Emergency medicine has had a remarkable run in the 43 years since it joined the American Board of Medical Specialties, going from relative obscurity to one of the most popular specialties for graduating medical students. Roughly 2700 medical school graduates matched into more than 250 EM programs this spring, a 40 percent increase from the 1602 medical school graduates who matriculated into EM programs in 2011.
Dark clouds, however, are gathered on the horizon of EM residency graduates' job opportunities. This is startling considering that the Institute of Medicine published a report only 15 years ago stating that the emergency physician supply might never meet employment demand. (Acad Emerg Med. 2006;13:1081; https://bit.ly/3u75XP0.)
Only 10 years later, Reiter, et al., predicted that enough emergency medicine residency-trained (EMRT) and emergency medicine board-certified (EMBC) physicians might be available to staff all emergency departments in the United States in five to 10 years. But they revisited this issue last February, and came up with a stunning conclusion: The supply of EMRT/EMBC physicians may exceed employment demand this year. (J Emerg Med. 2016;50:690; J Emerg Med. 2020;58:198.)
How did we get here? Readers of this column know the answer (but maybe did not see it coming so soon). It is multifaceted and includes:
- the explosion in the number of medical schools,
- the number of EM residencies,
- the number of advanced practice providers (APPs) working in emergency departments, and
- the corporatization of medicine.
Regardless of its cause, supply exceeding demand for emergency physicians will force everyone involved with emergency medicine to re-evaluate their careers in the future.
It starts with medical students. Our residency program received a record number of applications this year. This was not due to an increase in the number of international medical graduates or applicants from the rapidly growing number of osteopathic schools. In fact, the proportion of allopathic, osteopathic, and international medical school applicants has been consistent for the past two decades for our program. Instead, we simply had more applicants wanting to train in emergency medicine than ever before.
Early indications were that a record number of medical students from our affiliated medical school, the University of South Carolina School of Medicine in Columbia, will pursue training in emergency medicine in 2022. It's great that they love what we do, but we doubt they understand the dynamic change in employment opportunities occurring in the specialty. We also strongly suspect that ours is not the only medical school with a lot of students planning careers in emergency medicine. Most of our applicants this year did not even come from our school, and many schools sent more applicants to us than in the past.
The bottom line is that this is a national issue. We do not see any indication from other EM program directors or the Council of Residency Directors in Emergency Medicine that we might have a huge problem in the near future. Besides, with so many new programs, the last thing a director of a fledgling EM residency wants to do is discourage medical students from choosing our specialty. This will likely create a dystopic future for many young physicians.
Current EM residents might feel that the rug is being pulled out from under them. Like all EM residents for the past 30 years, getting into residency was equated with the guarantee of a long and lucrative career. The days of picking and choosing need to be dialed back, and more pending graduates will look to corporate EM to find work. By doing so, however, they will accept terms they would have resisted in the past. This subsequently empowers health care corporations to expand their operations and limit the traditional options for EM employment in the future. The net effect is that the “democratic group” of emergency physicians is an endangered species.
For current board-certified emergency physicians, the idea of a stable job for an entire career is not likely viable, especially for popular urban locations. Corporate medicine is leveraging the advantage presented to them through mergers and aggressively employing APPs. As a group, board-certified emergency physicians must accept new ways of doing business that include employee status, restrictive covenants, shrinking influence on hospital management, and operating increasingly complicated electronic medical record systems that maximize reimbursement.
What can we do? Will emergency medicine continue as a phenomenal specialty that attracted so many physicians and medical students in a relatively short period of time? We are reminded of the old saying, “It is not how you fall, but how you get up.”
But our impression is that the proverbial train has left the station for many issues that create anxiety for us today. Our ability to control the number of emergency health care personnel is out of our hands, but every crisis creates opportunities. It is imperative that we develop opportunities for emergency medicine to attract talented medical students and provide stable and meaningful employment for physicians in the years to come.
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Dr. Adleris a practicing emergency physician at the University of Maryland Medical Center, where he serves as the director of compliance and reimbursement. he is also the vice president of practice improvement at Brault Practice Solutions, where he oversees provider education and group practice analytics. Follow him on Twitter@ercoderguy. 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.