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After the Match

After the Match

What Will EM Do Without Enough Applicants?

Cook, Thomas P. MD

doi: 10.1097/01.EEM.0000815548.04077.45
    EM workforce, emergency medicine residency

    Numerous resources have documented the potential for a dramatic surplus of emergency physicians by the end of the decade, and potentially troubling questions come to mind for EM training programs.

    How will all these EM residencies survive when U.S. medical students no longer choose to train in emergency medicine because of actual or perceived issues about securing future employment? Are a significant percentage of EM programs likely to close due to too many training programs and not enough applicants?

    I find myself thinking in terms of markets when contemplating this dilemma. If your domestic business is unable to produce a product at a reasonable cost, you may be forced to make it offshore. If your domestic service cannot find enough employees, you may import workers from another country.

    I receive hundreds of applications from non-U.S. medical school graduates every year hoping to train and eventually work in a country that can provide them with a highly stable, lucrative income for decades. This is not the case in nearly every other country, including wealthy industrialized nations.

    It is rare for U.S. EM program directors to consider most international medical graduates (IMGs) and even less likely to match them. The conventional thinking is that U.S. medical school graduates will have an easier time integrating into a U.S. training program due to the highly standardized medical school education provided here. Programs want to mitigate the risk that a new resident with a non-U.S. medical education will fail. Why chance it when you are looking at hundreds of applicants from domestic medical schools? By far, the greatest hassle for any program director is a struggling resident who must be terminated. It is an exhaustive and frustrating process.

    Should EM Worry?

    This brings us back to what anesthesiology experienced in the 1990s. (“The Anesthesiology Match May be a Harbinger for EM,” EMN. 2021;41[10]:22; The number of IMGs entering anesthesiology programs increased when fewer U.S. medical school graduates entered. Only 10 IMGs (1%) entered anesthesiology programs in 1990. That number increased to more than 120 (12%) by 1998. (See graph.) Anesthesiology programs stabilized in 2007, and the percentage of IMGs dropped to four percent. Currently, it is a little more than six percent.

    Emergency medicine had a 60 percent increase in IMGs (111 to 178) because of the rapid growth of new programs beginning in 2015. A little more than six percent of first-year EM residents were IMGs in 2021. That, however, is only 178 of 2840 first-year residents. Should emergency medicine graduate medical education worry about this?

    In a word, yes. What happened to anesthesiology residencies coincided with the rise of certified registered nurse anesthetists. A perceived job shortage may have encouraged senior medical students to go into other specialties, and what may happen to emergency medicine could be several times worse. EM not only faces losing jobs from the rapidly increasing number of nonphysician providers competing for EM jobs but also from the explosion in the number of residency programs. This will create the perfect storm to potentially drive away many more U.S. medical graduates from EM than what anesthesiology experienced three decades ago.

    This is a scenario that EM program directors should fear. If programs feel threatened with closure due to a lack of qualified applicants, we can expect to see more EM training programs turn to IMGs to fill their classes. If EM experiences twice the percentage of IMGs becoming new residents that anesthesiology faced in the 1990s, one in four first-year EM residents will be an IMG.

    Of course, many folks will appropriately ask if this matters. Family medicine and internal medicine routinely match a large percentage of IMGs each year, and those specialties are not burning to the ground. FM matched 1224 IMGs of 4823 first-year positions (25%) in 2021, and IM matched 3416 IMGs of 9024 (38%). The United States still has a sizable deficit in the number of primary care providers, and graduates from these specialties still enter a promising job market. The plight of emergency medicine is that if the number of emergency medicine graduates does not decrease in the relatively near future, the market will be flooded with highly trained EPs looking for work.

    We know the solution to EM's growing problem is fewer programs producing fewer residents, but it will take something outside the influence of individual programs to achieve this goal. Most programs will do anything to remain operational to survive. Even if the number of U.S. medical graduates applying to EM programs drops substantially, it is likely the number of programs will not decrease significantly. Instead, struggling programs will import more residents from foreign medical schools. The various organizations within our specialty looking for solutions to the overproduction of residents must understand that programs will not run out of applicants.

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    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 ( Friend him, follow him on Twitter@3rdRockUS, and read his past columns at

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