May 10, 2022

EM Workforce Section Town Hall - April 30, 2022

The following is a transcript of the EM Workforce Section Town Hall. Note: This audio transcript references a visual presentation included in the video above.

[Dr. Fletcher] Hi, good morning for those that are already here. I'm Debbie Fletcher. I am the ACEP Emergency Medicine Workforce Section chair. And we wanted to have a town hall so that everyone can know all of the things we're working with for workforce, and that ACEP is doing. And there's a lot going on right now. We're having some good wins. We are having a lot of good conversations with different groups. And it's actually been pretty fun watching all of the things that we're getting to do. So we have Dr. Schmitz, we have Dr. Kang. A lot of our other board members are here, Dr. Corey, Dr. Stanton. So those who are here, thank you. And we'll get started soon.

[Dr. Schmitz] Maybe we can start with just some introductions and give people just another 30 seconds or so, but just to be respectful of everybody's time. And Debbie, thank you so much for your leadership and your idea of doing this. I think one of our big goals this year was to increase communication and help with transparency. So this is a perfect way to kind of have that two way communication and be able to really talk about the exciting things that ACEP's doing. So, hi everybody, I'm Gillian Schmitz. I'm an emergency physician in San Antonio, Texas, and I am the ACEP president this year. And I will turn it over to Chris Kang.

[Dr. Kang] Hi, good to have everybody. Chris Kang, practicing physician in the Seattle Washington area, and I have the privilege of being on also on the ACEP board of directors. Gillian, if you wanna identify who you wanna bring next.

[Dr. Schmitz] Sure, Rami Khouri. You're on mute, Rami.

[Dr. Khouri] Good afternoon or good morning, everybody. I'm Rami Corey. I'm a practicing emergency physician, a democratic group in metropolitan Detroit. Also participate a lot in the operations in the business side of running a democratic group, and also ACEP board of directors and the liaison to this section.

[Dr. Schmitz] And Ryan Stanton.

[Dr. Stanton] Come on, it's two years of the pandemic. We gotta know the mute button. Hey, I'm Ryan Stanton, I'm an emergency physician out of Lexington, Kentucky. I'm actually in a vehicle, just landed in Dover, Delaware. So I'm an emergency physician in Lexington, but also traveling motor sports physician for NASCAR SRX and Road to Indie. So just landed here for a race weekend. But very much into the group management advocacy side of things. And one of those also proponents for the many, many wonderful and cool things that emergency physicians can do with these specialty and training that we have. So thanks for joining everybody and turning back over to you, Gillian.

[Schmitz] All right. So I got some of the questions ahead of time, and thank you for those who contributed some questions. I tried to weave them into a little bit of an update, so I can give you kind of a high level overview of what ACEP is doing. So we'll spend that kind of on the first half and the second half, we'll really kind of jump into some questions and get into kind of some feedback from the board. Can you guys see my screen okay?

All right, so this is a little bit of a workforce update. And as Debbie mentioned, things are changing like literally day-to-day. So I feel like these continuously get updated, but as of the end of April, here is where we are, and here's what we're working on.

Many of you may kind of feel ACEP's a little different, that things are changing, and that is intentional. This board has worked incredibly hard over the last really year on developing our strategic plan. And part of that is having a new executive director, which has been a nice way to take a fresh look at our strategic plan and really come up with a new roadmap of where we're going.

One of the things that I thought was really exciting that came out of our strategic plan was looking at who are we? Where are we going? And what do we really believe is sort of our mission and our vision. And everyone who came to our retreat; and this involved members, board members, staff, were given two different dots, a red dot and a blue dot. And we were asked to kind of look at who we advocate for? What is our purpose? And we put sort of the specialty of emergency medicine on one side, and then the individual emergency physician on the other side. And the red dots were meant to say, as of today, where is ACEP? Who do we advocate for? And you can see there's pretty wide distribution there, but we're pretty much in the middle. And that has always been sort of our historical purpose, was that when ACEP, started, the specialty didn't exist. And so much of what our advocacy efforts were focused on both the specialty, the patient and the physician.

And the blue dots, the bottom, were looking forward, what is our vision for change and where do we need to go? And this was really kind of an exciting, I think, 'a-ha' moment of where we need to kind of pivot and understand that we need to be a little bit more member-centric. And so we are always patient-focused, but there is an intentional effort now with our strategic plan to really be listening and mindful of the needs of the individual emergency physician. And I think that's where you're seeing a lot of sort of change and emphasis and energy of where our direction is going over the past several months.

So these were sort of the questions that I heard people talking about; reimbursement, consolidation, workforce, and scope of practice. ACEP is doing a lot of other things in different arenas, but we're gonna focus really on those four things today.

The most pivotable slide in all of this though to understanding workforce is people have to have an understanding of reimbursement. Everyone's payor mixes right by ED are a little bit different. But if we could take all 5,000 emergency departments and look at who comes and utilizes our service as an emergency medicine, the payor mix would be broken up roughly by this. And this was sort of pre-COVID. Then about a third of our patients have private insurance, things like Blue Cross Blue Shield, Aetna United, that generally reimburses fairly well. A third of our patients have Medicaid, and Medicaid pays maybe 10 cents on the dollar. So we lose a significant amount of money on Medicaid. Self Pay for all intents and purposes is really no pay. And that last third is made up of a combination of self pay, Medicare and TRICARE workers' comp. Medicare pay is better, but still is less in the cost of care. So effectively two thirds of our patients do not pay the cost of care. And that is unique to emergency medicine because we're the only one that has that EMTALA mandate that we are are proud to take care of anyone, anywhere, anytime, but it is an unfunded mandate. And so much of these workforce discussions revolve around the fact that a third of our patients have to pay for everybody else, that there has to be some cost shifting. And that has probably shrunk even during the pandemic to closer to a quarter of our payor mix. So if we are not getting adequately reimbursed by the private insurers, that whole health care safety net really falls apart pretty quickly.

