“Cold feet”: A qualitative study of medical students who seriously considered emergency medicine but chose another specialty

Abstract

Introduction

Emergency medicine (EM) has historically been among the most competitive specialties in the United States. However, in 2022 and 2023, 219 of 2921 and 554 of 3010 respective National Resident Matching Program positions were initially unfilled. Medical students’ selection of a medical specialty is a complex process. To better understand recent trends in the EM residency match, this qualitative study explored through one‐on‐one interviews the rationale of senior medical students who seriously considered EM but ultimately pursued another specialty.

Methods

A convenience sample of senior medical students from across the United States was recruited via multiple mechanisms after the 2023 match. Participant characteristics were collected via an online survey. Qualitative data were generated through a series of one‐on‐one semistructured interviews and thematic analysis of the data was performed using a constant comparative approach.

Results

Sixteen senior medical students from 12 different institutions participated in the study. Thematic saturation was reached after 12 interviews but data from all 16 interviews were included for qualitative analyses. Five major themes emerged as important in students’ consideration but ultimate rejection of EM as a career: (1) innate features of EM attracted or dissuaded students, (2) widespread awareness of a recent workforce report, (3) burnout in EM, (4) their perception of EM's standing in the health care landscape, and (5) early EM experience and exposure.

Conclusions

This qualitative study identified five major themes in the career decisions of senior medical students who seriously considered EM but chose another specialty. These findings may help inform the perceptions of students and guide future EM recruitment efforts.

INTRODUCTION

Medical students’ selection of a medical specialty is a complex and individualized process that often begins before and evolves during medical school. Among students matriculating with a particular specialty in mind, up to 80% change their mind by their final year. ¹ Students’ career decisions are influenced by many factors, including exposure through clerkships and shadowing, ¹ , ² , ³ , ⁴ competitiveness, ⁵ attending and resident interactions, ² , ⁴ , ⁵ work–life balance, ⁴ practice setting, ⁶ , ⁷ clinical pathology variety, ⁶ salary, ⁶ and perceptions regarding career opportunities. ⁴ Notably, some data suggest that early exposure may influence decision making favorably by allowing time to highlight positive factors of the specialty and dispel myths. ⁴

Since its recognition as a specialty by the American Board of Medical Specialties in 1979, emergency medicine (EM) has been among the more popular and, at times, competitive specialties. ⁸ For example, in 2015, EM was the fourth most commonly selected specialty, with a total of only four unfilled EM programs. ⁹ In 2022, 69 EM residency programs went unfilled, with 219 spots open for the supplemental match. ¹⁰ In 2023, 132 EM residency programs went unfilled, with 554 spots available for the supplemental match. ¹¹ Many experts have theorized reasons that may explain the recent increase in unfilled residency spots, though many knowledge gaps persist. ¹² , ¹³ , ¹⁴ What remains missing is the perspective of graduating medical students who underwent the process of choosing and applying to a specialty over the same period of time. To better understand recent changes in the EM residency match, this qualitative study explored, via one‐on‐one interviews, the perspectives of senior medical students who seriously considered EM but ultimately pursued another specialty.

METHODS

Study design

We conducted a qualitative study of senior U.S. medical students who self‐identified as having seriously considered EM and examined why they ultimately chose another specialty. Participant characteristics were collected via an online survey. Qualitative data were generated through a series of one‐on‐one semistructured interviews. The study was approved by the University of Washington Human Subjects Division Institutional Review Board.

Study setting and participants

We recruited senior medical students after the 2023 match (March 2023) from across the United States through a variety of mechanisms. First, we worked with administrators and the leadership of national organizations such as the Council of Residency Directors in Emergency Medicine and Clerkship Directors in Emergency Medicine to share and publicize study recruitment materials via email with their members. Second, we directly asked a convenience sample of EM clerkship directors who were personal contacts of authors to recruit study participants. Third, we were permitted by select moderators on Reddit (an online social news aggregation and discussion website) to post recruitment materials on subreddit communities for internal medicine, surgery, pediatrics, and radiology health care professionals. We were unable to postrecruitment materials on anesthesiology, family medicine, and psychiatry subreddit communities due to moderator rules. Finally, we asked participants via snowball sampling to recruit additional students who met study inclusion criteria (current medical students graduating in 2023 or 2024 and self‐identified “serious” consideration of EM as a career during their undergraduate medical education). Interviews occurred in May and June 2023. We provided a $25 Amazon gift card to each participant after study completion. Prior to data acquisition, it was determined that the necessary number of interviews would be contingent on when thematic saturation was achieved.

