Breaking News: A Catastrophic Match: Now What? : Emergency Medicine News

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A Catastrophic Match: Now What?

Cook, Thomas MD

Emergency Medicine News 45(4):p 1,21, April 2023. | DOI: 10.1097/01.EEM.0000927176.08165.1f

    Nearly half of EM programs did not fill, and leadership must do more than form a task force

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    Figure:
    emergency medicine, Match Day 2023, residency programs, corporate medicine, international medical graduates, American College of Emergency Physicians, EMRA, American Academy of Emergency Medicine, nonphysician providers, nurse practitioners, physician assistants
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    This year's match was a slow train wreck that any reasonable person could see coming. Emergency medicine had experienced growing popularity since 1980 that was the envy of nearly every medical specialty. We had a good ride for 40 years.

    This popularity, however, led to rapid expansion of residency programs over the past eight years and, ultimately, our demise. EM went from the coolest kid in school to a burning wreck in just two years.

    The data are staggering. Every metric says EM is sinking and medical students are jumping ship. Forty-six percent of all programs did not fill in the initial round, and the number of unfilled positions is up 3864 percent. Those are not typos. It's that bad. (National Resident Matching Program. March 17, 2023; https://bit.ly/3JTbp1N.)

    Now what?

    We must accept that this is just the beginning. Some will say it cannot get any worse. Trust me; it can. Our crisis is often compared with anesthesiology's plight in the 1990s. That specialty had six consecutive years starting in 1990 of decreasing fill rates with a cumulative drop of 77 percent. (EMN. 2021;43[10]:22; https://bit.ly/3B4T9M1.)

    EM is only in its second year of decreasing fill rates with a cumulative decrease of 18 percent. We have a long way down before the bleeding stops.

    Stop Opening New Programs

    I wrote an entire column about this. (EMN. 2022;44[2]:1; https://bit.ly/3oiU07q.) It seems like a no-brainer, yet 10 new programs were in the match this year. If you think that is incredible, consider this: Five new programs are opening in July 2024.

    The program director of a new EM residency opening next year in California posted on the Council of Residency Directors in Emergency Medicine website (on Match Day, no less) that her new program was necessary because their population is underserved. This is unbelievable. California has seven programs that did not fill in the initial round of this year's match. Where does this new program director think she will get residents next year, Mars? CORD must bluntly say, “Do not do this.”

    We have many established programs in communities with poor access to care that are struggling to fill because of hospitals like this one that rationalize that its needs outweigh the destruction of the specialty. We have a tradition in the academic community of welcoming new programs with open arms. Doing this now is to the detriment of every current resident and the entire specialty. We are shooting ourselves in the foot.

    Don't Use IMGs as a Backstop

    The number of international medical graduates (IMGs) who matched into EM increased by 89 percent. Again, this is not a typo. (National Resident Matching Program. March 17, 2023; https://bit.ly/3JTbp1N.) Indeed, many U.S. citizens train in foreign medical schools (think Caribbean) to practice here eventually.

    Do other countries in Europe, Latin America, and Asia like it when we pilfer their best and brightest medical school graduates for our programs? We can rationalize this by saying they receive better training and take these skills back to their country of origin, but we all know this is not what most IMGs want.

    I am all for people from other countries pursuing the American Dream like my parents did, but this is a borderline unethical solution to our problems. Why are we importing doctors into a specialty with a surplus of physicians? This is nuts.

    ACEP Should Divest Itself of Corporate Medicine

    When times were good, most of us turned our collective head away from the pernicious effect of corporate medicine. We thought, “Yes, those guys are making bank, but I get paid well.” But we are on the road to perdition when every hospital administrator is convinced by corporate medicine that they can convert their ED from a cost center to a revenue center.

    We saw an explosion in just a few years of nonphysician providers (NPPs) doing more of our work at a third of the cost. The American College of Emergency Physicians (ACEP) leadership will say they support the average emergency physician, but walk around the Scientific Assembly exhibit hall to see the dramatic influence of corporate emergency medicine.

    Their exhibits are huge and staffed by large groups of minions seducing young emergency physicians to join them. It's time for ACEP to become an adversary to corporate EM.

