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
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