Data collection and processing

Prior to the interview, participants completed a survey that asked about their demographic information, medical school characteristics, and their chosen specialty (Appendix S1). Survey data were collected through Research Electronic Data Capture tools hosted at the University of Washington. ¹⁵

Qualitative data were generated through a series of one‐on‐one, semistructured interviews conducted using online video conferencing software (Zoom Video Communications). Each interview was conducted or observed by the same two investigators (ARA, DWL) with use of the same interview guide (Appendix S2). All interviews were video‐recorded, with separate audio recording used as backup. Both interviewers are active EM faculty who regularly supervise and teach residents and students, though neither were in formal roles of education leadership (i.e., program director, assistant or associate program director, or clerkship director) and no participants were students from the same institution as the interviewers. To promote psychological safety and encourage frank discussions, we informed participants that all conversations were confidential. In addition, we made it clear to participants that they were free to decline answering any question during the interview. Finally, we emphasized that only deidentified study findings would be presented. Interviews were transcribed by Zoom software, and authenticity of the data was confirmed by an investigator (HE) who listened to recordings while reading and editing transcripts for accuracy.

The interview guide and semistructured questions were developed by the investigators through a modified nominal group technique ¹⁶ using information from published research findings, ⁵ , ¹⁷ , ¹⁸ informed by expert opinion (ARA, SAB, BGK, DWL), undergraduate and graduate medical educators (JH, CSG), and the professional experiences of the study team, which included an actively enrolled medical student (SAB). No additional pilot testing was performed and no iterative changes were made to the questions throughout the study.

Analytic methods

We used descriptive statistics to report study sample characteristics. We used Delve, a cloud‐based qualitative data analysis software application (Twenty To Nine, LLC), and a constant comparative approach to conduct thematic analysis of the data. ¹⁹ , ²⁰ Data analysis was performed by the two interviewers (ARA, DWL) and a third investigator (HE) who was a trainee in EM residency. Two investigators (ARA, HE) each independently and asynchronously coded eight of the 16 transcripts. A different author (DWL) reviewed all codes from all 16 transcripts. The team (ARA, HE, DWL) then met and synchronously reviewed the initial codes to identify preliminary categories and themes. This process was iterative, with repeated reading, review of transcripts, discussion, and refinement. The same two authors (ARA, HE) then conducted a second round of independent and asynchronous coding of each of their same initial eight transcripts. A different author (DWL) again reviewed all codes from all 16 transcripts to ensure consistency and agreement. The team (ARA, HE, DWL) then met to synchronously review the codes, make conceptual clarifications, resolve discrepancies, and revise codes. The resultant final coding scheme was discussed and agreed upon by the study team (ARA, HE, DWL), which met in‐person once more to synchronously review and interpret study findings.

We employed several strategies to ensure methodologic rigor and trustworthiness. ²¹ , ²² , ²³ These included confirming data authenticity through comparison of transcripts and video recordings; identifying negative cases in the data; linking central themes across participants to form conclusions; asking clarifying questions during interviews to ensure understanding; frequent research team meetings and discussions; maintenance of a master list of codes, themes, and meanings; and member checking to confirm interpretations resonated with participants’ experiences. We also acknowledged our own assumptions and biases as health care professionals who chose a career in EM.

RESULTS

Eighteen medical students responded to study recruitment efforts, two of whom later failed to follow up to study correspondence. Ultimately, 16 senior medical students from 12 different institutions across the country participated in our study. Participant characteristics are summarized in Table 1. We reached thematic saturation after 12 interviews but included data from all 16 interviews for analyses. We initially identified 23 themes and 93 subthemes. Key summative themes that emerged from qualitative data analyses are described below. A review of exemplary quotes by major themes and subthemes is presented in Table 2.