    We should desert the college if it does not.

    We can start with EM residencies leaving ACEP's Emergency Medicine Residents' Association (EMRA) and moving to the American Academy of Emergency Medicine's (AAEM) Resident Student Association.

    Why indoctrinate our residents with ACEP when it appears to serve companies that are significant contributors to our downfall?

    Robert McNamara, MD, is Absolutely Right

    Read my interview with Bob McNamara in this issue (p. 11), and you'll see his passion for helping emergency physicians. As he and AAEM have proselytized for years, corporate health care is first and foremost interested in making money at the expense of physicians and patients.

    ACEP, AAEM, and every other EM organization must support federal legislation requiring all physicians to see what is billed in their names. This provides a counterbalance to corporate medicine's drive to lower physician compensation.

    Supporting emergency physician compensation will be imperative to attract medical school graduates to our specialty. If medical students think our job market is tight and compensation is falling, we might as well just tell them to go away. Who is going to sign up for this?

    EM Must Corral Nonphysician Providers

    As I laid out two years ago, nurse practitioners are winning the right to practice independently in statehouses nationwide. (EMN. 2021;43[3]:1; https://bit.ly/3sFcdMi.) More than 13,000 physician assistants are also working in emergency medicine. (EMN. 2019;41[12]:1; http://bit.ly/37ZBQOv.) Will they follow NPs' example?

    NPPs have a place in our specialty, but there must be a limit on the number of them supervised by a single board-certified emergency physician. NPPs also must not be allowed to staff EDs without the presence of a board-certified EP. And never should we allow only virtual support of NPPs in EDs. Federal regulation must be a priority for ACEP, AAEM, and every other EM organization.

    Accept that EM Needs Fewer Programs

    Closing residency programs is painful. My program is my child. I have nurtured it for most of my career. I do not wish closing a program on anyone, but the reality is that the marketplace is the ultimate force. Markets are like sharks: They do not understand your pain; they just eat.

    During anesthesiology's crisis, 16 percent of programs closed, including the one at my hospital. (EMN. 2021;43[10]:22; https://bit.ly/3B4T9M1.) Around 50 EM programs will close if history repeats itself (it has so far). We do not want to think about it, but this is likely the bitter medicine we will have to swallow.

    Leadership Must Do the Hard Things

    The leaders of our professional organizations have failed. Not only were they late in comprehending the impending disaster, but when the landmark workforce study made dire predictions of a massive oversupply of emergency physicians (Ann Emerg Med. 2021;S0196; https://bit.ly/3lVrGYu), many EM leaders spent the next two years expressing optimism that everything would be OK.

    Once it became apparent that the 2023 match was a disaster, every professional EM organization put out a statement on Match Day about creating a task force to fix it. (March 13, 2023; http://bit.ly/401sjku.) This statement says some nice things about how they will “focus on solutions” and “support trainees.” It is complete oatmeal.

    We need leaders who are willing to say and do the hard things that this crisis requires. Three of the priorities of the “task force” should be federal legislation and regulation of physician access to services billed in their names, limits on the number of NPPs supervised by a single board-certified EP in the ED, and board-certified EP in-person supervision of all ED services.

    Is There a Light at the End of the Tunnel?

    I must refer again to the anesthesiology disaster. Their experience is looking eerily like our own. We need to scrutinize this and consider how much of what happened to them will happen to us. It took 16 years for them to return to baseline. The good news is that anesthesiology is thriving. They had only one unfilled program and three unfilled positions this year.

