national study of the emergency physician workforce, 2008

THE PRACTICE OF EMERGENCY MEDICINE/ORIGINAL RESEARCH

National Study of the Emergency Physician Workforce, 2008

Adit A. Ginde, MD, MPHAshley F. Sullivan, MS, MPHCarlos A. Camargo Jr, MD, DrPH

From the Department of Emergency Medicine, University of Colorado Denver School of Medicine,Aurora, CO (Ginde); and the Department of Emergency Medicine, Massachusetts General Hospital,Harvard Medical School, Boston, MA (Sullivan, Camargo).

Study objective: We describe the characteristics of the US emergency physician workforce.

Methods: We performed a cross-sectional analysis of the 2008 American Medical Association PhysicianMasterfile, which includes data on all physicians who have ever obtained a medical license in at least 1 USstate. We included all physicians who designated emergency medicine as their primary or secondary specialty.

Results: There were 39,061 clinically active emergency physicians, of which 57% were emergency medicineboard certified and 69% were emergency medicine trained or emergency medicine board certified. Familymedicine (31%) and internal medicine (23%) were the most common backgrounds for non-emergency medicine–trained/emergency medicine board certified emergency physicians, and most (75%) graduated from residencygreater than or equal to 20 years ago. Nearly all (98%) emergency physicians who graduated within the past 5years were emergency medicine trained or emergency medicine board certified. Rural emergency physicians weremuch less likely than urban emergency physicians to have emergency medicine training (31% versus 57%),emergency medicine board certified (43% versus 59%), and to have graduated in the past 5 years (8% versus19%). The density of all emergency physicians per 100,000 population was highest in New England (16.0) andin urban areas (14.5). The lowest emergency physician densities were in West South Central (10.2) and ruralareas (10.3). Density of emergency medicine–trained or emergency medicine board certified emergencyphysicians was 10.3 in urban, 5.3 in large rural, and 2.5 in small rural areas.

Conclusion: Although newer emergency physicians are almost all emergency medicine trained or emergencymedicine board certified, many non-emergency medicine–trained/emergency medicine board certified emergencyphysicians still provide clinical coverage of EDs. Demand for all emergency physicians will likely continue forseveral decades and the shortage may even increase in rural areas. [Ann Emerg Med. 2009;54:349-359.]

Provide feedback on this article at the journal’s Web site, www.annemergmed.com.

0196-0644/$-see front matterCopyright © 2009 by the American College of Emergency Physicians.doi:10.1016/j.annemergmed.2009.03.016

INTRODUCTIONBackground

The recent 2009 national report card on the state ofemergency medicine gave a D– grade for access to emergencycare, which, in part, reflected a shortage of emergency careproviders.1 Although physicians are not the only professionalsproviding health services, they are a key component of theoverall health care workforce.2 Emergency physicians provideround-the-clock medical care to all patients who request servicesand are a critical component of patient access to qualityemergency care. The volume of emergency department (ED)visits has increased steadily during the past decade, up to 119million in 2006,3 and this has contributed to a growing demandfor emergency physicians.

Although the American College of Emergency Physicians(ACEP) affirmed that “physicians who begin the practice ofemergency medicine in the 21st century must have completed
an accredited emergency medicine residency training program
Volume , . : September

and be eligible for [board] certification,”4 they also recognizedthat there is “a significant shortage of physicians appropriatelytrained and certified in emergency medicine.”5 Indeed, werecently reported that the shortage of emergency medicine–trained and emergency medicine board-certified emergencyphysicians will persist for decades.6 Moreover, the medianannual visit volume for the 4,828 US EDs in the 2005 NationalEmergency Department Inventory–USA was 18,118,7,8 andthese smaller, often rural, EDs have even more difficulty withemergency physician recruitment and retention.9-11

The 2006 Institute of Medicine report Hospital-BasedEmergency Care: At the Breaking Point recognizes that, givencurrent emergency physician workforce shortages and economicconditions in health care, EDs, particularly in rural areas, willrequire alternate staffing models.12,13 Suggestions includeincreased utilization of midlevel providers and enhancedcollaboration with primary care physicians, who often staff
smaller, rural EDs.14,15 Indeed, physician assistants and nurse
Annals of Emergency Medicine 349

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Emergency Physician Workforce Ginde, Sullivan & Camargo

practitioners have been increasingly popular to augment theemergency physician workforce, with these midlevel providersparticipating in the care of 13% of all US ED visits in 2005.16

Already, family physicians in Minnesota are collaborating withemergency physicians in a popular educational program fornon-emergency medicine–trained practitioners working inEDs.17

ImportanceFurther characterization of the emergency physician

workforce will help clarify the extent and distribution of theemergency physician shortage, to plan staffing, training, andeducation needs and to advance the ability to provide timely,high-quality emergency care. In recognition of the importanceof this aim, ACEP commissioned 3 national workforcestudies—in 1997,18 1999,15 and most recently in 2008 (resultsexpected in 2009). Although certainly contributing to ourunderstanding of the emergency physician workforce, thevalidity of these results has been questioned because of lowresponse rates (�50%) and the high potential for nonresponsebias.19 An analysis of all emergency providers would augmentthese ACEP reports.

