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Emergency Medicine Doesn't Need More Residencies

Blazar, Eric, MD

doi: 10.1097/01.EEM.0000553485.55048.7e
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Dr. Blazar is the emergency medicine clerkship director and the assistant research director at Inspira Regional Medical Center in Vineland, NJ, and an associate professor of emergency medicine at Rowan University in Glassboro, NJ. Follow him on Twitter @eblazar.

I'm going to say something that likely won't be popular: We probably don't need more emergency medicine residencies or more emergency physicians.

No matter where you look, the news is always that a physician shortage is looming. The New York Times, USA Today, and a study commissioned by the Association of American Medical Colleges all spoke about this phenomenon. The AAMC study predicted a shortage of 42,000 to 120,000 physicians by 2030. (AAMCNews Aug 3, 2018; http://bit.ly/2qa3Aen.)

Emergency medicine has taken note. A report on residency and fellowship training by the American Board of Emergency Medicine and the Accreditation Council for Graduate Medical Education shows growth in emergency medicine residencies. Post-graduate year-one emergency medicine residency spots increased by 27.5 percent over four years—from 1,786 spots in 2014 to 2,278 in 2018. (National Resident Matching Program, Results and Data: 2018 Main Residency Match. Washington, DC. 2018; http://bit.ly/2yvCIu6.)

Emergency medicine offered 2,047 post-graduate year-one positions in 2017 and filled 2,041 (99.7%) of them. We will add more than 2,000 new board-eligible emergency physicians yearly to the job pool by 2020. (Ann Emerg Med 2018;71:[5]636.)

This only accounts for ACGME-accredited program graduates and does not include the American College of Osteopathic Emergency Physicians programs that are graduating residents. Is the continued rapid expansion of EM training a wise direction for us professionals already in the field and for those new physicians entering the field?

Are we diluting the future job market for our specialty by rapidly increasing EM graduates? (Ann Emerg Med 2018;72[3]:302.) A disproportionate number of emergency physicians practice in urban and suburban settings with nearly 64 percent working in urban regions. Meanwhile, 27 percent of U.S. counties, mostly in the South and Midwest, have no emergency clinicians.

“Rural hospitals have unique needs for organizing and delivering emergency care and have reported that hiring nonemergency physicians and advanced practice providers is crucial because of greater local availability and lower salary compared with emergency physicians, which maximizes revenue efficiency,” the authors noted.

The study found that 32,039 board-certified emergency physicians billed Medicare in urban counties compared with 3,770 EPs working in rural counties. (Ann Emerg Med 2018;72[3]:302.) This is a staggering contrast. We are increasing emergency medicine trainees to meet a job market that likely does not exist. Reports in popular society are driving a trend that is incongruent with the reality in emergency medicine. It can be assumed that graduates, similar to current EM practitioners, will favor an urban or suburban setting just as years of graduates before them have done, which created this disparity.

If we continue to bolster the forces of available physicians to provide emergency care, it is reasonable to assume that urban and suburban salaries could decrease as jobs become more competitive. Newer physicians certainly would be more comfortable working at a decreased pay rate after never having worked for a higher wage.

Are we banishing new graduates—and ourselves—to work in rural settings far from the urban cores in which many of us currently practice and want to live? Are we increasing our trained physicians for jobs that will not pay EM wages? Are we growing for the right reasons?

The physician shortage emphasized by the media and medical education may be exaggerated for emergency medicine. Clearly, the response of increasing our workforce will test this. Rural communities staffed by non-EM-boarded and -trained physicians allow for continued operation and service to those communities at affordable rates for the health care system and patients.

Moving forward, it will be important for governing bodies to pay attention to these sentiments. As larger corporate groups work to maximize profits, salaries will decrease, and younger, newer members of the physician workforce will be forced toward undesirable locations to maximize income or will take decreased salaries to live in these suburban or urban locations. It will be worthwhile to track and trend salaries and monitor rural hiring to see if it is increasing along with the increasing number of graduates.

I believe we will be diluting our talent pool and seeing a significant salary decrease in the more desirable urban and suburban job markets unless we stabilize our rapid growth.

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