TABLE 1.

Participant demographics.

Characteristics	n (%)
Age (years), mean (95% CI)	27.9 (26.3–29.6, 95% CI)
Sex
Male	10 (62.5)
Female	6 (37.5)
Race/ethnicity
Asian	7 (43.8)
White (non‐Hispanic)	7 (43.8)
Multiracial	2 (12.5)
Relationship status
Married	5 (31.2)
In a relationship	7 (43.8)
Single	4 (25)
Children/dependents
Yes	1 (6.3)
No	15 (93.7)
Medical school degree
MD	15 (93.7)
DO	1 (6.3)
Medical school region
New England	1 (6.3)
Middle Atlantic	4 (25)
South Atlantic	4 (25)
East North Central	2 (12.5)
East South Central	1 (6.3)
West South Central	3 (18.7)
Pacific	1 (6.3)
Affiliated EM residency at medical school
Yes	14 (87.5)
No	2 (12.5)
Graduating year
2023	15 (93.7)
2024	1 (6.3)
Chosen specialty
Internal medicine	6 (37.5)
Family medicine	5 (31.2)
Neurology	2 (12.5)
Anesthesiology	1 (6.3)
Pathology	1 (6.3)
Radiology	1 (6.3)

Note: Data are reported as n (%) or mean (95% CI).

TABLE 2.

Exemplary quotations by themes and subthemes.

Themes	Quotes
1. Innate features of EM attracted or dissuaded students
1A. Personality fit with EM	“Out of all the places in the hospital, the ER fits my personality the best. I'm a big adrenaline kind of guy.”
1B. EM schedule pros and cons	“The hours can be strange and it can really throw off your routine, but at least there's a cap and you have your shift decided for you.”
1C. Perceived limits to EM practice flexibility	“As an ER doctor, I wouldn't really be able to do much clinically outside of work in an ER or urgent care.”
1D. Violence in the ED	“I saw a lot of violence [on my away rotation]. It's not that I'm scared of violence. I don't necessarily want to see or deal with it every day.”
2. Widespread awareness of workforce report
2A. Report deterred students from pursuing EM	“I would say that there would be a very strong chance I would have chosen EM [had it not been for the jobs report].”
2B. Responses to the workforce report	“I felt like I was asking pretty good questions [about the report], and I noticed that most people's initial responses were some sort of negativity … I just never saw much optimism or positivity.”
3. Burnout in EM
3A. Societal failure of vulnerable patients	“I felt like a lot of times I was just putting a bandaid on a lot of these people's conditions and not really solving the core thing.”
3B. Concerns about career longevity	“A student who matched in EM said, ‘Of course you're going to find me in an urgent care in 20 years, because I can't sustain this forever.’ It was off‐putting to know that even people who are excited about EM have that sort of mindset.”
4. EM's standing in the health care landscape	“I felt like EM physicians weren't necessarily getting the respect they deserve from other specialties.”
5. Early EM exposure enhanced career interest	“When I started medical school, I worked with a lot of EM physicians and I did some shadowing and really enjoyed it. That's what had [EM] initally at the top of my list.”

Theme 1: Innate features of EM attracted or dissuaded students

Subtheme 1A: Personality fit with the practice of EM

All participants highlighted the many positive aspects of EM that initially attracted them to the specialty. A common characteristic innate to EM that students identified was that the ED provided an intellectually stimulating environment due to its unpredictability, clinical variety, and exposure to undifferentiated patients.

I liked the diversity of the pathology you get to see and being that first contact for the patient. That is a thing I like about EM still.

The pace of EM was another draw for many students, though it was not a positive for all. Some participants mentioned that the pace of EM prevented them from developing aspects of clinical medicine that were important to them, such as building patient relationships. Although the snapshot encounters with ED patients were attractive to some students, others missed the continuity of care experienced in other specialties.

One of the things that initially drew me to EM was being able to have these very quick patient interactions. I was good at establishing relationships with patients early and quickly.