Goals of This InvestigationWe sought to describe the characteristics of the entire

emergency physician workforce, according to the American

Editor’s Capsule Summary

What is already known on this topicIn 1980, there were no board-certified emergencyphysicians. There are now more than 22,000.

What question this study addressedWhat are the training, certification, and backgroundof the current US emergency physician workforce?

What this study adds to our knowledgeAccording to self-reported information in the 2008American Medical Association database, 69% ofemergency physicians were residency trained orcertified in emergency medicine, with variationsacross geographic areas. Rural emergency physicianswere more often non–emergency medicine trained,non–emergency medicine certified, and further outof training.

How this might change clinical practiceThis will not change practice but provides usefulinformation for those planning future staffing needsand those contemplating a career in emergencymedicine.

Medical Association (AMA) Physician Masterfile. Using this

350 Annals of Emergency Medicine

complete database of every emergency physician with a medicallicense, our primary objective was to understand thedemographics, previous training, board certification, andgeographic distribution of all US emergency physicians.

MATERIALS AND METHODSStudy Design

This study was a cross-sectional secondary analysis of the2008 AMA Physician Masterfile database, which contains dataon all 940,000 US allopathic and osteopathic physicians,including international medical graduates and militaryphysicians, and has been successfully used for previous generalsurgery workforce studies.20,21 Physicians’ data are entered inthe Masterfile during their initial medical license application(including limited licenses for residents) and updated duringsubsequent renewals. Physicians must be licensed to practicemedicine in at least 1 state; membership in the AMA is notrequired for inclusion in the Masterfile.

Throughout a physician’s career, data are collected onLiaison Committee on Medical Education–accredited medicalschools, Accreditation Council for Graduate Medical Education(ACGME)–accredited training programs, board certification,medical licenses, and current location. The database is updatedweekly, and we purchased the commercially available database,which had names and contact information removed, onNovember 7, 2008, from Medical Marketing Service, Inc.(Wood Dale, IL), the sole vendor for AMA data. This study wasapproved by the Partners Human Research Committee as anexempt protocol.

Selection of ParticipantsWe included all US emergency physicians in active clinical

practice for analysis in this study. Professional activity data areupdated regularly at license renewal (every 1 to 3 years,depending on state) and by periodic survey. Physicians arerequired to self-designate one primary specialty and couldoptionally designate a secondary specialty. Additionally, theirprimary type of practice is requested and required of a completeapplication.

We included all emergency physicians, which we defined asany physician with the self-designated primary or secondaryspecialty of emergency medicine, internal medicine–emergencymedicine, pediatric emergency medicine, pediatric emergencymedicine–emergency medicine, or pediatrics–emergencymedicine. We included secondary specialty because manyemergency physicians, particularly in rural areas, practice in aprimary care specialty but also provide significant physiciancoverage for EDs. There were 48,770 physicians who met thesecriteria. To limit our analysis to clinically active emergencyphysicians, we excluded those with the following primary typeof practice: residency (n�4,963), retired (n�2,445),administration (n�973), teaching (n�465), research (n�188),and not active for other reasons (n�675). Thus, our analysis ofthe emergency physician workforce included 39,061 emergency
physicians in active clinical practice.

Ginde, Sullivan & Camargo Emergency Physician Workforce

Methods of MeasurementVariables were defined by self-report at state medical license

application or renewal. Demographics included age and sex; theMasterfile does not include race/ethnicity of emergencyphysicians. We defined international medical graduates asphysicians who graduated from medical schools outside theUnited States and Canada, without additional completion ofmedical school in the United States or Canada.

