You might think that emergency medicine (EM) residents would be in high demand due to COVID-19’s strain on the medical system. It seems logical, but in fact, the opposite is true. Many EM residents are no longer getting offers from multiple employers—in fact, they’re not getting offers from any. And this isn’t an overnight phenomenon, totally due to COVID-19, say healthcare experts.
The observations aren’t just anecdotal. An October 2020 survey from the American College of Emergency Physicians (ACEP) found that for the period March–June 2020, among emergency medicine group practices:
Here’s a nugget of good news, also from ACEP. It’s about those proposed Medicare cuts to reimbursement and now instead of a 6 percent reduction on January 1, 2021, emergency physicians may see at worst a 2 percent reduction, and might even see an overall positive increase.
"We’re the only country in the world that thinks healthcare should be a profit-making business, when it is a human right," says AAEM President Lisa Moreno, MD. She is professor of emergency medicine and director of both research and diversity for emergency medicine at Louisiana State University Health Sciences Center in New Orleans.
"During COVID, hospitals had to close for nonessential visits, all elective surgeries were canceled, and income went lower," she says. "Even more doctors were cut during hiring freezes—which came on heavy in June."
"We have seen the number of open EM jobs drop by more than 70 percent since 2018," says Mike Atkinson, vice president of CompHealth. "Healthcare staffing is always shifting so we would expect to see the emergency medicine jobs come back at some point in the future. Right now it’s difficult to guess when."
Emergency Medicine Residents’ Association (EMRA) President R.J. Sontag, MD, who did his residency at the University of Texas Health Science Center at San Antonio and now practices in Ohio, fondly remembers last year when he finished in June 2020 after applying for jobs the previous fall. He and his counterparts had enticing offers, but the next class has not been so lucky, he says.
"The pandemic is directly responsible, but there are also larger political and market forces at play here," Sontag says. Still, he says that some spring 2020 residents had already signed employment contracts but employers enacted a termination clause—definitely an enthusiastic resident’s worst nightmare.
"Employers, you need to support graduating residents, and yes, you have a legal right [to do what you did], but it’s not something you should do," he says. "In emergency medicine, we take care of people who have nowhere else to go and we’ve devoted eight years of our lives to education with three years as residents, and have spent $200,000 to $300,000 on that education. We also believe in the social justice of what we do."
"There is lots of self-sacrifice," says Fiona Gallahue, MD, associate professor in the department of emergency medicine at the University of Washington. She’s also program director of the emergency medicine residency program.
For many residents, anxiety is an issue, because they treat COVID patients and, like other healthcare professionals, are justifiably afraid they’re going to contract it and bring it home. Residents have also given up nights and birthdays, weekends, and holidays, and have spent many sleepless nights—in addition to all that money—in pursuit of their dream careers.
"Now they’re seeing some cracks in the system," Gallahue says.
"It’s a huge compromise for the residents, and it’s very unfortunate," says Haig Antablian, MD, a senior EM resident at UCLA Medical Center and president of the American Academy of Emergency Medicine (AAEM) Resident and Student Association (RSA).
"We trained for the worst as emergency physicians—for life and death—and a lot of us have even actually gotten used to COVID in some ways through all of this. Yes, we can do the medicine, but we still hope people will take care of themselves and do things like socially distance."
At Merritt Hawkins, Divisional Vice President of Recruiting Michael Belkin says, "Prior to the coronavirus, the job market for emergency medicine physicians was still robust, though not at previous peak levels. Market contraction is due to the pandemic having depressed emergency department visits and strained hospital budgets."
As to why EM residents are having problems, he says, "The number of physicians trained in emergency medicine has increased significantly over the last twenty years, while there have been a corresponding number of hospital closures."
"We are certainly seeing the job market as more challenging this year," adds Gallahue. "COVID has exposed problems in emergency medicine that have been developing for a number of years."
Many in emergency medicine point to these reasons for reductions in EM resident opportunities:
"What has happened with emergency departments has been contradictory, for you would think EDs would be busy, but people are specifically avoiding going in," says Atkinson.