I didn't like [the pace]. I got to know my patients briefly when I was figuring out what was going on, but I couldn't really build relationships with them. It sort of bothered me that it was very efficiency‐based, like get them in or out as quickly as possible.

Many participants framed their attraction or aversion to these innate qualities of EM as a personality fit—or lack thereof—with the specialty and its providers.

I still to this day think the most fun people to work with are hands down in EM. So it kind of breaks my heart that I've chosen away from it.

I think [not choosing EM] was probably just a personality thing for me. I like having time to eat lunch, you know?

Subtheme 1B: Pros and cons of an EM schedule

Students stressed the importance that the nature of EM scheduling had on their decisions, especially with regard to shiftwork, work—life balance, and sleep. Many recognized the benefits of shiftwork, including its allowance for flexible scheduling, clear delineation of home versus work time, and the ability to set aside longer periods of time for personal life needs and interests.

As someone who wants to have a family at some point, and as a woman in medicine, [shiftwork and schedule flexibility in EM] were appealing to me.

In contrast, other students noted that although they expected shiftwork to be a positive aspect of EM, in reality, they found that the lack of a consistent schedule coupled with the necessity of working overnight shifts were damaging to their sleep and did not translate into tangible benefits.

I think despite the concept of all of that free time with shiftwork, there was a lot more time sunk into resting and recovery from the switching cycles than I'd realized.

Subtheme 1C: Perceived limits to EM practice flexibility

Despite citing the broad set of skills possessed by emergency physicians, some students were deterred from choosing EM because they worried it would limit them in terms of practice environment and scope. In contrast to other specialties that were perceived to have more options, students were concerned that an EM career meant they would only be able to work in an ED or urgent care setting in the future.

Other fields allow you to work in different settings, like being able to work in a clinic, in a hospital, or being able to, if you're a sub‐specialist in neurology, read EEGs in a non‐patient‐facing role. So I was attracted to the innate flexibility built into other fields that wasn't so standard in EM.

Subtheme 1D: Violence in the ED

A notable factor in some students’ decision‐making process was concern over mistreatment and abuse perpetrated by ED patients. Violence in the ED, particularly toward clinicians, was perceived as an innate and potentially unavoidable part of EM practice that students did not want to expose themselves to long term.

I just don't know how sustainable it was for me to deal with violence, racism, and all that, ten, twenty, thirty years from now.

Perhaps most importantly, several participants mentioned that the response to this violence, from both health care and the specialty, seemed insufficient. One student during his EM rotation expected a more substantial reaction to a patient's assault of a provider:

A nurse got bit by a patient, and I remember asking an attending, “What are we going to do about this?” And I feel like they said all the right things, and it just wasn't enough … The answers were correct, but none of them made it seem like anything was going to change.

Theme 2: Widespread awareness of the workforce report

Subtheme 2A: Workforce report findings deterred students from pursuing EM

Many participants indicated that the EM workforce report, which refers to a 2021 publication about the EM workforce that projected a “moderate surplus” of EM physicians by 2030, ²⁴ was a significant contributor in their decision to not choose EM. Even among those students who reported that their decision to pursue another specialty was not influenced by the workforce report, many noted that they were aware of peers who were deterred from applying to EM as a result of the publication's findings.

The catalyst to me really second guessing everything was the workforce report in 2021. It got me thinking, what else is there, if this specialty is doomed to collapse?

Participants specifically raised concerns about residency program oversaturation, the encroachment of advanced practice providers, and their future ability to find a job.

What I took away from [the workforce report] was the overabundance of EM graduates as a result of things like [for‐profit corporations] capitalizing on the ability to create EM residencies and pump out as many residents as they could for cheap labor

I get that in EM, it's probably a big threat, encroachment by NPs and PAs, especially with hospitals trying to cut costs and medicine becoming more of a business.

There were a lot of people who wrote long things [on the internet] saying, “If you're a medical student considering EM, really consider all your other options because things are looking bleak.”

The workforce report also prompted some participants to consider the impact of private equity investment and corporatization trends in EM. Although students recognized that these changes were seen throughout medicine, many felt it was a bigger factor in EM than in other specialties.

