Emergency Medicine at a Crossroads

 Emergency Medicine at a Crossroads

Over the past several years, conversations with my emergency medicine colleagues have felt different. Usually, the beginning of the academic year brings stories of new residents, the quirks of Match Day celebrations, and the craziness of new resident orientation. Instead, since the end of the pandemic (around 2022 - 2023), our discussions were filled with worry and a collective sigh of relief from program directors who have successfully filled their slots. Most programs had empty spots. Some programs saw entire classes go unmatched. Colleagues spoke of revamping interview strategies and even wondering if their programs would survive.

Emergency medicine has been considered a highly competitive and vibrant specialty, attracting students who thrive on unpredictability and teamwork. But recent Match cycles have exposed deep cracks in the system. What happened, and where do we go from here?

The Shock of the 2022 and 2023 Match

The numbers are stark. In 2022, nearly 8% of emergency medicine PGY-1 positions went unfilled. The following year, the problem worsened: 18.4% of positions — more than 550 slots across 131 programs — were left vacant. For a specialty that just a few years earlier filled nearly every spot, the sudden reversal was stunning.

Gettel and colleagues (1) analyzed the unfilled positions across 2022 and 2023, showing that certain program characteristics — such as newer accreditation (less than five years), prior osteopathic accreditation, community-based or corporate-owned models, and certain geographic regions — were more likely to struggle in the Match. These data gave shape to what many program directors already felt anecdotally: some programs, especially smaller and less well-established ones, were at higher risk of being left behind. But also, if the primary clinical site (emergency department) was under for-profit ownership there was a 50% greater risk of not filling all of their positions.

Preiksaitis and colleagues (2) dug deeper into the 2023 cycle. Their work identified six risk factors strongly associated with unfilled positions. Programs that had already gone unfilled in 2022 (Odds Ratio [OR] 48.14, 95% confidence interval [CI] 21.04 to 110.15). Smaller programs were also less likely to be filled (less than 8 residents, OR 18.39, 95% CI 3.90 to 86.66; 8 to 10 residents, OR 6.29, 95% CI 1.50 to 26.28; 11 to 13 residents, OR 5.88, 95% CI 1.55 to 22.32). Two regions of the country were associated with unfilled positions-programs in the Mid Atlantic (OR 14.03, 95% CI 2.56 to 77.04) area and the East North Central (OR 6.94, 95% CI 1.25 to 38.47) area. Prior AOA accreditation with subsequent ACGME accreditation under the Single Accreditation System (SAS) were more likely to have unfilled positions (OR 10.13, 95% CI 2.82 to 36.36). And finally, they also found that corporate ownership structure was associated with unfilled positions (OR 3.21, 95% CI 1.06 to 9.72). This was defined as being majority ownership interest being by a private equity firm.

When I have spoken with colleagues from Emergency Medicine programs, there is a sense of uncertainty. Some say that they feel invisible to applicants, they are having trouble getting their name and the quality of their program seen by applicants. Some feel overshadowed by larger or more established programs. Others worry that their ownership model or geographic location is now a stigma. Many of these programs are not a part of a university or School of Medicine so their access to medical students may be limited. The sense of vulnerability is real.

A Supply and Demand Story?

But focusing only on program characteristics risks missing the forest for the trees. Pelletier-Bui and colleagues (3) argue that this is primarily a supply and demand problem. A national leader from the academic emergency medicine community famously said that they want every ER in the country staffed with board-certified EM physicians. From 2014 to 2023, the number of emergency medicine residency programs ballooned from 170 to 287, with positions increasing nearly 70% (1786 to 3010). Applicant numbers, however, plateaued in 2021 and then began to decline. By 2023, even if every single applicant who ranked emergency medicine had matched, there still would not have been enough students to fill the available spots.

Voskanov and colleagues’ (4) recent analysis of applicant composition from 2015 to 2025 adds nuance. The number of applicants increased from 1,821 (in 2015) to 3,068 (in 2025). From 2015 to 2021, more than 94% of programs filled, but from 2022 on there was a dramatic decline. They show that while emergency medicine once attracted a broad applicant pool, the mix has shifted. Applications from U.S. allopathic seniors have declined significantly, while osteopathic and international graduates have increased proportionally. Allopathic seniors filled 73% of positions from 2015 to 2021, but only 52% afterwards. That change reflects both the oversupply of positions and shifting perceptions among U.S. medical students about job prospects in emergency medicine. The question is: was it too many, too fast? Or are the US allopathic students just not as interested?

