Five-hundred and fifty-five. That’s the number of first-year emergency medicine (EM) residency spots that went unfilled in the Match. Before discussing the implications for nationwide residency programs, applicants, and patients, we must ask how we got here?! Emergency medicine used to be a “sexy” specialty. The TV series ER ran for 15 seasons. Emergency medicine was once a part of the infamous E-ROAD (EM, radiology, ophthalmology, anesthesiology, dermatology) lifestyle specialties. So, let’s unpack the series of unfortunate events that left even the most prestigious EM programs across the country scrambling to fill empty spots in time for July 1st.
Boarding. The COVID-19 pandemic exacerbated an already overarching problem in emergency departments (EDs) across the country-boarding. The practice of monitoring admitted patients in the ED awaiting an inpatient bed results in increased mortality and medical errors. Despite worse outcomes, the financial incentives of hospital boarding exceed its costs, making it difficult for hospitals to deter the practice. But what about the emotional costs? EM physicians, nurses, and staff bore the brunt of overcrowded and understaffed hospitals during much of the pandemic. Stretchers in hallways became the norm. A corner of rooms reserved for ICU patients who had been admitted for days was no longer unheard of. EM physicians are practicing waiting-room medicine across the country. Surely, overcrowding, understaffing, and worse medical outcomes contributed to increased stress in the workplace environment. Medical students were paying attention. They watched as residents and attending physicians struggled to care for sick patients in hallways safely. They watched as patients came to the ED because their primary care doctors’ wait times were up to 6 months. We must address ED boarding to improve health care outcomes and make EM a more appealing specialty.
Compensation. Medical students invest hundreds of thousands of dollars in their education. A disproportionate amount of student loan debt lies with Black and brown students and physicians. The National Health Service Corps attempts to alleviate some student debt by offering loan forgiveness for students entering primary care specialties. Primary care specialties for physicians include family medicine, general internal medicine, general pediatrics, and geriatrics. However, a recent Oxford Unity Press Public Health Emergency Collection article by Tapia et al. showed that 13 to 27 percent of ED civilian visits are appropriate for appointment-based settings with primary care physicians. Any EM physician can tell you that a significant part of any shift is spent refilling anti-hypertensive medications or managing other chronic afflictions. If almost a third of ED visits are primary care visits, why shouldn’t EM physicians be eligible for a percentage of loan forgiveness dedicated to those who practice primary care? There are other loan forgiveness programs, such as Public Service Loan Forgiveness, for which EM physicians may be eligible.
Nonetheless, it’s difficult to argue that additional loan forgiveness for EM physicians doesn’t make the specialty more appealing. This is particularly true when medical student loan debt is about $200,000 on average. To incentivize medical students to go into EM, we must compensate them for the primary care services they provide in the form of additional student loan forgiveness options.
COVID-19. You can’t discuss the struggling health care system or disappointing match results without discussing COVID-19. The pandemic took over 1.1 million American lives and negatively impacted almost every aspect of the public and private sector. The pandemic revealed for many the perils of the overstressed health care system and the ED’s role as the system’s safety net. Front line health care and essential workers stepped up to the plate. We did it with inadequate PPE, staffing, supplies, and space. Furthermore, health care is not simply transactional. Health care workers watched real people suffer and die from a highly infectious virus, for which we initially had no treatment or vaccine. The emotional toll on EM physicians, who are also people with families, friends, and fears, is immeasurable. For instance, according to Medscape’s U.S. Physician Burnout and Depression Report, 53 percent of physicians reported burnout in 2022. Emergency medicine physicians had the highest rates of burnout at 65 percent. Medical students were paying attention. Stakeholders need to use the COVID-19 pandemic as an opportunity to alleviate how social drivers of health, financial matters, and difficulty accessing care contribute to a dangerous work environment in the ED.
The Match has always been an elusive process, more akin to black magic than a scientific algorithm. It was also a call to action for the field of emergency medicine. Why aren’t students standing in line to staff our EDs? The structural factors contributing to crowded and under-sourced EDs, physician burnout, and worse medical outcomes will impact the specialty for years to come. It is up to graduate medical education leadership and stakeholders to restructure the Match to reflect the needs of the workforce and patient population.
Katrina Gipson is an emergency medicine physician.
