By Dr. James M. Dahle, WCI Founder
The House of Medicine is a surprisingly stable place. Over the years, the highest-paying specialties—like neurosurgery, plastics, and orthopedics—have been among the most difficult to match into, and the lowest-paying specialties—like PM&R, preventive medicine, pediatrics, family medicine, and internal medicine—have been among the easiest to match into. Other specialties are somewhere in between. For my entire career in emergency medicine, we have been in between. We've been about midway up as far as pay goes and as far as competitiveness in the match.
Typically, about 93% of US MD graduates who want to match into EM are able to do so. Usually, there are very few spots open for the SOAP (scramble). Seriously. Like a handful. And it was a huge embarrassment if your program had one. So, imagine the shock and awe that hit emergency medicine during Match Week 2023 when it was revealed that the number of unmatched positions had increased by more than 100X. That's right, 555 residency spots were entered into the SOAP in March 2023. That's out of just 3,011 total spots, meaning 18.4% of spots went unmatched. Compare that to internal medicine (545/11,911 = 4.6%) or family medicine (589/5,100 = 11.5%).
Emergency medicine has officially become the easiest specialty to match into. It is now the least competitive and arguably the least desirable to medical students. What happened, and can it happen to other specialties? Is there something unique here, or is EM just the canary in the gold mine as the ED often is for our broken healthcare system?
What Happened to Emergency Medicine?
This is likely multi-factorial, and there may be dozens or more factors that have contributed. However, I think there are four main reasons, and I'm going to list them in the order in which I think they contributed, starting with the most important.
#1 Too Many New Residency Positions
Not many years ago, it was determined that we were not going to have anywhere near as many emergency physicians as we needed, especially if we wanted to staff rural EDs with emergency physicians instead of the internists, family practitioners, general practitioners, and APCs that have been working in them. There was encouragement to start more residencies and to expand the existing ones. Contract management groups and for-profit hospitals started having trouble staffing their EDs and found themselves having to pay $400 or even $500 an hour to staff undesirable shifts. They decided to do something about it. They started their own residency programs. Somehow, despite having few experienced academic faculty members or any sort of track record, these residencies were approved and opened. The number of training slots in EM has ballooned over the last few years. Mary R. C. Haas, et al, published an article in 2020 titled “Too Big Too Fast: Potential Implications of the Rapid Increase in Emergency Medicine Residency Positions.” The paper included this chart:
Check out the change in slope after 2015. The increase in the number of training slots has been even more impressive.
Remember this chart ends in 2020. The 2023 number is 3,011. In three decades, we've 6Xed the number of residency spots. We've more than doubled the number of spots since I graduated in 2006. The number of spots since 2015 has increased by 65%. That was the year that this year's EM residency graduates were applying to medical school. Sixty-five percent. That's a massive increase. Yes, the entire Match has gotten bigger in that time period. PGY1 positions for all specialties increased from 27,293 to 36,277 (a 33% increase). But the increase in EM was double that.
The paper speculated about the implications of this increase. The authors' worries included:
- New graduates unable to get a job
- Zero-hours contracts where new hires are not guaranteed any hours
- Worsening primary care shortage (due to more people going into EM rather than primary care)
- Increased difficulty paying off student loans
These new EM programs are clearly a concern for these students considering entering the field of EM. One needs only to peruse online forums such as the r/emergencymedicine subreddit or the EM subforum at StudentDoctor.net to find out what current and potential residents think of the new programs, particularly those started by hospital corporation HCA. Consider this post: “SOAP warning EM HCA residency” where a PGY3 created a throwaway account just to bash their own residency.
As this person wrote:
“Please let this be a warning to all medical students planning to SOAP into a HCA residency. I am a PGY-3 EM resident at a HCA EM program. My experience at this program has been the absolute worst and one of the biggest mistakes I have ever made. I have suffered through for 3 years because I had no other options after $400k+ student loans and a family to support.
Speaking with friends at other HCA programs, a few things are recurring themes, including continuously adding on scut work and shifts for residents to milk every dollar they can, having no organization or constant leadership for programs, constantly having ‘away rotations' to try to meet bare minimums for procedures (many of my colleagues have not completed all required procedures including lumbar punctures, deliveries, trauma resuscitations, etc.) We have constantly rotating ‘faculty,' many of whom have no interest in residents or teaching and are just here for a quick locums gig. I honestly feel totally unprepared to even begin practicing on my own.
We are constantly getting new requirements to meet certain metrics from the HCA overlords and pressure on shift from malignant attendings to meet them. There is hardly ever any organized didactics, and forget about teaching on shift; you will be just trying to meet the endless metrics and keep the patients moving. It it clear that all HCA wants to do is exploit cheap labor and increase their bottom line, and your training as an emergency medicine resident is not a priority. To top it all off, many of us are still struggling to find jobs. Sure, there are some openings in rural wherever but none of us have signed in a desirable location and over half of us are still looking for a job. We have no support or connections to help us through the job process.”
