EM Leaders Call for Stop to New or Expanded Programs

Alicia Ault

April 07, 2023

Despite widespread concern from national emergency medicine (EM) groups about a large shortfall during Match Day 2023, EM programs filled most of their available residency slots when final results were released.

Still, the initial deficit led some EM leaders to call for a swift halt to expanding or opening new EM residency programs and to further scrutinize the influence of private equity money on the specialty.

Before Match Day, the American College of Emergency Physicians (ACEP) and other EM organizations issued a joint statement about the high rate of unfilled emergency medicine (EM) positions expected this year. As they feared, 554 of 3010 positions offered by 287 institutions remained unfilled, an increase of 335 over last year.

The initial Match rate was about 82%. But by the end of the Supplemental Offer and Acceptance Program (SOAP) process, which finds alternative programs for unfilled positions or unmatched applicants during Match Week, only 44 of the unmatched EM positions, or about 8%, were left unfilled, said Donna Lamb, DHSc, MBA, BSN, president and CEO of the National Residency Match Program.

Those few remaining positions should be filled by July 1, the start date for programs, Bryan Carmody, MD, MPH, a pediatric nephrologist known for his medical school commentaries, told Medscape Medical News. There were at least 8000 unmatched applicants before the SOAP, so there shouldn't be a shortage of doctors interested in filling the remaining positions, he said.

Concerns about the initial match results remain, largely because of the increase in EM residency programs. For comparison, in 2018, the EM match rate was 99.4%; 220 EM residency positions offered 2278 slots.

Residence slots have increased by 20% in the past 5 years, Lamb told Medscape. "Is that too fast? I can't answer that."

"There's too many [residency programs], hands down," said Leah B. Colucci, MD, president of the American Academy of Emergency Medicine–Resident and Student Association.

ACEP President Christopher S. Kang, MD, disagreed. He doesn't believe there are too many programs. He blamed a "distribution problem" ― too many are concentrated in certain areas, leaving other regions underserved.

Declining Interest

Kang said residency slots increased in the past few years as medical organizations projected physician shortages across all specialties in the wake of the pandemic.

At the same time, EM was becoming more popular, he said. "You've seen now a mismatch." He noted that as programs have rapidly expanded to meet an initial demand, interest has declined, especially in less desirable geographic areas.

Lamb said that 36% fewer US medical school seniors included EM on their rank order list this year, compared with the specialty's peak in 2021, and 35% fewer of those seniors rated EM as number 1 on their rank order list.

"The specialty needs to focus in on and think about what's creating this barrier for applicants, in particular, US MD seniors, from going into the specialty, and how do we address it while ensuring that we are safeguarding the health of our population," she said.

Among the factors ACEP's Kang believes are causing a declining interest in the specialty:

  • Burnout from serving on the front lines of the pandemic

  • A 2021 ACEP report that predicted an oversupply of some 8000 physicians by 2030

  • Concerns about verbal and physical assaults of healthcare workers

  • Coping with the mental health crisis and the opioid epidemic

Medical students shy away from the specialty for fear of burnout, a stressful work environment, and the potential of an oversaturated job market, said Jessica Adkins Murphy, MD, president of the Emergency Medicine Residents Association.

"A lot of our medical student members actually said, 'I believe in myself and my ability to get a job, but I don't want to go through residency just to be miserable,' " said Murphy, a third-year resident at the University of Kentucky in Lexington.

Impact of Private Equity

Murphy and Colucci said they believe concern over profit-seeking in the ED influences medical students as they evaluate potential specialties.

Medicare reimburses hospitals for residents' salaries, although there's pressure to reduce salaries as a result of an increase in competition and private equity–backed hospitals. "Medical students are seeing that," said Colucci, a second-year resident.

EM doctors don't choose the specialty to make money, she said. She explained that many of the patients EM physicians see are uninsured, very sick, or lack primary care. "Those are the people we want to serve," Colucci said.

"Physicians go through years of medical school, years of residency, sometimes a fellowship, and then they come out and they don't have autonomy in their practice" because of corporate management oversight, she said. "And that's really disheartening."

Murphy said she's concerned that "there might some profit incentive to open new programs or to rapidly expand existing ones."

For example, HCA Healthcare sponsors 18 accredited EM residency programs ― 11 of which began in the past 5 years. All of HCA's EM residency positions were filled on Match Day, according to spokesman Harlow Sumerford. He also pointed to the 68 new EM residency programs that have been added over the past 5 years outside of HCA, according to the Acccreditation Council for Graduate Medical Education.

An ACEP spokesperson said the organization has been working with hospitals, healthcare systems, and residency program directors to determine how to grow programs in a responsible way.

Finding Solutions

The surplus of residency programs will not be solved by closing programs, Murphy said.

She and Colucci agree that leaders in graduate education should examine the quality of education that residents receive — especially in private equity-backed programs.

Demanding higher standards — such as requiring a certain number of intubations per month — could potentially remove programs that do not meet certain benchmarks and reduce residency slots, they said.

"If we were to increase residency training standards, it would inadvertently have the effect of closing down programs with less training opportunities, less learning opportunities, and training without specifically violating antitrust regulations," Murphy said.

Such changes can't come soon enough, said Colucci, who predicted worse outcomes for EM residents in Match 2024. "I wouldn't be surprised if we aren't losing applicants right now for this upcoming match," she said.

Alicia Ault is a Saint Petersburg, Florida–based freelance journalist whose work has appeared in publications including JAMA and Smithsonian.com. You can find her on Twitter @aliciaault.

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