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Featured topic and speakers
In today’s AMA Update, Holly Caretta-Weyer, MD, associate residency program director of the Stanford University Emergency Medicine Residency, recaps 2023 residency Match results in Emergency Medicine (EM). Also discussing previous years' EM Match results, changes to the specialty caused by the COVID-19 pandemic, physician burnout in emergency rooms and the life changing experience of being on the front lines of patient care. AMA Chief Experience Officer Todd Unger hosts.
Speaker
- Holly Caretta-Weyer, MD, associate residency program director, Stanford University Emergency Medicine Residency
Transcript
Unger: Hello and welcome to the AMA Update video and podcast series. Today we're diving into this year's Match results for emergency medicine programs and discussing what we can learn from them. I'm joined today by Dr. Holly Caretta-Weyer, associate residency program director of the Stanford University Emergency Medicine residency in Palo Alto, California. She's also a PI in the AMA Reimagining Residency initiative. Welcome Dr. Caretta-Weyer. How are you?
Dr. Caretta-Weyer: Very well. Thanks for having me, Todd.
Unger: A pleasure. Well, let's start by going back a year for just a moment. The 2022 emergency medicine Match saw what at the time was an unprecedented 219 unmatched positions. And I think that many people kind of wrote that off as a byproduct of the pandemic. But fast forward now to this year's Match and EM saw that number more than double. I think it was around 555 initially unmatched positions. Let's just start. Kind of what was your reaction when you saw this year's numbers?
Dr. Caretta-Weyer: Sure. I think I probably speak for all of us in emergency medicine. We were all shocked. We felt like it would likely be similar, if not maybe slightly more than last year, but I think 555 came as a shock to all of us.
Unger: Well, a joint statement released by 11 emergency medicine groups during Match week cited a number of possible reasons for the decline. But if we go back let's say three or four years, emergency medicine was one of the most competitive specialties. And so given this, it's only natural to kind of look at the pandemic, obviously, as a big or at least partial reason. What do you think?
Dr. Caretta-Weyer: Sure. I think the pandemic certainly plays a role. Obviously, we as emergency physicians were on the front lines of the pandemic. And initially, that meant taking a lot of risk but also being viewed as a hero. And a lot of students felt the call to emergency medicine at that point but also felt like their eyes were open that, yes, there is inherent risks in the position that they're seeking, but inherent rewards in that you're viewed as the front lines of the health care system by society.
Fast forward now to today when we're no longer viewed necessarily as heroes but as the ones mitigating the bursting volumes of the health care system, the issues with lower staffing, and just incredible increase in volumes of patients coming to the hospital, boarding in the emergency department and seeking care, and often feeling like we can't provide the best possible care that we had hoped prior to the pandemic.
Unger: Well, that ties in nicely to our next topic area which is about workforce projections. That's another reason possibly cited for this. But overall, when we talk about physicians, we are looking at a looming shortage. But that's not necessarily the case within this particular specialty. And a study published in the Annals of Emergency Medicine last August projected what could be a surplus of emergency physicians by the year 2030. How are you thinking about this at Stanford? And what role do you think it played in the declining applicants this year?
Dr. Caretta-Weyer: The jobs report definitely played a role. You talk to advisors for medical schools and residency program directors, and many applicants were asking, "What are my job prospects once I finish my training?" So the ASAP jobs report definitely is top of mind for a lot of applicants but also us as residency program leadership teams. And it's interesting because ASAP and other organizations have sort of walked back the jobs report to some extent because we've seen an incredible amount of attrition of practicing emergency physicians kind of as the pandemic has tailed off so we may actually not have the surplus that that jobs report projected.
So this is kind of a compounding problem now that we have less students entering emergency medicine, both because of the pandemic and this jobs report. We at Stanford are taking the approach that it is simply our job, our responsibility as program leadership to continue to train our residents to the best of our ability to be amazing emergency physicians but also prepare for the future of the specialty in order for them to get the jobs that they're after in a place that they are interested in working.
To date, we've had excellent success with that. But I think that is very much top of mind not just for us but for every emergency medicine residency program in ensuring their graduates are able to get the job that they're after in a place that they want to work.
Unger: So interesting that you should mention issues about attrition. We know from research coming out of late from the AMA that due to issues like burnout, lack of autonomy burden, we're seeing one in five physicians saying they may leave medicine. So these are issues, obviously, that are broader than emergency medicine. But obviously, when you're thinking about your programs and how you support residents, particularly in this environment, you're thinking about how do I address this. Tell us more about that.
Yeah. So it's hard. Burnout is not necessarily something that we can deal with on an individual level. It's not more meditation. It's not more pizza. It's not taking time to take breaks on shift necessarily. It's really this idea of systems level issues making individual providers more resilient.
And so in the emergency department, big contributors to that are being able to take care of patients the way we feel like we should be taking care of patients, optimally providing good patient care. And the overcrowding, and the long wait times and boarding in the emergency department has certainly led to residents feeling like we're not providing the best possible care to patients because they're waiting to get their ultimate treatment.