These facts/opinions are clearly out there among MS4s based on the results of the initial pre-SOAP match. These figures are the list of unfilled spots/total spots for the HCA sponsored programs:
- HCA Healthcare East FL Division GME: Emergency Medicine/Aventura 8/12
- HCA Healthcare East FL Division GME: Emergency Medicine/St Lucie 4/5
- HCA Healthcare East FL Division GME: Emergency Medicine/Westside 8/13
- HCA Healthcare/USF Morsani GME-Brandon-FL 8/12
- HCA Healthcare/USF Morsani GME-Oak Hill-FL 5/6
- HCA Houston Healthcare/U Houston-TX 6/13
- HCA Medical City Healthcare-TX 1/8
Forty out of 69 spots (58%) at these HCA residencies didn't fill. How would you like to be the lone doctor in either of those two residencies where you're the only doctor who actually wanted to go there?
Last year, there were more than 200 unmatched spots. This year, there were over 500. Clearly, the article in 2020 was right. EM has gotten too big, too fast.
#2 Jobs Forecast
EM really did this to itself. Besides the Residency Review Committee (RRC-EM) approving all of these new residencies (and possibly having way too low of standards for approval), we published numerous “The Sky is Falling” type articles about there being no future jobs in EM. Despite not having a functional crystal ball, our most prominent journal in 2021 published a projection of EM workforce supply and demand for 2030. Here are the results of its study, and the conclusion from the abstract:
Results
The task force consensus was that the most likely future scenario is described by: 2% annual graduate medical education growth, 3% annual emergency physician attrition, 20% encounters seen by a nurse practitioner or physician assistant, and 11% increase in emergency department visits relative to 2018. This scenario would result in a surplus of 7,845 emergency physicians in 2030.
Conclusion
The specialty of emergency medicine is facing the likely oversupply of emergency physicians in 2030. The factors leading to this include the increasing supply of and changing demand for emergency physicians. An organized, collective approach to a balanced workforce by the specialty of emergency medicine is imperative.
If you were an impressionable MS3 and you saw that, would that make you more or less likely to go into EM? All of those folks that were on the fence about it probably decided to apply to another specialty.
Medical students have been concerned about Advanced Practice Clinicians (APCs: i.e. NPs and PAs) taking all of their jobs since the first PA graduate showed up on the scene in 1967. This was certainly a concern when I was a pre-med in the 1990s. It seems worse now that there are so many online NP programs and plenty of states that allow independent NP practice. There is even at least one ED in the country that is run entirely by APCs, despite at least one EM-specific paper showing APCs provide no economies of scale and another showing worse outcomes and higher costs. However, even in the workforce projection, only 20% of ED patients will be seen by APCs in 2030. I can't imagine that number is any lower in primary care or even in specialty clinics. I think this fear is probably at least somewhat overblown among students, although there is data showing more ED patients are being seen by APCs (an 18%-25% increase from 2010-2017) despite rising acuity.
#3 The Pandemic
The pandemic wasn't easy on any of us, but it was particularly tough on EM. My residency mate was the first doc to get COVID when it hit the Seattle area. He barely survived after weeks on ECMO. First, our volumes (and pay) dropped 40%, and many almost went broke. Then, when the pandemic finally made it from Seattle and New York City to our towns, our volumes surged and our staffing collapsed. Everything is slower and harder when you have to do it in full PPE. ED boarding increased. We ran out of PPE. It took me literally years to feel comfortable throwing away those precious first few N95s I could get my hands on.
I still remember those first few shifts. It felt an awful lot like being deployed with the military and not being 100% sure you were going to come home to your family. Worse, it felt like you were bringing Al Qaeda home with you at the end of the deployment. It was hard. It's still hard. As I write this, my hospital still (more than three years later) requires me to wear a mask the whole shift, and I can't admit any psychiatric patients without a COVID test. Burnout went through the roof. EM was always a high burnout rate specialty. It's worse now.
#4 Job Got Worse
EM, as a job, has been worsening over most of my career. Hospitals change corporations and EMRs every few years. EMTALA, HIPAA, board certification hassles, specific mandatory CME (stroke, trauma, opiates), and merit badge medicine (ATLS, ACLS, PALS, etc.) all contribute. A bigger issue is the increasing corporatization of medicine. Only about 8% of emergency doctors own their jobs, and even those democratic groups may have the worst business in America. Between 20%-40% of patients are self-pay (aka no-pay), and in reality, you only have one client—the hospital. If the hospital drops your contract, your business folds. When they say, “Jump!” we say “How high?” Even so, I don't know any partner docs that would prefer to be employees.
Recent laws against “surprise billing” (better titled “surprise coverage gaps”) have put downward pressure on emergency physician incomes. While nobody likes a surprise bill, emergency physicians have no recourse against insurance companies that refuse to contract fairly with them. This isn't only theoretical. After these laws were passed, Blue Cross Blue Shield of North Carolina proposed in-network contract termination for physician groups unless they agreed to 15% payment reductions, and United Healthcare proposed the termination of physician contracts unless they accepted a 40% paycut. Hospital systems are more and more likely to be owned by corporations and private equity with a relentless focus on metrics and profitability. Even when they try to focus on improving the patient experience and quality of care, they end up measuring the wrong things and do so in non-statistically significant ways. It's just not as good of a job as it used to be.
