I was a senior resident on an anesthesiology elective in Austin in 1992, and like every emergency medicine resident, I wanted to do as many intubations as possible.
I thought it was remarkable that a nurse anesthetist managed the airway for every single case. The only anesthesiologist present stayed in the doctors' lounge, drinking coffee and reading a newspaper.
He wandered into the operating room at the beginning of each case to chat with the nurse anesthetist and scribble a quick note in the chart. Even then, I thought this was a reckless business strategy that could threaten the future of the specialty. Why give up your bread-and-butter procedure to someone else? You make more money managing 10 rooms with one anesthesiologist and 10 (cheaper) nurse anesthetists, but this decreases the amount of work available for other anesthesiologists, especially those looking for jobs after graduation.
Given the plight of emergency medicine recently documented in stunning detail by ACEP's “Emergency Medicine Physician Workforce Projections for 2030” (Ann Emerg Med. 2021;S0196; https://bit.ly/3lVrGYu), my experience with anesthesiology made me think about how that affected its residency programs. After all, if fewer jobs are available for anesthesiologists because nurse anesthetists are replacing them, it stands to reason medical school graduates would choose other specialties.
The National Residency Matching Program (NRMP) has been publishing the comprehensive results of each match since 1984, and what happened with the anesthesiology match in the 1990s might be a harbinger of what lies ahead for emergency medicine. (https://www.nrmp.org/report-archives.)
What the Data Show
A comparison of the percentages of available residency positions filled with U.S. senior medical students from 1990 to 2021 in anesthesiology and emergency medicine strikingly demonstrated an enormous drop in the percentage of anesthesiology residency positions matched by U.S. senior medical students in the 1990s. (Graph 1.) The nadir occurred in 1996, when only 18 percent of available positions were filled.
That was also four years removed from what I witnessed in Austin on my anesthesiology rotation, and coincidentally also the final year the academic medical center where I now work had an anesthesiology residency. The percentage of anesthesiology positions filled by U.S. senior medical students returned to the 1990 level in 2007. The drop and subsequent recovery for anesthesiology matches with U.S. senior medical students took 17 years.
Predictably, a dramatic drop was seen in the number of anesthesiology positions available in the 1996 match compared with 1990. (Graph 2.) This number stayed flat through 2000 and then slowly rose over the next 20 years. It was not until 2012 that the number of anesthesiology positions reached levels seen in the early 1990s. By contrast, emergency medicine had steady growth in the number of offered positions from 1990 through 2015 before exploding over the past six years.
More than 50 percent of anesthesiology residency programs did not fill all their positions just three years after the 1996 nadir. (Graph 3.) This is not just U.S. senior medical students, but all applicants, including other U.S. medical school graduates and international medical graduates. It was not until 2007 that the number of unfilled programs stabilized around 10 percent. Emergency medicine did well from 1999 through 2021, and it had no unfilled programs in 2012 and only one in 2016. Since 2019, anesthesiology has had fewer programs that do not fill in the match. (Unfortunately, the annual NRMP match reports only provide data for this metric from 1990 to 2021.)
Since 2008, roughly the year the number of unfilled residency positions for anesthesiology stabilized, that specialty has attracted considerably more U.S. senior medical student applicants per offered residency position than emergency medicine. (Graph 4.) Since 2017, applicants per EM position dropped from 0.90 to 0.73, while applicants per position for anesthesiology increased from 1.18 to 1.38. Again, the NRMP annual match reports only provide data for this metric from 2008 to 2021.
The number of available jobs for emergency medicine residency graduates is decreasing because of too many programs, residents, and nonphysician providers. The lessons we can learn from anesthesiology are profound.
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.