Working in the ER Used to Be a Cool Job. Now Medical Students Shun It.

The Washington Post / Fenit Nirappil

16:16 JST, March 19, 2023

Daryl Traylor dreamed of becoming an emergency room doctor ever since working as an ER technician in the mid-1990s helping physicians care for children who broke their arms or nearly drowned.

But now he’s a first-year medical student, and those same doctors are urging Traylor not to follow in their footsteps.

They warn of burnout after covid and patients’ increasing suspicion of doctors. The pay is not as good, they say, especially as hospitals rely more on nurse practitioners and physician assistants to staff emergency departments. And job prospects may be grim, they caution, as emergency medicine residency programs aggressively expanded in recent years.

Traylor, 51, was stunned to learn that more than 550 emergency medicine positions were unfilled headed into Match Week, when graduating medical students are assigned to the hospitals that will train them. That was more than double the 219 unfilled positions at the same time last year.

Applicants to emergency medicine training programs have plunged 35 percent from a high of 3,734 in 2021 to 2,765 this year, according to National Resident Matching Program data.

Doctors and industry associations say the declining interest is a symptom of a medical field in trouble as the United States emerges from the worst of the pandemic. Emergency departments are under strain as they become congested with patients waiting for beds, veteran providers quit and violence against the remaining staff grows. These factors are damaging the emergency room’s reputation as an ideal place to learn by caring for a steady stream of patients with a wide range of problems.

“When students see us super burned out and dealing with a health care system that treats the emergency department like a release valve, they see the toll it takes on us,” said Jessica Adkins Murphy, president of the Emergency Medicine Residents Association, who is in her final year of residency at the University of Kentucky Hospital at Lexington. “And in that environment we don’t always have the emotional bandwidth to teach students as much as we should.”

But she said the learning experiences are still valuable. Most open residency positions are eventually taken following a supplemental process that pairs programs that could not fill every slot with students who did not originally receive offers. That process filled 501 of the open emergency residency spots this week.

But the growing number of vacancies in the first round signals an abrupt shift for a specialty once considered among the most coveted in medicine, allowing program leaders to be selective in seeking the best and the brightest. The medical drama “ER” was America’s most viewed TV show in the mid-’90s. Emergency physicians were hailed as early pandemic heroes, risking their lives caring for a deluge of covid patients overwhelming hospitals.

Now students like Traylor – who were drawn to the unpredictability and challenges of emergency medicine and the opportunity to care for society’s most vulnerable – are having second thoughts.

“Nothing really excites me as much as emergency medicine,” said Traylor, who studies at the University of the Incarnate Word School of Osteopathic Medicine in San Antonio. “But I have to keep an open mind because maybe I’ll find something that resonates more.”

Emergency departments that used to have their pick of the best medical students now have to cast a wider net. Even well-known hospitals in major cities – Duke University School of Medicine in Durham, N.C., Einstein Medical Center in Philadelphia and Baylor University Medical Center in Dallas – had open emergency resident slots after the first round, according to a list circulated to students who did not match in the first round. The three hospitals said all of their positions were eventually filled.

The declining interest in emergency medicine does not mean the United States is facing an immediate shortage of doctors to staff ERs. Applications for emergency residencies are back to pre-pandemic levels after peaking in 2021. But the number of emergency residency programs has also surged from 171 in 2015 to 287 this year, allowing them to offer more than 3,000 slots for the first time, according to matching program data.

In fact, one of the factors that seems to be dissuading medical students is a 2021 report predicting an oversupply of emergency physicians with 8,000 more than needed by 2030.

But industry groups worry an overcorrection could leave emergency departments understaffed if the next generation of doctors turn to other specialties and if burnout continues.

“With the current state of health care right now, there are more and more people leaving medicine and that may have us revisit oversupply,” said Chris Kang, president of the American College of Emergency Physicians.

Charlie, a third-year medical student in New England who spoke on the condition that his last name not be published to protect his job prospects, said his time as an emergency medical technician in Colorado during the height of the pandemic made him reconsider his goal to work as an ER doctor.

Instead of receiving additional help, emergency physicians told Charlie they were forced to work with fewer resources as burned out nurses left for better paying travel jobs. The emergency department bears the brunt of America’s public health failures, from uninsured people admitted with preventable conditions to people experiencing homelessness who do not receive basic care, he said.

Charlie said he still considers emergency department work to be a “noble profession.” But as the end of his medical school career draws near, he said he is also considering residencies in psychiatry, internal medicine and family medicine.

“It’s just frustrating to watch some of these brilliant minds get ground down by just the pressures of the system that they have very little influence and control over,” Charlie said. “I really need to think about whether this is something sustainable that I can make a career out of.”

Emergency residency program directors have been urging each other to consider students graduating from osteopathic and international medical schools if they have not in the past.

Thomas Cook, who leads the emergency room residency program for Prisma Health in Columbia, S.C., said he interviewed 30 more applicants than normal this year, as he expected more students to view emergency medicine as a backup option

Cook, who has analyzed and written about emergency residency trends, said the rise of hospitals launching ER programs even while applications decline would result in programs considering more students with middling grades. But students who graduate at the top of their class don’t necessarily make the best emergency room doctors, he said.

“This is a blue collar job. We are the cops of medicine,” Cook said, noting how the emergency room guarantees treatment for everyone, including the uninsured as well as people experiencing mental health and substance abuse crises. “We’ve always been that safety net, and I think the biggest skill you have to have is a strong work ethic and an enormous amount of compassion.”

Bayhealth in southern Delaware is among the health systems that are launching an emergency medicine residency program this year. But it was unable to fill any of its six positions in the first round of residency applications, prompting it to turn to international students as it scrambled this week to fill the vacancies.

Dean Johnson, who leads the program, said the projections of an emergency physician oversupply and the pandemic highlighting the difficult nature of emergency room work made recruitment more difficult.

“They are voting with their feet,” Johnson said.

To overcome the challenges, he says, he needs to highlight the job prospects in underserved communities, the opportunities created by the unexpectedly high attrition rate and the value of emergency room training for any doctor.

Declining interest in emergency medicine residencies can also be a boon for the students most dedicated to the field.

Drew Hopper, a first-year medical student in central Washington, longed to be an emergency physician ever since he shadowed one as a high-schooler in the Portland area. As a father of two young children, he also saw emergency medicine as an opportunity to have a better work-life balance and to land a well-paying job without the extensive training required in other jobs.

On one hand, he’s happy to have less competition to end up in his dream job. But he also worries about the corporatization of American medicine and being pushed by administrators to work faster with fewer resources, compromising the mission of providing quality care for society’s most vulnerable.

“It’s really sad to see a field once so competitive have so many extraordinary issues,” said Hopper, 32. “I was told over and over again: ‘If you can see yourself doing anything other than medicine, do that thing.’ It’s the same with emergency medicine: If you can see yourself doing anything other than emergency, do that thing.”