They're waiting in the waiting room to even be seen by a provider and potentially getting sicker than they need to while they're waiting. So that all kind of creates this suboptimal learning environment in which you feel like you're not doing your best as a resident or as an attending physician to take care of patients when that's really what you signed up to do.
The other thing in emergency medicine is this idea of between physician conflicts. Since we're the front of the house, we're calling to admit patients. We're calling to consult with other providers. And there's often this conflict between residents and attendings and providers on other services when you don't call the right person or you call someone and they feel like this person's better served on a different service. And all of a sudden the emergency medicine resident is the phone tree for the hospital instead of taking care of patients and having that direct patient care or feeling like they're doing the right thing in the most efficient way possible for their patients.
And so it's not just taking care of patients. It's also taking care of yourself on shift and how you deal with those interpersonal conflicts or feeling like you're hitting your head against a wall when you're just trying to do the right thing.
Unger: Well, it sounds like, based on what we talked about, there are a number of potential drivers for what we saw in terms of the Match results this year. But regardless, we've had two years of some concerns. There's been a Match task force convened to identify which of those drivers are really at work here and to develop strategies to mitigate them. Is this kind of an emergency medicine problem that needs to be solved right now with urgency?
Dr. Caretta-Weyer: I mean we're emergency physicians. I think we solve a lot of things with urgency. So it makes sense that this is the response. I do think that there are things that will course correct naturally.
I do think that you will see residency programs perhaps that have lower volumes of patients or perhaps less conducive learning environments perhaps shrink the same way we saw those in anesthesia in the '90s also have a similar contraction in residency positions naturally based on exposure to caseload and patient mix. You think about emergency departments with a volume of 30,000 or less supporting a residency program. That can be very difficult.
So I think you'll see some natural contraction on the program side for a number of spots based on patient volume. And thinking about states where there are a lot of residency programs per population versus states where there are very few residency programs based on the state population, I think making a little bit more of a match between those two things.
When you think about the things that probably need to be addressed urgently, it may not be the Match itself. It's more of the environment of emergency medicine and how we talk about our specialty. Because I think a lot of the burnout and the harm that's been done to emergency physicians as part of the pandemic and in the years afterward has certainly trickled down to students in hearing about our specialty in a very specific way.
And I think a lot of the things that are going to fix that are going to be addressing the burnout, the corporatization of medicine, autonomy, systems issues more urgently than perhaps the symptoms, which is what you're seeing in the ... entrance into emergency medicine as a specialty through the Match.
Unger: Is there anything else that you want to see come out of this task force?
Dr. Caretta-Weyer: Ooh. I mean, I think the big things are looking at the drivers. Why are people not choosing emergency medicine? And yeah. I think there's the obvious ones of the pandemic, the boarding, the burnout, the loss of autonomy. The jobs report I think is a big one.
I think it's really more looking at what are the root causes, what's driving this and what do we need to look internally for and fix at our own house and then what are the external things that we're going to need to load the boat with as far as thinking about national organizations. Is it going to the governmental level and saying we're providing poor patient care in a lot of instances because of boarding and overcrowding?
We need to address staffing. We need to address the number of emergency departments per capita in certain areas. There's going to be a lot of things that are going to be really clearly within our control in the immediate future and then things that are going to be bigger picture in the long range.
Unger: Dr. Caretta-Weyer, we've talked a lot about the challenges. And again, these are pretty global right now in medicine. But there are a lot of great reasons to go into emergency medicine. So for students who are watching or listening to this right now, what do you want them to know about emergency medicine and why they should choose it or consider it as a career path?
Dr. Caretta-Weyer: I think the big reason to consider emergency medicine first and foremost is the same as it's always been. If you want to take care of anyone, any time, any place without consideration as to their ability to pay, this is the specialty for you. I didn't want to give up seeing kids. I didn't want to give up seeing adults. Surgical problems, medical problems, psychiatric problems. I wanted to be able to take care of anyone, any time, any place. If someone is sick on a plane, I wanted to be the person that they called. And that is still the reason to do emergency medicine.
The second reason is we are at the forefront of the future of medicine. We are thinking about how care gets delivered, not just in the hospital, not just in the emergency department, but how it gets delivered to people who are at home outside of the hospital after the hospital.
You think about the explosion of the subspecialties of social emergency medicine. It's how do we think about our patient's zip code or their social determinants of health. How does that affect their aftercare? How does that affect us getting them care before they come to the emergency department? Much the same as DoorDash is thinking about how to get people their food using a drone, we're thinking about how to get people care at the pre-hospital level, hospital at home.
So you think about ChatGPT to take your test. It's more thinking about how emergency medicine is going to deliver care to anyone, any time, any place, not just the hospital now. So if you're someone who's really into innovation, this is really a specialty that's for you.
Unger: Well, I like that. You've got the marketing down right there. Thank you so much for being here, Dr. Caretta-Weyer. It's been really informative. And we'll continue to track this throughout the year. That's it for today's episode. We'll be back soon with another. In the meantime, you can find all our videos and podcasts at ama-assn.org/podcasts. Thanks for joining us today. Please take care.
Disclaimer: The viewpoints expressed in this podcast are those of the participants and/or do not necessarily reflect the views and policies of the AMA.