Ownership and Program Models Under the Microscope

The debate about who runs emergency medicine residencies is also intensifying. Guzmán Das and Bennett’s (5) work on program ownership models highlights the growing presence of programs located in for-profit sponsoring institutions. While these programs can bring resources and efficiency, they also raise concerns about whether profit motives overshadow education. Preiksaitis’ findings (2) reinforce those worries — corporate-owned programs were more likely to go unfilled. Emergency physicians in academic centers often wonder aloud if some of these new programs were created more for staffing than for training. Whether fair or not, perception matters, and students may be influenced by these sentiments.

The Residency Length Debate

As if these challenges were not enough, the field is now facing another seismic potential change: the Review Committee for Emergency Medicine (6) at the Accreditation Council for Graduate Medical Education (ACGME) has a proposal to increase the length of training for all EM programs to four years (up from three years).  At first glance, longer training may seem like a way to ensure better-prepared physicians. But as some of my colleagues pointed out during recent discussions, the evidence does not clearly show that graduates of four-year programs perform better than those from three-year ones. In fact, studies in other specialties with changes in length there was not clear evidence of improvement.

If enacted, this change could further destabilize already vulnerable programs. Smaller, community-based residencies may not have the patient volume or resources to meet the new patient volume per resident requirements, leading to closures. And from the student perspective, an extra year of training means more debt and delayed entry into the workforce. Not sure how that will go over from the student interest side?

What Needs to Change?

So, what needs to change? A few themes emerge across the data and my conversations with colleagues:

Contraction and / or Restraint: There may be too many positions. It is not clear at this point. There are clearly more positions than the number of qualified US allopathic applicants, but there are a lot of applicants from osteopathic, non-US allopathic, and international schools that may be qualified. The field needs to consider halting expansion and perhaps even reducing class sizes. Other specialties, like anesthesiology, faced similar cycles in the past and learned that unchecked growth leads to long-term instability.

Transparency and Mentorship: Students need accurate information about workforce projections, the realities of Emergency Medicine practice, and the benefits that remain. Mentorship at the medical school level is crucial to counterbalance headlines of oversupply and burnout. The national leadership needs to take a hard look at workforce projections and match those up with residency training positions. It is not realistic to say there is going to be board-certified emergency medicine physicians staffing every ED in the country.

Scrutiny of Ownership Models: The specialty should not shy away from asking hard questions about why programs exist, who benefits, and whether the clinical learning environment prioritizes education. There also needs to be a serious look in the other direction at the motives of criticisms of those models from traditional legacy programs. In truth, many legacy University programs (in many specialties) exist at their current size for service needs as much as anything.

Evidence Before Change: If the field is going to mandate four years of training, it must be based on robust data, not assumptions. The decision has a huge impact on Sponsoring Institutions and will shape generations of residents. Institutions will seriously look at decreasing the size of their class of residents in order to maintain the total number of positions. Changes to the Emergency Medicine program requirements do not occur in a vacuum and should be tied to evidence and outcomes, not convenience or finances.

Support for Vulnerable Programs: Smaller, newer, or geographically disadvantaged programs may need targeted support. That might mean collaboration with medical schools, shared resources, or deliberate recruitment strategies to ensure their survival. That may be hard for some of the larger academic programs to stomach. They are worried about their own supply of new residents, and frankly sometimes seem a bit snobbish towards these newer, smaller, and community-based programs.

Looking Ahead 

As a specialty, Emergency Medicine cannot dismiss what the Match is saying. Emergency Medicine is essential to the health system, but the pathway into the specialty is in flux. The crisis of unfilled positions is not just a numbers game; it is a reflection of how students view their job prospects and the future of the field. I hear both anxiety and determination. Anxiety about whether programs will survive, and determination from faculty and programs to make the necessary changes — to reframe recruitment, to advocate for evidence-based changes, and to ensure that the next generation of emergency physicians enters a specialty on solid footing.

The crisis is real, but so is the opportunity.

