Unfilled residency spots and the future of emergency medicine [PODCAST]

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Join us for an enlightening podcast episode as we delve into the challenges facing emergency medicine residency programs and applicants. With 555 unfilled first-year residency spots in the Match, we explore the factors that have contributed to this situation. Our guest, Katrina Gipson, an experienced emergency medicine physician, sheds light on the issues of boarding in emergency departments, the impact of student loan debt on specialty choice, and the effects of the COVID-19 pandemic on health care professionals. We discuss the need for improvements in health care outcomes, compensation, and support for EM physicians. Tune in to gain valuable perspectives into the field of emergency medicine and the changes needed to address the workforce and patient population’s needs.

Katrina Gipson is an emergency medicine physician.

She shares her story and discusses her KevinMD article, “The struggle to fill emergency medicine residency spots: Exploring the factors behind the unfilled match.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast and get CME for this episode by clicking on the CME link in the show notes. Today we welcome back Katrina Gipson. She’s an emergency physician. Her KevinMD article is titled “The struggle to fill emergency medicine residency spots: Exploring the factors behind the unfilled match.” Katrina, welcome back to the show.

Katrina Gipson: Thank you once again for having me. I’m sorry that it’s under these conditions, that this article needed to be written in the first place.

Kevin Pho: So we’ll talk about that article in a little bit, but for those who didn’t listen to our first episode together, just briefly share your story and journey to where you are today.

Katrina Gipson: Sure. I am currently an assistant professor of emergency medicine at Emory in Atlanta, Georgia. I practice clinically at Grady, which, for those of you who do not know, is the fourth-busiest emergency department in the entire country. I came here from Washington, D.C., where I completed a health policy fellowship at George Washington University, but I was born and raised in Ann Arbor, Michigan, so the Midwest is still and will always be home.

I’ve been all over the country for my education and training, like a lot of people in our field. I went to Yale for undergrad, studied biomedical engineering, and did some work at the University of Pennsylvania before ending up back in the Midwest, in Cleveland, Ohio, for medical school, which was at Case Western Reserve University. I had the pleasure of staying there for my emergency medicine training before heading to D.C., and I have now been in Atlanta for almost five years. It’s been a whirlwind of a journey.

I think my true north throughout this entire training process has been health equity. I truly believe that it is a form of social justice; social justice is health equity, and the reverse is true as well. My research focuses on vulnerable populations, whether that be elderly patients versus the under- or uninsured, or racial or religious minorities, and how they access and utilize the emergency department. Using that as my focus has really allowed me to define and adjust the lens through which I practice medicine and how I choose other topics of interest as well.

Kevin Pho: The news that led you to write this article, of course, was the unfilled emergency medicine slots in the most recent match. You talk about some of those reasons in your KevinMD article, “The struggle to fill emergency medicine residency spots: Exploring the factors behind the unfilled match.” Now, before you talk about the article, give us some context. Talk about those most recent match results.

Katrina Gipson: Sure. I’m sure that most of your listeners are familiar with the match process. After four years of college and four years of medical school, the journey to become a physician is still not done. You need to match into a specialty of your choosing. Historically, emergency medicine has been extremely competitive, and it wasn’t until 2022 that the specialty started to see a decline in unmatched positions. For instance, in 2022, 219 unmatched positions was considered unprecedented. This was the first major decrease in quite some time.

However, recently the Annals of Emergency Medicine predicted a surplus of emergency docs in 2030. Residents, medical students, and even other, already seasoned physicians and attendings were paying attention. A lot of students are not going to want to pursue a specialty in which they feel like they cannot get a job. In 2023, there were about 3,282 medical students, which is actually down from 4,391 medical students, who were applying for just over 3,000 positions in emergency medicine. So of course, there’s always a surplus of students for a certain number of spots. However, this is the largest number of unmatched positions that we’ve seen. We thought that 219 was surprising in 2022. Just recently, in March of this year, we more than doubled that number of unmatched positions in the field of emergency medicine.

So of course, those of us in academia or in the community are all scrambling to figure out why this may be, and of course, some of the explanations are more tangible, objective, and obvious than others.

