The American Academy of Emergency Medicine recently made a remarkable prediction that didn't seem to receive a lot of attention.
Concerned with the emergency medicine workforce's rapid growth, “fueled by the accelerating growth in emergency medicine residencies” and “the increasing number of advanced practice providers,” the academy said the historic emergency physician shortage was rapidly resolving. If current trends continued, AAEM said “an oversupply of emergency physicians is likely to develop, which may lead to negative consequences.” (AAEM Position Statement, Spring 2019; http://bit.ly/2EQPDd9.)
My home state of South Carolina had a single EM residency program with nine residents in each class when I was a resident. Not even 20 years later, there are designs to open the fifth program in a state that ranks 25th in population with just more than four million people. The combination of these five residency programs will graduate around 50 residents a year. Do we need that many graduates? Can they all find meaningful jobs?
One of the most common questions I am asked by applicants I interview for our residency is if our graduates get good jobs after they complete training. This has been a softball for the past 20 years. Back in the early 1990s with fewer than 100 programs in the United States graduating several hundred residents a year in total, staffing emergency departments with residency-trained, board-certified emergency physicians was an impossible goal. Finding a good job was a foregone conclusion for any EM residency graduate in good standing, and pay increased substantially since that time because of high demand and low supply. The benchmark hourly rate when I graduated in 1993 was around $100 per hour ($175 adjusted for inflation). Many jobs today pay more than $300 per hour.
Are we approaching a point where the relatively low supply of residency-trained emergency physicians and steadily increasing pay are coming to an end? Is the AAEM statement a realistic warning of the economic threat to our specialty? If so, how will it affect emergency physicians in practice and the employment expectations of current and future residents? Will new residency graduates entering practice be required to do more for less compensation while simultaneously repaying the overwhelming debt created by attending medical school?
Head of the Class
The common theme for many years in the lay press and medical publications has been that the United States is facing a shortage of physicians and it is imperative to increase the number to meet the needs of an aging population. The call has been to increase the number of primary care physicians in particular, which for the most part includes family medicine, pediatrics, internal medicine, and obstetrics/gynecology. Has there been progress toward this goal? The National Residency Matching Program publishes a comparison of the match results each year of the previous five years. (See table.)
The data indicate that seven of the 10 largest specialties (by the number of residents) have increased the number of available positions by double-digit percentages over the past five years. The proportional growth of emergency medicine positions tops the list with an increase of 37 percent, although it is fourth in the total number of residents behind internal medicine, family medicine, and pediatrics. This is almost double the percentage increase in internal medicine and more than triple that in OB/GYN and pediatrics.
It is likely that the efforts of EM's national organizations to improve the nation's emergency medical care through expanded training opportunities helped generate this dramatic increase in residency positions. Other forces are also clearly at play, the most compelling of which is the rapid development of programs administered and funded by large medical corporations to increase their access to emergency physicians through a policy of train and retain. (Read more about that in my article, “Corporations Rush In to Fill MD Shortage,” EMN. 2017;39:1; http://bit.ly/2ER1asX.)
The current path to opening a residency program in any specialty is through the Accreditation Council for Graduate Medical Education, but it is unlikely that the council is coordinating the number of available residency positions in EM or any other specialty with what is actually needed or desired. Their mandate has always been to establish parameters for providing quality post-graduate education, not analyzing the economic implications of physician overproduction on the provision of care. I suspect this is a case of lack of oversight. Does the ACGME even know what it should be looking for?
It's not just the increasing number of residents but also the rapidly increasing production of advanced practice providers that is affecting the number of emergency physician positions and income. They are regarded by hospitals and some groups as highly desirable alternatives who provide care at a fraction of the cost of a physician.
In coming months, I will take a closer look at these threats and how realistic it is that they will affect the future employment status of emergency physicians.
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Dr. Cookis the program director of the emergency medicine residency at Palmetto Health Richland in Columbia, SC. He is also the founder of 3rd Rock Ultrasound (http://emergencyultrasound.com). Friend him atwww.facebook.com/3rdRockUltrasound, follow him on Twitter@3rdRockUS, and read his past columns athttp://bit.ly/EMN-Match.