More information here:
What Happens If You Don’t Match Into Residency and What to Do
Consequences
Now that EM is no longer a competitive specialty to match into, what is going to happen? Let's start with what is not going to happen. Those programs aren't going to not fill. Those spots will just be filled in the SOAP. More than 95% of unmatched positions are filled in the SOAP these days. It's the doctors who are left holding the bag, not the programs. Between 6%-8% of US MD and DO grads (and as many as 50% of IMGs/FMGs (15% overall)) don't match anywhere. For many IMGs, any residency is better than no residency. The overall SOAP has become much more competitive in recent years as the increase in residency spots has not kept pace with the increase in medical school graduates. Believe it or not, there were times in the 1970s and '80s when there were more residency spots than applicants in the match. There will be more DOs, IMGs, and FMGs in EM programs that have not traditionally taken DOs, IMGs, and FMGs.
[Update after publication: There actually were open spots after the soap, but only around 50 and I am as of yet unable to figure out which programs they are in. Still, there were many more doctors matched in EM this year than last year even with 50 spots not filled.]]
There won't be less pressure on the EM job market either. Since those programs are going to fill and graduate residents, it's still going to be nearly impossible to get jobs in highly desirable places and increasingly hard to get them in less desirable places. While I have no idea how accurate the EM workforce projections for 2030 really will turn out to be, there's no reason to think the decreasing competitiveness of EM in the match is going to change that.
Emergency physicians won't be paid more either. The supply and demand calculations haven't changed. Besides, medicine isn't really a functional market anyway. Supply and demand have little to do with how much most doctors are paid.
What is going to happen is that EM residencies are, on average, going to be filled with less competitive applicants. Instead of filling with people in the top half of their MD med school class like most of the residencies I applied to 20 years ago, they'll have a combination of top MD applicants, less competitive MD applicants, DOs, IMGs, and FMGs. That will likely make the job of residency faculty more difficult than it has been in the past, especially those faculty in brand-new, corporate-sponsored residency programs that may not even want to be faculty anyway. Over time, the quality of the physicians in the ED is likely to decrease at least somewhat. While one specialty's loss will presumably be another specialty's gain, it does make me sad.
More information here:
My Spouse Is Quitting Medicine
Are Physicians Who Retire Early Abusing the System That Made Them Rich?
What Is to Be Done?
The major organizations in EM put out a joint statement, and they are creating a task force. Most are skeptical that it will really do anything. Our biggest organization, the American College of Emergency Physicians (ACEP), is widely viewed in the specialty to be “in bed” with corporate medicine—particularly the large Contract Management Groups (CMGs)—and many feel they have a massive conflict of interest in matters like these (57% of revenue for the organization is not from dues). However, there are a few things that can and should be done. They cannot all be done by emergency physicians themselves, unfortunately.
#1 Quit Approving Crappy Residencies and Put the Current Crappy Ones on Probation
The RRC-EM needs to be strict, especially if we're dealing with less qualified docs entering programs. If residents aren't getting the clinical experience, procedures, and didactics they need to be great docs, their residency programs need to be fixed or shut down. Yes, it stinks to be a resident in a program on probation or in one that closes. But hiding the problem doesn't make it go away.
#2 Make Fair Surprise Coverage Gap Laws
More work can be done here to ensure that insurance companies don't take advantage of hospitals and physicians, particularly those forced to work for free due to EMTALA. While we're at it, how about funding EMTALA? Also on my Christmas list is adequate funding of Medicare and especially Medicaid. We're not supposed to lose money on “insured” patients. EM is always going to be a tough job. It should be paid like it.
#3 More Physician Ownership
We need to do everything we can to boost physician ownership so they can control their own jobs. Doctors need to be the ones deciding how to deliver care, how to staff their own schedule, how to split up the earnings of the business, and who they work with. The corporatization of medicine is bad for doctors and patients. Our organizations need to support physician-owned models and hospitals, and patients and government entities need to be educated on the benefits of long-term, stable doctor-owned businesses providing their care.
#4 Better Community, Government, and Hospital Support of Emergency Departments
In some ways, emergency departments are like fire departments, police departments, and public health departments. There needs to be some slack in the system so when the excrement hits the ventilatory system, there is room to flex. There should be some people standing around in the ED not doing much most of the time so that when it gets really bad, there are enough resources to take care of a rapid influx of patients. If the hospital cannot afford that, the community and government entities need to make up the difference. Frankly, just funding EMTALA would probably be enough.
I can't make my grocer, landlord, or pharmacist work for free, but somehow I can make my emergency physician (and on-call colleagues) do so? That's not right. Ensuring doctors and hospitals got paid something for the no-pay patients would go a long way to providing slack in the system. Perhaps we need a great compromise: hospitals and doctors promise to overstaff and society agrees to pay for it. Frankly, EM probably isn't the only field that needs this. Have you tried to place a patient into a pediatric psychiatric unit lately?
#5 Quit Complaining to Students
I like to whine as much as the next doctor. Doctors are pros at it. In the military, there is a saying that “Complaints go up.” That is, you only complain to your superior officers, i.e. the people that can presumably do something about it. If we want the best students to join us in emergency medicine, we have to quit “complaining down” about the current situation to impressionable pre-meds and medical students. I don't mean that we should hide the truth from students. Emergency medicine has always had its warts. But let's make sure they also hear about all of the best parts.
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.
What do you think? Why do you think this happened and what should be done about it? What lessons should other specialties learn from this? Comment below!
Heck yes, tell students the truth- it’s a tough job that’s getting worse, we as a specialty are guilty of overselling and hyping it and we owe the highly indebted students the truth, it’s a moribund field showing no signs of improvement.
I wouldn’t encourage anyone to go into EM without some major, major changes. Students may literally go into a field with no or very poor job prospects. They deserve better.