A lot of private equity groups seem to be buying up EDs and urgent cares, and then making them very much about the bottom line. That annoys me, to understate it. I think it's more severe in EM than a lot of specialties.

Subtheme 2B: EM and other specialties’ responses to the workforce report

Many students felt that their concerns regarding findings from the workforce report were not sufficiently addressed by faculty in their institutions. Several participants described reaching out to EM faculty to ask their opinions about the report and felt that their responses were pessimistic or insufficient to ease their fears.

It felt like they were kind of beating around the bush and just saying the data isn't great, this was a flawed report, or finding something to put the blame on to declare it as false.

In contrast, students noted that providers from other specialties were aware of and spoke to the report, referencing it as a significant negative in choosing a career in EM.

Whenever I mentioned I was interested in EM, they were like, “Well, there may be too many [EM physicians].” A lot of them did use [the workforce report] as a reason why I shouldn't do EM, and then would follow it with, “We need a lot more of X or Y” or whatever their specialty is.

It was clear from our interviews that a significant amount of students’ exposure to analysis of the workforce report was from social media. Participants often discussed reading views and opinions from EM physicians and residents about the report on Twitter (now X), Reddit, and Student Doctor Network, although nearly all expressed that they read these posts with a degree of skepticism.

I saw a lot on Med Twitter and Reddit. There's definitely selection bias on those platforms. People will go there to complain about their job search. I tried to take it with a grain of salt, but a lot of people were saying if I could go back now, I would have chosen a different specialty.

Theme 3: Burnout in EM

Subtheme 3A: Societal failure of vulnerable patients

Participants discussed burnout in relation to their career choice at length. Although an in‐depth exploration of what contributes to EM clinician burnout was not the focus of this study, students most commonly noted that many patients needed help and outpatient resources that could not be realistically provided in the ED. Students described that this failure on the part of society, government, and the health care system led to frequent and repetitive ED visits by patients whose long‐term needs remain fundamentally unaddressed.

The social work aspect [of EM] was a negative for me. I think it's important, and it needs to be done. But I think that would really wear on me by not being able to connect patients with the resources that they need.

Even more notably, the inability to provide definitive solutions for individual patients appears to have been a negative for choosing EM as a specialty:

As an EM doc, you kind of have to deal with every way in which society fails people, especially the most marginalized, vulnerable people. And you can't do anything about it. Not truly. I mean you can bandage them, patch them up, send them back out, and they'll show up a few days later. Sometimes you can maybe help, but I think sometimes the failings of the system were so much more evident in EM [than in other specialties].

Subtheme 3B: Concerns about career longevity

Although a few students felt burnout ultimately had no impact on their decision (“I felt like I would have similar burnout with whatever specialty I went into”), most students’ concerns about burnout centered on its potential impact on their career longevity. Many participants remarked that the EM workforce often appeared fatigued. Others cited examples of EM physicians and residents describing ED clinical work as undesirable and how they were actively looking for “buy‐downs” or a way out of clinical medicine.

Burnout was huge. It was one of the biggest reasons why I switched to family medicine.

I could tell people were tired, and a lot of them were talking about their exit strategy, and I didn't want that to be me.

Theme 4: EM's standing in the health care landscape

Some participants cited the health care system's lack of respect or support for EM as a factor that deterred them from pursuing the specialty. Students heard these sentiments when they rotated on other services. They also experienced them during their EM clerkships when they received pushback from admitting and consulting services that questioned clinical decisions and workups in the ED.

When I would say I was interested [in EM] people would be surprised, and they would say, “Why would you want to do that?” And that kind of got me started thinking a little.

One thing that did intimidate me about EM was having to go up against the questioning of your clinical calls and pushback from everyone else in the hospital.

This perceived lack of respect from other specialties also extended to hospital administration, and it was most pronounced during the peak of the COVID‐19 pandemic.

EM was taking the brunt of patient care during COVID and I saw our administration not being super supportive of the people in EM who were on the very, very front lines of all that.