One of the main discussions of how we have to start talking about how we change paying for health care, because this is becoming increasingly unsustainable. And why many groups are looking to extend nurse practitioner or PA coverage, or to expand their residency programs, or to open new residency programs, because everyone is trying to make that margin work that has become smaller and smaller and smaller over time.

The other thing that changed a number of years ago was that we are moving from a fee for service, where you used to get paid on how many tests you ordered, to really being paid for value. And what is value? Well, it's basically quality divided by cost. And so everyone is looking at, well, how do we shave off that cost to try and increase our value? And at the same time, there's been an increasing amount of private equity investment in healthcare. Why? Because it's one of the major sectors in the US economy, but also because there were opportunities to really improve that scale. And so they have invested in all aspects of healthcare, whether it's pharmacies, the technology, the physician staffing groups, the hospitals and health systems themselves, is really transforming the landscape of medicine. And that really moved to value and quality has really shifted market forces towards mergers and acquisitions.

We've seen, I mean, thousands of mergers and acquisitions, and this is escalating at an increasing pace where hospitals are now mega health systems. There used to be dozens and dozens of insurance companies. And now for all intents and purposes, there's three or four. In many counties and many states, there really are only one or two. So we're seeing these sort of relative monopolies of the payers.

And when that happens, many of the physician staffing groups and hospitals are also trying to merge to be able to have that same leverage, right? If an insurance company has a relative monopoly, they can control the rates and say, take it or break it, this is what we're offering you. So the larger you are, the more negotiating power you have. And this is driven this increase in consolidations on both sides as sort of a tug of war between the payers on one side and the physicians and hospitals on the other side. And we've seen, this is a study that was published in Annals that looked at this really group practice size consolidation, emergency medicine. And it used to be that there was about one in seven emergency physicians were looking, working for a larger group, now is estimated to be one in four or even less than that. And we know that starting in about 2017 for the first time, the majority of physicians no longer own their own practices. We are employed either by a group or a hospital or a health system. And it has driven a lot of questions about how does that impact our autonomy and our practice. And it really begs the question, is bigger better?

This is happening across all different industries and why the federal trade commission has been so interested in this impact of Home Depot is now sort of the CMG of the mom and pop hardware stores. Amazon has put a number of companies out of business because everyone is trying to gain leverage of that scale. That when you have that size, not only do you have the negotiating powers, but you're able to better distribute those costs and be able to sell things potentially at a lower cost. And so this is impacting not just healthcare, but really many different aspects of the economy. And the concern is with this increase in consolidation, does that actually decrease competition? Would it increase prices because now there's only one or two people or players in that industry?

In emergency medicine, there's something called horizontal integration and vertical integration. So horizontal is when one group buys another group and becomes larger. But what we're starting to see with an increasing sort of passion in emergency medicine is this vertical integration where now groups are coming in and they're not just buying another emergency medicine group, they're getting into anesthesia, into the hospitalists, into other parts that they offer a potentially more lucrative, valuable package as seen from the eyes of the hospital. And because of that economy of scale, they don't need a subsidy. And those subsidies are rapidly going away that we often think as the customer being the patient. But from a business perspective, the customer really is the hospital, as the one who determines who gets the contract. And if a group comes in and they can bring in not just emergency medicine, but they can staff many different departments in the hospital, from the hospital's perspective, that is a valuable thing. And so what we're seeing is this change in contracts and the change in how that healthcare delivery and staffing is occurring as this vertical consolidation has really accelerated throughout all of healthcare. And this is driven again, largely by market forces.

I think this is one of the frustrating things for many of us is that we can influence certain aspects of the market, but we don't control market forces. This is gonna be followed by really money of where is that money going? What is driving that consolidation? And how do we influence those different levers to be able to ensure fair practices for physicians? And so the Federal Trade Commission had reached out publicly and said, we wanna hear not just how this impacts the end user, the patients, we also wanna hear how this impacts the staff, the employers, the people who work for different industries. And so they put out a call for comments publicly.

ACEP took this one step further and asked for feedback individually so we could comprise a letter kind of combining and have actual data that we could present, not just one kind of anecdote at a time, but of everyone we surveyed, here's what we're hearing. And so we did that a few weeks ago and had a couple meetings with the Federal Trade Commission to understand exactly what it was they wanted us to answer so that we could hit really all parts of their question to try and consolidate those really responses. We had a pretty robust response. We had over a hundred responses. And we also encouraged our members to reach out individually so that their voices were heard.

There was some mixed feedback, but overall it was pretty negative about how people viewed consolidation, and how it was impacting their process specifically related to losing their practice rights with due process, with transparency and billing. There was concern about monopolies and not being able to have a choice of where they worked, that that competition has really been removed. And many people who are concerned about where things are going. We submitted our formal letter just last week, that is publicly available. And I'm happy to share it with anyone who would like to review it. And we are waiting to kind of hear back their response at this point.

This is a copy of that letter again, on behalf of our 40,000 members, really speaking to the effects of consolidation and the impact that we're seeing on emergency medicine practice. We also supported the AAEM-PG lawsuit against envision. This was based on a number of principles that ACEP has always had about what we believe about the corporate practice of medicine. That we absolutely believe that physicians should have due process. We absolutely believe that it should be a physician, not somebody else making the decision about how you staff an emergency department, how you make those clinical decisions at the bedside. And that that patient physician relationship is sacred. And that really corporate influence should never be impacting patient care.

We submitted an amicus brief last month to help really push and advocate for what we believe about the corporate practice of management. Just last week, we introduced a resolution that will be going to the AMA. This was a resolution that came out of our ACEP Council meeting to really look at whistleblower protections surrounding wrongful termination. And we've heard a number of individual stories this year about people not having due process, or being fired for speaking up about not having adequate PPE or other kinds of quality, really safety things for the hospital. And this is a fundamental right for emergency physicians, and we should be speaking up for this and we have. We will be introducing a bill working with several members of Congress on due process. And that's gonna be one of our three really advocacy asks at our leadership and advocacy conference just next week.