I couldn’t agree more with the sentiment of overselling EM.It’s time to stop attempting to fulfill the needs of every patient that comes thru the doors 24/7 as well as screening for all the public health issues not to mention making profits for the CMGs. There are still many opportunities for the well trained board certified emergency physician in rural areas to those who are willing to go to these places and have the confidence to practice with minimal back up.
Dr. D – Wonderful and well thought out article. I’m hopeful that as you run out of personal finance topics, this website continues to push out articles on business operation. This ties directly into personal finance (earning vs spending). Your second order thinking is excellent, and this shows why your are also likely an effective executive. Stay strong and thanks for writing.
Ha ha. Run out of personal finance topics. That’s good.
Interestingly, when the data came out I assumed it was just an EM hopefuls problem. Now I realize that the pandemic and corporatization of medicine made anesthesia and radiology hopefuls much worse off as well. It doesn’t take too many EM hopefuls flocking to these smaller specialties to make it way tougher to match, and just a few years ago people were amending ROAD to e-ROAD.
Wow. I had no idea.
Dr. D, that was one excellent, but sad article. You should send it to whoever runs your professional organizations, as well as to the AMA, the heads of all the ER residency programs, and the Deans of all the US medical schools.
I’m not kidding. You are FI and working by choice. You have little to lose by sending a link (via email) to all of those people. I’m betting it would be news to many of them.
Of course, the corporatization of medicine is bad in general. I saw many of these challenges in my 30 year career in Psychiatry.
When I was worked 100-130 hours per week in 1990 as a OB/GYN intern, I subsequently left the “AOA only” program. I interviewed at a highly competitive EM program with a new ER and at three psychiatry programs. I did not get the 2nd year EM slot. Thank goodness others bested me in the process. It would have killed me. I had PTSD symptoms from one year in OB/GYN and would have fared worse in EM.
Based on your data and concerns, I would not choose EM. Back in my day, it filled 99% of its slots like OB/GYN. It was for AOA grads only (clinically top 10%), like Derm, Plastics, Ortho, ENT, and a few others.
I hope the right people get to see your post. I hope they correct the course of EM. Your post suggests it is not a good current choice. Personally, I think it was also the pandemic made the warts more noticeable, tipping the decision to “nope”.
I was in the ER doing psych evaluations on my side gig weekends. It was terrifying in 2020 before the vaccines, for all medical people on the front line over age 55.
I’m so happy to be able to work half time and see my 150 patients from my basement on a screen these days. No risk to me from COVID, RSV, Flu, violent patients, and the next thing (another bird flu?, swine flu?, a nasty COVID variant?…).
I’m too old for the front line these days, especially with non-MD’s making crucial decisions that could harm me or my family. The job of making sure your staff are safe, first and foremost, making sure staffing is adequate, and that people are paid a fair wage…are waning, and not just in EM.
Best of luck to you and all the ER and front line staff in our country.
Hi Jim, I have been a big fan and promoter of WCI for many years. Your article points out a lot of the issues with ER residencies and match problems in general. It underlies the big problem in healthcare nationwide, IT IS A BUSINESS AND WE ARE JUST PAWNS. Similar to the airline industry where the corporations don’t like the pilots but they cannot fly the planes without them.
Also, I sense some of the old Prejudices towards DO’s and IMG’s in your article. As a DO Cardiac surgeon I have had to fight this battle on many fronts for many years. While your comments may have been unintentional, there’s still a subliminal message that should no longer resonate in our healthcare system. All I ask is that you’re more mindful of this in the future.
Keep up the good work educating all on various topics
Agree, why you poo-pooing on DOs White coat, I expected a bit more from you😒
Not sure he’s relaying HIS prejudices rather than relaying the prejudices of the PROGRAMS that traditionally did not interview or rank DOs, IMGs, and FMGs, and may need to change that attitude in order to fill.
Conventional wisdom when I was applying to EM residencies was that there were just some programs that wouldn’t take DOs – even if you had sky-high step scores and were the top of your class. I’m sure we all knew that to some degree, and adjusted our applications more towards schools that had taken DOs in the past.
I don’t have the list of programs that didn’t fill, but I do recall seeing some well-established, highly-respected programs on it, but I don’t recall how many were programs that didn’t take DOs. I bet there’s a few on there. Schadenfreude, as the cool kids like to say.
Steven try not to be so sensitive.
There are plenty of programs out there and physician groups out there and employers out there who, all else being equal, would take an MD over a DO. All else is of course never equal. You can go argue with them all individually if you want, but to fail to recognize that this phenomenon exists is just burying your head in the sand. It’s a smaller issue than it used to be and match rates reflect that.
The older, relatively prestigious program I trained at had not ever taken a DO until a few years ago. It had no trouble filling this year but most classes now have a DO or two. 3/15 in the current PGY3 class. I don’t think the program has ever taken an IMG/FMG still though.
Psychiatrist and DO here. WCI, I generally find your work to be excellent and this article meets that general standard.
That said, it’s important to recognize the weight your voice carries in the profession. The comments you make about DOs, FMGs and IMGs being less than are insensitive at best. It would’ve been easy to advocate for a change in attitudes, or barring that citing evidence of a lesser standard of care like you did with advanced practitioners. To my knowledge, that evidence doesn’t exist.
