Many rural emergency departments operate without constant on-site physician availability.
A national survey of emergency departments revealed that hundreds of facilities operated in 2022 without an attending physician present around the clock. The review, published earlier this year and based on data from more than 4,600 departments, found that 344 locations reported no 24-hour on-site physician coverage. This was the first survey to measure the issue nationwide, so there is no confirmed trend yet, but the findings have sparked debate over safety, staffing, and costs pertaining to a lack of having full-time doctors available.
The states with the highest share of departments without full-time physician coverage were North Dakota, South Dakota, and Montana, where roughly half or more of facilities fell into that category. Nearly all of these departments saw fewer than 10,000 visits a year, suggesting they served smaller communities. The majority were in rural areas, and most were located in hospitals classified as critical access facilities, which typically have limited resources. A small fraction were freestanding emergency centers.
The absence of constant physician presence is a divisive topic in the medical field. Major organizations representing doctors, including the American Medical Association and the American College of Emergency Physicians, advocate for regulations requiring a physician on duty in every emergency department at all times. Others argue that experienced nurse practitioners and physician assistants can manage care effectively when paired with adequate support and access to physician consultation. This position has gained traction in areas where recruiting full-time physicians is challenging.
Lead researcher Dr. Carlos Camargo of Harvard Medical School noted that some doctors support 24/7 coverage requirements but stress that lawmakers would need to provide more funding to hospitals to make it feasible. Hospitals in rural and low-volume areas often struggle to pay for round-the-clock physician staffing, and without added financial support, such mandates could put further strain on their budgets.
The study also highlighted that most of the departments without continuous physician coverage were in small hospitals serving remote or less populated areas. For these facilities, staffing is often a balance between meeting patient needs and staying financially viable. While patient safety remains a top concern, these hospitals face the reality that physician shortages, budget limits, and low patient volumes can make it difficult to maintain full-time on-site doctors.
Those in favor of mandating full-time physician coverage point to the unpredictable nature of emergency medicine, where minutes can make the difference in life-threatening situations. They argue that while advanced practice providers can handle many cases, having a physician on-site ensures immediate access to higher-level decision-making and critical procedures. Opponents counter that in smaller communities, requiring constant physician presence could lead to service cuts or closures if hospitals cannot afford the staffing.
The conversation is complicated by the uneven distribution of healthcare resources across the country fueling lack of full-time doctors. Urban hospitals often have no difficulty filling physician schedules, while rural hospitals may recruit for years without finding enough qualified candidates. Technology, such as telemedicine, has helped bridge some of these gaps by allowing remote physician oversight, but it does not replace the ability to act instantly in emergencies.
With no prior national benchmark, it is unclear if the proportion of departments without 24/7 physician coverage is growing. What is clear is that the debate will continue as healthcare leaders, policymakers, and local communities weigh safety, cost, and access. For now, hundreds of emergency departments operate without a doctor on-site at all hours, a reality shaped by geography, economics, and workforce challenges that the healthcare system has yet to resolve.
Sources:
344 EDs do not have 24/7 physician coverage: What to know
Experts say rural emergency rooms are increasingly run without doctors
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