ERs grapple with boarding, burnout and déjà vu

Emergency departments and the specialty of emergency medicine are like the well-adjusted friend who is in need of help, but everyone assumes is doing just fine. 

The specialty made headlines over the past few years for troubling reasons, including its high rate of burnout and boarding in emergency departments reaching a crisis level. COVID-19 placed an extra bright spotlight on EDs across the country, which have always been the front door of the U.S. healthcare system but took on renewed importance and even symbolism during the pandemic. It is one of the few remaining places in a divided society that cannot turn anyone away. 

As a result of this pandemic-born exposure, the specialty is also grappling with some recency bias, in which the challenges and setbacks it faces are chalked up to COVID-19's strain. In reality, the problems date back far further. It is alarming how little has improved or changed. For instance, Time Magazine devoted a cover to depict a clinician and a patient with one word in capital letters: "EMERGENCY!" Overwhelmed and understaffed, medicine's front lines are collapsing across America. It was the May 28, 1990, issue of the magazine. 

Nearly 33 years later, the specialty made news again, this time for a clunker of a Match Week. In 2023, more than 550 emergency medicine residency positions were unfilled, more than double the 219 unfilled positions a year prior. The Supplemental Offer and Acceptance Program ended up filling 501 of the open spots, reducing the near-term threat to EDs. But questions and concerns about the specialty's appeal and talent pipeline remain.

It's interesting when a specialty and place well-accustomed to crises, trauma and high stress endures emergencies of its very own. Christopher Kang, MD, president of the American College of Emergency Physicians, discussed the Match Week numbers with the calm, undaunted attitude that is a trademark of his profession. 

"Every specialty has encountered this," Dr. Kang said about the supply-demand mismatch. ACEP and other emergency medicine organizations have closely monitored the increasing number of residency and residency spots over the past several years and conveyed their concerns to the Accreditation Council for Graduate Medical Education.

Dr. Kang pointed to other medical specialties that received increased interest or demand among aspiring physicians that can eventually exceed the space available to teach them. It takes years, then, to develop and stand up new residency programs. A lag can then occur, in which the high demand lessens and the increased supply of residency spots results in a surplus. The number of emergency medicine residency programs grew from 82 in 1990 to 239 in 2018, according to figures from the ACGME.

EDs that have one or two unfilled residency positions within their programs may feel the shortfall, but Dr. Kang doesn't expect Match Week 2023 to be palpable for patients in the day to day. Instead, he sees the need to identify what caused the number of initially unfilled positions to more than double in one year. Did applicants' expectations change? Did emergency medicine residency programs do enough to recruit talent, or was there some resting on laurels at play? How have working conditions in emergency departments changed over the course of the pandemic?

As individual programs assess specific needs, ACEP plans to review the more complete picture of match data in May to address the wide range of concerns with the totality of available data.

"This is an opportunity for programs to evaluate what they offer," Dr. Kang said. "The younger generation may have different priorities and expectations."

While the initial shortfall of emergency medicine residents may not be felt by patients, another persistent problem is — ED boarding, in which patients are held in the emergency department after admission to the hospital because no inpatient beds are available. Boarding came to light as a source of concern in the 1980s. It is linked to increased medication errors, increased ambulance diversions, inadequate patient privacy and longer wait times, among other adverse effects.

As of late, the problem has been compounded by shortages of healthcare workers. This past fall, a charge nurse named Kelsay Irby in Washington made headlines for contacting a 911 dispatcher from her own overcrowded emergency room, requesting backup from local fire and backup workers. The shift was understaffed for a scene that resembled "an airport gate where the flight's just been canceled," with people sitting in wheelchairs because there weren't enough regular chairs, sitting on the floor, sick kids and their parents and ambulance crews with patients waiting to be seen, according to a report about the incident featured on This American Life.

In November, ED boarding reached a point where ACEP led the call to declare this crisis a public health emergency, joined by numerous medical associations and patient groups. They wrote to President Joe Biden asking that he convene a summit of stakeholders from across the healthcare system to identify long-term solutions to boarding.

Dr. Kang, as representative of about 40,000 members of the specialty, reconvened with representatives from the White House and federal agencies in mid-March to alert them that ED boarding was not a symptom of the "tripledemic," but is an ongoing problem hurting patients, communities and healthcare workers. The White House has yet to identify next steps.

"The public has increasingly complex health issues, such as delayed diagnoses without primary care, substance use and mental health," Dr. Kang said. "These issues have been ignored now for 20 to 30 years, in addition to boarding."

Dysfunction is unwanted in any healthcare setting, but the ED is a particularly high-stakes one for systemic problems to play out. Emergency medicine physicians are the key decision-makers for about half of all inpatient hospital admissions, a 2013 Rand Corp. study found. Nearly half of all U.S. medical care is delivered by EDs, a 2017 study out of University of Maryland School of Medicine found. ED visits for mental health and substance-use issues have been on the rise for years, and a weak primary care system means EDs are the safety-net for the most vulnerable, making the departments decisive spaces for progress toward health equity.

At the same time, the cost of care delivered in EDs is in policymakers' and payers' crosshairs, leading to payment and reimbursement cuts. Reimbursement by Medicare for the 20 most common emergency medicine services decreased by an average of 29 percent from 2000 to 2020 after adjusting for inflation, according to the Annals of Emergency Medicine.

"We were there throughout COVID-19, ready for any disaster. Who gives business to the specialties? Who coordinates the number of cases for radiology, lab and pharmacy? Who serves the public whenever they walk through the doors or via EMS?" said Dr. Kang. Somewhere along the way, he says, there has been gradual loss of respect and "lack of acknowledgement."

Lack of acknowledgement. It's one more thing emergency medicine has long wrestled with, going unrecognized as a medical specialty by the American Board of Medical Specialties until 1979. In addition to misgivings about its validity (Dr. Kang says emergency physicians are still asked when they will choose a specialty), a rise in violence against ED staff compounds any sense of underappreciation.

Pre-pandemic, nearly half of emergency physicians said they had been assaulted and about 70 percent of emergency nurses said they had been hit and kicked on the job. These numbers are likely significantly higher today, given that nearly 70 percent of emergency physicians last year said violence has increased in the past five years, with 25 percent reporting it has surged.

As many problems as emergency medicine and EDs face, Dr. Kang is resolute that despite them — or even because of them — the specialty will continue to draw mission-driven people.

"Hundreds of excited medical students are thrilled to match into emergency medicine. If you want to serve anybody at any time anywhere they come — that's the heart of our specialty. Emergency medicine physicians are usually ready to take on any challenge; that speaks to the character of the specialty," he said.

"None of those things have changed. The working conditions have changed, and somewhere along the way reimbursement and employment have been impacted. Those are big challenges. What are we going to do about them? Because the core of emergency medicine is still there, and it's still true."

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