There has been much hand-wringing about the 555 (18.4 percent) unfilled match spots in this year’s emergency medicine (EM) residency match. Several long-standing, excellent programs with outstanding patient pathology and well-known faculty in major metropolitan areas did not fill.
Most hand-wringing has focused not on inherent attributes of the specialty, but temporal issues likely to fluctuate over time, including:
1. An overproduction of 8,000 emergency physicians (EPs)
2. EPs replaced by over 27,000 mid-level/advanced practice provider (APP) NPs and PAs. The proportion of EM providers who area APPs increased from 20.9 percent to 26.1 percent between 2013 and 2019; the number of patients seen by NPs/PAs grew from 15 million to 40 million visits between 2007 and 2016.
3. Pre-COVID burnout rates up to 60 percent.
4. Fallout from the COVID pandemic.
I call these issues temporary because they will change with market forces and supply/demand, or are strongly associated with a powerful, though temporary, event (COVID). Ten years from now, many will no longer be issues:
1. The overproduction of EPs will slow when programs close or reduce the number of open positions as they continue to underfill. (People claim this year is a course correction, though most, if not all, spots that did not fill in the Match filled through the SOAP scramble. I don’t know how filling all the spots via SOAP corrects overproduction. But I trust this will eventually occur.)
2. As evidence accumulates that APPs are somewhat less-productive and more costly downstream (e.g., more admissions, more imaging), and patients prefer to see an MD/DO to an NP/PA, hospitals will require EDs to reduce the number of APPs.
3. Memories of COVID will fade.
However, even after these issues have been resolved, EM still has long-term weaknesses owing to inherent problems with the specialty as conceived and implemented. Namely, the specialty is incongruent with what we know are the best ways for people to be physically, socially, and psychologically healthy.
If you had to design the anti-perfect system for well-being, emergency medicine would be it.
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Human flourishing requires
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EM offers |
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Brief relationships with patients (“Meet ’em, greet ’em, treat ’em, street ’em.”) |
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Frequent interruptions (12.5 times/hour, the most of any specialty), attention-shifting, and multitasking (which is not healthy or even real; instead, our brains switch between items of attention, losing focus, quality, and time with each transition.) |
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Excessive cognitive load (i.e., keeping useless information in our working memory). I remember phone numbers of consultants/hospital departments/locations, but not more important things in life. |
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An irregular schedule |
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An awkward sleep schedule (EPs report high usage of sleep aids diphenhydramine, alcohol, or melatonin.) |
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Predictability in work responsibilities and projects |
Unpredictable workload and intensity |
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Hormetic stress: Long periods of stressless time intermingled with only brief outbursts of stress increases well-being and resilience. |
Chronic stress (8 to 12 hours per day, 3 to 4 times per week), which increases cardiovascular and cancer risk. Even if patients aren’t critically-ill, time pressure to “move the meat” is stressful; EM’s most-important metrics are based on speed (“door-to-doc,” “door-to-disposition”) and customer satisfaction (Press-Ganey), most of which is beyond EP’s control. |
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Personally-meaningless corporate metrics, many of which lack patient benefit. |
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Exposure to nature, even at work |
Working all day (and night) with little or no exposure to nature, even through windows |
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Awe and excitement |
Decreasing opportunities for awe and excitement. There are fewer severely ill or critically ill patients. Peak COVID (2020 to 2021) notwithstanding, ED visits by acutely ill patients during the last 20 years have decreased (lower ICU and overall hospital admission rates). |
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Largely individual work instead of teamwork. We collaborate with ED colleagues during resuscitations. Otherwise, typical workflow involves EPs writing orders carried out by nurses, only rarely collaboratively “thinking through” cases. Additionally, EPs often get pushback from non-ED colleagues regarding admissions/consults/ |
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Walking at work for exercise/relaxation/ |
Sedentary work with much computer time. Plus, taking a break from seeing patients during which to walk for leisure is very difficult. Whose sense of duty, heart rate, and anxiety don’t go up when another patient is added to the board who hasn’t been “picked up.” |
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Rushing from one patient to another. Rare is the opportunity to think deeply about a case or enjoy discussing cases with colleagues and asking their opinions. |
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It is uncommon for most EPs (being “front-line” workers) to be able to use our creative brains on research/educational/ |
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Lack of control. Corporatization in community or academic practice deprives EPs of control over income, volume, environment, metric-setting, and resources, thereby producing a low sense of ownership/investment/ |
These have been inherent aspects of EM since its foundation in the 1970s. Depression, suicidal ideation, suicide, and burnout were high among emergency physicians before the pandemic because of inherent, not temporary, or context-specific (COVID) problems with the specialty.
So, why might people now be making career/life decisions based on human flourishing? Because we’re increasingly aware of and value these things. Recent changes in work expectations and societal behavior that reflect this include:
- Duty hour restrictions and patient volume caps
- Meditation/yoga/mindfulness exercises
- Creative freedom at work
- Control over our space (work from home, designing one’s office space)
- Control over our time (restaurant/grocery food delivery, online shopping, mobile pet grooming vans).
EM contradicts many of these new values and behaviors.
I like EM and being an emergency physician: EM fulfills important societal functions, particularly for those with limited access to care and the critically ill. There’s a great variety. We are the first to consider a differential diagnosis or confirm a suspected diagnosis. Some patients are truly very sick. We are with patients and family members during moments of crisis. It’s ethical to see patients regardless of their ability to pay.
The author is an anonymous physician.
