By Dorothy Brooks
Match Day is a special event for graduating fourth-year medical students: This is the day they learn where they will intern.
Students interview with hospital programs across the United States for the specialty they wish to pursue, and then rank their choices. The programs rank which students they prefer. After mixing the student and hospital rankings, the student “matches” with his or her highest-ranked choice program that is willing to accept them.
However, during this year’s Match Day, 555 residency positions in emergency medicine (EM) went unfilled, more than double the number from Match Day 2022. Even though these positions eventually were filled in the days that followed, the results sent a strong signal suggesting the once-competitive EM specialty may be losing some of its appeal.
The American College of Emergency Physicians (ACEP), the American Academy of Emergency Medicine (AAEM), and other EM-related professional organizations released a statement, noting they were appointing a “Match Task Force” to establish better understanding of what led to the Match Day results, and “to define a path forward.”1
Many experts note the burdens placed on frontline providers during the COVID-19 pandemic have taken a toll, and the apparent fall-off in demand for EM residency positions is not necessarily surprising. Nonetheless, there is heightened concern suggesting solutions are needed to address multiple workforce challenges. These range from declining reimbursements and high levels of burnout to concerns about the proliferation of EM residency programs, some of which may be churning out candidates who are not adequately prepared.
Jonathan Fisher, MD, MPH, FACEP, senior director for workforce and EM practice at ACEP, maintains there were multiple contributing factors that led to the unfilled positions. But Fisher also notes these factors are reflective of the difficulties emergency physicians face daily. “Emergency physicians continue to be challenged by the strain of the pandemic and face high rates of burnout from bearing the brunt of many systemic challenges, including the prevalence of violence in EDs and the growing trends of consolidation and corporatization in medicine,” he argues.
Other experts suggest the Match Day results primarily were the result of an oversupply of residency spots, as well as changes on the demand side. “The number of residency spots for EM physicians has grown almost exponentially over the last decade,” according to Jonathan Jones, MD, FAAEM, president of AAEM. “While 10 or 20 years ago, there was a need for more EM residency spots, there wasn’t a need for this exponential growth.”
Jones contends medical students are less interested in EM because of diminished job prospects. “Students realize that if there is a chance they are going to have a hard time finding a job, they aren’t going to choose this specialty,” he explains. “Many current residents are having a hard time finding jobs. I know this from working with our resident students association.”
Several organizations are projecting a surplus of nearly 8,000 emergency physicians by 2030.2 What is driving this? Adam Brown, MD, a practicing emergency physician, says it is a matter of incentives. “Some of the regulations around medical education give benefits to new start-up programs,” says Brown, founder of ABIG Health, a consulting firm. “There needs to be some regulatory oversight, not only over the number of residency programs but also how many slots these programs may have. There also needs to be oversight on the quality of the programs.”
Jones concurs, arguing most of the newer residency slots are in non-academic programs that were started by contract management groups or for-profit healthcare systems.3 “We think that has had a negative impact on the situation,” he says. “We are graduating residents who, quite frankly, are not prepared to practice independently.”
Jones suggests one way to alleviate the glut and improve quality is to bolster standards. “We are encouraging ACGME [the Accreditation Council for Graduate Medical Education] to revise their minimum standards to fit what we actually feel [would provide] a safe environment,” Jones reports. “We don’t want ACGME to increase standards just to make the programs harder, but we specifically feel that the current standards are not adequate to ensure patient safety.”
Another factor is the expanded role advanced practice providers (AAP) are playing in EM. “Year over year, we have seen the percentage of nurse practitioners and physician assistants within the ED growing,” Brown says.4
ACEP has been clear about its concerns regarding what Fisher terms “the dangers” of expanding the scope of practice for APPs. “ACEP believes that an emergency physician should lead every emergency care team in the country,” Fisher stresses. “Physician assistants and nurse practitioners are integral and valued members of the care team, but they do not have the training or expertise of an emergency physician.”5,6
Fisher notes ACEP is working toward the launch of a tiered ED accreditation program. “This initiative will recognize hospitals and EDs committed to high standards that include staffing by board-certified emergency physicians, safe and fair work environments, and the implementation of evidence-based policies and practices across practice settings and staffing models,” he explains.
Other ACEP efforts include addressing the challenges facing the emergency physician workforce. “Initiatives underway will help emergency physicians stay on top of job market trends, raise residency standards, and advocate for policies that improve practice environments,” Fisher notes.
ACEP also is looking to expand opportunities for the emergency physician workforce. “ACEP created a ‘New Practice Models and Alternative Career Options Task Force’ to examine and expand career opportunities,” Fisher says. “The expansion of telehealth is just one example of how the practice of emergency medicine is no longer limited within the walls of a traditional ED.”
Jones suggests there are solutions to EM’s current workforce woes, although none of them are quick or easy. Jones says one solution is physicians helping make the decisions about the correct staffing ratios in hospitals.
“A big part of this involves trying to eliminate or decrease the influence of private equity in EM contracts and EM groups,” Jones says. “The main way AAEM is working on that is by trying to get states to enforce laws that already are on the books that ban the corporate practice of medicine.”7
Jones believes such changes will significantly improve the appeal of EM as a specialty and will make practicing “not necessarily easy, but equitable and fair.”
Jones, Brown, and Fisher agree EM physicians have a strong stake in how the future of the profession unfolds, and that the way to help shape that future is to be involved in policymaking. “By nature, emergency physicians are fixers,” Fisher says. “The best way for emergency physicians to meet the many challenges we face is [by] working together on solutions.”
Jones also encourages EM physicians to talk to people about the profession. “If the public knows that emergency physicians are specialists, and EM is all that they do, then they will want that specialist to take of them,” Jones suggests.
Brown adds emergency physicians must stay attuned to market shifts and the growth in digital tools and telehealth. “Emergency physicians should be at the forefront of those initiatives,” he says. “It helps you as a clinician to learn new perspectives and know what is happening in the business world ... it takes a very important stakeholder and puts [him or her] at the boardroom table where decisions are being made.”
REFERENCES
1. American College of Emergency Physicians. Joint statement on the emergency medicine 2023 Match results. March 14, 2023.
2. Marco CA, Courtney DM, Ling LJ, et al. The emergency medicine physician workforce projections for 2030. Ann Emerg Med 2021;78:726-737.
3. Applebaum E, Batt R. Private equity buyouts in healthcare: Who wins, who loses? Institute for New Economic Thinking. March 15, 2020.
4. Wu F, Darracq MA. Comparing physician assistant and nurse practitioner practice in U.S. emergency departments, 2010-2017. West J Emerg Med 2021;22:1150-1155.
5. Brooks D. Organizations take issue with data regarding nurse practitioner care in the ED. ED Management. March 1, 2023.
6. Kusterbeck S. Nurse practitioners working in ED pose unique legal risks. ED Management. March 1, 2023.
7. State corporate practice of medicine (CPOM) doctrines & nonprofit exceptions.
Many experts note the burdens placed on frontline providers during the COVID-19 pandemic have taken a toll, and the apparent fall-off in demand for emergency medicine residency positions is not necessarily surprising. Nonetheless, there is concern suggesting solutions are needed to address multiple workforce challenges.
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