Physicians could provide home or work address as theirprimary location, and the Masterfile included location data tothe level of ZIP code and county. Although 28,367 (73%)physicians provided home location, we assumed that physicianslived and worked in the same county for the purpose of thisanalysis. Location was classified into the 9 US Census divisions:New England (Connecticut, Massachusetts, Maine, NewHampshire, Rhode Island, Vermont); Mid-Atlantic (NewJersey, New York, Pennsylvania); East North Central (Illinois,Indiana, Michigan, Ohio, Wisconsin); West North Central(Iowa, Kansas, Minnesota, Missouri, North Dakota, Nebraska,South Dakota); South Atlantic (Washington, DC; Delaware,Florida, Georgia, Maryland, North Carolina, South Carolina,Virginia, West Virginia); East South Central (Alabama,Kentucky, Mississippi, Tennessee); West South Central(Arkansas, Louisiana, Oklahoma, Texas); Mountain (Arizona,Colorado, Idaho, Montana, New Mexico, Nevada, Utah,Wyoming); and Pacific (Alaska, California, Hawaii, Oregon,Washington).22 We further classified population size of theMetropolitan Statistical Area, according to conventional USOffice of Management and Budget groups: less than 100,000;100,000 to 249,999; 250,000 to 999,999; and greater than orequal to 1,000,000 people.23

We applied Urban Influence Codes, a county-level definitionof rural and urban status, for each emergency physician.24

Urban Influence Codes were developed by the US Departmentof Agriculture as a method to measure urbanization and rurality.This classification scheme has an advantage over other methodsbecause it is based on commuting and economic centers ofinfluence, in addition to area population sizes. The most recentversion of Urban Influence Codes, based on the 2000 Census,classified all 3,141 US counties into 13 categories.25 Wecollapsed these categories into 3 groups of counties: urban(n�1,090), large rural (n�674), and small rural (n�1,378), aspreviously described.20 Urban areas contained all countiesdesignated within metropolitan areas, defined as counties with 1or more cities with population greater than or equal to 50,000and adjacent outlying counties that are economically tied to thecore by greater than or equal to 25% commuting to the centralcounty (categories 1 and 2). Large rural areas contained countieswith the newly designated micropolitan classification, designedto distinguish rural counties with an urban cluster of at least10,000 people and economically tied adjacent counties(categories 3, 5, and 8). Small rural areas were all “noncore”counties, defined as nonmetropolitan and nonmicropolitan
areas (categories 4, 6, 7, 9, 10, 11, 12, 13). According to US

Census data, 83% of the population lived in urban counties,10% in large rural counties, and 7% in small rural counties.25

We used completion of ACGME-accredited program toclassify residency and fellowship training. We definedemergency medicine training as completion of emergencymedicine residency, combined internal medicine–emergencymedicine residency, or pediatric emergency medicine fellowshipprograms. For non-emergency medicine–trained physicians, weclassified their training as family medicine, internal medicine,pediatrics, general surgery, and other residency training,according to the most recently completed program (if morethan 1 residency program was completed). Physicians whosubsequently subspecialized through fellowship training wereclassified by their original residency training (ie, physician whocompleted internal medicine residency and gastroenterologyfellowship would be classified as internal medicine).Transitional or preliminary internship years were listedseparately and those physicians who completed an internshipyear but no subsequent residency were classified as internshiponly. Years since training was based on the graduation year fromthe most recently completed ACGME-accredited internship,residency, or fellowship program.

Emergency medicine board certification was defined assuccessful completion of emergency medicine or pediatricemergency medicine examination administered by the AmericanBoard of Emergency Medicine (ABEM) or the American Boardof Pediatrics. Because the AMA Physician Masterfile is linked toboard certification data only through the American Board ofMedical Specialties, we could not include emergency medicineboard certification by the American Osteopathic Board ofEmergency Medicine or the Board of Certification inEmergency Medicine programs. Since 1988, completion of anACGME-accredited emergency medicine residency programwas required for eligibility for emergency medicine boardcertification by ABEM. Before 1988, emergency physicians whotrained in non–emergency medicine specialties could alsobecome ABEM certified. To obtain ABEM or American Boardof Pediatrics certification in pediatric emergency medicine,emergency physicians must have completed an emergencymedicine or pediatrics residency, respectively, followed by anACGME-accredited pediatric emergency medicine fellowship. Ittypically takes emergency physicians 1 to 3 years after residency/fellowship graduation to become emergency medicine boardcertified. Thus, we additionally created a category for emergencymedicine–trained or emergency medicine board-certifiedemergency physicians to reflect the often used “board eligible/board certified” term that is no longer endorsed by ABEM.26

Board certification in other specialty was created as an additionalcategory for emergency physicians who obtained board certificationfrom an American Board of Medical Specialties–recognized boardin a non–emergency medicine specialty.

Primary Data AnalysisWe performed statistical analysis with Stata 9.0 (StatCorp,

College Station, TX) and summarized data with descriptive



statistics. Because the AMA Physician Masterfile represents theentire population of emergency physicians (ie, no samplingused), we did not use confidence limits around our estimates.We used 2007 US Census Bureau estimates, extrapolated fromthe 2000 Census,22 to calculate the number of emergencyphysicians per 100,000 civilian population overall and forgeographic subgroups. Maps of emergency physician density bycounty were created by geospatially mapping each emergencyphysician with ArcMap 9.2 (ESRI, Redlands, CA).