References

(1) Gettel CJ, Bennett CL, Rothenberg C, Smith JL, Goldflam K, Sun WW, Venkatesh AK. Unfilled in emergency medicine: An analysis of the 2022 and 2023 Match by program accreditation, ownership, and geography. AEM Educ Train 2023; 7 (4): e10902. doi: 10.1002/aet2.10902. PMID: 37600854; PMCID: PMC10436034.

(2) Preiksaitis C, Krzyzaniak S, Bowers K, Little A, et al. Characteristics of Emergency Medicine Residency Programs With Unfilled Positions in the 2023 Match. Annals of Emergency Medicine 2023; 82 (5): 598-607.

(3) Pelletier-Bui AE, Hopson LR, Reminick JI, Bond MC, Hayes A, Love E. Cracking the code on the emergency medicine match: It is about supply and demand, not interviews. AEM Education and Training 2024; 8 (2): e10961 https://doi.org/10.1002/aet2.10961.

(4) Voskanov M, Johnson C, Campbell R, Homme J, Gettel C, Hunter D. Emergency Medicine Residency Match Trends and Evolving Applicant Composition, 2015-2025. Annals of Emergency Medicine (in press) August 23, 2025. DOI: https://doi.org/10.1016/j.annemergmed.2025.07.019 

(5) Guzmán Das I, Bennett CL. Emergency Medicine Training in Transition: An Analysis of Program Length and Ownership Models. Annals of Emergency Medicine 2025; 86 (5): 556-558. https://doi.org/10.1016/j.annemergmed.2025.06.617  

(6) https://www.acep.org/news/acep-newsroom-articles/acgme-releases-proposed-changes-to-em-program-requirements

The Dual Identity of Clinician-Teachers: Navigating Boundaries and Burdens

The Dual Identity of Clinician-Teachers: Navigating Boundaries and Burdens

Every clinician-teacher knows the feeling: one moment you are focused on patient care—managing a complex case, coordinating the team, navigating the electronic medical record—and the next moment, a medical student or resident is by your side, asking a question, eager to learn. In that instant, you are not only a physician but also a teacher, expected to explain, model, and inspire. This dual identity is both the beauty and the burden of academic medicine.

In recent years, there has been an attempt to examine more deeply what it means to live at the intersection of the clinician and teacher roles. A 2024 article in Medical Education by Alexandraki (1) highlights the tensions and opportunities that arise when these identities overlap. The author describes how clinical educators navigate role boundaries, often without explicit institutional support, and how these tensions shape both the quality of teaching and the satisfaction of faculty members. This got me thinking more about the pressures that our faculty are under.

The Boundaries of Identity

Clinician-teachers face constant negotiation of boundaries. On one hand, patient care demands efficiency, accuracy, and often rapid decision-making while on the other hand, teaching requires slowing down, making thinking visible, and creating space for questions. Some of the very qualities that make one an excellent physician—efficiency, decisiveness, independence—can conflict with the qualities that make one an excellent teacher—patience, transparency, collaboration.

The article notes that these boundaries are often blurred. Teaching can enhance clinical care by improving communication, reinforcing clinical reasoning, and engaging learners as team members. Yet, teaching can also slow workflow, reduce productivity, and create friction in systems that prioritize volume over value. An oft-quoted study by Vinson and colleagues (2) found that when a student was in their practice, a family physician sees less patients. In fact, their clinical productivity decreased from 3.9 to 3.3 patients per hour. Clinician-teachers are left to reconcile these conflicting demands, often without formal recognition or protected time.

Systemic Pressures

The challenges of dual identity are not just personal—they are systemic. In most practices and institutions, clinical productivity is measured in relative value units (RVUs), a measure of the work done in a patient encounter, while teaching contributions are harder to quantify. Dr Vinson (2) found that the amount of time the faculty physician spent working increased by 52 minutes per day. Another study by Denton, Pangaro, and colleagues (3) found that having a medical student working with a physician in the outpatient internal medicine clinic adds 32 minutes to a clinic session. Faculty may be praised for “going above and beyond” in teaching, but rarely are they rewarded in tangible ways. In medical schools, promotion systems often prioritize research and academic recognition while leaving educational contributions undervalued. As a result, clinician-teachers may feel like they are constantly falling short of their clinical expectations. Grayson and colleagues (4) surveyed preceptors and found that 61% reported a decrease in the number of patients seen.

