This past Match Day, I was saddened to bear witness to the slow decline of my medical specialty — one that has been tortured enough as of late.
As an emergency medicine (EM) physician, for years I took Match Day for granted. A decade ago when I entered this specialty, EM was competitive and only became more so as years progressed. It was understood that residencies in EM would largely fill, and unfortunately it was also expected that some medical students would have their dreams dashed by a supply and demand issue.
All of that has changed, especially since the pandemic. A specialty that prides itself on saving lives and an open-door policy has now, it seems, become too volatile and uncertain for many trainees to even consider. This year, it was shockingly revealed that 555 residency spots in EM were left unfilled; over double compared to the year before and more than the previous 10 years combined. I find the stark change in perception of the field jarring.
Members within the specialty argue on how this decline could have happened, but the reality is that it is likely multifactorial.
One of the contributing theories is that the decline of EM has occurred as a direct result of the specialty being overtaken by private equity-owned or -backed contract management groups (CMGs). EM specialty societies have argued that this change has led to the dehumanizing of medical care in EDs, whereby care becomes metric-driven. This new normal has been exceedingly frustrating for those providing the care, as the most expeditious or “lean” mode of care is not the best-case scenario for a patient with a true emergency. Pushing a human physician to see more patients per hour and decreasing staffing models does not amount to good patient care.
In addition, over the years more and more residency spots have been added, some with CMG-run hospitals rather than academic institutions. A workforce study published in 2021 highlighted these concerns, and suddenly the conversation stopped being, EM is so competitive, and started being, Will we have more supply than demand if this rapid rate of spots continues to increase? And if so, will there be jobs for all the new graduates? While emergencies will always exist, the number of brick-and-mortar EDs is not infinite: for health care systems, an ED is more of a necessity, and not quite the money-making venture a specialty clinic or surgical center may be. The workforce study likely did not take into adequate consideration the enormous access issues and health care disparities growing among our patient populations. Instead, it resulted in raising alarm across the specialty and into our medical schools on the prospects of job security.
Further complicating issues, the rates of burnout in EM physicians have skyrocketed to the head of the pack, especially since the pandemic. One reason for this is the disproportionate burden placed on EDs. Depending on geographic location, an ED can be the only option for patients, even for lower-acuity issues. In places where urgent cares don’t exist and there is no PCP availability for weeks, what choice do patients have but to go to an ED? Even in the age of telemedicine, barriers in equitable care options can occur if certain insurances or self-pay are not accepted, broadband/cable internet is not available, templates are already full, or there are social determinants barring a patient from using an alternate care option (like lack of tech literacy or a smartphone). So, the consequence has become overrun ED waiting rooms full of patients self-referred or sent in by another health care professional due to access constraints. Walk into many EDs these days and you’ll find swollen waiting rooms and internal rooms full of “boarding” patients who in some cases are waiting days for an inpatient bed to open for them to finally get transferred upstairs.
As a result of this and other factors, a recent survey found that 65% of EM physicians are burnt out — ahead of any other specialty in medicine. Yet EM physicians must overcome all the above obstacles and more to be the safety net for patients, including on weekends, holidays, and overnight shifts. And the range of care required to provide is immense — medical, procedural, and behavioral health. While on duty, treatment can be anything from a child with a common cold, to a stroke patient, to a gunshot victim, to an older adult in cardiac arrest — all in a single shift. The moral injury of witnessing the tragedies of humanity day after day without an end in sight is significant.
The new question is: If this trend continues, will enough of us be left to hold the safety net for our patients? A major shift in health care is needed and sooner than we expected. Sadly, it seems the pandemic and multiple other factors have stripped the joy from our practice. Despite an innate desire to “do the right thing” and treat all that come through our doors, the breaking point is coming for many, and without change it will be patients who suffer most.
Where do you see the future of EM heading? Share your predictions in the comments.
Dr. Shah is an associate professor of emergency medicine (EM) and clinical informaticist based in Chicago who is actively board certified and practicing in both EM and medical informatics. Her clinical experience spans almost 15 years of both community and academic EM practice, and expertise has expanded into alternate modes of care such as telemedicine, mobile health, optimizing patient access, the patient digital experience and working toward optimal value-based care.
Image by Jennifer Bogartz