Nearly half of EM programs did not fill, and leadership must do more than form a task force
BY THOMAS COOK, MD
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.)
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;43:22; 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;44:1; 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 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 (this will appear in the April issue on April 1), 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;43:1; https://bit.ly/3sFcdMi.) More than 13,000 physician assistants are also working in emergency medicine. (EMN. 2019;41:1; 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;43:22; 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. Cook is 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 at www.facebook.com/3rdRockUltrasound, follow him on Twitter @3rdRockUS, and read his past columns at http://bit.ly/EMN-Match.