To double down and write another is being too sensitive rather than take the comment to heart demonstrates a need for your own self examination.
These graduates are highly competent and there are plenty of MDs who are “less competitive” applicants. Old discriminatory stereotypes need to be thrown out, not propagated by those still holding their noses in the air.
Thanks for the feedback. There were several DOs offended by that comment who wrote in by email or by leaving a comment. Interestingly, there were no FMGs or IMGs or MDs who graduated in the bottom of their class who wrote in.
In recent years the overall DO match rate has climbed and climbed and is now essentially the same as the MD match. I don’t think that is the case in particularly competitive specialties or programs yet though. You can comb through the data here and decide for yourself whether my point has any merit or not:
https://www.nrmp.org/wp-content/uploads/2023/03/2023-Advance-Data-Tables-FINAL.pdf
Here’s a tiny selection of the data though:
1,511 (33%) of 4,511 slots in FM were filled by DOs
1,688 (18%) of 9,345 slots in IM were filled by DOs
3 (1%) of 240 slots in Neurosurgery were filled by DOs
1 (2%) of 49 slots in Thoracic Surgery were filled by DOs
4 (2%) of 92 slots in Vascular Surgery were filled by DOs
0 (0%) of 7 slots in Rad Onc were filled by DOs
119 (13%) of 899 slots in Orthopedics were filled by DOs
23 (6%) of 371 slots in ENT were filled by DOs
Now, one can interpret that data as “People who go to DO school would rather be family docs or internists than surgical subspecialists and radiation oncologists”, but I don’t think that is the best explanation of that data.
It is what it is. Maybe it’s discriminatory. But that doesn’t mean a difference doesn’t exist.
Those who think it’s fine point to the lower Science GPA and MCAT for DO matriculants vs MD matriculants. (3.7 vs 3.5 on the GPA side and I believe a difference on the MCAT Side too, but you can do the calculations yourself: https://www.shemmassianconsulting.com/blog/average-gpa-and-mcat-score-for-every-medical-school). Whether that matters or not, is of course arguable. All of us know great DO docs and bad MD docs too.
I don’t know what I think. But I can tell you this, 24 years ago I applied to and interviewed at both MD and DO schools and when I asked the DO students why they chose to go there most of them told me it was because they applied to but didn’t get accepted into an MD school. I did, so I went there. I’d probably do the same today and would advise a pre-med to do the same IF ALL ELSE WERE EQUAL (which it never is). Even if only 10% of doctors thought DOs were lesser docs, why take that risk that one of those could torpedo your desired career or job?
Agree, thought DO bashing was an old fashioned thought. But good, well presented article otherwise.
Seconded.
I don’t think anyone is saying that DOs or International grads are bad doctors.
But it is an absolute fact that if you are a DO or IMG, it will be significantly more difficult to match into a competitive specialty compared to an MD with the same grades and test scores.
The residency program I graduated from has never taken a DO, though we get plenty of applicants. It’s not fair, and I’m sure we’ve missed out on some excellent potential surgeons but that’s how it is.
Although the difference between difficulty levels is now likely much less than it was than when I was applying 20 years ago. Certainly in EM it is not going to matter much at all going forward.
This is saddening and sobering – and absolutely emblematic of the bigger forces that are making healthcare so difficult for physicians and patients.
I would add another factor that adds to EM burnout: the loss of/lack of other medical services that turn the ED into a dumping ground for chronic, subacute and non-life-threatening conditions that would be better cared for in a PCP or psychiatry office (and I say that as a PCP). Not good for our patients, not good for docs who went into EM to care for very sick patients.
Agree that underperforming and exploitative residency programs should lose accreditation. And maybe attendings should refuse to work for these corporate entities.
I’m wondering if you can see the cognitive dissonance in your statement.
Don’t work for corporate entities.
EM docs can’t find jobs.
Didn’t Jim just say that only a small fraction of EM docs are self-employed at this point? Grads have loans to pay and lives to live – saying don’t work for corporate medicine is not a solution.
Why is no one talking about unionization? It’s becoming increasingly clear to me everyday that it is going to be our only solution. It certainly isn’t a perfect solution, But it’s the only one that gives us enough clout as a group to have a chance against these corporate behemoths and insurance companies.
Who cuts rates 40%? We’re in the highest inflation environment we’ve seen in our lifetimes. It’s just absolutely asinine….
I did my ER residency long before EMTALA….which was our first step down the slippery slope of work -for -nothing /unfunded mandate /slavery. my 28 yrs of practice was filled with empty promises…”just show up for work and we’ll fix all the problems “….understaffed, overworked, underpaid, abused…
sorry to break the news, but I didn’t sign up for the Peace Corps or missionary work. when everything I need is free, I’ll work for free.
I had the highest loan debt of any Tulane Grad when I graduated….my financial aide advisor was worried that I wouldn’t pay it as an ER doc. I lived a conservative financial life, and retired early.
history of worker abuse has shown us the power of unions and strikes. John Q Public is clueless about any of these issues, let alone our training and sacrifices to do the work we do. Even my “certified er nurses” don’t know that ER is a medical specialty, years of training, debt, etc. Don’t think for even a second that corporate medicine is any cleaner than politics.
Unions and Strikes get attention…..when well-planned, they can educate the public and force the hand of corporate medicine.
good luck all of you.
As a non-EM doc, I think you all need to highlight some of the benefits of the ER. You have obviously pointed out some of the downsides (and yes, there are definitely downsides).
