Resuscitating EM | Post-Match '23 Solutions
Also: “The Kids Are Not Alright”, Doximity delivers good news for EM pay, Rural Emergency Hospital update, and why are hospitals losing so much money?
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Several thought-provoking articles have been written by emergency medicine leaders since EM’s dreadful performance in the 2023 Residency Match, with 18% of available EM positions left unfilled.
A succinct summary, from Dr. James Dahle’s White Coat Investor blog post: “Emergency medicine is a great specialty. The medicine and the patients are interesting. Everyone has an ER story, for better or worse—you get to make a difference on the worst day of people's lives. You can still be the white knight of medicine. But it has issues, and if they are not resolved soon, the House of Medicine is going to regard us exactly the way it did when we started the specialty: losers, castoffs, leftovers, and chumps.”
Emergency physicians excel at making decisions and taking action with limited and evolving information. In this post, I’ll summarize the recommendations for the House of EM in articles by Dahle, EMRA (written by Dr. Jessica Adkins Murphy), Dr. Thomas Cook, Dr. Janice Blanchard, and Dr. Andy Little - arranged by impact and feasibility.
High impact, doable
The ACGME should increase emergency medicine residency procedure & faculty requirements. EMRA is currently advocating for this change. Per Murphy, “The ACGME could increase residency requirements such as procedure numbers and faculty requirements in order to ensure the quality of residencies remains high despite this growth. This may inadvertently reduce the number of programs or downsize programs if they cannot meet more stringent ACGME standards. As a parallel, orthopedic programs and positions have expanded more slowly than EM’s. This is in part due to their ACGME requirements, which mandate, for example, that orthopedic residents log at least 1,000 procedures and 200 pediatric procedures to graduate.”
Allow the Residency Match’s market forces to work their wonders. This is the “anesthesia model”. An article by Dr. Mary Hass summarizes, “In the late 1980s and early 1990s, anesthesiology residency programs and positions greatly expanded, with the number of graduates quadrupling between 1984 and 1993. In 1994, the American Society of Anesthesiologists commissioned a study that projected a major oversupply of anesthesiologists in the coming decades. Simultaneously, the Council on Graduate Medical Education (COGME) advocated for efforts to increase the number of primary care physicians and limit the number of U.S. specialty physician trainees. A Wall Street Journal article and other media accounts highlighted difficulties experienced by graduating anesthesiology seeking jobs. In response to these factors, medical students rapidly moved away from anesthesiology as a specialty choice, with the number of U.S. medical school applicants to anesthesiology plummeting by 56% from 1995 to 2000 (from 1,784 to 787).”
ACEP accreditation of EDs. This could be called the “trauma center model”. The American College of Surgeons runs the Verification, Review, and Consultation Program for Excellence in Trauma Centers, which raises the bar for trauma care. ACEP is looking to create a similar process to ensure EDs meet evidence-based standards. AAEM is also looking into creating specialty-wide standards for emergency department physician to PA & NP staffing ratios.
High impact, difficult
Increase hospital and ED nursing staffing capacity. Hospital flow is largely determined by nursing staffing levels. ED boarding is nearly guaranteed when nurses are understaffed.
Better scheduling of in-hospital elective procedures. A key factor leading to boarding is elective procedures being disproportionately scheduled a the beginning of the week, leading to a predictable lack of capacity on Mondays and Tuesdays.
Increase physicians’ ownership in their EM practices. Many argue that the decreased autonomy has led to a less rewarding practice environment for emergency physicians.
Improve EMR usability. Physician surveys have long shown that EMR and documentation are common causes of burnout. Let’s hope AI saves us from the EMR abyss.
Low impact, difficult
Several Match response articles recommended that emergency physicians be more positive about their specialty when speaking to medical students. This is a nice goal. However, a quick glance at EM social media makes it clear how far EM is from general positivity. Additionally, increases in the number of residency-trained emergency physicians would further exacerbate the supply-demand mismatch.
AAEM has long advocated for ACEP to “divest itself from corporate medicine.” However, ACEP aims to represent the house of EM. Whether we like it or not, a quarter of EDs are staffed by private equity-owned firms. We’ll see how the California corporate practice of medicine lawsuit, filed by AAEM and backed by ACEP, impacts EM practice ownership.
Lobby health systems not to open new EM residencies. It’s hard to imagine that emergency physicians will be able to convince health systems to significantly change their residency plans. EM residencies are profitable and an oversupply of emergency physicians benefits health systems.
Some authors have lamented that the 2021 EM Workforce Task Force projected an oversupply of emergency physicians. However, until new data to indicate otherwise, the projections will continue to influence medical student decisions to enter EM. Decreasing medical students entering EM is part of the workforce solution.
High impact, not doable
Many on social media have called for the ACGME to shut down EM residencies in order to prevent the oversupply of emergency physicians in the US. However, the ACGME is not allowed to make such judgments due to antitrust considerations.
Others have called for not accepting international medical school graduates into emergency medicine residencies. There is no mechanism for such an action.
EM Practice
“The Kids are Not Alright” explores EM burnout in early career emergency physicians.
Emergency physician salaries increased by 6.2% in 2022, per Doximity. However, significant gender pay disparities remain.
Santa Clara Valley Medical Center has changed EM contract holders after a tumultuous two years with US Acute Care Solutions.
No Surprises Act dispute arbitration proceedings have restarted, with more favorable terms for emergency medicine providers.
Letter to the Washington Post editor: Emergency Medicine is still cool.
House of Medicine
Becker’s Healthcare podcast had an eye (& ear)-opening episode discussion with a PE investor about how PE purchases of physician practices work.
Match Day’s Winners & Losers, by Dr. Brian Carmody
Hospitals & Health Systems
Excellent podcast episode about the history of Ben Taub Hospital in Houston.
JAMA update on Rural Emergency Hospitals.
Sutter Health lost $249m in 2022. Bon Secours Mercy Health lost $1.2b. SSM reported a 2022 operating loss of $249m. Health Affairs explores how much of the non-profit health system losses were due to investment losses.
The Washington Monthly explores the private equity ownership model for rural hospitals.
Nursing & Allied Health
White paper urging “Safe Staffing” legislation in New Jersey. “Understaffing is driving our healthcare system to the brink of collapse. That is why HPAE, New Jersey’s largest union of healthcare workers, is pushing the state legislature to pass a law in Trenton this year mandating enforceable staffing ratios.”
Nurses are increasing their presence on hospital Boards of Directors.