In the emergency room today, everyone is suffering. Many emergency medicine physicians are struggling to provide quality care amid staffing shortages, increased pressure to meet productivity metrics, and frustrated patients battling prolonged wait times. Their situation is compounded by a sense that they have been abandoned by hospital leadership, leading to increasing levels of physician burnout and attrition.
Medical students have picked up on the chaos within the emergency medicine physician community — and it’s making them less interested in entering our specialty.
Every year medical students participate in the National Resident Matching Program, or The Match, where students apply for residency positions across specialties. Historically, nearly all emergency medicine residency positions in The Match were filled by applicants, making the field highly competitive to enter. In 2022 emergency medicine saw its first major decrease in applicants, which resulted in 219 unfilled residency positions. In 2023, 3,282 students (down sharply from 4,391 in 2021) applied for 3,010 positions leaving 555 unfilled positions. (Yes, that is still more applicants than positions; it’s a function of the way the Match works.) We are three emergency physicians — and we are worried about the future of the field.
Even before the Covid-19 pandemic, urgent and emergency department visits were on the rise. With over 130 million visits per year in 2020, hospitals are struggling to provide timely, cost-conscious, high-quality care to their patients. As a possible bridge to this gap, many hospitals have expanded their use of advanced practice providers like nurse practitioners and physician assistants, and staffing groups have sought to grow the number of emergency medicine doctors by increasing the number and size of training programs. While we used to be hopeful that reinforcements were coming, the 2023 Match results made it clear that this is no longer the case.
The pandemic has wreaked havoc on the health care system, and emergency departments have been at the forefront of the crisis. The toll this has taken on the emergency medicine workforce has been brutally apparent. Emergency physicians swap stories of overcrowded emergency departments, inadequate personal protective equipment, and the pressure to make life-and-death decisions. Meanwhile, they face increasing pressure to meet productivity metrics like decreased door-to-doctor times and total amount of time patients spend in the ER while somehow also performing enough imaging and lab studies to ensure patients will not need to return and are satisfied with their care. All of this and they are working more hours at declining relative compensation while most are paying malpractice insurance and student loan premiums.
This has contributed to a state of general anxiety within the emergency medicine physician community, leading to some of the highest rates of burnout and attrition within the medical field. It was in this vortex of pressure that, during the beginning months of the Covid-19 pandemic, Lorna Breen, an emergency medicine physician, died by suicide. Perhaps even more than many of her peers, Breen was seen as an “unflappable” overachiever, a hero who prided herself on supporting her community and acted as the medical director of “the Allen” hospital of NewYork-Presbyterian. Breen’s tragic death highlighted the mental health toll that the Covid-19 pandemic has taken on health care providers, who have been working long hours, often under extreme stress and in difficult conditions, to care for patients. Named in her honor, the Lorna Breen Health Care Provider Protection Act, which President Biden signed in 2022, is a stark reminder of the impact the pandemic has had on health care providers. It aims to improve their mental health and well-being by raising awareness of these issues as well as funding grants to support research and mitigate these effects.
Working in emergency medicine has never been easy, yet the field continued to attract students. In fact, in 2021, Annals of Emergency Medicine released a pivotal assessment of the future of the emergency medicine workforce in which it estimated an oversupply of emergency physicians by 2030. Suddenly, medical students rotating in emergency departments were asking program leadership if they believed there would be a job available for them when they graduated. Furthermore, as more and more students came to experience emergency medicine during the pandemic, their ideals were met with the realities and moral injuries of providing care in an often resource-constrained setting. Medical students are also aware that workplace violence, whether verbal or physical, is a very real possibility; a study in the American Journal of Emergency Medicine has reported this affects up to 100% of ED nursing staff.
While some may believe that expanding the use of advanced practice providers (APPs) could be a solution to the shortage of emergency physicians, this is likely only a temporizing measure. The evidence is limited and mixed: It suggests that while this expansion of practice may improve access and patient satisfaction, it could also mean an increase in costs and errors. Ultimately, it has been largely viewed as a cost-saving measure. There are other potential challenges associated with increasing the number of APPs in emergency medicine, too, including ensuring adequate training, supervision, and support for APPs, as well as addressing concerns around scope of practice and professional identity.
The problem of attracting medical students to emergency medicine is multifaceted, so the solution will have to be, too. Simply adding more trainees to the field — even if people were willing — will not adequately address the widening gap between the number of physicians needed and the number who want to do it. It is important for emergency medicine providers to support one another and use this as an opportunity to shape the future of the specialty. That includes working to take back the field from private equity firms and ensure profits are put in the hands of those providing direct patient care; implementing new policies and laws, like the Lorna Breen Act, to help combat burnout among our colleagues; and thoughtfully implementing artificial intelligence and other technologies to aid in issues of efficiency and access to care. It may even be time to consider forming an emergency medicine physician union to address these issues.
All specialties are suffering from the crumbling health care system. The decline in students’ interest in emergency medicine does not only affect the workforce — it also affects our patients. Emergency medicine is the safety net for all patients at all hours of the day. Focusing on supporting physicians with the resources to provide quality patient care, eliminating corporate pressures, ensuring safe, nonviolent workplaces, and revisiting the number and quality of training programs are all part of the solution. Protecting our specialty will ensure there is an emergency medicine-trained physician available when patients need them the most.
Christian Rose is an assistant professor of emergency medicine and informaticist at Stanford University School of Medicine. He specializes at the intersection of clinical medicine, innovation, and humanism with the goal of building computational systems that help amplify the human experience in medical care. Adaira I. Landry is an emergency medicine physician at Brigham and Women’s Hospital and an assistant professor of emergency medicine at Harvard Medical School. Kaitlin M. Bowers is an emergency medicine physician at UNC Health Nash and an adjunct assistant professor of emergency medicine at Campbell University School of Osteopathic Medicine.
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