First, let’s talk about boarding, this practice of admitted hospital patients physically staying in the emergency department. We ask ourselves, “Well, what does that really mean?” From an emergency medicine standpoint, as far as physicians and staffing go, it leads to worse outcomes for our patients. For instance, if you have sick patients who require ICU, step-down, or telemetry settings, trying to take care of those patients in a busy hallway is difficult. It’s difficult for our nurses, physicians, and support staff, and it can be dangerous for patients.

Our nurses are overwhelmed. We’ve heard about how there’s been a nursing shortage; nurses are burned out. It’s easier to make mistakes when you are taking care of more patients, particularly when those patients have more complex medical needs than what the emergency department can often offer them. That is further exacerbated by wait times of anywhere from six to seven hours, or sometimes upwards of two to three days, for admitted patients in the emergency department. So of course, boarding has made it difficult for people to practice emergency medicine, and medical students are paying attention. I think that this is one of the contributing factors, one of the most monumental, that led so many positions to remain unfilled.

Another thing is compensation. Of course, none of us are going into emergency medicine, or medicine for that matter, to get rich. OK, sure, we have to live; we have bills to pay. But there’s a certain amount of altruism that goes into pursuing a career in emergency medicine. One of the things that I think people are paying more attention to now is loan forgiveness, particularly as the Biden administration is discussing it. Public Service Loan Forgiveness has always been questionable. The National Health Service Corps provides debt forgiveness for primary care specialties. So what is primary care? That’s internal medicine, OB/GYN, family medicine, and pediatrics. However, as an emergency medicine physician, anywhere from 13 to 27 percent of my ED visits are appropriate for primary care settings.

So what does that mean? I know a lot of us watch television, one of our favorite shows, ER, and we think that you’re always running traumatic arrests or putting in chest tubes and intubating. And of course, that is a lot of what we do, particularly if you’re in a level one, two, or three trauma center. But a lot of what we do also includes refilling somebody’s antihypertensives, because not only did they run out of medication, but perhaps they have a primary care doctor, yet do they really have access to a primary care physician if it takes three, four, five, or even six months in some cases to actually access those physicians? So a lot of our patients come to us not because they are having a life- or limb-threatening medical condition, but simply because they need their medication refills and they don’t have any other options. And it’s our duty to take care of those patients and to offer them those preventive services so that they don’t have a medical emergency down the line.

So where am I going with this? If a third of the care that emergency medicine physicians are providing is considered appropriate for a primary care visit, then we should also be eligible for these loan forgiveness opportunities for primary care providers.

Another thing is, what about hazard pay? Working in the emergency department, even outside of a pandemic, is dangerous. However, let us not forget that at the beginning of the pandemic, a lot of our hospitals didn’t even have basic personal protective equipment. I’m talking about being told how to reuse our N95 masks. Sometimes we didn’t have gowns; we didn’t have adequate gloves. And this was in a setting before we even had a COVID vaccine or other antibodies to treat this relatively new, novel disease that was life-threatening for a lot of people.

And of course, certain populations, Black and brown people, or those of lower socioeconomic status, were disproportionately affected by COVID for a myriad of reasons. They weren’t able to work from home, they didn’t have access to health care, or they were underinsured or uninsured, and this all put a burden on the health care system as well. I know it’s 2023 now, and we’re not looking at COVID-19 as the same pandemic emergency that it was in the last couple of years. However, we’re still seeing the effects and fallout of this disease. Over 1.1 million Americans lost their lives, and this isn’t even including the worldwide loss of lives, as well as productivity, and this affected how we practice medicine.

As far as medical students, this also took a toll on their clinical opportunities. There was a time period when medical students were pulled from their rotations; they weren’t allowed to practice in the emergency department during the height of COVID due to safety reasons, and I think that that’s completely appropriate. However, it also decreased their exposure to the specialty. And once we started to integrate these medical students back into our specialty, trust and believe, they were paying attention. They looked around, and they saw us at our emergency departments at 130 to 150 percent capacity. They saw sick patients being taken care of in the hallway, they saw us reusing our masks, and they saw the burnout that comes from working in such a high-stress environment.

Learners now are thinking that just as important as their compensation is their quality of life. With burnout being such an issue for physicians in general, emergency medicine physicians reported some of the highest levels of burnout. These are all contributing factors, things that we’re talking about, things that medical students see, and things that residents are seeing, and it’s really changing not only where they want to practice but what they want to practice.