But yesterday we were finalizing kind of a resolution that we will also be submitting to the AMA. And it's based really on model legislation that came out of Arizona, that will help really remove any third party requirements that would waive a due process rights or limit the ability of a physician to speak out if they have questions about safety and sort of workplace environment that compromises patient care.

We also put out a statement on private equity and corporate investment and emergency medicine. And this was passed at our board meeting, I think just last month, where we're talking about that really any practice can have good or bad behaviors, but that private equity deserves a little extra layer of scrutiny. The practice model of having to make a profit in short term, and to flip a company of where those dollars are going, raises an additional level of scrutiny that we are concerned about the role of private equity and corporate investment in healthcare. And now have the statement speaking to that as well.

I've met with a number of people over the last year looking at different practice models and understanding really the business of emergency medicine. And one analogy that someone brought up to me that I thought was interesting was looking at Blockbuster. And Blockbuster used to be really one of the most thriving businesses in the United States. And many people spent their weekends looking for videos and really having that little tagline of, be kind, please rewind that seems so dated now. But much of this is that they didn't anticipate how the landscape was changing around them. They didn't see Netflix or Apple TV coming, and they made themselves largely irrelevant.

Now in Texas, many of those Blockbusters, ironically, are now freestanding emergency departments, but this is something that we don't want to be Blockbuster. We wanna be ahead of the eight ball and looking at how do we sort out what is changing in the landscape of emergency medicine and continue to be competitive? And there are a number of emergency physicians and healthcare economists who have growing concerns that the current model of a small democratic group may not be sustainable in this reimbursement environment. In particular, as Medicare continues to get slashed and not even keeping up with inflation. Depending on the impact of Adam network billing, the CBO had estimated a 15 to 20% cut in reimbursement for all emergency medicine groups. That that is going to really make it difficult for small groups to stay relevant. So how do we protect that model of care? How do we make sure that those practices can thrive?

And so one of the things that ACEP is doing new this year is putting together an Independent EM Group Master Class. We're calling it the Indy Class that's partnering with embassy, which is made up of a group of all small democratic groups. It's gonna be August 23- 25. And it's going to be really teaching groups that want to either start their own group, or groups that are currently small democratic groups of really understanding the nitty gritty of how to maintain your contract, how to put in a successful RFP, how to take back really your practice, and ensure that you are competitive with this very concerning reimbursement environment that we're working in to ensure that that model remains sustainable and doesn't turn into Blockbuster. That we are doing everything we can to advocate for competitive practices and people being able to start their own groups.

I'm gonna pivot a little bit to workforce, because there were a number of questions about workforce. So many people were concerned with this year's Match-- what does this mean and how is this different from prior years? So for the first time we saw before the SOAP, which used to be the scramble, that we had a 7.5% unfilled rate. And that this was concerning because historically, emergency medicine has always filled our slots.

There was a lot of conspiracy theories on social media and different platforms of why this was and what happened. And a lot of misinformation that I heard about that the medical students are leaving in mass exodus. That people are not applying to emergency medicine. And that is not true. The number of applicants was actually pretty roughly the same of where we've been historically over time. This [data] was taken from the mid-Match season. So in December, you can kind of see that trend over time of the number of applicants and those that were MD, DO, or international medical grads.

What happened in 2021? That was match year starting in 2020 and match day 2021 was that, that was really the first year of the pandemic. It was when people were banging pots and pans, and we were health care heroes. So we saw this unusual surge in the number of applications really that year. And then in 2022, after the Workforce study, after the pandemic has been going on for two years, there was a drop if you just look at that one year, but I think that really gives sort of a not a good characterization, if you just look at one year.

I think it's more helpful to look at trends over time. And if you see where we are today relative to really the last five years, the number of applicants is pretty much the same. In fact, we had more this year than we did in 2019. So we're still one of the more competitive specialties, and we hope to stay that way in emergency medicine.

I think the reason we didn't fill was actually more multifactorial. Part of it was that we are continuing to increase the number of residency slots. We've had a 30% increase in residency slots over the last five years. And the more you dilute that denominator, the more our not going to fill.

The second reason is that many programs, frankly, just didn't do a fantastic job of making their rank list long enough. Many people thought they would stop at at 30 and they didn't rank a number of their applicants. And had they expanded their list to 60 or 90 spots, they probably would have filled. We don't know the results of the scramble just yet so we'll have to see how everything turns out. But I think that, combined with the fact that there were no in-person  rotations and interviews this year, that all of those things caused a little bit of chaos in the match. And it's really too early to say what those trends are going to be, but we're clearly watching it very carefully.

So what is ACEP doing? I've talked a lot about the five pillars, but just to give kind of an update of what ACEP is doing to address workforce issues.

Pillar number one is really defining the residency standards for the future. We have been meeting every two weeks for the last six months with all of the EM organizations to look about how we address standards, looking at the future. And do we need to tweak the number of procedures, the types of scholarly activity, the types of core faculty to ensure that our residents graduating in the future have the skills that they need as our specialty continues to evolve and change. We will be submitting those recommendations to the ACGME hopefully in the next couple weeks. And they start in their deep dive of strategic planning in May to really look at, how do we change those standards for the future?

We've talked a little bit about, and I know there were some questions about can't we just put a moratorium on residency programs? Although I wish we could, we can't. And the ACGME has made it very clear that they are interested in looking at the standards to define quality and education, but not making changes just because of workforce issues. But if we raise the standards sufficiently, if we are really looking at, what is required to start a residency it will secondarily have some impact on workforce and the number of programs that can open. And these are just some of the general topics of things that we have discussed with all the EM organizations.

I will just say it has been a pleasure to work with everyone. It has been incredibly collaborative, and it is impressive with such varied opinions and backgrounds, how much alignment and agreement there was on how we can raise the bar.

