Medical students are avoiding EM because unrealistic expectations are ruining the specialty
The 2023 match did not go well for emergency medicine, to say the least. We are now the least competitive specialty.
Multiple factors contributed to the 554 residency positions that went unfilled: new residencies created by for-profit hospitals, a well-publicized projection (of unknown accuracy) that we are heading toward a surplus of EPs, systemic replacement of EPs with NPs and PAs, increasing administrative burdens, and decreasing EP compensation despite three years on the front line of a global pandemic.
I think any EP who has been out of residency long enough to be board certified would agree that the career we have is not quite the career we envisioned. Kudos to these new medical school grads for clearly seeing the dumpster fires in our nation's EDs.
I try hard not to quash anybody's dream when young doctors-to-be ask me about my career. One doctor having a bad day who chooses to emote negativity can be the reason an impressionable student steers clear of our specialty.
I wanted to pursue surgery, but one Sunday morning in med school a frustrated surgeon looked at me during her case and said, “Do you want to be a mom and actually see your kids?” When I responded that I did, she told me in no uncertain terms that I should never become a surgeon. I took her advice to heart and have at times wondered where I'd be if I had never crossed paths with her.
Now, when techs or scribes (before they took them away) turn to me for advice about EM, I'm torn. I don't want to be dishonest and send them naively into the dumpster fire without forewarning, but at the same time I don't want to squelch their passion for EM.
I can still appreciate how cool it is to specialize in the exciting niche EM carved out for itself. I remember learning about the history of our specialty during a dinner at ACEP 2015 in Boston. I sat across from the legendary James Roberts, MD, one of the first five board-certified EPs.
He described how the ED used to be just a single room with few, if any, medical care capabilities. Internists and surgeons typically did not want their patients to have procedures like lumbar punctures or wound repairs there, and patients were directed instead to medical and surgical services.
Gradually, as our specialty evolved to meet the need for more timely diagnosis and stabilization, EDs expanded to include more testing and treating capabilities. We have become master diagnosticians in the 50 years since our specialty was founded. Our ability to act decisively in a moment of crisis can be the difference between life and death or between disability and a productive life. EM is undeniably interesting and action-packed, and we have consequently enjoyed a long-lasting heyday among med school graduates.
Unfortunately, expectations for EDs and EPs have expanded beyond what is sustainable. We have been too successful in our turf battles, and now “just go to the ED” seems to be the default answer when patients call their doctors.
We take pride in being the safety net for our broken health care system, but the net is unraveling as the profit-over-patient health care business increases its demands while decreasing our resources. The pendulum has swung from the one-room ER of Dr. Roberts' youth, past what the founders of our specialty envisioned, to such unreasonable do-more-with-less expectations that we are set up to fail.
Times Have Changed
Knowing that history repeats itself, I researched the history of EM to see if the first 50 years of our specialty could offer insight into whether the pendulum will swing back in the decades to come. I found it hard, however, to compare the more altruistic health care practices of our parents' era to today's for-profit health care industry. Times have changed to the point that today's EPs feel like highly educated blue-collar workers in health care sweatshops. Perhaps it would make more sense to read about the labor movement in the late 1800s to predict our specialty's future.
With today's rapid dissemination of information online, it's no secret that we are not OK in EM, so of course 2023's med school grads thought twice about joining our ranks. Several of my former ED scribes are members of this class of 2023, and although I tried not to deter them, they all picked other specialties.
It's disappointing on many levels when the next generation doesn't want to follow in our footsteps, but there's a parental instinct in us that applauds them for trying to avoid the pain they see us endure. My sons also decided—without any intentional dissuasion from me—that they do not want to go into medicine. I'm proud of their wisdom. I feel the same way about my former scribes and all the newly minted doctors who avoided the current EM dumpster fire.
No matter how cool and enticing the clinical medicine in the ED may be, the reality is that EPs are but cogs in the wheel of corporate medicine, reduced to how we appear via metrics and patient satisfaction scores. This year's match is a wakeup call. It's going to get worse before it gets better.
Waiting for ACEP to fix our predicament is not the answer because ACEP helped us get here. Perhaps we need a revolution in the trenches. At the very least, we need a fire extinguisher.
DR. SIMONS is a full-time night emergency physician in Richmond, VA, and a mother of two. Follow her on Twitter @ERGoddessMD, and read her past columns at http://bit.ly/EMN-ERGoddess.
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