But I am frequently jealous of my EM friends. They can frequently take 1-2 week vacations if they plan their shifts correctly. Seems like many of my friends are taking a vacation every month or two. Some of us don’t have that luxury. We have staff’s that are 50-60 employees deep and a clinic and surgery schedule that prevents us from taking off very often. It just wouldn’t work with our business models. We also have very inflexible schedules. My Monday-Friday schedule is pretty much full. Sure I have weekends all to myself (which is great). But if I want to take a random Tuesday off because I went to a late concert on Monday night, it basically ain’t happening.
I’m not complaining, as it is the life I have chosen. I make very good money. I enjoy what I do. But when people ask me, I don’t highlight all the bad things about my specialty. Instead I highlight the things that make it good. I discuss the downsides because being honest is important. But there are no Tuesday afternoon wakeboarding days for me. I only get to go on a boat on the weekends with the rest of the riff raff 😉
Agree it’s important to show the good and the bad.
It’s not just the days off that are good about EM (although they’re great). You never know what you’ll see on shift. Generally the work tends to be interesting, even if there are a lot of issues you can’t really fix like the systemic problems, social determinants of health, etc. It’s best to focus on where you can actually do some good work. Often you get to make an important difference in someone’s life on most shifts. Opportunities to practice compassion and kindness are endless. You get to work with interesting, hard-working, generally positive people. And at the end of a long day or night, it’s an honest job that allows you to take pride in your work. We also have a lot of job flexibility, we’re in demand everywhere, and I’m grateful to advice from this blog that if your job sucks you can change it.
I don’t enjoy working nights, weekends, or holidays more than anyone else but I think it’s worth taking in the fact that many people work those shifts in essential jobs, and they typically don’t get paid as well as physicians. Think about police, firefighters, medics, even the people who staff 24/7 retail businesses for minimum wage. Recognizing this fact helps me avoid the complaining trap.
The proliferation of low quality, profit-focused corporate residency programs is a huge problem. It does tend to flood the market with new docs who need to find a job, even if it’s at one of these low quality CMG practices. As mentioned above, many of these new docs will not have received the quality of training that they deserved from a residency program. While we hope that additional EM grads would help bring emergency physicians to communities badly in need, sadly many of these grads from low quality programs may not be adequately prepared to staff a rural / remote ED where they would be on their own with whatever comes through the door.
Great additional insight!
We also have a lot of job flexibility, we’re in demand everywhere,
really?
Today’s Washington Post had an extensive article about the shortage of ER docs. The reader responses were interesting, many by physicians.
Too many, too few…..predicting the future is so hard.
I don’t buy the call on “shortage of medical providers, shortage of PCPs, shortage of etc etc” in general. It’s a distribution problem. But pumping out more of anything is not going to fix that, because all else being equal nobody wants to go practice in BFE. Unless someone’s got a fix for that problem I think the “shortage” in name your specialty is eternal.
Seemingly an unpopular opinion on the internet but as a fairly new EM attending, I am quite happy with my career choice. I think the key is not working too much. The bad days, the circadian changes, and the overall downsides are all a lot more manageable when you’re doing it less. There are still lots of things to enjoy about the job if you just focus on them. I still like getting to see everything, doing critical stuff at times, and when you’re happy…most patients are pretty nice. And I certainly don’t work in an affluent, healthy area. I work with a primarily sick and underinsured population. I have a whole lot more good days than bad days. I like the interaction with patients, nurses, ems, and other staff. Lots of days I leave in a better mood than when I entered.
I feel bad for the people who work 9-5. Seems like such a grind. I take at least one good trip a month. And It’s not like I get punished for it when I get back. No inbox full of patient messages, etc. Honestly, my life is as good/better than I imagined when I picked this specialty. Disclaimers: I don’t work for a CMG, I work about 110-120 hours a month, spouse works part time with flexible hours, kids are still young.
There have been too many low quality residencies open up for sure. That’s a problem worth working on. Things within the job have changed (so has every other job in/out of medicine) that are also worth working on. But I think the sky is falling view has been overblown and definitely over broadcasted. I heard the same thing a few months into COVID when jobs were scarce, and 18 months later there were tons of great jobs available begging for applicants.
Great insight I expect you to have a long and fulfilling career. The key drivers to burnout have been well studied and finances and work/life balance play a huge role that often is underappreciated/adhered to.
That being said – Jim you are spot on about your reasons for why this is happening – that being said I dont think the solutions are as actionable as we’d all like.
Another unpopular opinion is that the CMG’s arent really to blame. As asomeone that’s been a part of a small democratic group, that then got purchased by a CMG, married to someone in academia, the problems are universal – reduced compensation, higher acuity, less physicians, and more clinical requirements. The CMG actually saved us from when we were a SDG.
Great article. My wife is EM and we have been discussing the issues she is facing professionally for some time now. She is a well respected doc in a metro area in the Midwest and the job is driving her to look into other options professionally. Every year since she graduated the expectations have increased and the resources have decreased. She loves the medicine but her group is cutting overall provider hours and mandating extra shifts because they cannot find docs to hire. In my perspective the latest match is evidence that the overall EM system is broken. Groups in our area cannot find docs to hire but yet pay is going down.