RESULTSOf the 39,061 emergency physicians in the United States,

22,314 (57%) were emergency medicine board certified and26,826 (69%) were emergency medicine trained or emergencymedicine board certified; 12,235 (31%) were neither emergencymedicine trained nor emergency medicine board certified.Emergency medicine training preceded emergency medicineboard certification for 16,822 (75%) emergency medicineboard-certified emergency physicians. The most commonalternate training pathways to board certification, used by non-emergency medicine–trained emergency physicians before 1988,were internal medicine (9%), internship only (4%), generalsurgery (4%), and family medicine (3%). Pediatric emergencymedicine was specifically designated as the emergencymedicine–related specialty for 1,132 (3%) emergencyphysicians; 101 (0.2%) reported both pediatric emergencymedicine and general emergency medicine, whereas 37,828(97%) reported general emergency medicine only.

Characteristics of emergency physicians stratified by trainingand board certification status are presented in Table 1. Non-emergency medicine–trained/board-certified emergencyphysicians were older and more likely to be men andinternational medical graduates. Additionally, more than doublethe proportion were in smaller population and rural areascompared with emergency medicine–trained or emergencymedicine board-certified emergency physicians. Familymedicine and internal medicine were the most commonresidency training backgrounds for non-emergency medicine–trained/emergency medicine board-certified emergencyphysicians, and most graduated from residency greater than orequal to 20 years ago. Although these emergency physicianswere neither trained nor board certified in emergency medicine,more than half reported that emergency medicine was theirprimary specialty.

Among all emergency physicians, 7,433 (19%) reported thatemergency medicine was their secondary specialty. The mostcommon primary specialties for these emergency physicianswere family medicine (n�3,143), internal medicine (n�1,650),general surgery (n�726), and pediatrics (n�684), includingtheir related subspecialties. These individuals were older(median age 57 years), and most (69%) had completed traininggreater than or equal to 20 years before.

Table 2 compares characteristics of emergency physicians inurban versus rural areas. Rural emergency physicians were also
older, more likely to be men, and more likely from West North

Central, East South Central, and Mountain US Censusdivisions. Additionally, rural emergency physicians, particularlythose from small rural areas, were much less likely than urbanemergency physicians to have emergency medicine training, tobe emergency medicine board certified, and to have graduatedtraining in the past 5 years.

Characteristics of emergency physicians stratified by timesince training graduation are displayed in Table 3. Thepercentage of female emergency physicians has steadily increasedover time; 34% of emergency physicians who graduated fromtraining programs less than 5 years ago were women. Clearly,there is a trend toward emergency medicine–trained andemergency medicine board-certified emergency physiciansamong newer training graduates. Emergency physicians whocompleted training less than 10 years ago were much morelikely than those who completed training greater than or equalto 10 years ago to have completed emergency medicine training(95% versus 37%) and to be emergency medicine boardcertified (67% versus 54%). The rate of emergency medicineboard certification among the newer emergency physicians islikely to increase as the recent graduates complete their writtenand oral examinations. Figure 1 displays a higher proportion ofemergency medicine–trained or emergency medicine board-certified emergency physicians practicing in rural areas withlonger time since training graduation.

There was also a large variation in emergency physiciandensity by geographic area and rurality, as shown in Table 4.Overall, there were 7.3 emergency medicine board certified, 8.8emergency medicine trained or emergency medicine boardcertified, and 12.8 total emergency physicians per 100,000 UScivilian population. The highest emergency physician densitieswere found in New England and in urban areas. The lowestemergency physician densities were found in West SouthCentral and in rural areas. Although density of all emergencyphysicians was similar in small versus large rural areas, theemergency physician density of emergency medicine boardcertified and emergency medicine trained or emergencymedicine board certified in small rural areas was less than halfthat of large rural areas. These geographic disparities arereflected in US maps of all emergency physician density (Figure2A) and emergency medicine–trained or emergency medicineboard-certified emergency physician density (Figure 2B).

LIMITATIONSThis study has several potential limitations. Although the

AMA Physician Masterfile is updated weekly, individualemergency physician data are typically updated at state medicallicense renewal, which occurs every 1 to 3 years. Althoughinformation is also updated through periodic surveys by theAMA, the data in the database may be outdated by up to 3 yearsfor emergency physicians. Although the AMA seeks to achieve ahigh degree of data accuracy through standard data elements atmedical license renewal supplemented by periodic surveys, wecannot be entirely sure that all data elements are consistently
requested by every state licensing board at each licensure.

olitan


Classification of a physician in the Masterfile as an emergencyphysician is based on self-report. Although the potential formisclassification exists, most physicians who designateemergency medicine as a specialty likely spend a significantamount of their practice time in EDs, even for physicians whodesignate emergency medicine as a secondary specialty.27

