Preventing the Next EM Crisis: A Chat With ACEP's President

This interview has been edited for length and clarity.

Gillian Schmitz, MD, FACEP

The American College of Emergency Physicians (ACEP) recently announced that Gillian Schmitz, MD, FACEP, is the president for the 2021-2022 term.

Medscape had the opportunity to interview Schmitz and ask her about the topics she plans to devote her time on as the ACEP president.

Resource Allocation

The first thing that I want to ask is, how did the COVID-19 pandemic affect the allocation of resources (beds, staffing) that are integral to the practice of emergency medicine? And how is the situation now?

Nationally, about 76% of intensive care units (ICU) beds are occupied, and about a quarter of those are patients with COVID-19.

In some states that are hit the hardest, they're still scrambling to find beds for patients in emergency departments that are very full. This is in contrast to the beginning of the pandemic when we saw this sort of paradoxical vacancy when people were more hesitant to come to the emergency department.

Now our volumes are back up, and if anything, we're actually more crowded now in some communities than we were before the start of the pandemic. It's causing capacity issues in the emergency department, inside the hospitals and in the ICUs.

Despite efforts to vaccinate the public and healthcare workers, my understanding is that more unvaccinated patients are currently being seen in the emergency department. Is that correct? And that's causing some of the capacity issues these days.

Yes, unfortunately. Despite proven science and the real-world evidence that millions of people are safely vaccinated, misinformation and hesitancy still cause some to question whether they should get the vaccine.

Emergency physicians see the risks of avoiding the vaccine firsthand because the majority of patients that we are seeing with COVID-related illness are unvaccinated. We know that some portion of patients who received the vaccine may still get COVID, but they tend to have more minor illnesses. The overwhelming majority of patients who require hospitalization or have severe cases of COVID that requires more ICU monitoring are typically those who are unvaccinated.

It seems that smaller rural hospitals, where the ICU availability and bed capacity is somewhat limited, are hit the hardest. Then there's a demand to provide medical care for patients coming in with sepsis, heart attacks, and strokes.

You bring up a good point. Just because we're seeing surges of COVID doesn't mean that cases of appendicitis, car accidents, or heart attacks go away. If anything, the capacity issues make it more challenging to care for anyone with COVID or any other illness or injury that we see typically in the emergency department.

It is particularly difficult for those small rural hospitals that don't have the same inpatient census and the capacity. They have to transfer those patients, oftentimes even across state lines. I practice in Texas, and I am hearing that some of my colleagues have had to transfer patients as far as Baltimore or Washington, DC, because they could not find any beds.

How does ACEP plan to provide guidance and support to healthcare systems that are strained for resources?

Different regions have been able to approach this a little bit differently. At the beginning of the pandemic, areas like Washington state had a regionalized tool that allowed all of the hospitals to talk to one another. They had a dashboard that they could track personal protective equipment (PPE) and hospital beds that helped inform where they could send patients and supplies.

We have a similar system set up in the San Antonio, Texas, area called STRAC, to help navigate who has beds, facilitate EMS transfers, and integrate local capabilities to help patients get the care that they need. Nationally, we need a better infrastructure to be able to help physicians find available hospital beds and provide resources to rural hospitals.

We are seeing an increase in the use of telemedicine and other ways to be able to contact specialty sources and to share information and specialty expertise. I've even seen emergency physicians on social media asking for help to identify who has beds to help with patient transfers. This is really a situation we've never encountered before.

Disaster Planning

Knowing what you know now, what kind of guidance and support does ACEP plan to provide to help avert disaster crises in the future?

ACEP has a disaster section, and there is a formal process for people who want to volunteer during a disaster. We don't want well-intentioned medical professionals just showing up unannounced in the middle of a disaster because that can cause more confusion amid chaos.

While ACEP is frequently contacted when tragedies occur, the association is not a disaster relief organization and does not directly coordinate physician relief efforts. ACEP does offer guidance for healthcare professionals interested in assisting disaster medical response all over the world.

How does ACEP plan to address the issue of providing routine medical care and having to compete with the needs of the COVID patients that are in the emergency departments, especially in the rural settings?

There's not necessarily a one-size-fits-all answer to these questions. Emergency physicians' needs can vary based on the community or practice setting. Some physicians will be out of various medical supplies. Some may be running short on ventilators while others may be short on beds. It really is more of a local, institutional, or hospital-driven policy to manage their resources and determine crisis protocols.

A better infrastructure and stronger supply chain would help coordinate the allocation and distribution of resources to wherever they are needed the most.