#3
Despite higher patient satisfaction scores and improved outcomes, physician-owned hospitals were banned from opening new facilites or expanding existing ones under section 6001 of the 2010 ACA (thanks in part to the lobbying of the American Hospital Assocation). As the oft cited example goes, imagine a lawyer not being able to own a law firm or a baker not being able to own a bakery. Absolutely crazy. This needs to be talked about more.
There should be more discussion about that. Want to do a guest post?
https://www.whitecoatinvestor.com/contact/guest-post-policy/
This is not an EM problem. It is a healthcare system problem.
Ex: Patient has no healthcare, goes to ED for non emergencies. Patient should be going to primary care but there is a shortage of that and they don’t have insurance so they end up in the ED.
A single payer system will fix most of that.
Heathcare in the US needs to be single payer + if you want you can buy private insurance.
Everyone gets paid for their work.
Physicians need to be able to negotiate pay.
The current system does not work and going cash only will not work. More sick people without insurance will end up in the ED. It is much more expensive and far less efficient to do it this way than to just have a single payer system + the ability to go private if one chooses.
Yes, wait times will increase. So what. It’s better than not getting care at all. Physicians will have the ability to have hybrid practices where they can take single payer and some private or cash services. It will reduce billing complexity and out of network billing.
And what the heck is up with you CAPTCHA???
What issue are you having with the CAPTCHA?
It kept dropping me. I had to go back in several times to post. Thus the double post. I did not do that.
Allow me to push back on the single payor idea. With single payor, incentives to see volume are generally limited and pay is commensurate with that. Not just wait times per se, but access in general to subspecialties drops. If a physician or group can’t negotiate with the largest payor in the country, geographic pay arbitrage no longer influences physicians to practice in rural settings. I have friends in the western and northern provinces in Canada who have to refer patients several hundreds of miles because there is no subspecialty care nearby. Further, appealing on behalf of the patient for non-covered care becomes near impossible in a one payor system. I feel those stories of success in one payor systems are either the cherry-picked impoverished suffering from life threatening illnesses who were saved with eleventh hour heroics or are countries who fund social programs with oil money (Norway et al). Greece is being crushed by their social programs of which medicine is a large contributor, and England had strikes by residents years before ours in the US due to the arduous coverage demands, valiantly trying to backfill poorly paid and overworked hospitals doling out “free” care.
Unexpected consequences are common.
This is pretty similar to what happened when Family Medicine expanded their training slots too quickly in the 1990’s. Back when the specialty started they were attracting some of the best and the brightest graduates, but by the time I applied for residency in 2008 they were near the bottom of the list for average board score and near the top of the list for scrambles and FMG’s, and the best/brightest who might have chosen FM in the past were typically choosing med/peds programs instead.
It’s a bad job and getting worse. I don’t blame them (I’d do exactly the same), but groups selling out, to PE especially, has absorbed most of the positives of the job. In turn, this has left new grads with mainly the downsides as you work for someone like Envision or American Physician Partners.
If it’s truly your calling and you gotta do it then save that money so you can buy your way out of your nights, holidays, and weekends when older!
This is the BEST piece on this topic I have ever read. Thank you many times over, Dr Dahle!
The dissection of the problem and the accompanying solutions are thoughtful, spot-on, and need to be taken to heart by all of us.
The article makes me want to ask:
1) Can we get someone from the RRC-EM (maybe Linda Regan, Jan Shoenberger, David Caro?) to sit down and explain why they are continuing to approve CMG-affiliated programs in crappy hospitals when workforce models state this is unnecessary? The members of the RRC-EM are here: https://www.acgme.org/specialties/emergency-medicine/review-committee-members/
2) If the see-saw is tilted toward CMGs and flooding the zone with residency programs, who is on the other side of this and how do we engage with them?
3) ACEPNow had a widely pushed piece recently on the 2023 EM Match (written by Cedric Dark MD) — interestingly, it mentioned lots of possible causes, but did NOT mention the problem with CMGs and the extra 1000 residency slots they are responsible for creating over the past 5 years. Hmmm … your conflict of interest point with CMG funding relating to ACEP rings true!
https://www.acepnow.com/article/a-profession-in-peril/
“Think about police, firefighters, medics, even the people who staff 24/7 retail businesses for minimum wage. Recognizing this fact helps me avoid the complaining trap.”
I think it’s important to also recognize that not many jobs require as much education as that of the physician track. PhDs are very educated but they usually do not have as much personal responsibility as that of physicians; they don’t pay 15-50k a yr in malpractice insurance a yr. Most of them do not take decisions that could lead to loss of life nor limb.
There are days that me and many of my physician colleagues wish we had a “typical” job requiring much, much less schooling. You’d be surprised how many people can make low 6 figures with less than a bachelors degree or barely more than college education.
My standpoint is that of a poor immigrant background and having worked in fast food and many other low paid jobs before medicine.
As an MD/PHD still doing bench research out of personal interest while working about half-FTE equivalent of shifts in the community for income: the stresses of pursuing an academic career as a PhD are no less then those that an emergency physician faces; in many ways they are worse due to being long-term rather than something you leave in the department when your shift ends. Compensation is exploitative for PhDs in academia. I think of it as similar to EMTs and paramedics; it’s a difficult job that is underpaid, and docs that are much better compensated complaining about these fields as being “easier” has terrible optics.
Great article. Agree that EM physicians are the canaries of the coal mine. One solution would be for all EM physicians (possibly all physicians) forming a labor union to negotiate, but very unlikely to happen.
