The 2023 emergency medicine match: Alarming symptom of a health care system in crisis

The 2021 American College of Emergency Physicians (ACEP) workforce study offered a sophisticated analysis of physician supply and demand. The relevant modeling, which assumed modest growth in graduate medical education (GME) programs, increasing contributions to care by advanced practice providers (APPs), and declining emergency department (ED) utilization, projected a surplus of nearly 8000 emergency physicians by 2030. The study reverberated throughout the specialty while serving as a call to action to assure a balanced emergency medicine (EM) workforce, one that is positioned to meet the changing demands for emergency physicians. ¹

In the wake of these projections, the landscape of EM GME has changed in a way that is potentially disruptive not only to emergency care but also to the entire U.S. health care system. The 2023 National Resident Matching Program (NRMP) produced alarming results for EM. In the initial Match, prior to the Supplemental Offer and Acceptance Program (“SOAP”), EM saw 555 (18%) of its 3010 available positions go unfilled, distributed among 46% (129/278) of EM programs. This outcome follows the 2022 Match, which resulted in a heretofore unprecedented 219 unfilled positions. ² These results constitute a remarkable turn of events for a specialty that was previously among the more competitive, with fewer than 30 unfilled spots per year for more than a decade. ³ The number of unfilled residency positions can largely be attributed to a marked fall in the number of applications to Accreditation Council for Graduate Medical Education (ACGME)‐accredited EM residency programs in the past 2 years. Following a record number of applicants at its peak in 2021, EM experienced a 16.8% decrease in applications from 2021 to 2022 and a further 18.1% decrease from 2022 to 2023. While the decline was notable among all applicant types, it was sharpest among U.S. MD applicants. Despite a modest rise in the current 2024 Electronic Residency Application Service (ERAS) cycle, composed of increases in the number of doctor of osteopathic medicine (DO) and international medical graduate (IMG) applicants, the number of overall applicants to EM is still the second lowest in many years (Figure 1). ⁴ Another major contributor to the projected surplus of emergency physicians is the marked increase in the number of ACGME‐accredited residency programs, which grew from 117 to 276 between 2001 and 2021. This includes a substantial increase in new for‐profit–affiliated EM residency programs, which grew from one to 29 between 2016 and 2021. ⁵

FIGURE 1.

Recent trend of overall number of applications to emergency medicine. DO, doctor of osteopathic medicine; ERAS, electronic residency application service; IMG, international medical graduate; MD, doctor of medicine.

While the workforce study and match trends are concerning for the specialty of EM, they carry implications for the entire health care system and the patients it serves. As the only specialty that provides care to “anyone, anything, anytime,” and disproportionately to underserved populations without other means to access health care, a decline in qualified emergency physicians will directly impact the overall quality of health care delivered in the United States. The situation will likely be exacerbated as millions lose Medicaid coverage upon the conclusion of the COVID‐19 public health emergency. ⁶ For these reasons and more, it is worth considering the factors influencing the recent EM Match, along with measures to support the practice of EM that will ultimately benefit patient care and the medical community at large.

Among the purported reasons for declining interest in EM are workforce projections, increased clinical demands, boarding, the COVID‐19 pandemic, economic challenges, and the “corporatization” of medicine. ² While burnout rates skyrocketed across all specialties during the pandemic, EM physicians have been the hardest hit, with one study indicating that 65% of emergency physicians admitted feeling burnt out. ⁷ One likely reason is boarding, which reached unprecedented levels during the COVID‐19 pandemic, further adding to job dissatisfaction and moral injury. Direct and indirect economic forces influencing care delivery, reimbursement, and compensation are also root causes of the declining interest in EM. ED staffing models utilize ever increasing numbers of APPs. The push for independent practice pathways for APPs eliminates the need for physician supervision in some states. Consolidation of corporate EM groups by private equity has also exerted downward pressures on compensation due to decreased practice ownership. Finally, the No Surprises Act, aimed at protecting patients covered under group and individual health plans from receiving surprise medical bills, includes among its targets emergency services, thereby further reducing EM physician reimbursement. ⁸

Just as the causes undergirding the state of EM GME are many, the proposed solutions within the specialty must be multipronged. In response to the results of the 2021 workforce study, the ACEP EM Workforce Taskforce was created. Its works in progress include proposals aimed at ensuring that business interests do not supersede educational needs and patient care; that care in all communities, including rural environments, is supported; that APPs are appropriately supervised; and that EM practice expands to address evolving needs for acute unscheduled care. The taskforce also proposed to increase residency requirements such as scholarship or procedure logs to the ACGME. ⁹ By so doing, the ACGME can better ensure the quality of training while eliminating programs which fail to meet new standards. Other ongoing strategies include addressing record levels of boarding, rejecting profit‐driven use of APPs, pushing back against the rise of private equity in medicine, and peer physician support for combating burnout. ⁸ , ¹⁰ In response to the 2023 EM Match, a Match taskforce representing the major EM organizations was convened to identify factors behind the drastic rise in unfilled residency positions in hopes of finding potential solutions. ²

The factors contributing to the recent EM Match represent issues that pertain to many other specialties. Among these are the burdens encumbered by electronic health records, competition from APPs, declining reimbursement and compensation, workplace violence, and a desperate need for mental health and liability reform. For EM in particular, the impact of boarding on patient outcomes is well documented and includes “lower quality of care, decreased patient safety, reduced timeliness of care, reduced patient satisfaction, an increased number of patients leaving without being seen, and increased mortality.” Furthermore, boarding negatively “impacts physician and staff wellness and retention.” Boarding is a symptom of failed hospital‐wide processes. ¹¹ Best practices to reduce boarding do exist, such as allocating appropriate resources in the form of inpatient provider and nursing support to admitted patients in the ED, smoothing out the elective surgical schedule, increasing morning and weekend discharges, and distributing admitted patients to inpatient hallways, if necessary. Implementing these solutions will require hospitals to address misaligned financial incentives and competing physician interests. It is critical that physicians of all specialties recognize the untoward consequences of boarding and take a proactive approach to address it head on, not for the sake of EM but for all patients who seek care.

The core aspects of EM practice that have long made it an attractive specialty to many prevail in the current clinical environment. They include the opportunity to work as frontline diagnosticians and “resuscitationists” for undifferentiated patients and the opportunity to deliver acute care to all regardless of their socioeconomic status. The disappointing results of the 2023 EM Match are a symptom of larger systemic ailments within the U.S. health care system. While EM can use this watershed moment to examine training and practice, the specialty's efforts to advocate for better working conditions are well aligned with every specialty's common goal of improving patient care. However, engagement and support are required from the medical community at large. By improving the practice of EM, a competent and fulfilled cohort of EM physicians will, in turn, benefit all the patients under their care as well as the health care system as a whole.

AUTHOR CONTRIBUTIONS

Alexander Y. Sheng and Eli Y. Adashi provided conceptual design of the manuscript. Alexander Y. Sheng drafted the manuscript. All authors provided critical revisions of the manuscript.

CONFLICT OF INTEREST STATEMENT

The authors declare no conflicts of interest.

Sheng AY, Gruppuso PA, Suner S, Adashi EY. The 2023 emergency medicine match: Alarming symptom of a health care system in crisis. AEM Educ Train. 2024;8:e10947. doi: 10.1002/aet2.10947