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After the Match

After the Match

The Disappointing Match Was Exactly What EM Needed

Cook, Thomas P. MD

doi: 10.1097/01.EEM.0000834092.52542.42
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    Match Day, NRMP, residency
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    “...beware the ides of March.”

    —William Shakespeare, in “Julius Caesar”

    A week in the middle of March was a wake-up call for emergency medicine. A specialty that enjoyed enormous popularity and growth for four decades was punched in the mouth. Just like the death of Caesar in Shakespeare's epic play, a lot of people saw this coming.

    Program directors receive an email on the Monday of Match Week each year with a small piece of critical information. It simply states whether their program filled in the first round of the match, meaning that enough applicants ranked the program high enough to fill all the vacancies for their new class beginning in July. Unfortunately, more emergency medicine programs received bad news this year than ever before in the history of the specialty.

    Sixty-nine of 277 programs (nearly 25%) did not fill their spots in the first round, and 219 individual residency positions went unfilled. These programs subsequently entered the Supplemental Offer and Acceptance Program, known as SOAP (formerly referred to as the scramble). The number of EM programs that ultimately filled all of their available positions was unknown at press time, but most of them likely did.

    EM Gets Roughed Up

    The results from this day, however, reverberated across the entire academic medical community. Emergency medicine, the specialty that routinely filled 99 percent of its available positions, was roughed up. How difficult this match was for emergency medicine is shown in stark relief in the data from 2015 to 2021:

    • The average annual number of unfilled positions for those years was 12. That number was 219 in 2022.
    • The average number of unfilled programs was seven from 2015 to 2021 but 61 in 2022.
    • The average annual increase in the total number of applicants from the previous year was 230. This number decreased by 653 in 2022.
    • The average annual increase in the number of senior allopathic applicants was 78 from 2015 to 2021, a number that decreased by 386 in 2022. (See table.)

    The National Resident Matching Program does not publicly release the names of programs that did not fill in the initial match, but social media quickly leaked this information (in addition to some fascinating commentary from applicants and current residents). These data may be inaccurate, but the posted information on unfilled programs did correlate with regional data supplied by NRMP on unfilled positions. If this information were correct, many programs sponsored by HCA hospitals did poorly, possibly indicating resistance from applicants against large corporate involvement in academic EM. (Reddit. March 2022; https://bit.ly/3vSvYTP.)

    Cold Feet

    Anecdotally, several of the applicants we recruited for our program did not match in emergency medicine. Some of them sent correspondence to me about how much they wanted to train with us before the match, but they subsequently chose other specialties. This phenomenon appears to have occurred with many applicants around the country, according to social media, so it is reasonable to infer that these applicants got cold feet about emergency medicine during the interview process.

    Should we have seen this coming? The obvious answer now is yes, but humans tend to stick their heads in the sand when it comes to unpleasant projections. The 2021 publication about future EM workforce projections rattled a lot of medical students considering emergency medicine as a career, and now we are seeing the fallout. (Ann Emerg Med. 2021;78[6]:726; https://bit.ly/3lVrGYu.)

    Is there any good news from this match? My thinking might surprise you. Unlike most, I think this was the perfect match at this pivotal time in our history. This match was exactly what you wanted if you are a recent graduate, current resident, or medical student dead set on becoming an emergency physician.

    Markets are like sharks. It's nothing personal; it's just business. A market out of balance yields opportunity, but it also delivers pain. It does not matter if it is tulip bulbs in 17th century Amsterdam or oil fracking in 22nd century Texas, someone is getting hurt. The opportunity created by our workforce market for emergency medicine in 2022 is that more employers can hire highly-trained emergency medicine graduates from great EM programs. The pain, however, is the potential for reduced incomes and the difficulty in finding good jobs.

    I think this was an excellent match for our specialty because EM must feel pain at some point. It reminded me of an old TV commercial selling oil filters. An auto mechanic explained that “you can pay me now or pay me later.” The implication was that the oil filter was cheap and the engine repair from not installing a new oil filter was expensive. It is much better for emergency medicine to feel some pain now than wait until the damage is catastrophic.