Staffing Shortages

One of the biggest concerns is the critical staffing shortage that's developing at hospitals. There is an increasing number of respiratory therapists, nurses, and physicians that are either resigning to seek other types of employment, or they are resigning due to current vaccine mandates. How does ACEP plan to address this looming crisis of staff shortages?

ACEP works closely with a number of other emergency medicine organizations to address critical needs in the emergency department, including the Emergency Nurses Association (ENA). Emergency medicine and healthcare is a team sport. It requires the team to comprise everyone who provides care in the emergency department. I'm proud of ENA for putting out a statement recently encouraging vaccines and supporting the vaccine mandate.

It's important that that all members of the healthcare team get vaccinated, which is why ACEP signed a joint letter in support of healthcare facilities that implement vaccine requirements.

We do have a critical shortage of emergency nurses right now, which puts an additional strain on our practice in the emergency department. Emergency physicians are trying to adapt the best they can because that's what we do in emergency medicine. Oftentimes, we don't have all the right supplies or information, and we try to MacGyver the best we can with what we have. Everyone chips in. I've seen paramedics and techs stepping into nursing roles and helping with drawing IVs and placing Foley catheters. Emergency physicians and care teams will continue doing whatever we can to support each other. Ultimately, it's about taking the best care of the patient and utilizing what resources we do have.

Managing Burnout

There's significant burnout occurring among many of the emergency physicians and clinicians who were already tasked at the initial stages of the pandemic. What additional steps is ACEP currently taking to promote mental health and wellness among the hospital workers?

I think it's important to remember that physicians are people too. Just because we are physicians doesn't mean that we are immune from any disease or mental health issues. Certainly after 18-20 months of going through this pandemic, it has exacerbated what everyone in the country is feeling.

Emergency physicians have mental health issues that we are trying to address and destigmatize. Unfortunately, there is a legitimate fear of consequences that often deters physicians from seeking the mental health care that they need.

ACEP had a poll in 2020 that showed that 3 out of 5 emergency physicians report that they would be concerned for their job if they were to seek mental health treatment. That's because several state licensing boards will ask these questions about their mental health histories or past treatments.

That was never the intent of the American Disabilities Act, which prohibits discrimination against people with disabilities, including psychiatric disorders. But those intrusive questions, particularly when they're not relevant to a physician's current ability to practice, can adversely affect their job and their privileges. So, many physicians do not feel safe seeking treatment.

ACEP is making progress in efforts to destigmatize, address, and dismantle those barriers for physicians who are seeking mental health treatment, but it will take a concerted effort from policymakers, regulators, and hospital leaders. We really should be promoting access and mental health, not discouraging it.

One of the key pieces of legislation that ACEP supports is the Dr Lorna Breen Health Care Provider Protection Act. This bill recently passed in the Senate, and discussion of these measures is ongoing in the House Energy and Commerce Committee.

Dr Breen was one of our dear members, an emergency physician who was a medical director in New York who we tragically lost to suicide in April 2020 after the COVID surge in New York City. The bill named for her would take major steps to reduce and prevent suicide and burnout by creating behavioral health and well-being training programs, establishing grants to establish and expand mental health support services, and launching other initiatives to benefit physicians and prevent future tragedies.

We will continue doing everything we can to support our members through this pandemic and beyond. Along with extensive COVID-19 tools and resources, ACEP has a peer-to-peer support program, free mental health counseling for our members, and a 24-hour support line.

The Lorna Breen Health Care Provider Protection Act would help provide these resources at a national level and would really put in action steps to reduce and prevent suicide and burnout.
 

Understaffed or Overstaffed in the Emergency Departments?

The ACEP taskforce modeling study predicts an excess of 7845 emergency physicians in 2030 [if the number of emergency medicine graduates continues to increase at current rates]. On the other hand, the model suggests that if there is no increase in the number of residency graduates, a 4% attrition rate, with no increase in numbers of ED visits, and no change in the percentage of APP encounters, there could theoretically be a shortage of nearly 2855 physicians.

Given the uncertainty, how can the ACEP plan accordingly?

We still don't know what the full impact of the pandemic will be on the workforce. The reality of a forward-looking workforce study is that the minute you start talking about it, market forces are starting to address the projections. There could be unforeseen attrition among medical students, as one example. Maybe medical students who would have pursued a career in emergency medicine make a different choice.

A number of dynamic factors will likely make those predictions inaccurate, and a large part of the motivation for doing the study was to be able to have the time to impact its trajectory.