Kevin Pho: Now, you have some unique insight from the academic perspective of emergency medicine. When you first read about these statistics about unfilled slots, what was the first thing that went through your mind? Were you surprised? Did you see it coming?

Katrina Gipson: You know, I think nothing really surprises me anymore, which is concerning, but I did see this coming. From a personal standpoint, these last several years professionally have been extremely difficult, and I think that these circumstances are giving us the opportunity to really acknowledge not only our professional difficulties but our personal difficulties. When I say we, I mean not only the specialty of emergency medicine but medicine in general: We’re starting to chime in to talk about burnout, fatigue, and wellness. These are things that we were taught we were just supposed to suffer in silence about, keep your head down, and keep it pushing, or else you were weak, you weren’t a good doctor, or maybe this wasn’t the specialty or field for you.

Now that I’m seeing the ways that all of us are affected, both personally and professionally, it only makes sense that people don’t want to work in environments where they feel like there isn’t the infrastructure for them to be not only excellent physicians but whole and well people as well, because you can’t have one without the other. Of course, certain shifts are going to be more stressful than others, but it would be helpful knowing that if you come into the emergency department and you are going to have to take care of a number of sick people, you have adequate nursing staff who have the resources and the morale to take care of those patients. You want to know that you have the equipment in place to be safe and protect yourself, so that when you go home to your family or friends, you’re not a risk for them as well, bringing home whatever communicable diseases you may have.

You’d also like to think that after all these years of education, you’re going to be able to pay off your loans, which in many cases are six figures plus. Medical students are graduating with hundreds and hundreds of thousands of dollars of debt, and as we’ve discussed before, certain populations, namely Black and brown students, often shoulder a disproportionate amount of that debt due to social drivers of health. So these are all things that people are taking into consideration when they choose a specialty. Compensation, wellness, happiness, and family and work-life balance are things that we’re starting to talk about, and we shouldn’t be surprised when medical students are starting to listen and choose their specialty accordingly.

Kevin Pho: So talking among the physician community, I know the ramifications of this, but from a patient perspective, why are these unfilled slots important to patients?

Katrina Gipson: Sure. If you’re in the emergency department, the vast majority of the time you’re not having the best day of your life. It can be a disorienting place for our patients, it can be a scary place for our patients, and unfortunately, depending upon the circumstances, it can be a dangerous place. But for patients, the concern is, “Am I going to be taken care of to the best of the system’s ability?” So what does that mean? Is the nurse who’s taking care of me going to have four patients, or are they going to have six to seven patients, one of whom might be on a drip that needs to be titrated to maintain their blood pressure?

So patients are waiting longer, maybe for medication, and maybe they’re not having face time with their nurses and physicians, not because we don’t care or aren’t dedicated to their needs, but because there are limitations on one’s physical bandwidth as well as our mental bandwidth. That just puts stressors on individuals, which then of course create stressors on the infrastructure that already exists. So patients are waiting longer to be seen. Sometimes they’re being denied care, and they’re leaving the emergency department due to long wait times, when that chest pain that they’re thinking could maybe have just been indigestion could actually have been some sort of heart attack or coronary syndrome.

And when people are tired and burnt out, that also affects our empathy, our sympathy, and how we interact with patients, and this can have different ramifications for certain populations. Everything I talk about is always going to go back to the social drivers of health. When people are tired and under stress, maybe they’re going to be less cognizant of their implicit biases when they interact with a patient who doesn’t look like them. That can really set the tone not only for that emergency department visit but for how that patient or their family views a system that may already not take the best care of patients who look like them, whether it be because of their race, ethnicity, able-bodiedness, or gender identification.

Kevin Pho: So what’s being done among the emergency physician professional societies to turn this around?

Katrina Gipson: Yes, so, excellent question. It’s easy to get caught up in talking about the problems and feeling overwhelmed by them, because a lot of them are systemic, as opposed to just individual or local institutional types of problems. So what does this mean for us as academic programs? I think one of the things that’s important is reassuring our residents that they can find work after they’ve invested all of this time and effort into gaining this expertise and training.