Number two has been ensuring business interest, do not supersede education or patient care. There have been a number of hospitals and health systems who have started residency programs really over the last number of years. And it expands really all ownership types. It's for profit, it's not for profit, it's public. Everyone is getting into this game because it makes sense from a business perspective to really open up new residency programs. And one of the things I did not realize until I really started looking at this, is that what we're seeing is this really shift in community hospitals that are now starting residency programs. And the reason is because they're not held to the cap that was instituted a number of years ago on the number of residency slots.

If I'm a community hospital, I've never had GME, I can start a residency program in six months. And I have five years to maximize my number of slots before that cap is set. So if I'm doing it to start really to help get GME funding, I'm going to go big and I'm gonna go fast, and I'm going to start as many residency programs as I can in five years to maximize that cap. And of all the different specialties, emergency medicine is one of the easiest residencies to start. And so this has been a concern of how and where that growth is occurring.

We've been trying to meet with many of these health systems that are starting residency programs, one, to make sure that they know what our workforce data shows and to really express our concern and leverage really ACEP's 40,000 members to say that we are watching this very carefully, and that we have grave concerns about the long term impacts of this residency growth. And their chief clinical officer has met with us a couple times now and expanded that they are being responsive to our feedback. They're looking at where they're opening residencies and rural and urban areas. And they are looking to even potentially convert some of their GME slots in emergency medicine to other specialties and subspecialties. So I appreciate that we have that dialogue and really that unique opportunity to meet with many of these groups that are starting residencies, to make sure that we're really working off the same set of data and that our long term goals and objectives are in alignment, and that they understand really what our concerns are regarding the emergency medicine workforce.

We're also looking at how do we support emergency physicians in rural communities, knowing that currently there are actually a ton of jobs, but they're just not being filled by emergency physicians. And how do we make these jobs more lucrative, more incentive for emergency physicians to take those jobs?

One way is looking at loan repayment. I work in the military system where many of my residents are committed to a four longer year to serve the country and have their medical student debt forgiven. What if we did the same thing in rural areas? And if people worked in rural Kansas for four years after graduation, that they would have their medical student debt forgiven and would that increase their likelihood of staying after they finished that short term commitment? So that's something that we're looking at, as well as increasing the number of rural rotations during residency and exposure, so they have that confidence and that training of working in a very different type of environment, and a resource kind of poor environment where you may not have all the subspecialties.

A big effort over the last couple of months has been focusing on scope of practice for nurse practitioners and PAs. And we are hearing this very loudly from many of our members about how do we emphasize the value of emergency medicine and be a collaborative team, but really still emphasize physician-led care?

Last year we joined the AMA scope of practice partnership. This has been a great partnership to work with not just emergency medicine, but all specialties who are impacted by these scope of practice laws, and really being able to share resources, talking points, advocacy issues, to be able to increase our voice, and really fight with multiple other different specialties who are aligned in our talking points and our message about scope expansion.

We launched a campaign last month on Doctor's Day on the value of emergency medicine. So taking the AMA stuff, but now making it specific to emergency medicine of who is the most qualified person in an emergency department? And let's highlight really the difference in training and education. And all of those videos, there's a longer one. And then we broke them into sort of 30 to 90 second videos to be able to share that a nurse practitioner does 500 hours of training, but for a physician, it's at least 12,000 hours. And by the way, those 12,000 hours are all in-person. They're not online. They're on real patients, they're not simulated cases. And that that training is incredibly important and vital when we're talking about emergency medicine, because we deal with the undifferent patient and the risks and mistakes are so much higher.

We've testified in a number of states in many of our state chapters, because this is a state issue have been really strong in fighting and pushing back against this. We had some wins recently in South Dakota and in Wisconsin, but in a number of states, this will continue to be an ongoing issue. And we need to really help strengthen our state chapters to ensure they have the resources they need to try and fight this at a state advocacy level as well.

On that note, we passed a number of policies to help really give some teeth and strength to what we believe is ACEP in scope of practice. And so we passed a policy back a year ago now using the term resident and residency training in a medical setting should only apply to physicians that we recognize that nurse practitioners and PAs may have ongoing postgraduate programs, but they're not residents. And that words matter. And that we need to stand by our members and their training to really ensure that those words mean something and differentiate a physician from a non-physician.

Last year, actually two years ago, excuse me, we put together a task force of all the different EM groups. So AAM, CORD, SAEM. We included SEMPA, which represents the PAs and the nurse practitioner organizations to get everyone at the same table and see, can we agree on definitions of what is supervision in the emergency department and what is adequate supervision? And that's incredibly challenging when you have so many different stakeholders with so many different beliefs. But the group did really good work. And the task force came up, essentially, with three definitions of what is currently really happening in emergency departments across the country.

They made a couple definitions. The first is direct supervision where an emergency physician sees every patient in the ed. Indirect supervision is where they discuss the plan in real time, but they don't necessarily go back and see the patient or reexamine them. And this can either be done onsite or offsite through telemedicine. And they defined a third category called oversight where an emergency physician is available, but doesn't necessarily know about every patient in real time. That the PA or NP decides which patient they're going to present. And then the chart is reviewed sort of after the fact.

So ACEP took this back and said, well, that's what the task force said, but what does ACEP believe is supervision? And we decided that oversight is not supervision. That if there's not real-time discussion of every patient before they leave the department, that is quality assurance if you're reviewing the chart, but that's not really supervision. And so we don't count that as a form of supervision. We also had a robust discussion on offsite and decided that if you're supervising via telemedicine, we acknowledge that many rural critical access hospitals may never have a board certified emergency physician, although that is the gold standard. But that if we're going to be doing any kind of remote supervision, that that would only be allowable in really rural EDs and critical access hospitals. But would not be in any way, shape or form acceptable in urban or suburban areas.

One of the ways we're looking at really doing this is looking at accreditation. So just like the College of Surgeons credit trauma centers by level I, II, what if ACEP could a credit hospital based emergency departments by looking at different structures like, do they have direct and indirect supervision? Do they have a lactation room for mothers? Do they have a number of other things where we determine what is the value and what is the gold standard for accreditation?

