Unfulfilled Emergency Physicians -> 555 Unfilled EM Residency Match Positions
Also: Doctors & hospitals disagree on noncompetes, quality care drives clinician job satisfaction, NSA delays, and health systems struggle with staffing costs.
Top of the Week
(Note: this section is an excerpt from this article, published today in ACEPNow. Written with Drs. Jonathan Fisher and Cedric Dark.)
For decades, emergency physicians took pride in being a much-desired specialty for graduating medical students. Emergency medicine residencies routinely filled 99% of their available positions in the Match. This year, 555 emergency medicine residency spots went unfilled in the Match, a dramatic and abrupt increase in just a couple of years.
EM’s desirability among medical students has dramatically decreased over the past two residency application cycles, falling below the number of applicants who applied to emergency medicine before the onset of the COVID-19 pandemic. U.S. medical student applicants to ACGME and AOA-accredited emergency medicine residencies dropped by 16.8% from 2021 to 2022. In the 2023 Residency Match year, EM applicants dropped by an additional 18.1%. In this article, we explore key reasons for the abrupt decrease in the competitiveness of the EM Match and recommend changes the specialty can undertake to reverse this trend.
The 2021 Match results marked a change for the specialty. Long-term challenges such as night shifts, intoxicated patients, and the administrative burden of EMRs cannot explain the recent change in medical student preferences. The decrease in applications for EM residencies is specialty-specific. While total residency applications grew at a steady rate and other specialties have faced the same COVID-19 pandemic and similar nursing workforce shortages, they did not see the declines in applications that emergency medicine has witnessed.
In March 2021, eight EM organizations released the “Emergency Medicine Physician Workforce: Projections for 2030” report with its data published in the December 2021 issue of Annals of Emergency Medicine. The report painted a startling picture of the future jobs of emergency physicians. The analysis’ base case “scenario would result in a surplus of 7,845 emergency physicians in 2030.” After seeing residents face unprecedented challenges finding attending jobs in 2020-21, medical students were faced with the prospect that job shortages were not just a one-time pandemic-related problem, but a systemic problem in emergency medicine.
Details within the workforce projections were especially concerning for future emergency physician prospects. While EM residency graduates had been increasing by 3.5% per year over the past decade, the number of physician assistants (PAs) and nurse practitioners (NPs) working in emergency medicine had been increasing by 6% per year. Between 2013 and 2019, the number of PAs & NPs working in emergency medicine practices increased by 48.4%, compared with an increase of 11.1% for physicians. Since PAs and NPs earn significantly less than residency-trained physicians, the prospect of being pushed aside by lower-skilled, lower-cost professions may have driven some medical students to choose other specialties.
Concurrent with predictions of career insecurity for emergency physicians, the job became more difficult and less fulfilling. In the 2018 Medscape Physician Burnout Report, 45% of emergency physicians reported being burned out. By 2023, the percentage who reported burnout increased to 65%, five percent higher than any other specialty. As emergency physician burnout rises, there has been a corresponding increase in emergency physician attrition. A recent survey of all physicians (not just EM) by the Massachusetts Medical Society showed that 50% of physicians plan to reduce their clinical workload by June of 2023, and about 25% plan on leaving medicine in the next two years.
The underlying cause of EM’s burnout crisis stems largely from moral injury, the “social, psychological, and spiritual harm that arises from a betrayal of one’s core values, such as justice, fairness, and loyalty.” Delivering high-quality patient care in the ED has always been challenging. But in America’s post-pandemic healthcare system, it has been nearly impossible.
Over the last two years, decreased hospital staffing has caused increased ED boarding nationwide. Already under-resourced EDs were tasked with caring for admitted patients in addition to incoming ED patients. That led to ED patients waiting for prolonged periods, becoming frustrated, and suffering adverse outcomes. Dr. Laura Haselden, MD, MPM, an emergency physician in Maryland opined on Twitter, “The number of times I’ve said ‘I don’t want to teach you to practice waiting room medicine but it’s what we’ve got’ probably didn’t help sell anybody.” The sickest patients, often needing transfer to higher levels to care, were stuck in community EDs where emergency physicians did their best, knowing the care being delivered was substandard. Meanwhile, hospital administrators have been depositing ever-increasing paychecks.
Prior to the pandemic, many emergency physicians could turn to a close-knit group of nurse and clinician colleagues for support. However, 2021-2022 saw an unprecedented level of nursing turnover. At the same time, EM groups were rapidly consolidating, fraying bonds previously formed within smaller partnerships.
While emergency physician job security and career satisfaction were being eroded, so were financial prospects. In the 2017 Medscape Physician Compensation Report, 68% of emergency physicians reported feeling fairly compensated, the highest among the specialties surveyed. By the 2022 survey, only 53% of emergency physicians reported feeling fairly compensated, a decrease of 15 percentage points. Compensation no longer matched the rigors of the profession.
The compensation headwinds have come from several sources. Because of sales of EM practices to consolidators such as private equity firms, emergency physicians now have the lowest rate of practice ownership among the specialties surveyed by the AMA. The No Surprises Act, passed in 2021, has limited emergency medicine groups’ bargaining power with private insurers. Simultaneously, government payers have been chipping away at physician reimbursement.
The complete article can be found at ACEPNow. Thanks to Drs. Jonathan Fisher & Cedric Dark for their work on this article!
EM Practice
ACEP & AAEM have released strong statements supporting the Federal Trade Commission’s proposed ban on noncompetes in employment contracts. The American Hospital Association disagrees.
Why are freestandings opening in Alabama as other hospitals close? Money. New freestandings are being built in wealthy neighborhoods; hospitals in poor areas are going bankrupt.
Ed Gaines provides quick-hit insights about the No Surprises Act in his podcast. For deeper dives into the NSA’s impact on EM reimbursement, check out this or this article.
House of Medicine
From Harvard Business Review: “What Makes Health Care Workers Stay in Their Jobs?”: Delivering quality patient care. “In our analyses, for all types of health care personnel, their organizations’ commitment to quality and patient-centered care was among the top drivers of their likelihood to stay. When employees gave their organization low ratings on these issues, they were more than six times as likely to say they were preparing to leave. These issues were important to security guards, maintenance, and clerical personnel as well as clinicians.”
Health insurer profits over the past few years have come largely from Medicare Advantage.
How the University of California Davis School of Medicine became the third-most diverse med school in the country, within a state that banned affirmative action.
Argument in favor of legalizing physician-owned hospitals.
Hospitals & Health Systems
Small rural hospitals will face even steeper hurdles once pandemic aid stops. KHN explores how pandemic aid has kept a rural hospital financially viable.
Hospital contract labor costs increased by 258% between 2019 and 2022. Labor costs are still increasing in 2023.
Providence reported a $1.7b operating loss for 2022. Trinity Health posted a $298m operating loss for the second half of 2022.
Nursing & Allied Health
Story of how nursing shortages are causing delays in patient care in Wichita, KS. "You might end up being lucky to get a gurney to lay down, but you're going to do so in the middle of 50 people coughing, puking, bleeding," said Paula Nichols, an ER patient. You might think Paula Nichols is describing something out of a horror film, but she's not. She's describing what she says are the conditions in Wichita emergency rooms.”
Mississippi hospitals are struggling to find nurses.
The Dispo
An Illinois-based ER doctor’s heroic response to Turkey’s devastating earthquake.