Theme 5: Early EM experience and exposure enhanced interest in EM as a career

Outside of issues inherent to the practice of EM, students noted that their early exposure to EM—both prior to and during medical school—spurred their initial interest in EM. Many participants reported their gateway experience with EM as ED scribes, EMS personnel, or research assistants. Others cited structural components (e.g., shadowing, simulation and procedure labs, EM interest groups, early and required EM clerkships) built into their medical school curriculum as catalysts for their EM interest. Many of these experiences were meaningful and impactful for students primarily because of the interactions they had with EM physicians and faculty, who were viewed as role models and mentors.

In medical school, what you choose is so much a product of your rotation experience, how nice or engaging your attending was.

I think [one thing] my school could have done better was to have a mandatory EM elective, especially because we have an incredible ED.

Less impactful career decision factors

In our interviews, participants generally did not find other factors (i.e., salary expectations, educational debt, family expectations, the COVID‐19 pandemic, fellowship options, and EM workforce diversity) to be important to their decision‐making process.

DISCUSSION

In this qualitative study of senior medical students who seriously considered EM but ultimately chose another specialty, we gained insights into important components of students’ decision‐making process on whether to choose EM as a specialty. First, we found that intrinsic characteristics of the practice and lifestyle of EM remain important to applicants. Some of these were positive and others were ultimately viewed as detractors. Features innate to the practice of EM, such as clinical variety, pace, procedures, and shiftwork, were what initially drew some students to the specialty. EM has traditionally been viewed as one of the specialties with a “controllable lifestyle” relative to other specialties. ³ , ⁵ , ⁷ , ¹⁸ Our study confirmed that students’ choice of specialty was influenced by their perceived fit with the specialty ²⁵ or, in this case, lack thereof with EM. Some participants cited that one deterrent to choosing EM was the perceived limits to EM practice flexibility in terms of setting and scope. Our analysis indicated that fellowship opportunities and expansions in EM scope and practice were not at the forefront of these students’ minds when considering the specialty. The continued development of and student education on current and future non–ED‐based EM‐related work opportunities—including available subspecialties and other acute on‐demand care innovations—may address this concern among some students. Notably, another deterrent to EM for some students was the violence experienced by ED providers. While workplace violence in the ED has been well described, ²⁶ its impact on medical students and their specialty choice may be a novel finding. Given the frequency of health care–associated violence, further research to explore the impact of violence on learners is necessary.

Second, the report on the EM workforce in 2021 ²⁴ seemed to have a significant impact on students who were considering but ultimately decided against a career in EM. There has been much debate and discussion about the impact and likely predictive accuracy of the study's findings since its publication. Although most participants noted that they were aware of some of the limitations of the study and that they read the report with a “grain of salt,” it still had a negative impact on the decisions of many participants to not pursue EM. Interestingly, participants in our study indicated that they looked to the EM community for guidance regarding the workforce report but felt that the response was insufficient to quell their workforce fears. Perhaps due to the limited response to the workforce report from EM faculty and mentors at their institutions, many participants turned to Reddit, Student Doctor Network, X (formerly Twitter), and other social media platforms for analysis of the report. In addition, participants frequently noted that faculty and residents in non‐EM specialties, as well as non–EM‐bound students, knew of and discussed the report, and this seemed to have a significant impact on some participants’ career decisions. The 2021 workforce report was a modeling exercise based on multiple assumptions and acknowledged significant uncertainty. Subsequent studies have, and future work should, update our understanding of workforce trends that are dynamic and dependent on a multitude of variables. National EM organizations and academic emergency departments may also want to ensure appropriate messaging and responses to this report as well as similar reports that may come out in the future.

Third, our participants highlighted concerns regarding burnout in EM and its impact on career longevity. Notably for some students, the inability to adequately address the many problems embedded in the U.S. health care system and society at large were viewed as a major contributing factor to burnout in EM. This frustration shares commonalities with what is termed moral injury, which can occur when individuals perpetrate, bear witness to, or fail to prevent events that transgress deeply held moral beliefs. ²⁷ These experiences contributing to moral injury and burnout are not unique to EM, however. The practice of medicine in the United States is increasingly subject to business pressures, and student‐cited concerns about the constant push for efficient throughput, the corporatization of physician groups, and midlevel encroachment are also seen in other specialties. ²⁸ We did not explore whether our participants were aware that their chosen specialties may be subject to similar pressures, if they felt these specialties were more immune to them, or if the positives of their chosen specialties simply outweighed these negatives. Nonetheless there remains a need for systems‐wide efforts to address these and other contributors of clinician burnout, particularly as they relate to emergency physicians, who report some of the highest levels of burnout of any specialty. ²⁹ Opportunities and mechanisms for mentorship and discussion of these issues between students and their faculty advisors during or beyond their EM clerkships are also essential.