And the last pillar that I'm really excited about is looking at how do we expand demand for emergency medicine services. And we're not the only specialty to go through this. Anesthesia went through a potential workforce surplus in the 1980s, where they had a ton of students applying to anesthesia. And in the height of managed care, there was a lot of panic that that would decrease the number of elective surgeries and that there wouldn't be a need for anesthesiologists anymore. And what we saw in the early nineties was that there was a huge drop off in the number of students who then applied to anesthesia because of concerns about the workforce and a potential surplus.

And at one point, 50% of anesthesia residents were international medical grads because the demand from the US medical students just plummeted. If you fast forward 30 years, now anesthesia is one of the most sought-after specialties. And that pendulum has totally swung the other way, where it's incredibly difficult to hire an anesthesiologist.

So what changed? What did they do well? Well, one: They expanded their scope outside of just airway and realized they had to get into pain management and kind of some other issues to use their skill sets. And two: They really broadened where they could practice. It wasn't just hospital based operating rooms. It was ambulatory surgical centers. And a lot of that concern about managed care then never even came to fruition because they were able to proactively change the demand for their specialty.

This is where I think we need to really start looking of where can we use our skill sets outside the four walls of a hospital, whether that's telemedicine and in groups like Avel eCare that now manage over 150 critical access hospitals from a remote site. Whether it's looking at new healthcare models. This is one of the micro hospitals and a hybrid emergency department that's just two miles down the street from my house.

If you look, 80% of patients that we see in the ED actually get discharged. So we don't necessarily need more hospitals. We need more rapid diagnostic centers, and who better to do that than emergency medicine? Where we know both the inpatient and outpatient world, that we are really the intersection of those two things.

So I think there's a lot changing and I'm really excited about where ACEP is going in addressing many of these workforce issues that are impacting our specialty. So we'll continue to keep you posted. We're really looking forward to the future of emergency medicine. And I will stop there so that we have some time for questions and answers. So Debbie, I will turn it back over to you.

[Dr. Fletcher] Oh, that's a great presentation. I like how it's divided up into the five pillars. We can see what is being worked on in the individual sections. A couple of comments that I've noted in the chat, and one was from Stewart Godwin about the increased residency spots. And I think you addressed a lot of that working on that with the different groups. And one thing I was talking to one of my friends who was actually a residency director, and we were talking about other things, and I was wondering, could we maybe have something like a Flexner Report for residencies like we've had before for medical school? Because that was something he had mentioned. And I just actually thought about while you were going over that.

[Dr. Schmitz] Yeah, I see the chat there. Yeah, being careful about shortage. And I think that is a great point. And anesthesia, when I ask them about their experience, they're concern with Flexner Reports and workforce reports so that any of those reports are just projections, right? They're based on a number of assumptions that are constantly changing. And certainly our workforce study was done really pre-COVID, and so attrition rates are likely higher now than they were before. And some of those market forces are already changing just because of the workforce report.

We do have to be careful when we publish those because it's almost difficult to win, right? If you come out and say there's a shortage, then the MPs come out and say, well we'll help, we'll practice in those areas. Even though we know in many rural areas, they say they will, but they don't actually take those jobs in rural areas either. But if you come out and say there's a surplus, then you scare emergency medicine physicians from going into the specialty. So we have to be careful.

I think it's important to collect data, to be able to pivot and kind of, from a macro level, understand how things are changing and shifting. But how you message those, how we report those publicly, I think it's a really good, valid point that we need to be careful.

[Dr. Fletcher] Exactly. And someone had mentioned one of the questions that they had submitted earlier about if given the workforce study, if there was a consideration for the consultant responsible for the study to change or update the formula based on the waves of COVID.

[Dr. Schmitz] So we do have a plan to continue looking at that. I know there's a publication in the works right now who's looking at some of the modifications and attrition. So I think we are going to constantly collect data, and we have been doing this historically every five to 10 years. It is a huge lift to do this well. It was a several million dollar project to be able to do this study. So it's not something we can do like every six months, but shortly, we want to collect some data to understand what is changing. But I think given the comments in the chat, I agree that whether those comments are published and in a widespread report like that, you have to be careful of the unintended consequences. We don't wanna move that pendulum too far, one way or the other and have unintended consequences. But I do think data collection important to be able to understand how things are changing, particularly when you have so many other variables, like the pandemic that are certainly going to impact what those initial projections were.

[Dr. Fletcher] Okay, thank you. And just to pivot on a different question, Dr. Bensoni had asked about, if we were working on anything related to informed consent and trying to get the nurse practitioners to be in liability lawsuits as physicians where they would not be held to a nursing standard, but to a higher standard.

[Dr. Schmitz] So I want to involve some of my colleagues too, so that they get a chance to introduce themselves and speak on this too. Ryan and Rami and Chris, if you feel like you want to jump in, please go right ahead. This is something that's been frustrating, is that many nurses, technically "don't practice medicine." So they can't be held to the medical board. And from what I'm hearing, the nursing board doesn't really hold them accountable to many of the issues and concerns that we have. The difficulty comes when you try to define what is practicing medicine. And that has been a huge topic of conversation. But Ryan, you wanna jump in?

[Dr. Stanton] Yeah, absolutely. I think for one, it's a great point because it's the transparency and our patients knowing who's caring for them is key. But also, so I've done a couple of talks at the EMerald Coast Conference down in Destin a couple years back with a trial lawyer friend of mine from back in college days in Western Tennessee. And we talked about that aspect of the imbalance in the responsibility associated with this. And he says that there is a shift happening that they are looking more and more into it and targeting the primary, whoever that person was, whether it be an NP or PA, and they say, hey, I'm more to the physician so it's physician's fault. And really saying who's responsible? Now, is that gonna be a free pass? No, absolutely. I think there has to be transparency in terms of who's caring for them. Ideally the physician being as involved as possible, if not directly. In my case, we do have PAs and NPs, but I closely monitor every single patient throughout the care course and looking at them to make sure that I'm comfortable with where things are and where things are going, and seeing the ones, actually almost all of them other than the very low acuities.