"The census is definitely down in EDs," says Moreno. "Some groups cut the number of physician hours per week and some found other things for physicians to do," she says. "Our group is run independently, not corporately, and some of our physicians got shifts doing telemedicine or helped others who were displaced during the hurricanes or at clinics—everyone took a pay cut."
Public messaging was confusing, and added to patients’ hesitancy, she says. "People were being told to stay home [with COVID] until they couldn’t breathe. Then when we took care of them they were much sicker."
"Some have sat at home with facial droops [a stroke symptom] when we could have saved a life," Sontag says.
When volume decreases, a normal business might shorten hours, but thanks to The Emergency Medical Treatment and Labor Act (EMTALA) of 1986, and emergency medical care as a guaranteed right, EDs "keep the lights on with full staff, testing, and surgical abilities at the ready," Sontag says.
Other factors include that EM physicians are paid by volume, reimbursed when people show up—and then it’s hoped they have some kind of insurance. Costs to run an ED continue to increase, putting even more of a squeeze on the salary piece of a hospital’s budget.
Non-physician providers cost less than physicians and with 28 states granting nurse practitioners full practice authority, hospitals may find them more suitable during a budget crunch, Gallahue says, and this has been exacerbated by COVID.
"We see a really big chasm between what patients want—trained physicians caring for them—and what hospitals provide," she says.
"The last several years, there’s been a surge in residency programs that have applied and been approved to train residents," Moreno says.
"Nationally, we currently have 273 programs producing more than 2,200 graduates a year, and that changes the market," says Gallahue. "Corporate medicine-for-profit groups are subsidizing their own residency programs—which are getting accredited—and driving down salaries."
"There are projections of a huge supply of residents if we continue this way," says Antablian. "But if you went to a ‘good residents’ program,’ you will probably be OK and will probably find a job."
In addition to identifying how many training programs are really appropriate for emergency medicine—a physically demanding specialty—it’s also important to determine the attrition rate, Gallahue says. "How many residents do we really need to be producing to care for patients?" she says.
Hospitals in major metropolitan areas such as New York City or Los Angeles, where COVID surges are occurring, really do have clogged EDs, says Sontag. But depending upon where hotspots are, ED volumes can be very light, and that means fewer doctors are needed.
"In rural areas, there are still not enough EM physicians," Gallahue says. "And for residents, there is not a lot of support and it can be difficult to transfer patients. Some hospitals operate in an isolated fashion, with not a lot of networking. More EM physicians there are retiring and not being replaced. Let’s find ways at a national level to have more streamlined ways of doing some of those things, to make those rural jobs more attractive."
EM groups often have to buy personal protective equipment (PPE), and that takes away from the bottom line. "As many hospitals adjust to adding telehealth and finding ways to treat patient remotely, buying technology and training for it are expensive," Sontag says.
"To those who don’t have a job right now, advocate for yourselves," says Antablian.
"It’s important for residents coming out to understand current market dynamics and broaden their job search criteria," Belkin says. "They may need to be more open to opportunities in geographic areas they might not have previously considered, and perhaps adjust their financial expectations downward somewhat. They may wish to start their job search earlier and be open to virtual interviews. Competition for openings has increased, so the effort residents put into finding a job should increase accordingly."
Moreno says she, too, is telling residents to look in places traditionally less desirable, instead of choosing a place "that’s fun to live." "Even though you may not want to, look in rural areas that don’t have hiring freezes, or work in places like urgent care, even though you may not be using all your skills there. Try to consider going to that place you wouldn’t normally go."
"At the end of the day," Belkin says one factor is consistent. "Letting physicians go is something employers are reluctant to do. They know eventually they will need these physicians back and they definitely do not want to undermine relations with their physicians—it’s a difficult decision to make."
With so many shocks to EM residents’ systems recently, Moreno portends that adaptability will be a key to success for them now and in the future. "My friends who are virologists say this is going to be like influenza and mutate, requiring a new vaccine. It may be the start of many pandemics that we see during this century."