In response to the findings, ACEP developed a framework of five pillars to address emergency physician supply and demand. First, we will re-examine the accreditation standards for emergency medicine training programs. Updated standards should take into account how our practice is changing and how we can best prepare our residents for the future.

The second pillar focuses on putting patients above profits. We want to put pressure on all stakeholders to grow our workforce in a responsible manner and ensure that hospitals and health systems are aware of the results of our workforce study.

It's important to note that until now, every prior workforce study had predicted exactly the opposite — that we would never have enough emergency physicians. So, many well-intentioned health systems made it part of their mission to develop graduate medical education (GME) and start residency programs, but many were unaware of our current workforce issues, and we want to make sure that graduate medical education (GME) spots are delegated to specialties and geographic areas where there is the most need.

A third pillar addresses physician scope-of-practice issues. There is no substitute for a licensed, trained, and board-certified emergency physician, and ACEP supports efforts to ensure that there are physician-led teams in every emergency department.

A recent ACEP/Morning Consult poll reinforces that patients overwhelmingly trust emergency physicians to lead their care in the emergency department and prefer to see a physician when they're having an emergency. We want to make sure that patients have access to the most highly trained experts available.

Fourth, physicians have a geographic distribution challenge. There are jobs, but not necessarily in everyone's first choice of location, and many of those are in rural areas. We are trying to address that gap by looking at loan forgiveness, identifying ways to better train our residents to have the skills they need to practice in rural areas, and to address these gaps in the job market.

The fifth pillar involves expanding demand by looking at who we are as emergency physicians and what our practice could become. If anything, this pandemic has taught us that emergency medicine extends far beyond the four walls of a hospital.

Our skill sets are relevant to so many different practice models. Whether it's through telemedicine and providing emergency medical care through a computer over Zoom, or whether we are expanding into new healthcare delivery models and post-acute care, we need to really look at how we best take care of patients and how we use those skill sets. It's really an exciting time for us to take a step back and understand how we can continue to adapt and evolve our specialty and our training to best take care of patients.

Future Opportunities in EM

What types of formal training or subspecialty opportunities are there in emergency medicine?

There are many different types of subspecialties. We have started looking at palliative care, geriatric care, pain management, and post-acute care. Right now, there is really a huge need for improving the way we collaborate to manage what happens after a patient's discharge from the emergency department. How do we keep patients healthy and prevent them from bouncing back to the hospital?

Looking at telemedicine, how we can provide care remotely? Can we improve patient access by expanding our healthcare delivery models? How can we continue to redefine what emergency acute care can look like across the entire spectrum of acute unscheduled care?

Given climate change (and an uptick of fires and hurricanes), will disaster management be part of that spectrum?

ACEP and more than 30 medical organizations are part of the Medical Society Consortium on Climate and Health, a group that's looking at how medical societies can address climate change through advocacy and research.

We have a research arm called the Emergency Medicine Foundation that has a specific research grant this year to look at climate change, and how we can make an impact to address this because we're seeing disasters more frequently. This falls into our realm of public health and emergency care.

Any final recommendations or comments to our emergency medicine physicians and pending graduates? Or other thoughts and views that you would like to share?

I would just like to send a message of hope. The past 20 months have been very difficult on us and we've been tested both personally and professionally. Many people have felt a sense of despair with decreasing reimbursement and threats to our workforce, a never-ending pandemic, and the belief that patients have lost trust in the vaccine and in us. It's been very difficult for physicians to keep going.

But I do see light at the end of the tunnel. I think this is an opportunity for us to face those challenges and realize that there are also opportunities, and this gives us a chance to adapt. It's given us the ability to innovate, to redefine who we are, and imagine what we can do in the future.

To emergency physicians and patients, please know that we are going to get through this pandemic. And while we have some work to do, I'm very optimistic about the future of emergency medicine.

Gillian Schmitz, MD, FACEP, has held leadership roles within ACEP and the emergency medicine community, including past chair of the Academic Affairs Committee, subcommittee chair for the Medical Legal Committee, and chair for the Young Physicians Section. She is a former president of ACEP's Government Services Chapter and past board member of the Emergency Medicine Resident's Association (EMRA). Schmitz is a recognized leader in emergency medicine with honors including the National Early Career Faculty Award from the Academy for Women in Academic Emergency Medicine (AWAEM), EMRA's 45 under 45 and Mentorship Award, and ACEP's National Teaching Faculty award.

Anya Romanowski, MS, RD, is an editorial director at Medscape who primarily covers emergency medicine, hospital medicine, and critical care. Follow her on Twitter @Anya13

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