This misalignment creates stress and, over time, may contribute to burnout. Clinician-teachers often report feelings of being pulled in too many directions, of their educational work being “invisible labor,” and of struggling to sustain enthusiasm in the face of mounting clinical pressures. These challenges may be compounded for women, underrepresented minorities, and international faculty, who may experience additional burdens related to equity, representation, and bias. 

The Rewards of Dual Identity

Yet, the story is not only about burden—it is also about joy. Many clinician-teachers describe teaching as the most rewarding part of their day. Educating the next generation of physicians provides a sense of purpose, continuity, and meaning. It reinforces one’s own knowledge, sharpens clinical reasoning, and fosters professional community. Learners can bring fresh perspectives, challenge assumptions, and remind faculty why they entered medicine in the first place. Dr Grayson’s survey of preceptors (4) found that: 82% felt more enjoyment of the practice of medicine, while 66% spent increased amount of time reviewing clinical medicine, and 49% had a desire to keep up with recent developments in medicine.

The dual identity, if well supported, can be profoundly enriching. It offers a professional life that integrates service and scholarship, mentorship, and practice. Clinician-teachers often become role models not only for clinical excellence but also for professional identity formation, showing learners how to balance compassion with competence, efficiency with empathy. 

Strategies for Support

How can institutions better support clinician-teachers in navigating these boundaries? 

1. Clarify Expectations – Institutions should clearly define the role of clinician-teachers, setting realistic expectations for clinical productivity and educational engagement. Without clarity, faculty are left to guess, often feeling like they are falling short in both domains.

2. Provide Protected Time – Teaching should not be an extracurricular activity squeezed between patient visits and after hours. Providing protected time for education signals that it is valued and essential, not optional.

3. Recognize and Reward Teaching – Promotion and tenure criteria must align with the real contributions of clinician-teachers. This means valuing curriculum design, mentorship, and educational leadership as much as publications and RVUs.

4. Invest in Faculty Development – Clinician-teachers need training not only in pedagogy but also in boundary negotiation, time management, and professional identity formation. Faculty development programs should explicitly address the dual identity challenge.

5. Promote Equity – Support should be distributed fairly, with attention to equity across gender, race, specialty, and career stage. Institutions should be intentional about mentorship and sponsorship for underrepresented groups. Finances should not just support the high dollar specialties. 

6. Model Integration – Leaders who themselves are clinician-teachers can model integration of roles, demonstrating how clinical care and teaching can enrich one another rather than compete.

Looking Forward

The future of academic medicine depends on clinician-teachers who can thrive in both roles. As medicine becomes more complex, the need for skilled educators embedded in clinical settings will only grow. If institutions fail to support this dual identity, they risk losing talented faculty and weakening the pipeline of future educators.

The challenge, then, is not to choose between clinician and teacher but to create systems where both roles are fully supported and mutually reinforcing. This requires intentional policies, cultural shifts, and recognition that teaching is not peripheral but central to the mission of academic medicine.

In the end, the dual identity of clinician-teachers is not a problem to be solved but a reality to be embraced. By acknowledging the boundaries, addressing the burdens, and celebrating the rewards, we can create an environment where clinician-teachers not only survive but flourish. And when they flourish, so too do the learners and patients they serve.

REFERENCES

1) Alexandraki I. Exploring the boundaries between clinician and teacher. Med Educ 2025; 59 (2): 136-138. doi:10.1111/medu.15586. 

2) Vinson DC, Paden C, Devera-Sales A. Impact of medical student teaching on family physicians' use of time. Journal of Family Practice  1996; 42 (3): 243-249. PMID: 8636675.

3) Denton GD, Durning SJ, Hemmer PA, & Pangaro LN. RESEARCH BASIC TO MEDICAL EDUCATION: A Time and Motion Study of the Effect of Ambulatory Medical Students on the Duration of General Internal Medicine Clinics. Teaching and Learning in Medicine  2005; 17 (3): 285–289. https://doi.org/10.1207/s15328015tlm1703_15

4) Grayson MS, Klein M, Lugo J, & Visintainer P. Benefits and Costs to Community-Based Physicians Teaching Primary Care to Medical Students. J General Internal Medicine  1998; 13 (7): 485-488. https://doi.org/10.1046/j.1525-1497.1998.00139.x