were caucasian. The training profile found practitioners were EM-trained in 42%, ABEM-certified in 50%, and certified in emergency medicine including non-ABEM “certification” pathways.
The trends noted included an increase in FTEs per institution from 5.11 to 5.35, but a 5% decline in number of hospitals overall. The staffing requirements suggested were 39,500 physicians if working a single site and 32,000 incorporating multiple-site-employed physicians.
Therefore, conclusions can be drawn concerning the ED provider work force. There are approximately 5000 hospitals and 4500 Emergency departments with 40% employee physicians and 60% subcontracted that service.4 There are approximately 40,000 ED jobs nationally with about half certified in emergency medicine with EM training in 40%.
Currently, one half of ED’s saw less than 20,000 visits annually.4 A staffing model can be predicted by ED patients seen where 15,000 annual visits or less finds it difficult to support 5 EM physicians without a significant financial stipend. This size of a facility is often staffed with family practice providers or non-ABEM EM-certified EDPs.
On the other hand, a volume of 20 to 25,000 visits with adequate payor mixture should be able to support an EM-certified physician group. It is this middle ground with 15 – 20,000 annual visits that may require a modest “investment” or stipend to obtain proper emergency department staffing with EM-trained or certified physicians.
Another commonly asked question is, “When do I need a midlevel provider to assist in the ED operation?” The single physician model allows one to see approximately 17,500 patients annually, while a 2physician model allows 26,300 patient visits. Common recommendations find that a midlevel provider is utilized in the model where between 18 – 22,000 ED visits are evaluated annually.
Certainly, these approaches and recommendations need be individualized to the specific location.
1. Holliman, C.J., Wuerz, R.C., Chapman, D.M., Hirshberg, A.J. “Workforce projections for emergency medicine: how many emergency physicians does the United States need?” Acad Emergency Medicine 1997; 4(7): 725 – 30.
2. Moorhead, J.C., Gallery, M.E., Manile, T., Chaney, W.C., Conrad, L.C., Dalsey, W.C., Herman, S., Hockberger, R.S., McDonald, S.C., Packard, D.C., Rapp, M.T., Rorrie, C.C. Jr., Schafermeyer, R.W., Schulman, R., Whitehead, D.C., Hirschkorn, C., Hogan, P. “A study of the workforce in emergency medicine.” Annals of Emergency Medicine 1998; 31(5): 595 – 607.
3. Moorhead, J.C., Gallery, M.E., Hirshkorn, C., Barnaby, D.P., Barsan, W.G., Conrad, L.C., Dalsey, W.C., Fried, M., Herman, S.H., Hogan, P., Mannie, T.E., Packard, D.C., Perina, D.G., Pollack, C.V., Rapp, M.T., Rorrie, C.C., Schafermeyer, R.W. “A study of the workforce in emergency medicine: 1999.” Annals of Emergency Medicine 2002; 40(1): 3 – 15.
4. Burt, C.W., McCaig, L.F. “Staffing, Capacity, and Ambulance Diversion in Emergency Departments: United States, 2003–04.” Advance Data From Vital and Health Statistics, U.S. Department of Health and Human Services 2006; 376; September 27: 1–12.