A second-year medical student from California emailed me a few months ago, asking whether he should train in emergency medicine. He had never set foot in South Carolina and did not seem interested in our program, but he had read some of my columns and wanted to know what I thought he should do.
We met virtually, and he expressed his long-held desire to become an emergency physician. The 2022 match and reports of a workforce surplus had given him second thoughts.
The 2022 emergency medicine match was historic. We saw a significant contraction in the number of applicants as well as many unfilled residency positions. Before this match, there were substantial indications that we were headed for trouble, but no one was sure if or when we would see the effects of unchecked growth in the number and size of EM residency programs.
The current problem is not due to a lack of good jobs or declining salaries. Great opportunities exist in rural areas that traditionally did not have access to an adequate number of board-certified emergency physicians. Some readers even wrote to me about their difficulty in getting new EM grads to look at their job openings. The 2022 graduates from my program all secured wonderful jobs in urban and rural locations, and most chose from several options. It became evident by the middle of March 2022, however, to medical school students considering a career in emergency medicine that the effect of too much growth was already happening. And they were afraid to take that leap of faith.
I have said before that the 2022 match was just what our specialty needed—a wake-up call. (EMN. 2022;44:1; https://bit.ly/3t9ASLN.) At some point, unbalanced markets readjust. The sooner we start this process, the sooner we recover. Ironically, it is not residency programs moving the needle but medical students.
No New Programs
We are now in the early stages of the 2023 match, and applicants are actively interviewing. These are the variables we should focus on to indicate whether we are moving in the right direction:
- The number of applicants
- The number of EM programs
- The number of EM residency positions
- The number of unmatched positions
- The number of unmatched programs
The number of applicants dropped 18 percent in 2022. This is unprecedented, and it almost certainly was caused by the wide dissemination of the ACEP task force report on the projected oversupply of emergency physicians by 2030. Another considerable drop in applicants for the 2023 match would indicate that pending medical school graduates are still afraid. But it means less competition to train at desirable programs for those medical students set on a career in emergency medicine, a benefit for them.
It also means one of three things for programs that do not fill: Train fewer residents, fill their programs with less accomplished domestic applicants, or look more aggressively at international medical graduates (IMGs) to fill their programs.
I think we still want the total number of applicants to go down. A drop in applicants may result in more IMGs in EM residency positions, but no evidence supports that this has negatively affected internal medicine or family practice programs, both of which train relatively large numbers of IMGs.
The number of EM programs modestly increased from 2021 to 2022. Only four new programs were in the 2022 match, while the annual increases were no less than 17 new programs over the previous six years. We obviously do not want any new programs in 2023, and we would welcome a decrease.
No Easy Answer
Getting approval from the Accreditation Council for Graduate Medical Education to increase the class size of an existing program is not typically difficult, and larger academic and corporate institutions depend on these residency programs to provide clinical care. Of course, everyone at this point knows increasing class size is not the right thing to do, but it is easy to think that one or two (or 10) more graduates each year will not do much damage. But we want the number of available positions and EM programs to stay flat or go down.
What do we want for the number of unfilled residency positions and unfilled residency programs? What is the just-right Goldilocks number? The ACEP workforce study suggested that we will have too many EPs by the end of the decade without expanding employment opportunities for EM graduates into areas that did not exist or that we did not previously exploit. If that is the case, we need fewer programs, and more unfilled programs may force some to close. This happened to anesthesiology in the 1990s as programs shut down due to smaller applicant pools.
This can cause a lot of damage, however. EM programs with negative balance sheets that provide care to underserved communities might become casualties even if they are the medical safety net for large numbers of patients. On the other hand, well-funded programs at emergency departments that make money will have a distinct advantage. There is no easy answer. We have to find jobs for graduates if we keep the number of programs that we currently have.
The 2023 match will be watched closely, and it may be deemed a success or failure by analyzing the five variables I mentioned. One person's interpretation of a successful match may be a step in the wrong direction for someone else. Corporate medicine will be happy if more graduates flood the labor market, while new residency graduates will be anxious about how it will affect their professional futures.
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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 (http://emergencyultrasound.com). Friend him athttps://www.facebook.com/3rdRockUltrasound, follow him on Twitter@3rdRockUS, and read his past columns athttp://bit.ly/EMN-Match.