Fourth, many participants noted that the health care system's negative perception of EM played a role in their specialty choice. Some noted that providers in other medical specialties openly voiced a lack of respect for EM clinicians or demonstrated a lack of understanding of what it means to work in the ED. Of note, many participants observed these sentiments during the height of the COVID‐19 pandemic, when frontline EM providers struggled to get the appropriate level of institutional support (e.g., personal protective equipment, staffing) they needed. This observation regarding EM not being respected is not new. EM is one of the youngest medical specialties in the house of medicine. While EM has come a long way in establishing its unique role and expertise since 1979, efforts to continue building relationships with other specialties will need to continue. ³⁰ , ³¹

Finally, participants identified many structural and curricular factors in their medical education that sparked their initial interest in EM. These include early exposure to the specialty via EM interest groups, shadowing opportunities, research, and mentorship. Additionally, educational experiences with EM faculty through simulation sessions, procedure labs, and doctoring groups during preclinical years played a large role in stimulating student interest in EM. This is consistent with prior work that showed early exposure to EM was associated with earlier selection of EM. ⁶ , ¹⁷ , ³² Encouragement and incentives for EM faculty to participate in these undergraduate medical education programs may spur further student interest in EM. In addition, a concerted multiorganizational and multiyear effort that identifies and engages EM‐interested students and that maximizes and capitalizes on their early exposure to EM may be helpful in future recruitment efforts. The requirement status and timing of EM clerkships were also cited as factors in students’ choice of specialty. This is in keeping with research showing that the presence of a required EM rotation increased the proportion of students applying in EM. ¹⁷ , ³² Lastly, we found that EM faculty and resident engagement with students during their EM clerkship was paramount in fostering interest in the specialty. Like prior work, ⁶ , ³³ students’ experience of their EM clerkships was often described as very influential in their career decisions. While students should see an authentic experience (warts and all) of EM during their time in the ED, it is important for EM faculty and residents alike to be mindful of what we say and how we act in front of impressionable students.

LIMITATIONS

This study had several limitations. First, our 16 participants came from a convenience sample of medical students from across the country and, when compared to national data, ³⁴ they were predominantly male, White, or Asian and from allopathic medical schools. There was also the risk of selection bias, as our participants may have been disproportionately drawn from groups that felt compelled to discuss their reasons for not choosing EM. Furthermore, some of our students were recruited via social media and, as such, they may have been more likely to base their career choices on information circulating prominently on social media platforms. Second, recruited students self‐identified as being “seriously interested” in EM at some point in their medical school education. While we found that sentiment to be true throughout all our one‐on‐one interviews, we could not verify this interest in another objective way. Finally, while the interviewers stressed study confidentiality and participants’ ability to decline to answer any question, students may not have been fully candid in their interviews since the interviewers were EM faculty.

CONCLUSIONS

In this qualitative study we identified five major themes in the career decisions of senior medical students who seriously considered emergency medicine but chose another specialty. Innate features of emergency medicine, awareness of the workforce report, burnout, emergency medicine's standing in the healthcare landscape, and early emergency medicine experience and exposure played significant roles in students’ ultimate choice of specialty. These findings may help guide future efforts to recruit students to pursue emergency medicine as a career.

CONFLICT OF INTEREST STATEMENT

The authors declare no conflicts of interest.

Supporting information

Appendix S1

Appendix S2

Akhavan AR, Kontrick AV, Egan H, et al. “Cold feet”: A qualitative study of medical students who seriously considered emergency medicine but chose another specialty. AEM Educ Train. 2024;8:e10967. doi: 10.1002/aet2.10967