But that being said, also you look at places like, I believe it's South Carolina that says you cannot sue a nurse practitioner because they're not technically practitioners. They aren't actually providing care. Well, how's that the case? And so there has to be working from state to state and federally on how do we align the fact that if you are the one that's evaluating that patient and making decisions, then you take on same responsibility as the MD or DO that is involved as well. And so there's a lot of work to be done. It's multifaceted, but I think the aspect the accreditation programs that we're looking at for the emergency departments is one first a step because one of the main goals, one of the main reasons for that is so patients know who's caring for them, who's gonna see them and what access they're going to see based on the specialty. And that's one of my big drives is, we are a specialty and we've got to continue to lift up and raise up as a specialty, not as what it was in the past, but where we're going in the future as a specifically trained expertise in the house of medicine.

[Dr. Kang] Yeah, I just wanna go ahead and add onto what Ryan said. This is a complicated issue. It doesn't mean that we don't tackle it head-on. But you have to understand the playing field that you're on and the rules of the game that you're playing by. And one of them is the licensing for nursing versus physicians. And as Ryan touched upon, this is gonna be a state-by-state battle because of how they define it. And that's gonna be a challenge for us.

The second thing is I do believe that informing and educating both publics as well as our own members is critically important. And so as we have this discussion about what we bring to the table, by what emergency physician's training entails, I think that we can respect all of the other professions, but we can also, it show patients what they're really getting. And that is when you look at emergency medicine training, the physician is paramount. And is the gold standard in the leader, physician assistants have a lot of rigorous programs and they're trying to emulate what has been done. But we know that a lot of nurse practitioner training is better heterogeneous. A lot may be online without emergency medicine, specific inpatient care things. And if we can highlight that, I think we're gonna change a little bit of expectations and narrative, but this is gonna have to be a strategic and a committed strategy for us over the next several years.

[Dr. Khouri] Those are great points. And what I wanna add and say, changes inevitable, embrace it, make it your own. We dealt with a similar issue in the state of Michigan and what they actually asked at the state level is that they basically get a buy on the malpractice coverages. And the fact that the matter is like a double sword, if you bring them up to snap and hold them accountable to physicians, you could have potentially two outcomes. One, the problem goes away and it forces, basically that physician not oversight, but supervision on everything. Or two, nursing changes, and then they start competing directly. So you have to recognize what the downstream effects of these things are. I think for us primarily is to improve EMTALA based port reform on a federal level. But I would be very weary in how to approach this because it is not that simple. And it is a state by state issue.

[Dr. Schmitz] I agree. And speaking to the Flexner Report that you asked about, Debbie too, it's challenging. And ACEP asked, one of the questions that came out of the workforce report is should our organizations advocate for a higher level for nurse practitioners to try to "raise the bar for NPs?" But as you may recall, there was a lot of attention on that because a lot of people are concerned that if we were to develop standards, that the unintended consequences is that the nurse practitioners may use those standards to say they are accredited and that they would use that to become independent practice. So there's been a lot of different opinions on that. And ultimately ACEP decided not to pursue developing standards for nurse practitioners. I know that EMP has created an exam. And from what I understand, the pass rate of that is pretty low, which speaks, I think to a lot of the concerns we have about level of education. And ACEP did just collaboratively sign on to a statement with SAAM and AAM, and several others in response to the nurse practitioner research article that came out and said, given this variability, we don't think we should be practicing independently. And we applaud them for coming out and really making that statement on their own specialty. But to highlight really what our concerns about that variability and training, and do we need to put in some higher standards amongst the nursing organizations to raise their own bar of really what that looks like in the future?

I do wanna make a quick comment. I'm seeing in the chat too, some questions about the workforce recommendations for the ACGME accreditation. And as a former kind of associate PD, this is something that's near and dear to my heart. It's challenging, right? If you put the bar too high, you penalize many of our own programs who have been existing. But we are confident that if all of these are enacted, and again, it's not our decision, this will be ACGME, but if you raise the bar on scholarly activity, if you raise the bar on core protected time, which we are kind of proposing in the percentage of faculty, that that's gonna be a heavy lift for money programs. And because it all comes down to money.

One of the battles that ACEP has really been fighting for the last five years is trying to protect core faculty time. It is very time intensive for me to do research, for me to mentor my medical students, to do simulation and ultrasound and didactics outside of conference time, which is where I'm going after this. But if that time is not protected, it's challenging financially to provide those hours. And one of the things that the ACGME changed was the percentage of time for core faculty. And that's something all of us have really been advocating for of how important that is for emergency medicine. And that we're different than surgery. I don't have two hours of downtime between two OR cases. It's not like I can do my "academic work" when I'm on shift. I can barely go to the bathroom when I'm on shift, much less do everything else that I'm required to do for my job.

In those recommendations, if we are able to really advocate for that protected time and the requirement, to not only be increased level of faculty teaching during didactics, but increased amount of really involvement and that time, that translates to money. So you're gonna have to have groups that are invested in protecting that time and really having those resources to ensure that not just the residents, but the faculty are having scholarly activity. That there is a time dedicated and the scaling to have the amount of faculty to support the residents in that program.

Again, I wish we could just put a moratorium on new residencies, but we have been told that that is not going to fly, and that is an antitrust concern. So to the best of our ability, we're trying to balance what those requirements are that will make it more challenging for groups to flip that switch and to continue to put really pressure on those that are starting programs to look at the demand from medical students, and is this really needed and how do we really control the growth responsibly? Rami, I see your hand up.

[Dr. Khouri] Yeah, thank you for saying that, Gillian. I will also add would that as with everything, the majority of practicing emergency physicians are out in the community rural, not pure academic level I at university based trauma centers. I think part of this is being aware of what we're training and training 'em for all the different environments in the skill sets needed as a practicing emergency physician. Not to be trained to just work in a level I trauma center, but to be able to manage a trauma by yourself where really you're the neurologist, anesthesiologist and the general surgeon as you try to get 'em transferred. So we have to be aware of that. And I think we need to figure out a way in time to start assessing the programs based on the ability to put out residents that are meeting the needs of the American people.