    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 © 2023 Wolters Kluwer Health, Inc. All rights reserved.
    • robbooth9931:00:19 PMDr. Cook, I have only a few points to interject. As was previously mentioned, EM grew at least somewhat in part due to the help of television. The grind of EM is miserable, and no rational person would sign up for the abuse of the ED. The never-ending flood of patients, most of which are not emergencies, the ungrateful patients, the violent patients, the persistent pressure from administration to do more with less, the metrics...oh man, the metrics. I think COVID was the final straw. Medicine in this country is not breaking; it is broken. Unfortunately, the ED&#160;is the toilet of medicine where everything everyone else doesn't want to deal with ends up. It is where we are forced to accommodate the impatience of the American consumers and feel their wrath if we don't say &quot;how high&quot; when they say &quot;jump.&quot;&#160;It is the area of medicine where the doctor has the least amount of power or control. I would like to specifically respond to the component of your article regarding PAs functioning independently in critical access EDs. I am that of whom you speak. I am a fellowship trained EMPA-C of 18 years. I work as a solo provider in a critical access ED&#160;in rural Maine. I provide access to EM care that you will not because EPs&#160;will not come out here. Per ACEP's own data, only two percent&#160;of residency-trained MDs work in rural/critical access EDs. So, what are we to do with the 60 million Americans who live in rural America? Give them no care? As an EM PA, I can provide competent life-saving medical care, stabilize and transfer my patients to the higher level tertiary centers where EPs like to stay with all of your multitude of assets--specialists, interventions, radiology studies, and collegial support. I would encourage you to read my article in&#160;<em>JAAPA </em>that specifically deals with this matter&#58;&#160; http&#58;//bit.ly/3nMsulq.&#160;You say you must “corral NPPs.”&#160;I do not speak for NPs, but I will say for EM PAs, you would be better served dropping your elitism and embracing the team approach to medicine. SEMPA and ACEP could do some amazing things if egos would get out of the way. You have empty seats in your residency programs? Offer them to PAs, particularly to PAs who are going to be working as solo providers in critical access EDs that you are not willing to staff. If you are truly interested in providing the most good to the most patients&#160;and this is not just about ego and territorial protection, then partner with us. We use a telehealth service with Dartmouth. I am able to reach out to outstanding EPs with the push of a button when I need support. That is doing good. That is force multiplication. That is the future of care in the middle of nowhere. I am not as well trained as you, but I am not nothing. The care I provide out here is greatly appreciated by the community. Instead of stomping your feet, come out here, or jump on a telehealth line and help out.
    • robbooth99312:33:01 PMI witnessed this in a large urban ED&#160;about a decade ago. The EM group was mostly med/peds docs who were EM boarded&#160;with a couple of EM residency-trained docs. These were excellent docs, practicing EM for decades. The EM residency-trained docs convinced the administration that it would improve the ED&#160;image in the community if they only staffed EM residency-trained docs. They subsequently &quot;fired&quot; all of the docs who were not EM residency-trained. It was unbelievable to witness. The arrogance of the residency-trained docs was just incredible. They were no better at EM than the med/peds-boarded docs. But, man, did they have an ego on them! Sad to see them tear each other down like that. It made me realize how none of this is about providing patient care, it is only about ego and protecting one's slice of the territorial pie. Pathetic profession really.
    • chivosky4:35:42 PMAmen. In the words of sage Nate Diaz, &quot;I am not surprised.&quot;<br>
    • rycorson2:03:21 PMThis is not a surprise. From 1980 until the early 2000s, emergency medicine was one of the most popular residency choices because these were kids who grew up watching TV shows like &quot;ER&quot; and &quot;Trauma Life in the ER,&quot; and they were led to believe that this was an exciting job that&#160;relieved them of having to be on call or go to the clinic. Unfortunately, what they weren't told was that more than 50 percent&#160;and most likely closer to 80 percent&#160;of what we do in emergency medicine is primary care. When you are overwhelmed with primary care patients in the ED,&#160;who should be seen by a primary care practitioner whether that is&#160;at an urgent care or at a primary care clinic, your patience can only go so far. I did not do four&#160;years of medical school, a three-year family practice residency, and a three-year emergency medicine residency to be stuck taking care of primary care in the emergency department. As an organization, ACEP and other emergency medicine professional organizations have done absolutely nothing to relieve the burden of seeing nonemergent, primary care patients in the emergency department. This is completely unacceptable, and it is leading to an astronomical number of burned out emergency physicians. And course, the COVID pandemic just made the burnout even worse. It seems to me that EM