An emergency for emergency medicine?
Match Week was a rude awakening for a field that has taken a beating the last few years.
Yesterday was “Match Day” in the United States. It’s the day when graduating medical students literally open an envelope and find out where they will go for their residency training.
(I’ve written about the catharsis of Match Day before. I still think it’s the best system one could come up with for the problem of thousands of applicants applying to thousands of hospitals, and in varying fields of medicine. Still, there are some ways it should be improved.)
More generally, this past week was “Match Week.” On Monday, applicants to residency learned if they matched, but not where. Those who did not match entered a process called SOAP (the Supplemental Offer and Acceptance Program) which brings together applicants who did not match into a residency via “the algorithm” with programs that did not fill all of their open positions. By Friday, everyone who matched (whether prior to Monday or in the SOAP scramble this week) received their envelopes and read their futures.
Monday was a bad, bad day for my field. We found out that of around 3,000 open positions in emergency medicine residency programs nationwide, 555 spots had gone unfilled in the initial match. Left unfilled, this would be more than the last 14 years combined, according to Dr. Bryan Carmody, an expert on the residency application system (and, also, pediatric kidneys). We won’t know for a couple of months how many of those 555 spots were filled during this week’s SOAP process, but either way, this was not good news for the field.
Emergency medicine has had ups and downs. In the 1990s hardly anyone outside of medicine even knew that emergency medicine was its own field. The NBC drama ER did more to fix that than anything. Over time, the field became more competitive. Each year, there were more applicants, making it more competitive at the top. But residencies were also opening anew. There’s been a bit of an arms race. Applications are up 25% in the last decade. But open spots increased by 60%. At some point, supply might exceed demand.
It looks like we are getting close to that, and it’s easy to understand why. In the past few years, the field of emergency medicine has taken a hit. There are projections that show an over supply of ER doctors by 2030. The Covid-19 pandemic made temporary heroes of ER doctors, but it also exposed medical students to the reality that the ER gets under-resourced in many places. It’s not an easy place to work. ERs are full of “boarders”—hospital inpatients with no open hospital beds who must wait in ERs, sometimes taking up a room and other times languishing in the hallway. There’s burnout. There’s workplace violence against ER doctors.
Look, it ain’t easy.
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Still, I love my job. I would still encourage medical students to consider it as a career. There’s no other field in medicine that takes all comers, regardless of ability to pay, any day, any time. There’s no other field in medicine that sees as much variety as we do, be it the kinds of medical conditions we diagnose and treat, or the diversity in the patients we serve. It’s the place where the most equitable care takes place (albeit, we’ve got work to do). I believe emergency medicine is both an essential element of medicine and a highly ethical one.
To keep the field vibrant and to improve it, though, we’ll need to recruit the best and brightest possible. This year’s match results may be a sign that we have taken steps in the wrong direction. Course correction is needed. What that exactly entails will be the subject of great discussion and debate in the months ahead.
In the meantime, I’m sure you all agree: if you have an emergency, you want to be diagnosed and treated by someone who is board certified in diagnosing and treating immediately life, limb, and organ-threatening conditions. At its core, that is emergency medicine, and I’m proud to be in the field.
Ok, sorry, here's a rant: I graduated from my EM Residency in 2006. If I could go back in time and talk to my younger self, I would yell "DON'T DO IT". When I was an academic doc, I told med students to consider something other than EM. In my current job I have scribes who are mentees, and I tell them the same thing. Why? it's not just the night shifts which get harder and harder as you age; it's not just the boarders; it's not just the understaffing; it's not just the lawsuits.It's that we have virtually no autonomy over our professional lives. The majority of EM doctors now work as employees or independent contractors, rather than in democratic groups. Unless you work for the VA you are not in a union. And the saddest part is that we have done this to ourselves. AAEM still focuses on the group model, even as this in in retreat, and ACEP is a subsidiary of TeamHealth. We have not collectively worked to protect our professional autonomy, because that would require working together, and we have all been socialized to be as individualistic as possible. State and Federal governments mandate treatments and even redefine diseases (eg with Sepsis). Hospital administrators cut staffing to meet phantom budgets, even if the hospital in a registered non-profit. I could go on and on. EM will only return to its glory as a medical specialty when we can learn to work collectively to take back our independence and dignity.
I’m an almost completely retired family physician, I don’t know how primary care did in the match, but front page article in the Globe highlights that there are no primary care doctors taking new patients in Massachusetts-- and I know that’s true in Rhode Island as well. It’s a crisis.