BTW, the phrase “excrement hitting the ventilatory system” made me LOL. Thank you:)
I am a graduating ED resident from an established 4 yr program in the West. The overall trajectory of a large part of the specialty is definitely unfortunate. That said, I think there is still ample opportunity to find a well compensated, sustainable gig in EM if you are willing to be picky with your job and you get decent training. My opinion is that new med students going into EM should focus on getting standout training which can set them up to land positions outside of the CMG mill.
I empathize with graduates from these community HCA sites, I know my future employer wouldn’t hire them. The good jobs in EM are still going to exist 5 years from now, but if you don’t set yourself up well with good training you may have a very tough road
We’d look at it the same way. I can’t imagine us hiring a graduate from an HCA style residency into our partnership track. But I don’t think that bothers HCA. It basically forces their graduates to stay in their system, which is the whole point of starting those residencies anyway.
Imagine those of us who are getting press-ganged into having a residency at one of our sites. HCA in Austin/TeamHealth is still planning to open an EM residency in 2024 over staff objections.
Pretty uncomfortable situation for sure. I wonder what effect a few anonymous letters to the RRC-EM would have on their decision.
I’m not sure I agree with not sharing complaints with medical students. If someone asks me for career advice I tell them the good and the bad about my field. If they decide my field isn’t for them that’s fine with me.
Wow – what a great article! I’m not a physician, but have spent plenty of time in the hospital as a patient including some trips through the ER. It was very interesting to hear the perspective of someone “on the inside” on how things were going.
I can’t speak to the recommendations, other than point out that from a patient perspective it seems like the “anti balance billing” law that recently passed was driven by seemingly routine abuse of those predatory “not in network for anyone” EM departments that seem to exist at every in-network hospital I’ve ever seen. This arrangement seems intentionally designed to screw patients with outrageous bills at a time where they know that it’s basically not practical for a patient to shop around. Something needed to be done to protect patients.
The only other thing I’d point out is that US healthcare costs are going to have to get reined in somehow, as the current path those costs are on is just unsustainable. And so, because math, someone in the heathcare sector is going to have to take a haircut. Not sure if it will be the doctors or the hospital systems, or both, but someone is going to get less in the future than they do now. I do know that the physician costs tend to be only a fraction of any medical bills I have ever seen – the bulk of the money seems to go to the hospital in my experience. But since physicians are the ones that the public interact with the most, unfortunately I think physicians are likely to be the targets here.
I agree with you that something needed to be done. Not sure what we have now is the right something but hopefully as we keep muddling around we’ll get it right.
And yes, healthcare is a mess and people think doctors are the problem even despite the fact that their salaries are a tiny percentage of the health care dollar. The big players (hospitals, pharma, insurance companies) are much bigger and better organized.
and ER costs are a tiny fraction of total Healthcare costs…around 5% IIRC.
Lower than that I think it’s 2%.
Future could be two tier system: one of physician-owned care center at higher cost due to more training and expertise and one of corporate/midlevel care. Let the individual and payor decide with a premium health insurance option.
In answer to your question #2, this is who:
https://www.aaemphysiciangroup.com/news-and-updates/aaem-pg-files-suit-envision-healthcare-alleging-the-illegal-corporate-practice-of-medicine
re: “Continental Breakfast | March 22, 2023 at 3:31 pm MST
…
2) If the see-saw is tilted toward CMGs and flooding the zone with residency programs, who is on the other side of this and how do we engage with them?
…”
Jim,
One of the best summaries I have read. Any chance you would give a shout-out to the AAEM-PG? They are the only ones I know of who are actually trying to do something positive about this mess.
https://www.aaemphysiciangroup.com/news-and-updates/aaem-pg-files-suit-envision-healthcare-alleging-the-illegal-corporate-practice-of-medicine
I think you just did.
But yes, I’ve been following along on the suit and hope to see more of them.
I think this was an amazingly astute analysis of what’s going on. I was a on the ACEP Council in the early 2000’s – I remember thinking even then that we were growing too fast – and brought it up at a council meeting. You would not believe the incredulous and angry push back (so many leaders in EM at the time either owned contracts or were leadership in the large corporate groups). I was told that we need to grow as fast as possible – that every little ED in the country needed to be staffed 24/7 with board certified EM trained docs (a pipe dream for the innumerable places that see 25 people a day – and of course there is the PA/NP staffed fast tracks). I can’t tell if they believed the staffing myth – or they were just looking for cheap docs. The orthpods don’t let the programs get out of hand – and there is a great need nationwide. They are so much more business savvy than EM – and keep the level of quality high by limiting the programs number and size.
The more I think about it, the more I think the issue is just too many programs/training slots. EM isn’t even really any less popular. In fact, it may be MORE popular as the number of filled slots is far higher than it used to be. It’s less competitive to match now, but all of the great students you want to do EM can still do EM at the better programs.
Thank you for this very articulate and insightful article. I’m a “seasoned” EP graduating in 1992 . I just went part-time after 30 years in 2022. I still think EM is a fantastic specialty and express my passion for it to this day especially to med students where I teach. And, you are absolutely right. The job has changed a lot since my residency and not necessarily for the better. Corporatization has got to be the worst change. But, so far, I am willing to put up with all the baloney because it is still worth it. I love practicing EM.