[Dr. Fletcher] There are a number of other comments in the chat. I'll try to get to some of them. What we can't get to, I will try to address later offline. There is one from Dr. Shermer. Is anyone aware of any study or data gathering process that's underway to document the care of NPs? Most of the data that they have is outdated and done before the loose training standards, they become qualified these days.

[Dr. Schmitz] To my knowledge, it's difficult to collect that information but I would love to have it. For many doctors, that is collected in the national practitioner data bank, you have your own internal QI programs. But I don't know how heavily the nursing boards are enforcing that data collection, but let me pivot to Chris to see what his thoughts are.

[Dr. Kang] Oh, thank you. And that's part of the problem, is sometimes along the way, we all I'm sure have anecdotal stories of the call, the transfer, et cetera, from one of our colleagues and say, oh my God, how did this happen? Or where were they thinking? Or what are they doing? Having said that, those anecdotal cases, and even though we all have them, there is very limited access to and a drive to get that data. And then it's a double-edged sword because a lot of their profession will do these smaller studies that demonstrate in a very skewed and or different arena, that's not necessarily always accurate and objective to demonstrate that their quality "is the same." Most of them you'll see in primary care and using certain criteria and metrics and programs, and compliance with those versus actual making decisions, especially in our environment with the acute and differentiated patient.

[Dr. Fletcher] I see somebody mention the Hattiesburg study. That is one is an excellent study. It's got long-term data for 10 years. They collected that they were able to show that their nurse practitioners failed on the four metrics that they were looking at, which included quality, referrals, patient satisfaction, and cost. And on the quality metrics, they looked at 10 different things, and they failed on nine out of the 10. So they changed their pattern and they no longer let the nurse practitioners have their own panels. They will now only see that they have to see a physician every third visit, or once a year, whichever is sooner. It's a fantastic study. They actually didn't plan to publish it. We talked to them for Louisiana, because we're trying to use that on our scope battles that are in the process right now. But that would be super, if somebody could do that for emergency medicine.

[Schmitz] Agreed. I also see some comments in the chat a little bit about addressing some of these new residency programs and holding them accountable to certain training standards. This did come up at the core meeting and I think we have to be careful. I think a lot of people assume that certain residencies are "good" and certain are bad. I think my experience has been that everyone thinks they're the "good program." It is publicly available. You can look on the ACG websites to see which residencies are kind of being evaluated or concerned or had red flags. And, ironically, none of them are the HCA programs. The ones that are in trouble or in remediation are some of our longstanding academic programs. So I think we have to be fair and objective when we try to apply certain concern and standards.

That being said, I will say one of the things at least I'm hearing, a concern for many of these new residency programs is that they have one like research guy, and that they're flying in this vice chair of research to go to five different residency programs to check that box. That was specifically brought up in our discussions and is a big concern. That was never the intent, if that is going on, of making sure that the residents are getting adequate journal club and research kind of a curriculum. So one of the things that we have recommended in there is what we call a single site affiliation. So that if you're the research director at program X, that's your affiliation. You can't also check the box for program Y, Z or W 50 miles away. That each program should be required to have a certain core set of trained faculty, again, to ensure the residents are getting that exposure and that training. So that's gonna be one of the recommendations we make.

In regards to how do we enforce the kind of nurse practitioners and utilize how they're using them, my sense and this is just from what I'm seeing, but groups, when we talk about scaling the size of the residencies, and one of my concerns is that even with the workforce surplus, there are still residency programs that are expanding the size of their residencies. I'm like, why would you do that right now? But they have said, Gillian, we have staffing issues, that we are on a razor thin margin. So we have the option of either increasing the number of residents per class, or we can hire nurse practitioners. Neither of which is very tolerable. So academic programs is trying to make that work by increasing the size of their residencies' community programs, or trying to scale up the hours that are really seen by PA nurse practitioner and decreasing physician coverage.

All of that goes back to that third slide I have with that pie of that our payor mix is getting increasingly worse over time. And as reimbursement continues to drive down, groups are doing what they can to try and make things work. But how do we advocate for our members? How do we try and enforce the highest quality standards? This is where I think accreditation has a large role. If we come in and say that you have to have direct or indirect supervision, my hope is that groups that are really doing that oversight category, that that would have a little bit of teeth to the hospitals that we want a higher bar, we want a higher quality. That if you're just utilizing independent practice, you don't get accredited unless you meet this level of care and trying to put in those standards that we think are really best for patient care, and for our patients and for our population.

[Fletcher] I have definitely used the ACEP guidelines that were just put out for NP/PAs in our state legislature in the last week, so that I could tell the legislators, this is what our College recommends, and this is what we need to hold to. So I'm glad we have some of these statements.

[Schmitz] I know we're running out of time. So I wanna give people an opportunity to kind of give some closing comments. And Thomas, thanks for your comment. I mean, again, I think one of my big goals this year was to improve communication and transparency and really to help build trust. This is really our vision for change that came out of our strategic plan of how do we engage people. And it's interesting to me how different people communicate in different forms. Some people are on email, some people are on Instagram, some people are on emDOCs, like it's all over the place. But I think we're trying these different formats, whether it's Reddit, whether it's workforce webinars of trying to be as transparent as possible and to listen really to understand what our members are saying so we can take back this feedback, and advocate, and fight for you. That's who we are, and that's what we should be doing as an organization. So I am appreciative that we could open this up to both members and non-members, and really start some engaging conversations. So thank you for bringing forth this idea and letting us have this time.

But Ryan, I'll start with you. Do you have a couple closing comments?

[Dr. Stanton] Yeah, absolutely. And Thomas, I agree as well. I mean, as the American College of Emergency Physicians, we are advocating for every emergency physician out there. And we love for everybody to be members. We want everybody to be members and understand the power of the organization. This is our union opportunity to come together and advocate for our profession and our physicians to better care for our patients. But I also see this and this we've seen a lot of doom and gloom of late of workforce and things like that. But this honestly is opportunity. How do we evolve as a specialty into the future? Who do we become? How do we form our identity?

