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Life in Emergistan

Life in Emergistan

The Dark Age of Job Scarcity and Zero Leverage

Leap, Edwin MD

doi: 10.1097/01.EEM.0000758748.77812.7d
    jobs, workforce

    Many physicians have been writing about the impending job shortage in emergency medicine. One of the things I've learned as an observer of medicine over the years is that it's really hard to predict the future. Clichéd but nonetheless true: Only time will tell.

    Human beings, however, are hard-wired by evolutionary biology to believe that the worst thing is likely. It helps us prepare. It endows us with a surfeit of caution. I can't say whether thousands and thousands of our colleagues will struggle to find work, but I can reasonably predict that the nature of jobs will change, and I suspect that our esteem within hospitals and our value to them will fall. (Stop laughing! We're valuable! Well, kind of.) Our role will simultaneously devolve as we become mere puzzle pieces commoditized at a staggering rate.

    This is something for academics and corporations to consider as they add more and more residencies despite the drop-off in available jobs. The role of physicians in academic centers may be safe for a while, but their graduates will increasingly find themselves under the thumb of administrators and even coworkers who realize their predicament. CEOs and CFOs will quickly realize that replacing a physician will be as easy as thumbing through the ever-growing CV pile and making a call to someone who is scraping by working part-time shifts at best.

    Then and Now

    My first director, the late Jack Warren, MD, famously said, “Ed, if you don't make someone mad once a day, you aren't doing your job.” He was a sage, of course, and I have found that to be true over and over. But it isn't exactly a popular thought now, in this dark age of metrics and satisfaction scores.

    Our administration knew back then that Jack was rabid about his physicians and his department. They also knew it was no small task to find an emergency medicine-trained director supervising a group of emergency medicine-trained physicians in rural South Carolina. That let Jack go to the mat over issues that were important, and administration recognized that he had leverage. He didn't abuse it, nor did our group. But our viewpoints had weight when we had issues.

    Fast forward: Physicians are increasingly employed or working as independent contractors for large corporations. That means freethinking physicians are stripped of much of their power, financial freedom, and ultimately value. Obviously, this is accentuated by the customer service model. A physician can't make one patient angry, much less several over the course of a month, even if they need to be made angry (and some really do). This is perceived as a threat to reviews, community perception, and ultimately cash flow.

    The situation becomes more worrisome by the increasing tendency for physicians to be replaced by nurse practitioners and physician assistants, which makes our place in the medical ecosystem that much more tenuous. We may tut-tut, minimize the threat, and prattle on about our valued colleagues, but let's not delude ourselves for even a minute that large numbers of them will more than happily hold themselves out as our equals, especially once they complete their emergency medicine “residencies.” Academic emergency physicians who support this trend are simply adding one more hurdle to the future careers of their residency graduates and making it appear that the rigors of residency are unnecessary. (“EPs Object to PA ‘Residencies,’” EMN. 2021;43[5]:1;

    Pins and Needles

    The icing on the cake is that so many physicians will be competing for the same jobs. When that happens and all these other factors are added in, it will mean that physicians have zero leverage. There will be no pushback. There will be no arguing with administration over ethical and scientific issues. There will be no protracted contract negotiations. Staffing will be what it is, and if you don't like it, you'll leave. Added responsibilities will grow and grow, without commensurate pay. Credentialing requirements and in-house continuing educational requirements will explode.

    There will be no questioning of nursing administration or nonphysician practitioners if they choose to call the physician “disruptive.” Calls before committees or directors will result from any perceived negativity, however appropriate it might have been. Lawsuits? I suspect that a single malpractice claim will be more than enough to keep one from being hired or to be dismissed from a job. Why? Many other physicians won't have a job and will be happy to take yours. (Granted, many won't have the same experience, but that will be irrelevant.)

    If we continue the current course and keep adding residencies and residency graduates so that physicians have nice, safe academic places to work, then the problem won't just be finding a job. It will be finding one that is safe and stable and that doesn't put physicians on pins and needles every day for their entire career. I may be wrong, but I've been right an awful lot, and this one has me worried.

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    Dr. Leappractices emergency medicine in rural South Carolina and is an op-ed columnist for the Greenville News. He is also the author of four books, Life in Emergistan, available at, and Working Knights, Cats Don't Hike, and The Practice Test, all available, and of a blog, Read his past columns at

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    • ssteckel9:54:11 PMI’m scared too. I’ve already started training for independent precision medicine practice, but my heart is in the ED. I’ve never been one to keep quiet or “go with the enforced flow,” which has left me seasoned, wise, and without a job. I trained in the trenches and find value in team-coordinated patient care. I can’t stand metrics. I meet the patient on the EMS stretcher and don’t need incentives to care for patients in a time-sensitive, compassionate, thorough manner. Thank you for your continued insight and honesty.
    • temarnie5:43:12 PMAs usual, Dr. Leap, you are right on.