Breaking down the concerns about the future of emergency medicine

As interview season kicks off for Match 2023, I’m reflecting on my experience as a fourth-year medical student last year. I was embarking on my journey toward becoming an emergency medicine physician. I am originally from the West Coast, but I was in the Northeast on an audition when interview requests started rolling in.

I remember having my volume on my phone set as loud as possible, so as not to miss any notifications about interviews. I remember balancing books in front of my ring light so my laptop would be at eye level and receiving strange looks from the other customers at Starbucks.

I remember that life-changing email from the NRMP, with the first line simply stating, “Congratulations, you have matched!” I remember the phone call I received from my program director about 15 minutes after opening my Match Day letter, with cheering on the other end of the line as I was welcomed to my new training program. 

Once the excitement of securing a job after four years in medical school began to ease, I was shocked to learn that 219 emergency medicine (EM) positions went unfilled prior to SOAP. This was a drastic change from seven unfilled positions the year before, according to the 2022 NRMP Match Data. Many who were originally interested in pursuing emergency medicine have reconsidered their career path, creating concern about future EM residency classes.

This news was unsettling, and it was hard not to immediately assume that this drop in filled positions was the writing on the wall after the Annals of Emergency Medicine published a mathematical modeling study about the emergency physician workforce projections.

A broad task force that includes all the major emergency medicine organizations has suggested that there will be a surplus of EM physicians by 2030, creating concerns about the future of emergency medicine. I’ve summarized its findings below.

COVID-19

If I had a dollar for every time COVID-19 was blamed for unwelcome changes in health care, I’d have some extra spending money, to say the least. That being said, COVID-19 simply dislodged the brick from an already crumbling dam. According to data from 2019, 20% of EM residents reported difficulty finding a job in a preferred geographical area or at a salary they had anticipated.

This was amplified in 2020 during the initial outbreak of the pandemic as emergency department (ED) volumes across the country were cut significantly, leading to reduced hours of ED coverage, decreased salaries, layoffs and reduction in benefits per a large ACEP survey from 2020. Volume has since returned to the ED; however, there is anecdotal evidence to suggest that salaries have not recovered and the physician-to-patient ratio has become unsafe. 

Residency program growth

There are currently 276 accredited emergency medicine residency programs, up from 222 in 2015, meaning there has been a 20% jump in growth in EM positions over the past five years alone. There is concern that contract management groups (CMGs) play an even larger role in the boom of programs seen in the past 5 years. For a hospital that is planning to start a new EM residency, a CMG could be the behind-the-scenes enforcer of this decision. Within a residency program, CMGs are often responsible for hiring, supervising, leadership appointments, staffing levels, the use of APPs and more.

Beyond this, there is a noticeable difference in what types of hospitals are starting residencies. Most university-based programs have had their GME spots capped for several years. However, hospitals that are new to GME follow a different set of rules and have five years to max out their cap on funding for GME spots. As such, the growth that we are currently seeing in emergency medicine residencies is predominately from community hospitals.

To put that into perspective, one example that has been cited frequently in the literature is for-profit systems. HCA Healthcare, a Nashville-based organization, operates 183 hospitals and more than 300 emergency departments in 21 states. HCA has started 16 new emergency medicine residency programs, 30% of the newly formed EM residencies since 2015. 

This creates a concern for “overproduction” of residents, leading to an eventual saturation of the job market. Given the rapid expansion of CMGs, it has also led to a change in the job market for graduating residents and current practicing physicians. However, with expansion of these newer residency programs, there is an increase in access to health care for underserved communities. Programs have opened in areas where there are provider shortages and the new programs provide economic opportunities for health care workers. They also provide additional training opportunities for rising residents entering the Match.

With this model, CMGs are estimated to employ more than half of all EM physicians in the coming years, leading to a dominance over EM physician employment. There are many benefits to a CMG program, but it is important to note that while many CMGs remove the business aspect of medicine from a physician’s workload, there is also loss of autonomy in the practice environment and patient care. Decisions are driven by money, which guides health care policy, suggesting that EM board-certified physicians no longer play a critical role in health care.