Further testing of these assumptions would strengthen the data.Because the Masterfile can link only to ACGME-accreditedtraining programs and American Board of Medical Specialtiesboards, we were not able to report emergency medicine trainingfrom other programs or board certification from the AmericanOsteopathic Board of Emergency Medicine, which had 1,746diplomates in 2008 (American Osteopathic Board of

Table 1. Comparison of emergency physicians by emergency m

Characteristics

Emergency MedicTrained or EMBC

n�26,826, No. (%

DemographicsAge, y (median [IQR]) 44 (37–53)Female sex 6,666 (25)International medical graduate 1,833 (7)GeographyUS Census divisionNew England 1,649 (6)Mid Atlantic 3,651 (14)East North Central 4,300 (16)West North Central 1,355 (5)South Atlantic 5,307 (20)East South Central 1,116 (4)West South Central 2,277 (9)Mountain 2,097 (8)Pacific 4,801 (18)MSA population size�1,000,000 17,917 (67)250,000–999,999 4,345 (17)100,000–249,999 1,796 (7)�100,000 2,768 (10)Urban influenceUrban 24,507 (92)Large rural 1,544 (6)Small rural 502 (2)TrainingResidencyEmergency medicine 21,334 (80)Family medicine 618 (2)Internal medicine 2,205 (8)Pediatrics 219 (1)General surgery 954 (4)Internship only 1,000 (4)Other residency 163 (1)None 513 (2)Years since residency graduation�5 6,649 (25)5–9 5,769 (22)10–19 7,445 (28)�20 6,436 (24)Primary specialty, emergency medicine 24,880 (93)

EMBC, Emergency medicine board certified; IQR, interquartile range; MSA, Metrop

Emergency Medicine, unpublished data). Thus, our results


slightly underestimate the emergency medicine training andemergency medicine board certification statistics, although theycomprise a small proportion of emergency medicine–trained oremergency medicine board-certified emergency physicians.15

Because the AMA allows reporting of either home or workaddress, we assumed that emergency physicians lived andworked in the same county for the purpose of this analysis.Home to work, commuting from one county to another, mayaffect the rurality statistics and slightly alter the emergencyphysician density map. However, Urban Influence Codes doaccount for commuting and economic centers of influence,which limits the potential for misclassification of rurality.Inferences from temporal trends in the emergency physician

ne training and emergency medicine board certification status.

Not Emergency MedicineTrained/EMBC,

n�12,235, No. (%)

All EmergencyPhysicians,

n�39,061, No. (%)

57 (52–62) 49 (40–57)1,787 (15) 8,453 (22)2,543 (21) 4,376 (11)

636 (5) 2,285 (6)1,558 (13) 5,209 (13)1,922 (16) 6,222 (16)

805 (7) 2,160 (6)2,342 (19) 7,649 (20)

891 (7) 2,007 (5)1,254 (10) 3,531 (9)

852 (7) 2,949 (8)1,789 (15) 6,590 (17)

6,481 (53) 24,398 (62)2,178 (18) 6,523 (17)1,016 (8) 2,812 (7)2,560 (21) 5,328 (14)

9,902 (82) 34,409 (89)1,371 (11) 2,915 (8)

776 (6) 1,278 (3)

N/A 21,334 (55)3,790 (31) 4,408 (11)2,793 (23) 4,818 (12)1,035 (8) 1,254 (3)1,509 (12) 2,463 (6)1,249 (10) 2,249 (6)

432 (6) 595 (2)1,427 (12) 1,940 (5)

106 (1) 6,755 (18)383 (4) 6,152 (17)

2,166 (20) 9,611 (26)8,146 (75) 14,582 (39)6,748 (55) 31,628 (81)

Statistical Area; N/A, not applicable.

edici

ine,)

workforce, as suggested by time since training graduation, are



limited by the cross-sectional analysis. For instance, the higherproportion of emergency medicine–trained or emergencymedicine board-certified emergency physicians practicing inrural areas with longer time since training graduation (Figure 1)may reflect a relative lower preference for rural areas by thenewer graduates, migration from urban to rural areas asemergency physicians age, or both. Future research mightexplore this important but understudied issue.

