Journal Logo

After the Match

After the Match

Has the Supply of EPs Exceeded Demand?

Cook, Thomas MD; Adler, Jason MD

doi: 10.1097/01.EEM.0000743180.13144.84
    Figure
    Figure:
    supply and demand, corporate medicine, APPs, NP, PA
    Figure
    Figure
    Figure
    Figure

    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[10]: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[4]:690; J Emerg Med. 2020;58[2]:198.)

    Record Numbers

    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.

    Dystopic Future

    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.

    Share this article on Twitter and Facebook.

    Access the links in EMN by reading this on our website, www.EM-News.com.

    Comments? Write to us at [email protected].

    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.

    Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.
    • hrizvimd10:06:00 PMHospital administration is staffing EDs with unsupervised midlevels and doctors of nursing practice. Yet we are still quibbling over board certification. Academics have to call out the fraud by hospital administrators, state nursing boards, and those who are replacing EPs in the grand scheme of collaboration. Yes, we are now at the same oppressive state as migrant laborers waiting outside 7-Eleven to get picked up by the establishment fraudsters. When will we organize and be bold? When optometrists start replacing medical staff? It is already approved by legislatures in Wyoming and Pennsylvania.
    • iatros9:26:32 PMNo, there is not an oversupply of trained EM physicians, just the usual maldistribution common to so many other specialties. Basically smaller hospitals have a lot of difficulty in covering their EDs with EM-trained physicians, so they are forced to use those trained in more general specialties. There is no solution to this problem as long as emergency physicians continue to cling to the safety of large city hospitals (and spouses have a large say in this too). But the law of supply and demand will eventually dictate that the EM-trained physicians will have to spread out into the suburbs first, then the rural areas. Look at the fields such as cardiology and orthopedics who have remote clinics to see patients and harvest procedures to keep their practices solvent. Again, I see no immediate solution to the problem of maldistribution.
    • risitodeplata7:11:23 AMHave the authors actually looked at the true emergency medicine jobs? They couldn't have. Outside of the major metropolitan areas or the very upscale communities most EDs are staffed with only non-EM-trained physicians. Try just looking at the job posting and see the majority accept FP and IM boards. If there was an oversupply of EM-trained, this wouldn't be the case. After leaving University of Miami in 2014, I did locums for four years to the end of 2018. I worked at six different hospitals. None of them had any EM-trained or boarded doctors, and at one none of the physicians except myself was even board-certified in anything. The last three years I've worked at three facilities in the same county. Of more than 30 doctors working in the EDs, there are two or three who have EM boards. Where is this oversupply?
    • whitej2:54:21 PM<p>&quot;Steinasd&quot; is right on. Let me add to it though. This has been a recurring article topic in EMN for four or five years now. I don't have harsh things to say to the authors, but let me suggest that instead of recapitulating the sad and seemingly intractable story of oversupply, why not an article about some practical solutions? This magazine could easily be a venue to aggregate a group of physicians motivated enough to do something about it. Tell us how we can as individuals swing the tide more to our favor, exactly like dermatology and ophthalmology seem to have mastered? How about as an author interviewing some of the older stalwarts and thought leaders in those specialties that have circumvented this particular issue. They would be good sources to query about how we can right our course as a specialty in regard to this problem. Maybe a phone call interview to some specialty society past presidents? Do a bit of investigative journalism to try to cajole loose some of the angles they used? Angles that gave them a grip on this same potential problem! I have always enjoyed EMN. And my opinion is that these authors generally produce good material. But it’s common in media to trumpet the end is near. It engages emotions, and that makes people tune in. And viewership sells advertising. I do not think the article was a filler to engage readers with a dramatic news flash. But at the same time, this issue isn't a news flash at all. The problem is a known entity to all of us. So, redirect the effort to solution-based journalism. In physics terms, there is potential energy here that we could leverage for everyone's benefit if we group up and behave cohesively and if we had a little direction that was substantive. &quot;Substantive&quot; in this case means putting energy (and magazine column space) into helping the rank-and-file and have some suggestions and maybe even a coordinated plan of attack for the problem, not just restate the obvious in another article about EM oversupply. EMN could be a launchpad for initiatives like that, starting with this one in particular. Does this resonate with anyone or am I just asking too much (and being a little grouchy)?</p>
    • steinasd11:37:49 AMOther specialties saw this coming decades ago; EM just kept opening new programs. It's not like there weren't a few voices mentioning this at the ACEP council meetings 20 years ago who were soundly ridiculed. In retrospect, it seems the people in charge of this issue had an interest in cheap and plentiful manpower. Other specialties have kept a lid on numbers of trainees and recognized this decades ago.&#160;That's why it's so hard to get into an orthopedic or dermatology program. Perhaps historically these other specialties have been private businesses where the doctors had a clear understanding of what they bill and how they are reimbursed, and this made them more aware of the supply and demand effect. In EM, so-called democratic and physician-owned groups in practicality had docs working for a management team that kept some business aspects opaque to workers. There also is a disconnect between&#160;the EM business you individually do and how much time you spend actually getting patients to come to see you personally---advertising, schmoozing, giving talks, calling patients back, etc., to build your personal patient load. If we had to hustle like a sports medicine doc (even in academics where they show up at high school football games for free), we may have spent more time concerned with training our competition. The horse is out of the barn now, and in the United States that has no central medical system, no one is in charge of how training programs are distributed or we would mainly have primary care training, and it would be hard to do anything else. Can we stop opening any new programs?&#160;It seems a waste of money and effort. Can we start closing programs? Maybe have stringent criteria, and close places evaluated in the lowest 25 percent? Do we add primary care training to the experience and add a year or two? Work with FP or IM to make a double board situation in every program? This may be&#160;less desirable for the extra years, but more useful to the general public health care system and leave docs with more options. Maybe programs that can't get that arranged will need to close. I don't know what the answer is, but I haven't seen a lot of ideas out there yet.