When emergency medicine was still the new kid on the block in the 1990s, fellowship opportunities for graduates were few and far between, and the only options were EMS, pediatric emergency medicine, and toxicology. This made each graduate's choice a little easier in many ways. You could take a clinical job and make as much money as you could ($100 per hour was good money then), or you could take an academic position that paid considerably less (around $120,000 a year).
Funny what a few decades will do. Literally hundreds of fellowship positions are available to EM graduates these days with many options—academics, research, sports medicine, critical care, simulation medicine, global health, population health, palliative care, telemedicine, and clinical ultrasound. The Accreditation Council for Graduate Medical Education 2020 match results demonstrate that a substantial percentage of the three most popular EM fellowship programs went unfilled. (See table.)
These data come from the 2020 National Residency Matching Program (NRMP) report for fellowships, and this sample of fellowships in emergency medicine, pediatrics, internal medicine, and surgery shows that almost half of the available positions for the three most common EM fellowships did not fill. Clinical ultrasound trailed all of them by filling only 45 percent of programs. On the bright side, this created a buyer's market for pending EM grads, and 92 percent of the applicants to these fellowships matched.
Perhaps even more interesting were the number of new clinical ultrasound and EMS positions available this year—22 for clinical ultrasound, even though fewer than half of those positions filled in 2019. EMS was the same: Seventy-six percent of the available positions filled in 2019, and 10 positions were added in 2020, but the match rate fell to 62 percent. At least toxicology moved in the right direction by decreasing from 54 to 51 available positions in 2020, and the percentage of positions that filled went from 67 to 76 percent.
All of this is ironic given the popularity of emergency medicine residency training. Matching into an EM program is relatively competitive compared with other specialties that require three years of post-graduate training. Emergency medicine filled nearly all of its positions for the past 20 years, and 2020 was no different.
I have not mentioned pediatric emergency medicine as a common fellowship for EM graduates because the majority of these positions fill with graduates of pediatrics residencies. Some unpublished reports claim they outnumber EM grads by as many as 20 to 1. (ALiEM. Feb. 20, 2015; https://bit.ly/3aKjbrO.)
Pediatric EM programs are balancing the positions to applicants—all 191 positions matched in 2019, and 99 percent filled in 2020, with only two new positions added. Looking at matches since 2016, 98 percent of pediatric emergency medicine positions filled, but only 77 percent of applicants matched.
Driven by Money
What should we make of all of this? First, look at the sample of fellowships in the table for internal medicine and surgery. These fellowships have been around for decades. They have few unfilled programs, and at least 97 percent of the programs filled (except for thoracic surgery at 90 percent). The 2020 NRMP fellowship report lists 66 different types of fellowship training, and 47 of these (71%) filled at least 75 percent of the available positions. Thirty-four (52%) filled at least 85 percent.
To be sure, money drives a lot of these findings. Cardiology and gastroenterology fellowships generate considerably higher incomes compared with the income from just residency training in internal medicine. By contrast, EM fellowships typically do not provide higher levels of income compared with EM residency training alone. This discourages potential EM fellowship applicants from giving up one or two years of high compensation with no future financial reward.
The other interesting finding in the sample of non-EM programs in the table is that 63 to 77 percent of applicants matched. The exception is pediatric surgery, with only 55 percent of applicants matching.
It is evident that emergency medicine puts little thought into when and what to offer as additional post-graduate training through a fellowship. Academic centers are still creating programs in specialties with saturated markets and little chance of routinely filling. This wastes the efforts of academic faculty to perform meaningful work. The amount of time to build and maintain a post-graduate program is considerable. Yet once a fellowship graduate moves to another academic center, he begins work on developing a new program.
This has been particularly true with clinical ultrasound. At the turn of the millennium, there was only one program; now there are 129. That's an average of more than six new programs every year for 20 years. There are only 11 fellowship specialties listed in the NRMP report with more programs. None comes anywhere close to having as many unfilled positions as clinical ultrasound.
The academic centers for emergency medicine need to think strategically about building fellowship programs in tune with demand. There is an expanding number of niche interests in our specialty, and opportunities are available to exploit the low supply of experts in these areas. The current supply and demand for many EM fellowships can produce a dangerous situation in which program directors searching for someone to fill their program select an unqualified applicant. This could create problems in the emergency department when caring for complex patients with residents.
It may be a better time than ever for pending EM graduates to consider fellowship training. It's easy to embrace the idea of making as much money as you can. The explosion of new EM residency programs combined with a skyrocketing number of advanced practice providers, however, means having a niche skill may be the difference between getting and holding on to a great job versus having your hours cut or being forced out.
Dr. Cookis the program director of the emergency medicine residency at Prisma Health 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.