DISCUSSIONUsing the most complete nationally available source of

information on physicians, we found that there were 39,061clinically active emergency physicians in the United States in

Table 2. Comparison of emergency physicians in urban versus

CharacteristicsUrban,

n�34,409, No

DemographicsAge, y (median [IQR]) 48 (39–5Female sex 7,734 (22)International medical graduate 3,789 (11)GeographyUS Census divisionNew England 1,985 (6)Mid Atlantic 4,892 (14)East North Central 5,551 (16)West North Central 1,810 (5)South Atlantic 6,895 (20)East South Central 1,575 (5)West South Central 3,205 (9)Mountain 2,478 (7)Pacific 6,145 (18)MSA population size�1,000,000 24,037 (70)250,000–999,999 6,363 (18)100,000–249,999 2,765 (8)�100,000 1,244 (4)TrainingResidencyEmergency medicine 19,864 (58)Family medicine 3,313 (10)Internal medicine 4,222 (12)Pediatrics 1,134 (3)General surgery 2,117 (6)Internship only 1,839 (5)Other residency 478 (1)None 1,442 (4)Years since residency graduation�5 6,368 (19)5–9 5,695 (17)10–19 8,548 (26)�20 12,335 (37)Primary specialty, emergency medicine 28,389 (83)Board certificationEmergency medicine 20,303 (59)Other specialty 6,652 (19)None 7,454 (22)

*Four hundred fifty-nine missing county data and could not be classified.

2008. This figure is consistent with our previous analysis of the


National Emergency Department Inventory–USA database,which indicated approximately 40,030 emergency physicianswere needed to staff all 4,828 EDs in 2005.6 Additionally,although accounting for growth of ED visits and correspondingincreases in emergency physician workforce needs, our resultsare also consistent with the most recent ACEP workforce study,which suggested that 31,797 emergency physicians staffed USEDs in 1999.15 Our findings indicate that 34% of emergencyphysicians who graduated in the past 5 years were womencompared with 13% for those who graduated greater than orequal to 20 years ago and are still clinically active. However, asex disparity in emergency medicine still exists becauseapproximately half of US medical school graduates are

areas.*

Large Rural,n�2,915, No. (%)

Small Rural,n�1,278, No. (%)

54 (45–60) 56 (49–61)448 (15) 177 (14)299 (10) 138 (11)

194 (6) 108 (5)271 (9) 50 (2)497 (16) 250 (12)292 (10) 415 (21)561 (19) 319 (16)318 (11) 213 (11)241 (8) 265 (13)303 (10) 273 (14)349 (12) 120 (6)

168 (6) 3 (�1)120 (4) 4 (�1)34 (1) 3 (�1)

2,593 (89) 1,266 (99)

1,016 (35) 265 (21)656 (23) 413 (32)397 (14) 172 (13)85 (3) 24 (2)

214 (7) 112 (9)248 (9) 135 (11)69 (2) 41 (3)

230 (8) 116 (9)

275 (10) 54 (5)305 (11) 95 (8)692 (26) 293 (25)

1,411 (53) 722 (62)2,096 (72) 766 (62)

1,370 (47) 451 (35)847 (29) 491 (38)698 (29) 336 (26)

rural

. (%)

7)

women.28


liste


According to 4,828 EDs in the 2005 version of NationalEmergency Department Inventory–USA,7 and previousreports of 1.48 emergency physicians needed per 40-hourweek full time equivalent,15 we estimate a national average of5.5 full time equivalents per ED, consistent with theprevious 1999 ACEP workforce study, which reported anaverage 5.35 full time equivalents per ED.15 Because itwould require a minimum of approximately 5 standard fulltime equivalents to staff an ED with at least 1 emergencyphysician continuously,6 we would anticipate a highernational average of full time equivalents per ED becausemany EDs require more than minimal emergency physician

Table 3. Characteristics of emergency physicians by years sinc

Characteristics0–4

No. (%)

DemographicsAge, y (median [IQR]) 34 (32–37)Female sex 2,292 (34)International medical graduate 392 (6)GeographyUS Census divisionNew England 456 (7)Mid Atlantic 1,107 (17)East North Central 1,064 (16)West North Central 358 (5)South Atlantic 1,255 (19)East South Central 286 (4)West South Central 612 (9)Mountain 477 (7)Pacific 1,082 (16)MSA population size�1,000,000 4,866 (72)250,000–999,999 1,058 (16)100,000–249,999 373 (6)�100,000 458 (7)Urban influenceUrban 6,368 (95)Large rural 275 (4)Small rural 54 (1)TrainingResidencyEmergency medicine 6,614 (98)Family medicine 75 (1)Internal medicine 20 (�1)Pediatrics 16 (�1)General surgery 9 (�1)Internship only 3 (�1)Other residency 6 (�1)Primary specialty, emergency medicine 6,648 (98)Board certificationEmergency medicine 3,752 (56)Other specialty 424 (6)None 2,579 (38)Emergency medicine trained or emergency

medicine board certified6,649 (98)