organizations are more concerned with showing emergency medicine as the savior to the primary care crisis. We are not the saviors...we are the victims. If I wanted to do primary care and I wasn't committed to providing the finest emergency medical care, I would have stayed in family practice and not done my EM residency. My goal was to serve in rural areas in community access hospitals to provide the absolute highest level of emergency medicine care. There are plenty of clinics in my area, but when patients call, they are told there are no available appointments and that if they think this is an emergency&#160;they should be seen in the ED&#160;because of the clinic cannot get them in. This is completely unacceptable. Obviously, everybody thinks that their medical problem, no matter how minute it is, is some type of emergency. Nobody wants to wait for an appointment. Half of these people don't have insurance so they're going to come to the emergency department, and the hospital is going to be able to write off the bill. Furthermore, when I finished my emergency medicine residency in 2010, even the smaller community access hospitals were offering high salaries to board-eligible emergency physicians because they were trying to eliminate family practitioners in their emergency departments. What I have noticed over the past 10 years is that the hospitals finally figured out that they can pay a family practitioner, a nurse practitioner, or a PA a lot less than a board-certified emergency physician. So&#160;our salaries have gone down. But the workload has not diminished because nobody is doing anything to fix the primary care provider crisis in this country. Shift work is not what it's cracked up to be, but most medical students don't realize this because they are too busy getting beaten up in primary care rotations where they have to be on call and do clinic hours. Obviously, a career in emergency medicine relieves them from having to be on call and go to the clinic, but what they don't realize, until they get into it for a couple years, is that they're basically doing primary care in the ED. Next issue&#58; When you're working in a community access hospital and 80 percent&#160;of what you're seeing is primary care and completely nonemergent, you lose your critical care and advanced emergency medicine skills. This just sets you up for a lawsuit After seven&#160;years of practicing EM in a community-access hospital, I quit my full-time job in emergency medicine and took a job with the Montana State Prison where I was finally happy because I could practice medicine as I wanted and I had no insurance companies or hospital administrators breathing down my neck to make them more money. If something isn't done to relieve the barrage of patients we are seeing in the emergency department who do not require emergency medical care, then emergency medicine residency applications will go down even further. I'm sorry if this sounds harsh on our profession, but it's the truth. Do something to fix it!!
    • toddelarsen12:29:46 PMSo… when this happened to anesthesiology, they had a shortage of physicians for more than&#160;a decade. I was just at grand rounds at LAC-USC where the original article was taking into question (this was prior to the match). I don’t remember who gave the talk (came right after Dr. Sanjay Aurora’s talk if you check online;&#160;my audio for the playback isn’t working today). I have a number of medical students rotating with me and the discussions regarding the HCA residencies being profit-driven and using residents as labor has been something they have frequently brought up. Perhaps we don’t have too many programs but the ones that have recently opened have had a reputation that has turned off applicants. Also, we have a system now where interviews are virtual, which can be a problem because if one applicant interviews at 50 places, there might be a suggestion that this top candidate is interested in all 50 (bumping other candidates). Perhaps we should move to a token system similar to plastics, where you have 15 tokens as an applicant to give to programs to indicate significant interest.
    • jeremy12:02:25 PMImportant observations, but your article is missing one core truth&#58; This job just sucks. The hours are awful. We don’t get paid nearly what we’re worth. We’ve allowed patient complaints to receive more attention than staffing and appropriate medical care. We get sued regularly. A lot of this is of our own doing, or at best, we’ve slowly allowed these problems to take root via our own administrators. Why would a medical student want this job? Look at us.
    • chazz4610:23:30 AMI am 77 now and can remember when all the younger board-certified, residency-trained emergency&#160;physicians locked us older non-boarded, non-residency-trained EPs (with years of experience) out of the workplace by refusing to let us take the boards! Their greed was exemplified by hiring nurse practitioners instead of experienced physicians like myself&#160;who did residency in family practice and practiced in FP and EM for 21 years before dropping out of the dying FP field. Many a non-boarded, non-residency-trained experienced emergency&#160;physician was&#160;cast aside with no respect after the new EM residencies&#160;finally proliferated. Somehow, I just don’t feel sympathetic.
    • karltreffinger6:44:25 PMCatastrophic? I think not. As you have spelled out, this is the writing on the wall that everyone needed to see.