Fewer physicians are pursuing emergency medicine

The 2023 match saw 555 emergency medicine (EM) residency positions go unmatched. This increase from the previous year, when 219 positions were initially unclaimed, signifies medical students’ waning interest in the specialty, triggering alarm and introspection across the field. Night shifts, no lunch break, little continuity of care have always been well-known downsides of the EM physician “grin-and-bear-it” existence. What has changed?

Many EM physicians believe that an EM physician’s job has become less savory in recent years, leading to a decrease in student interest in the specialty.

Following this year’s match results, several stakeholder organizations including the American College of Osteopathic Emergency Physicians (ACOEP) and the American College of Emergency Physicians (ACEP), convened a Match Task Force to explore why so few students are choosing emergency medicine.

Potential reasons emergency medicine has become less desirable include the impact of COVID-19, economic workforce projections, scope creep by non-physician clinicians, increasing corporatization by contract management groups (CMGs), growing clinical demands outpacing pay, student loan burdens, physician suicide, inadequate staffing and growing malpractice exposure.

“Since leaving my position of dean of the New York Institute of Technology College of Osteopathic Medicine (NYITCOM) a few years ago, I had not followed the National Resident Matching Program (NRMP) process very closely,” said Jerry Balentine, DO. “I was therefore quite surprised the day the match results became public in March of 2023. I received text messages from several friends who are EM program directors asking if I knew of medical students interested in EM who were looking for spots.”

One of the biggest surprises of the 2023 NRMP match was the poor performance of emergency medicine residency programs. In past years, the EM fill rate was very high compared to the 2023 match which had a fill rate of only 82%. Some suggest that the trend was apparent with a 93% fill rate the year before, while in the past it was around 99%, but many will agree that 2023 was a surprise for most participants and program directors.

Since then, much has been written about possible reasons for such a disappointing match. No one has yet identified a specific reason for this decline in popularity. More than likely, it is the combination of multiple factors.

A cyclical shift in EM

There is a cyclical nature to the popularity of medical specialties. Anesthesia has experienced this several times. Traditionally, EM positions always go filled. Perhaps now the specialty is experiencing its own natural evolution.

The number of EM residencies and EM positions have increased significantly over the last 20-plus years. We must remember that more positions can lead to less competition. Perhaps an inflection point has been reached in terms of supply and demand as well.

Unfortunately, when emergency department (ED) capacity is exceeded and hospital leadership refuse to pay for increased staffing, the National Guard is forced to intervene. Mistakes and bad clinical outcomes occur at higher rates as provider-to-patient ratios decrease. This is the result of doctors and nurses spreading themselves dangerously thin out of necessity. Intuitive solutions such as increased staffing, hazard pay and greater protection from malpractice claims, have not followed.

Medical students do not want to be the future scapegoats for dysfunctional emergency departments operating in a broken health system.

Emergency departments, open 24 hours a day, have long served as society’s safety net. Unfortunately, an eroding standard of what is considered an emergency, profit incentives to keep departments busy, pharmaceutical companies’ fear-mongering advertisements and a baseline shortage of primary care doctors have had the aggregate effect of increasing emergency department volumes.

Impact of the pandemic, economic stressors, cultural factors and employment factors

The COVID-19 pandemic’s influence on the 2023 EM match cannot be understated. Many EDs around the country limited nonessential persons, medical students included, from potential hazardous exposures by restricting access. In hindsight, the specialty might recognize that having students in EDs plays an essential role in cultivating future generations of EM physicians and is a public health imperative that should not be sacrificed.

Those students who did manage to access the ED encountered an unwelcoming and atypical environment punctuated by overcrowding. A less-than-ideal work environment can make a student think twice about their choice of specialties. Unhappy doctors are typically poor ambassadors for the profession. Medical students certainly noticed. Of note, NRMP data indicates that the DO student applicant pool for EM only decreased slightly while it dipped significantly for U.S.-based MD student applicants.

Workforce projections published in the Annals of Emergency Medicine have predicted a surplus of 7,845 EM doctors by 2030. This is predicted on projections that ED visits will increase by 11% and that 20% of those patients will be managed by nurse practitioners (NPs) and physician assistants (PAs). This seems to contrast with the Association of American Medical Colleges’ (AAMC) data projecting a national shortage of 124,000 doctors by 2034, quietly suggesting a future where there are few new EDs opening while existing departments transition to staffing more nonphysician clinicians.

Nonphysician clinicians

Many EDs already employ non-physician clinicians. The Bureau of Labor project employment of PAs to increase by 28% before 2031.

This corresponds with PA emergency medicine specialty training programs emerging and a closing knowledge gap between medical students and PAs. This begs the counternarrative question—why would medical students devote themselves to a specialty that does not require medical school? The current arrangement creates resentment and potentially an aversion to going into the specialty.

Increased employment of non-physician clinicians will also affect salaries and opportunities for new emergency medicine physicians. With many other specialties addressing burnout by making adjustments to accommodate their physicians’ lifestyle needs, it’s possible emergency medicine is no longer one of the few specialties allowing free time and controlled working hours.

Economic factors

National trends in EM doctor pay suggest that the supply of EM doctors currently exceeds demand and serves to drive down pay. With inflation hitting 9.1% in July 2022, it follows that financially savvy and increasingly indebted medical students would want to avoid a specialty with a negative financial outlook. Obvious policy interventions, such as law SB 400 recently passed in Indiana, are designed to increase demand for EM doctors by mandating that every ED in the state be staffed by a doctor at all times. As a medical specialty, we must advocate for similar legislation in other states across the country.

Workplace assaults

The ED is also an increasingly dangerous place to work. In addition to dangerous occupational exposures to COVID-19 and blood-borne diseases, workplace assaults are on the rise.

Recent legislative proposals such as the SAVE Act promise to make assaulting a health care worker a federal crime, but still exempt those with mental illnesses and substance use disorders—the main perpetrators.

The future of EM

A July 2023 study identified a few characteristics of the programs with the highest number of open positions post-match. The programs most affected were smaller programs with less than eight PGY-1 positions, community-based programs, programs with close proximity to geographically competing programs and newer programs.

What are the implications for medical students interested in emergency medicine?

“I always advise students to find the specialty they enjoy the most, that has them excited about their future and make that their number one decision point,” said Dr. Balentine. “Take it from someone who practiced the specialty for many years and ran an EM residency and emergency department—taking care of the wide variety of patients and medical and surgical conditions seen in our emergency departments makes this a great specialty for many (but not all) of us.”

Although many program directors were not happy about the match results, there were certainly a lot of happy medical students who did not think they would match in EM or matched into their first choice in 2023. Perhaps it was a good match for emergency medicine—depending on your point of view.

Let’s see what March 11, 2024, will bring for emergency medicine.

Related reading:

Breaking down the concerns about the future of emergency medicine

The state of DO-MD relations: This emergency medicine physician has a unique take