*Excluded 1,961 (5%) because of no previous residency training (n�1,940) or no

staffing to handle their patient volume. However, more than


half of EDs have less than 18,118 annual visits,7 and wehypothesize that many of these lower-volume EDs are, attimes, staffed by midlevel providers only16 or by on-callemergency physicians who provide ED coverage for morethan 40 hours per week, possibly from home or hospital callrooms.10,14

We found that 57% of clinically active emergency physicianswere emergency medicine board certified and 69% wereemergency medicine trained or emergency medicine boardcertified compared with 54% and 58%, respectively, in 1997and 58% and 62%, respectively, in 1999.15,18 As highlighted inthe Institute of Medicine report,12 a significant shortage of

idency or fellowship graduation.*

Years Since Residency/Fellowship Graduation

5–9No. (%)

10–19No. (%)

>20No. (%)

39 (37–42) 47 (44–51) 58 (55–63)1,657 (27) 2,303 (24) 1,864 (13)

298 (5) 907 (9) 2,467 (17)

370 (6) 569 (6) 805 (6)852 (14) 1,230 (13) 1,775 (12)914 (15) 1,626 (17) 2,167 (15)330 (5) 534 (6) 787 (5)

1,254 (21) 1,989 (21) 2,854 (20)263 (4) 460 (5) 917 (6)573 (9) 851 (9) 1,262 (9)455 (7) 792 (8) 1,114 (8)

1,084 (18) 1,482 (16) 2,787 (19)

4,234 (69) 6,044 (63) 8,257 (57)937 (15) 1,587 (17) 2,603 (18)418 (7) 726 (8) 1,132 (8)563 (9) 1,254 (13) 2,590 (18)

5,695 (93) 8,548 (90) 12,335 (85)305 (5) 692 (7) 1,411 (10)

95 (2) 293 (3) 722 (5)

5,664 (92) 6,727 (70) 2,313 (16)250 (4) 1,034 (11) 3,046 (21)119 (2) 956 (10) 3,719 (26)

52 (1) 437 (5) 748 (5)39 (1) 265 (3) 2,140 (15)17 (�1) 144 (2) 2,093 (14)10 (�1) 46 (�1) 528 (4)

5,774 (94) 7,914 (82) 9,733 (67)

4,930 (80) 6,879 (72) 6,228 (43)441 (7) 1,709 (18) 5,352 (37)781 (13) 1,023 (11) 3,002 (21)

5,769 (94) 7,445 (78) 6,436 (44)

d graduation year (n�21).

e res

emergency medicine–trained, emergency medicine board-



certified emergency physicians persists, and coverage of EDswith physicians who are neither emergency medicine trainednor emergency medicine board certified remains a reality.Although some debate exists about who can and should practiceemergency medicine,9,19,29 emergency medicine–trained,emergency medicine board-certified emergency physicians are

Table 4. Number of emergency medicine trained or emergencymedicine board certified emergency physicians per 100,000civilian population.

Geography

No. Emergency Physicians/100,000

EMBCEmergency Medicine

Trained or EMBCAll Emergency

Physicians

Total 7.3 8.8 12.8US Census divisionNew England 9.7 11.6 16.0Mid Atlantic 7.0 9.0 12.9East North Central 7.6 9.3 13.4West North Central 5.6 6.8 10.8South Atlantic 7.7 9.2 13.2East South Central 5.2 6.2 11.2West South Central 5.5 6.6 10.2Mountain 8.4 9.8 13.8Pacific 8.6 9.9 13.5Urban influenceUrban 8.5 10.3 14.5Large rural 4.7 5.3 10.4Small rural 2.3 2.5 10.1

Figure 1. Proportion of emergency medicine–trained or emepracticing in rural areas by time since graduation from trainiincrements. Excluded 1,961 (5%) emergency physicians becgraduation year (n�21).

often regarded, as a group, as the criterion standard provider4—


and there are some positive signs toward progression toward thelonger-term national goal of an entire emergency physicianworkforce of emergency medicine–trained, emergency medicineboard-certified emergency physicians. With increasing numbersof emergency medicine training programs, approximately 1,350new emergency medicine graduates join the emergencyphysician workforce every year from the current 149 ACGME-approved emergency medicine and pediatric emergencymedicine training programs.30 Indeed, our results demonstratedthat nearly all (98%) of emergency physicians who graduatedwithin the past 5 years were emergency medicine trained oremergency medicine board certified compared with only 44%among those emergency physicians who graduated greater thanor equal to 20 years ago. Although this shows remarkabledevelopment of emergency medicine as a specialty, the shortageof emergency medicine–trained, emergency medicine board-certified emergency physicians is expected to continue fordecades as older emergency physicians retire or die and must bereplaced by new graduates.6