So some of the things that we’re doing are really investing in their wellness and their education, so they know what to do when they do feel burned out or overwhelmed and they’re not feeling that they have to vacate the specialty; and being more proactive in the recruitment process, not only in the medical student-to-residency pipeline, but also making sure that we have established working relationships with other institutions, so that after they graduate, they will find work.

I think it’s important that we as medical experts use our voices on the Hill. Policy for me is not only capital P but little p as well. When I say that, I mean what types of institutional policies, as well as regional and national policies, are in place that take into consideration what’s best not only for our patients but also for our nurses, our APPs, and physicians as well to practice medicine. So empowering patients is just as important as empowering physicians, and that means using our academic societies as a voice to make sure that we have the resources that we need, that our patients are not only insured but appropriately insured, and that there’s mental health parity for our patients. I think all of these types of preventive measures and resources can really change how our patients are using the emergency department.

I mean, people are always going to be sick; people are always going to have accidents. But when upwards of 30 percent of medical problems and care can be taken care of and addressed in an outpatient setting, and they’re ending up in the emergency department, we need to take a few steps back and figure out why. We always know that an ounce of prevention definitely exceeds treatment. So I think making sure that our patients have resources in the form of insurance, access to healthy foods, access to safe areas to exercise, all of the factors that exacerbate chronic disease and cause our patients to end up in the emergency department, particularly for those who are underinsured and uninsured, would really decrease the load for emergency medicine physicians and departments, so that we can truly focus on acute exacerbations of chronic illness or true medical emergencies or urgencies.

That just puts a lot of relief on the system. It keeps our patients healthier longer. Both a focus on prevention in the policies and making sure that patients have access to maintenance of care are, I think, extremely effective in addressing the number of patients that we see in the emergency department, and why.

Kevin Pho: I want to ask you about the impact of private equity. As you know, the trend is that a lot of these private equity groups are purchasing emergency department groups, and when that happens, cost cutting becomes paramount. Does that play a role in the appeal of the field going forward?

Katrina Gipson: I think it certainly does. As long as profit is valued over outcomes, we’ll continue to see certain trends, particularly in boarding, as opposed to, for instance, maybe hiring more nurses and support staff, or giving them raises, or paying them appropriately for the work that they do. If that’s not happening, then you’re going to see fewer physicians, and fewer nurses and support staff, available to take care of more and more patients.

For instance, here in Atlanta, one of the more devastating things that could have occurred to us in the last several years is the closing of Atlanta Medical Center, one of the other trauma hospitals in the area, and we’re seeing the effects of that. Our volumes, particularly our trauma volumes, have increased, and there needs to be some sort of accountability.

Of course, our health care system differs in that it is run as a business, and as a for-profit business, which doesn’t make sense. It makes it difficult or almost impossible to prioritize health outcomes and/or equity in a business model, because a lot of those same capitalistic views or goals that we may apply to other fields don’t translate when it comes to the preservation of human health and human life. Now, to a certain extent, those models look very different when you’re talking about academia versus a community setting and a teaching hospital, but nonetheless, all institutions have a bottom line, and when that bottom line is profit, health equity and health care can and will suffer.

Kevin Pho: And my final question, Katrina. Tell us some of your take-home messages that you want to leave with the KevinMD audience.

Katrina Gipson: Sure. I think that these incidences are reminders that we need to be a voice for our patients, as well as for our specialty and for the field of medicine. All of these issues are multifactorial; they’re multipronged. They’re things that need to be done at the institutional level and the federal level. But a lot of the people, the legislators and the politicians who are making these types of decisions, most of them have never stepped inside of a hospital or been there under the guise of a patient, and they’re just not familiar with or aware of the types of issues that come with adequate patient care. So the only people who can speak for us are us.

I realize that not everybody’s interested in health policy, and some of us want to just go to work, do the best that we can for our patients, and go home, and there’s nothing wrong with that. But I think it’s important that we acknowledge what that means. You need to be cognizant of who’s running your hospital, who your state and local lawmakers are, and who is setting the policies for how we practice medicine, how we’re compensated, and what our match processes look like, because all of these are contributing factors to how we’re able to practice as physicians, whether we’re able to maintain our wellness in doing so, and whether we’re able to deliver the utmost equitable health care to our patients.

Kevin Pho: Katrina, thanks again for coming back on the show and sharing your time and insight.

Katrina Gipson: Thank you so much for having me.

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