title: Board-certified emergency physicians comprise a minority of the emergency department workforce in iowa.
abstract: BACKGROUND
  The American College of Emergency Physicians (ACEP) endorses emergency medicine (EM) residency training as the only legitimate pathway to practicing EM, yet the economic reality of Iowa's rural population will continue to require the hiring of non-EM trained physicians. The objective of our study is to better understand the current staffing practices of Iowa emergency departments (EDs). Specifically, we seek to determine the Iowa community size required to support hiring an emergency physician (EP), identify the number of EDs staffed by advanced practice providers (APPs) in solo coverage in EDs, determine the changes in staffing over a 4-year period, and understand the market forces that contribute to staffing decisions.
  
  
  METHODS
  Researchers surveyed all 119 hospitals throughout the state of Iowa regarding their ED hiring practices, both in 2008 and 2012. From these data, we determined the mean population that supports hiring EPs and performed a qualitative examination of the reasons given for hiring preferences.
  
  
  RESULTS
  We found that a mean population of approximately 85,000 is needed to support EP-only staffing practices. In 2012, only 14 (11.8%) of Iowa's EDs were staffed exclusively with EPs. Seventy-two (60.5%) staff with a combination of EPs and FPs, 33 (27.7%) staff with FPs alone, and 72 (60.5%) have physician assistants or nurse practitioners working in solo coverage for at least part of the week. Comparing the data from 2008 and 2012, there is no statistical change in the hiring of EPs versus FPs over the 4 years (Chi-square 0.68, p=0.7118), although there is a significant increase in the number of APPs in solo practice (Chi-square 11.36, p= 0.0008). Administrators at hospitals cited several factors for preferring to hire EPs: quality of care provided by EPs, availability of EPs, high patient acuity, and high patient volume.
  
  
  CONCLUSIONS
  Many EDs in Iowa remain staffed by family medicine-trained physicians and are being increasingly staffed by APPs. Without the contribution of family physicians, large areas of the state would be unable to provide adequate emergency care. Board-certified emergency physicians remain concentrated in urban areas of the state, where patient volumes and acuity support their hiring.
authors.affiliation: University of Virginia, Department of Emergency Medicine, Charlottesville, Virginia.
authors.forename: Heather
authors.initials: H
authors.lastname: Groth
authors.forename: Hans
authors.initials: H
authors.lastname: House
authors.forename: Rachel
authors.initials: R
authors.lastname: Overton
authors.forename: Eric
authors.initials: E
authors.lastname: Deroo