The state of the emergency physician workforce in rural EDsis even more concerning. The geographic densities for anyemergency physicians, and in particular emergency medicine–trained or emergency medicine board-certified emergencyphysicians, are much lower in rural than urban areas. Ruralaccess to emergency medicine–trained, emergency medicineboard-certified emergency physicians has gained recent attentionbecause of the relatively higher shortage of these emergency

cy medicine board-certified emergency physicians currentlyample sizes (n) provided reflect data analyzed in 3-yearof no previous residency training (n�1,940) or no listed

rgenng. Sause

physicians and increased difficulty with recruitment and



Figure 2. Emergency physician density per 100,000 civilian population by county. A, All emergency physicians. B,Emergency medicine–trained or emergency medicine board-certified emergency physicians. Four hundred fifty-nine (1%)
emergency physicians had missing county data and could not be classified.
Volume , . : September Annals of Emergency Medicine 357


retention of emergency physicians in rural areas.9 Observationsof the emergency physician workforce in rural EDs aredisturbing. For instance, of the emergency physicians whograduated within the previous 5 years, only 1% are currentlypracticing in small rural areas and only 5% in any rural area.This is compared with 5% and 15%, respectively, foremergency physicians who graduated greater than or equal to 20years before. These data suggest that the disparity in rural accessto emergency physicians is likely to increase in the coming yearsas older emergency physicians retire or die and are replaced byfewer new graduates willing to work in rural areas. Severalmethods to enhance emergency physician recruitment andretention to rural areas have been proposed, including increasedexposure to rural environments during training,31 financialincentives,32-35 and the J1 visa waiver program.36 Furtherresearch to understand motivations for new emergencyphysician graduates’ choice of rural or urban locations and todevelop solutions to enhance recruitment is needed to reducethe emergency physician disparity in rural areas.

Until there are sufficient numbers and distribution ofemergency medicine–trained, emergency medicine board-certified emergency physicians, there will remain a minority ofnon-emergency medicine–trained/emergency medicine board-certified emergency physicians who provide clinical coverage forEDs. These emergency physicians have diverse trainingbackgrounds, including family medicine, internal medicine,general surgery, pediatrics, and internship only. Although thereis controversy about their inclusion within emergency medicineorganizations such as ACEP,29 these emergency physiciansprovide a valuable service because they often fill gaps in access toemergency care, such as in rural EDs that are unlikely to bestaffed by emergency medicine–trained, emergency medicineboard-certified emergency physicians.13 Nevertheless, Lew etal27 found that non-emergency medicine–trained/emergencymedicine board-certified emergency physicians in Oregonwould benefit from enhanced training in pediatric,multitrauma, and airway emergencies. Further understanding ofthe previous training and skills of this group, minimumrequirements for training and experience, and initiation oftargeted emergency medicine–based educational outreachwould likely improve access to quality emergency care to allAmericans, particularly in rural areas.14,17

In summary, two thirds of clinically active emergencyphysicians are now emergency medicine trained or emergencymedicine board certified. Newer emergency physicians arealmost all emergency medicine trained or emergency medicineboard certified, but 12,235 non-emergency medicine–trained/emergency medicine board-certified emergency physicians stillprovide clinical coverage of EDs, the majority in practice forgreater than or equal to 20 years, implying that they areapproaching the end of their careers. Large geographicdisparities in the emergency physician workforce exist, withfewer emergency physicians in middle America and in rural
areas. Demand for all emergency physicians will likely continue

for several decades, and the shortage of emergency physiciansmay even increase in rural areas.

The authors thank Ann Jyothis, MA, for her assistance withgeospatial mapping and Arlen Stauffer, MD, for his thoughtfulcomments on an early draft of the article.

Supervising editor: Donald M. Yealy, MD

Author contributions: AAG, AFS, and CAC conceived anddesigned the study. AAG provided statistical advice, acquiredthe data, and performed the analysis. All authors contributedto data interpretation, and AAG drafted the article. All authorscontributed substantially to article revision and approved thefinal version. AAG takes responsibility for the paper as awhole.

Funding and support: By Annals policy, all authors are requiredto disclose any and all commercial, financial, and otherrelationships in any way related to the subject of this articlethat might create any potential conflict of interest. The authorshave stated that no such relationships exist. See theManuscript Submission Agreement in this issue for examplesof specific conflicts covered by this statement.

Publication dates: Received for publication February 5, 2009.Revision received March 2, 2009. Accepted for publicationMarch 11, 2009. Available online April 24, 2009.

Reprints not available from the authors.

Address for correspondence: Adit A. Ginde, MD, MPH,Department of Emergency Medicine, University of ColoradoDenver School of Medicine, 12401 E 17th Ave, B-215, Aurora,CO 80045; 720-848-6777, fax 720-848-7374; [email protected].

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national study of the emergency physician workforce, 2008

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