    Emergency medicine residencies, not the applicants, residents, or recent graduates, are also feeling the pain. We must remember that the oversupply of emergency physicians predicted by the workforce study is not expected to start until 2030. EM graduates are still getting great jobs. All my seniors secured positions this year and are extremely happy.

    I think we will need a few more years of matches like this one to achieve the balance necessary for our specialty to prosper and grow responsibly. We all need to be patient and understanding. Some programs will get hurt, but there is no other way out of this. Ironically, we should be happy as a specialty that the 2022 match helped us take a big step in the right direction.

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    Comments? Write to us at [email protected].

    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.

    Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.
    • hugeldoc4:10:49 PMWell written. The&#160;problem is that for an EM graduate, avoiding contract management group corporate practice is increasingly almost impossible. In Las Vegas, for example, virtually all of the hospital EDs are CMG-run. Perhaps AAEM's recent lawsuit might begin a process to dismantle this. I doubt it, though. Just like the book “The Rape of Emergency Medicine” and the whole Spectrum saga, it generated a lot of nothing in the end. Only when the match results are replicated&#160;in&#160;the next few cycles will some change be forced.<br>
    • rprice9:49:45 AMCertainly, like most things, it's multifactorial and complex,&#160;but I think with social media and online resources, students are more informed in general about what they are getting into. And emergency medicine is just not attractive to a generation that probably has more emphasis on work-life balance than mine did (some may argue too much, but that's another discussion). Who would want to spend all the time and effort it takes to get through medical school and residency to be a cog in a corporate machine with no control over your practice environment, work hours, pay, benefits, etc.? Even in the best of circumstances, where I worked for 15 years, in a private, really democratic (as equitable as humanly possible) group, you're still stuck in a hospital run by MBAs, who tell you what EHR you're going to use, what your department staffing will be, and what boxes you are going to click in that EHR. You still have no control over your practice environment. You can't escape the hospital admin even if&#160;you're a private, democratic, equity-owned group. And then there's the physical toll as our shiftwork schedule literally takes years off our lives, the same as smoking, according to some data. I tell medical students who ask me about EM to get as far away from corporate medicine as possible, which means avoiding private equity and hospital-based medicine as much as they can. Find a specialty where you at least have a chance of owning your practice and having some semblance of control over your work-life balance. I'd never recommend EM&#160;because it's a bad business and&#160;lifestyle model. It has nothing to do with the actual medical side of things. I love the medicine part,&#160;but there are better and smarter ways to practice medicine than EM.<br>
    • hugeldoc4:51:54 PMAs my career in EM (ABEM residency 1987) wanes, and I downshift a bit, I find it sad that a profession with such an amazing history, such innovative, trailblazing, and dedicated clinicians now finds itself a victim of its own success and often hubris as we allowed corporate and financial forces determine our course, a public with insatiable and often wholly inappropriate demands in a lopsided health care system (”just go to the ER”) dictate so much of our practice via pseudo standards and metrics that were poorly or not validated and administrative forces that had little EP&#160;input, let alone ever stepped foot in an ED. I see the match “correction” in a more urgent and ominous light. EM as it is currently configured is going to have even more erosion of its allure and financial base from a variety of directions&#58; expansion of APPs including practice scope, the current domination of mega contract management groups and the staffing and workloads standards set, not by EPs but those who have profit as their only goal. Seriously, 12-hour shifts in a busy shop, single-physician&#160;coverage ever, the onerous EMRs that rob patients of face-to-face doc time (and decrease satisfaction and increase liability), absurd metrics that bear no validity in patient care true quality, micro-management at all levels from nursing staff to Press Ganey charts, etc., etc. We have created this; these match results are simply reaping what we sowed. The generations of medical students to come will hopefully demand a different course than we have taken and simply not accept the status quo.
    • scordovano11:12:10 PMCorporate for-profit private equity is driving the EM bus over the cliff. Nice going.<br>
    • lingx00310:30:47 AMThanks Dr. Cook, We knew this was going to happen at sometime. We have spent years in undersupply, and now that it is corrected, the time for emergency medicine as a specialty is now, to take action to get into balance.
    • gatrellc9:08:08 PMEmergency physicians may have had less personal control over their lives and practices during the pandemic than any other specialty. Many would-be applicants may have been scared off by the highly publicized coverage of the unending onslaught of COVID patients in emergency departments.