Cracking the code on the emergency medicine match: It's about supply and demand, not interviews

Emergency medicine (EM), a historically highly competitive specialty, experienced an abrupt change in the National Resident Matching Program (NRMP)'s Main Residency Match (hereafter referred to as “The Match”) results in 2022 and 2023. Unfilled residency positions increased from an average of 0.48% (2012–2021) to 7.4% (2022) and 18.4% (2023), leaving 46% of EM residency programs facing vacancies in 2023.¹

This drastic shift produced keen scrutiny to the cause. Potential factors fall into three areas: excess supply of positions, lack of student demand for EM and problems embedded in the recruitment process.

Key insights into EM's current challenges can be gleaned from publicly available data from the Electronic Residency Application Service (ERAS), the NRMP, and the Accreditation Council for Graduate Medical Education (ACGME) as well as data from Thalamus (a graduate medical education interview management platform representing approximately 25% of EM programs; “Thalamus”) and additional NRMP data as a result of a data sharing agreement with Thalamus (“NRMP/Thalamus”).

EM programs in The Match increased from 170 to 287 (69%) from 2014 to 2023,¹ which includes 50 American Osteopathic Association programs that transitioned to the ACGME.² EM positions increased from 1786 to 3010 (69%) over the same period through both contribution from new programs and expansion of existing programs.^{1, 2}

After a steady increase in applicants from 2019 to 2021, allopathic and osteopathic applicants decreased substantially in 2022 and 2023, with the steepest decline in allopathic applicants (Figure 1). Total applications from all applicant types declined by approximately 17% year-over-year for the last two Match cycles (email communication from ERAS Strategy & Engagement Director, Michele Oesterheld, May 2023). In both 2022 and 2023, the number of applicants preferring EM who submitted a rank order list (ROL) in EM was lower than the number of positions available (NRMP/Thalamus; Figure 1).

In sum, almost every 2023 EM applicant in ERAS would have needed to match in EM to fill the available positions, which was unrealistic. For the past 2 years, approximately 30% of applicants to EM also applied to at least one other specialty (email from ERAS Pilot Administration Director, Jayme Bograd, October 2022), with some preferring that other specialty (NRMP/Thalamus). Other applicants may have had academic challenges, visa, licensing, or credentialing issues that hindered their consideration at many institutions. These data clearly illustrate that a supply-and-demand mismatch exists between EM applicants and currently available positions.

Some propose that potentially modifiable program and applicant interview behaviors contribute to Match results.^{3, 4} These are likely limited in their impact.

We need to understand why the pipeline to EM is decreasing. One major concern is the projected surplus of 7845 EM physicians by 2030 limiting future job prospects.⁷ While there will still be EM job shortages in many areas,⁸ geography drives most individuals' decisions when choosing where to train and practice.¹ Whether or not the assumptions around the initial workforce study are sustained,⁸ the impact of the initial report will likely not rapidly abate.

Anesthesiology previously experienced similar workforce challenges. From the late 1980s to early 1990s, anesthesiology residency positions exploded. A 1994 workforce assessment predicted a future oversupply. Extensive publicity drove a precipitous decline of U.S. applicants.⁹ By 2000, IMGs comprised more than half of the graduating anesthesiologists in the United States.⁹ Total applicants to anesthesiology did not begin to recover until 2001 data forecasted a significant workforce shortage. Reassessment of the anesthesiology workforce in 2011 showed that entry rates into anesthesiology still remained below 1993 levels and projected continued workforce shortages due to further contraction of training positions.⁹ Extrapolating from anesthesiology, it is unlikely that student interest in EM will increase until they are confident of future job availability.

The excess supply of emergency medicine positions and lack of student demand are the primary drivers for the 2022 and 2023 emergency medicine Match experiences. Modifying interview behaviors will not resolve the situation. Improvement in future Match cycles will require a change in student interest. Emergency medicine must address its detractions including workforce projections and the work environment. We must educate applicants on the numerous benefits of selecting a career in emergency medicine. We will need to support our training programs through difficult decisions regarding program size and tackle institutional and national policy changes.

Alexis E. Pelletier-Bui: Study concept and design, drafting of the manuscript, critical revision of the manuscript for important intellectual content, analysis and interpretation of the data. Laura R. Hopson: Study concept and design, drafting of the manuscript, critical revision of the manuscript for important intellectual content, analysis and interpretation of the data. Michael C. Bond: Study concept and design, drafting of the manuscript, critical revision of the manuscript for important intellectual content, analysis and interpretation of the data. Alisa Hayes: Study concept and design, drafting of the manuscript, critical revision of the manuscript for important intellectual content, analysis and interpretation of the data. Jason I. Reminick: Study concept and design, drafting of the manuscript, critical revision of the manuscript for important intellectual content, acquisition of the data, analysis and interpretation of the data. Ephy Love: Study concept and design, drafting of the manuscript, critical revision of the manuscript for important intellectual content, acquisition of the data, analysis and interpretation of the data, statistical expertise.

LRH reports the following conflicts of interest: Research support from Toyota Motor Co. for unrelated work (PI-Brent, University of Michigan, ended August 2022), Member of CORD BoD and this work does not reflect organizational opinions. JIR and ERL report the following conflicts of interest: JIR and ERL are both shareholders and employees in Thalamus. The other authors declare no conflicts of interest.