Scope creep and its effect on the roles of emergency physicians

The Affordable Care Act awarded up $200 million to train and educate nurse practitioners, creating a workforce of just over 300,000 nurse practitioners. As such, they have in many ways alleviated the pressures of physician shortages, largely in primary care, both in urban and rural health care settings. Now, roughly half of nurse practitioners and physician assistants who work in EDs are working independently, meaning there is no physician supervision. This is a state-dependent decision and is currently up for debate in over 30 states.

Many physician groups, including the AOA and the American College of Emergency Physicians (ACEP), have addressed the growing concern of “scope creep” by educating both policy makers and the general public and promoting a physician-led model, which acknowledges the important role advanced practice providers (APPs) play in health care but also advocates for physician supervision given the wide differences in scope of practice and training between the two groups.

This model is only part of the solution, however, as health care has shifted dramatically in recent years. With hospitals closing in both urban and rural areas, this has led to further physician shortages, including a lack of EM physicians.

These barriers have been mitigated by incorporating telehealth and hiring non-physician providers; however, there is the question of if EM physicians will be able to lead in hospitals located in low-density areas, as it is cheaper to employ non-physician clinicians at a fraction of the cost, further tightening the market. 

So, what is being done to address these concerns?

It is easy to read the literature about changes that are occurring in the field of emergency medicine, especially if you are in the process of applying for residency, and think, “maybe it’s best to pursue a different specialty.”

This is a fair opinion in a time where health care in general can feel unstable in various circumstances. However, the field of emergency medicine is filled with proactive advocates and problem-solving is where we excel. For those applying to emergency medicine or who are interested in applying in the near future, here is what is being done:

• The Council of Residency Directors in Emergency Medicine (CORD) acknowledged the 20% reduction of applicants over last year and released a statement on how programs should adjust to the reduction of applicants during the 2022-23 cycle. This included encouraging programs to conduct a more holistic review of each candidate. CORD also recommends that residency programs offer interview invitations with an eye toward matching the profile of their current trainees as well as the mission of their program. Finally, CORD suggests that programs make sure they are interviewing and ranking appropriate numbers of candidates.
• In addition, emergency medicine has incorporated preference signaling as part of the ERAS application process for the 2022-23 cycle to encourage a more thorough evaluation of applications. Each applicant is allowed to “signal” up to five programs to show which they are most interested in. Preference signaling also allows programs to focus on applicants who sincerely intend to rank them.
• ACEP has begun exploring a variety of options, including loan forgiveness, expanding residency rotations in rural areas and generally encouraging and preparing residents to practice in underserved locations. This is a great opportunity for residents and attendings alike to become involved in the discussion and help advocate for changes to expand EM physician employment and “loosen” the job market. 
• There has been a lot of discussion on expanding growth in EM by following a model that was set by anesthesiologists who faced a similar physician surplus in the ‘80s and ‘90s. To address this surplus, they expanded their scope beyond airway and pain management. This is already in the works within EM, as there has been an increase in fellowship training in ultrasound, critical care, emergency medicine services, sports medicine, health policy and population health, to name a few. Understandably, fellowship training isn’t in every EM physician’s career plan and there is a lot of work being done to guide physicians on broadening their training and skill sets outside of the emergency department. 

Emergency physicians are facing a difficult pathway toward protecting their specialty and will continue to in the near future. That being said, if you are applying to emergency medicine as a medical student or are an EM resident about to enter the job market, do not despair. There is a lot of effort at local, regional and national levels to address this potential surplus. Knowledge is power. If you’re an EM resident or attending, now is the time to get involved in this conversation, to become informed and to start advocating for this career. 

Related reading:

How has the COVID pandemic changed health care?

Q&A: How the house of medicine can better support female physicians