For me, it's pursuing the things that I love, whether it be motor sports, emergency medicine, EMs, those types of things. There's a lot. There's a great deal that seek the specialization and the skillset of emergency physicians. And there's many. There's the majority that are going to love and engage and be in their emergency department practice throughout their career. There's also great things out there. You look at folks that are out there doing wildlife related. Ben Abo with his work with Shark Week. You look at some of the wilderness physicians, you look at all these opportunities for emergency physicians and how do we build that? How do we make this moving forward as folks going into emergency medicine residency, to say, this is your opportunity to find your why, to find the thing that really drives you and juices you as a human and as a physician. And so I see this as a great opportunity to define who we're going to be in the future. And I think not only as a special wide broad based specialty, but also continuing to raise that bar in order to provide better care for every patient that presents at our emergency departments. So thank you. I appreciate it.

[Dr. Khouri] Ryan, I wanna thank you for that statement. I think that's absolutely brilliant. I view this as all opportunity. We have an absolutely amazing skill that frankly, nobody else in the house of medicine has. We are what physicians were originally intended to be, and we see and do everything. And with that, that actually sets us up better for the future of medicine than anybody else in any other specialty. But the big piece is, let's not define it how we've always defined it in the past, which is the four walls. Medicine is changing, and we have to embrace that. We have to recognize that, you know, we need a singular voice. We have to recognize that we need to put money for advocacy so we can actually make those policy changes that'll make it better for the future of this specialty and our future colleagues. Recognizing full well that and some of the questions that were asked, it's a really difficult situation. And the margins are not just impacting us in the small groups. They're impacting the hospitals and that's how the decisions are being made. And I think we need to be very aware of that.

I think we need to teach what this is as the business and the upside and downside and prepare a future a little bit better. So again, I put a plug for the Indy Class. I think it is open for everybody. And I think there's a lot to learn from looking at the details in the business of emergency medicine. Thank you.

[Dr. Schmitz] Thank you, Rami. Chris, any last minute comments?

[Dr. Kang] Just several points, but I want to thank Dr. Fletcher as well as Dr. Schmitz for hosting this opportunity for more members to get an insight about what's going on and to be able to have some input. And I really applaud Gillian for the direction that she's taking the College about recognized not only as a professional organization, but we're a membership organization. And we need to do a better job of communicating with, listening to and advocating for our members and what's important to them. Ryan and Rami knows the prize stole my thunder there and that is just as Gillian talked about, we needed to come together. The opportunity that I'm looking forward to in this fall is opportunity, and that is as battered and bruised, and as tired and as anxious and scared as we all are, of all the pressures that we're facing.

And in the words of Dr. Steven Stack, first EP to be president of AMA, everyone else is telling us how to do our jobs and not letting us do what we believe is right. But we have an opportunity by not only having dialogue with each other, but somewhere along the way, mutual respect and a focus to say right now, as we merge from this pandemic and as a landscape of emergency medicine, and overall health care has changed, if we can come together enough and recognize that even though we may have some differences on priorities, we have an opportunity to redefine our specialty and the way we do things. Part of it is how we were representing ourselves, part of it is how we define the practice that we believe in our profession. And so I'm looking forward to continued input in communication. And I can guarantee that that's one of the three or four things that I want to continue is now to make sure that Dr. Schmitz continues to have a platform to continue with these advocacy issues that she's identified and then championed, but to make sure the communication with members, as well as nonmember continues to grow.

[Dr. Schmitz] And I want to thank the section and Debbie for your leadership, again, coming up with ideas of how we can help communicate. I thought this was great. And I'm very open to feedback from everyone on this call to let us know if this is something we should continue. Is this a good format to share and exchange information?

A couple plugs I'll put in: A couple people have put in the chat, they wish they could get more involved, and better engaged members. So a couple key deadlines, May 15th is the committee deadline. So our committees are really the workhorse of the college. We have over 40 different committees that really that's how the objectives are set from the council of what ACEP does. So if there's something you wanna really work on, committees are really the first way to get involved.

Second area is your state chapter. So get involved with your state chapter. Many of the advocacy issues we've been talking about with scope of practice and workforce are done at the state level. So having a leadership position and your state chapter board is a great way to get involved. Our council, the deadlines are coming up this summer for resolutions. So resolutions, we work for the council. Like we serve at their pleasure. So the resolutions are heavily debated and discussed of really what people want ACEP to do. And that it's a really fun couple days where we kind of go through these issues and debate them and really decide what is the future course of ACEP. So I encourage you to submit a resolution. If you don't know how to do that, we're happy to walk you through that process. But it's a great way to really help give some direction and help us really navigate the future of the specialty.

And the last plug I will give is for Leadership and Advocacy Conference is coming up next week, May 1-4. If you can't make it in-person, there's also a virtual option. The topics this year are gonna be very relevant to this section. We're gonna be spending a significant amount of time talking about scope of practice. We do have brought in some anesthesiologists to talk about workforce issues. We are gonna be talking about consolidation in medicine and looking at unionization, looking at how we do collective bargaining, looking at what are the levers that we have as emergency physicians to really look at this changing working environment. And then a number of advocacy issues on due process and on workplace violence and many things that we have all experienced in our emergency department.

So lots of great ways to get involved and much more information coming out shortly. But thank you for your time. Thank you for your questions. I hope this was helpful to people, and we're very open to feedback. And would love to try to do this again sometime. This was a great format. And thank you, Debbie, for helping us moderate today.

[Dr. Fletcher] Oh. LAC next week, for those that are interested, we will have a workforce section meeting at LAC so we can meet in-person.

[Dr. Khouri] Yeah, I will be joining at that. So I'd love everybody there as part of the section and liaison. So I look seeing everybody.

[Dr. Schmitz] Wonderful. Thank you everyone. Have a great afternoon.

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