There is no imaginable reality where accidents and emergencies cease to exist. By the very nature of both of those terms, unplanned events occur, often requiring specialized, curated, emergent care.
Therein lies the value of emergency medicine (EM)—”the medical specialty dedicated to the diagnosis and treatment of unforeseen illness or injury,” according to the American College of Emergency Physicians (ACEP). The organization’s formal definition provides insight into the broader scope of what EM entails: “Emergency medicine is not defined by location but may be practiced in a variety of settings including, but not limited to, hospital-based and freestanding emergency departments (EDs), urgent care clinics, observation medicine units, emergency medical response vehicles, at disaster sites, or via telehealth […] Emergency medicine encompasses planning, oversight, and medical direction for community emergency medical response, medical control, and disaster preparedness.”
However, although this expansive definition may shine light on the value of emergency medicine, there are a few key issues which are defiantly causing a crisis in the field.
The Job Market
As the Covid-19 coronavirus pandemic quickly gained traction in early 2020, first-responders and those on the front-lines of the battle against the virus were celebrated as “healthcare heroes.” Ironically, however, market forces refused to convey the same enthusiasm: the job market for EM physicians had never been worse. Despite large numbers of Covid-19 patients, emergency department volumes overall plummeted, leading to less demand and less volume–based need for EM physicians.
An ACEP survey conducted in October 2020, nearly 8 months after the pandemic started, described startling figures: “Many emergency medicine group practices were forced to make workforce, coverage, and benefit changes […] 21% have had to lay off physicians; 31% have had furloughed physicians; 56% of groups have cut pay for the same work; 83% have experienced a decrease in productivity; 83% of groups have cut hours of ED coverage; 47% of groups have deferred or cut benefits.” The survey also described the frustrations that many physicians were personally facing, including loss in compensation, working more hours, and lack of support infrastructure.
However, this phenomenon was not due to the pandemic alone. This has been a subtly growing trend that just happened to be exacerbated by Covid-19 significantly. Even before the pandemic, concerns of job market saturation were looming, given the increasing number of emergency medicine residency programs around the country. While growing interest in this relatively younger field of medicine was seen as a positive sign, it has resulted in an increasing supply, especially in large cities—hence causing physicians to take roles in more rural areas or pursue non-traditional paths with their clinical practice.
Litigation in healthcare is an ever-growing challenge to physicians, especially in the United States, which has one of the highest rates of litigation when compared to its global counterparts. In its 2019 Advocacy Handbook, the Emergency Medicine Resident Association (EMRA) published: “The impact of medical liability is massive; in fact, 99% of physicians in high-risk specialties by age 65 years old have already been subject to a claim, and approximately 7% of emergency physicians are sued each year […] Emergency medicine is a high-risk specialty for medical malpractice, with 1 out of every 14 emergency physicians getting sued each year.” These jarring figures have significantly risen over the past 3 decades, with malpractice suits and litigation continuing to exponentially skyrocket.
The “high-risk” nature of emergency medicine is congruent with the nature of the work: EM physicians are forced to employ cognitive agility and make quick decisions based on limited information in order to do what is best for the patient in that immediate moment.
But the conundrum of liability in emergency medicine is challenging, especially when reconciling with “defensive medicine.” The chief issue that organizational leaders continue to emphasize is that physicians should not be practicing defensive medicine, or the concept of ordering a variety of extensive diagnostic tests or procedures to ensure that nothing is missed, in an effort to mitigate liability.
However, emergency physicians, and physicians generally, are forced to straddle a thin line with this, as there is a perpetual fear that a missed diagnosis or failed treatment plan may result in a career-defining (and sometimes, career-ending) lawsuit. Given the emotional, financial, and cognitive toll that litigation entails, it’s evident that the balance is challenging.
Indeed, the fear of litigation remains among one of the largest and perpetually growing concerns for medical professionals in all practice areas.
The Battle Continues
I wrote last year about the already prevalent complexities of emergency medicine and prolonged ER wait times. Additionally, the country continues to face a growing physician shortage and quickly aging population. Indeed, the healthcare system simply cannot afford to lose more physicians at this juncture.
The reality is that most emergency physicians, and physicians generally, did not enter the field thinking about the compensation, the liability, or the opportunity to work in the city of their choice—they entered the field with the intention of helping patients at a time of critical need. Emergency medicine provides a unique opportunity to be involved in patient care at significant junctures—whether that entails routine non-emergent complaints, or traumatic injuries requiring immediate stabilization and treatment.
The scope of emergency medicine today also entails far more than just the fundamental definition of “emergent” care. For many people nationwide that perhaps do not have insurance, or want an immediate resolution to their problem, or require support that goes beyond just purely clinical medicine, the emergency room acts as an opportunity for primary care, mental health services, social services, and as a general repository for a wide variety of resources.
It is also critical to note that many of these issues aren’t solely limited to emergency medicine. It would be safe to say that medicine as a whole, across all specialties, is undergoing an existential crisis, with each field confronting their respective issues and growing pains.
Nevertheless, healthcare is a pursuit of passion, not meant for or easily tolerated by the faint-hearted. Therefore, despite the difficulties the profession is facing, emergency physicians and healthcare professionals generally will continue to persist and fight for what’s most important: the ability to provide the best patient-care possible.