Addressing an Uncertain Future: Targeted Programming to Prepare Emergency Medicine Residents to Enter the Workforce Amid a Pandemic

During a typical fall season, emergency medicine senior residents in the United States prepare their cover letters and update their resumes in anticipation of their post-residency job search.

Unfortunately, the COVID-19 pandemic, which took a toll on the lives of patients served by ED, also dramatically altered the transition process and job search timeline for this past year’s graduates.

Due to the substantial reduction in ED patient volumes, many EDs were forced to further adjust staffing ratios—which included layoffs, furloughs, and pay-cuts— and the demand for recruiting new physicians to the workforce decreased further.^1,2 In addition to being strained by the unique emotional challenge of delivering care at the height of a pandemic, EM senior residents were now also left feeling uncertain about how to navigate this complicated job environment. EM workforce supply-and-demand issues existed prior to the pandemic and were being investigated by the various EM governing bodies. Unfortunately, the pandemic potentiated these issues and forced the specialty to reconcile with them in an accelerated fashion.

We, as leaders of the Administration & Operations Committee and Health Policy Committee of EMRA, believed that providing education and high-level insight about the business and politics of EM could provide clarity to residents starting their careers. Our main objective was to help residents navigate the job landscape amidst the COVID-19 pandemic. We felt that residents could be even better prepared for their first 5-10 years out of residency if they understood in greater detail how EM is being impacted by the current pandemic and by health policy changes.

To promote this educational goal, we developed programming in the form of a virtual expert panel hosted at the American College of Emergency Physician Annual Meeting 2020.³ We invited six experts from academia, health policy, and business to provide multidisciplinary insight and share concrete guidance about how to best position oneself for today’s job market and the specialty’s continued evolution (Figure 1). Topics of conversation were pre-selected based on feedback from EMRA general body members. The following highlights the three most salient lessons from the discussion. The recording can be viewed here: https://www.emra.org/be-involved/events--activities/acep/acep20-on-demand/ao-n-hpc-on-demand/.

Lesson 1: The COVID-19 pandemic further disrupted the job market of EM. The best way to navigate this disruption is to be a “physician plus”.

The decrease in the demand for recruiting new members to the fully trained workforce comes at a time when the market is already increasingly competitive because of the steadily rising number of EM residency graduates.^4,5 In 1983, EM had its first Residency Match with 190 residency slots. In 2000, there were approximately 1000 slots. Now there are 257 programs with approximately 2600 residency slots. The increase in workforce supply with an abrupt decrease in demand secondary to the pandemic has left many graduating EM residents struggling to find secure options for employment.

To stand out in this increasingly competitive job market, the expert panel advised that EM trainees should embrace an innovative mindset. Potential employers are now looking for the “physician plus,” meaning that along with strong clinical skills, employers are seeking physicians who will bring additional skills. Examples of this include research training that can broaden the department’s academic scope, knowledge about diversity program development to broaden a patient-centered workforce, or medical finance experience that can improve charting/billing for the department. Completing a fellowship or advanced degree can be one way to obtain these desired skills. Though departments will always need staff to fulfill clinical responsibilities, the expert panel forecasted that having training in only clinical service may not be sufficiently competitive in the future EM job market.

Lesson 2: The COVID-19 pandemic exacerbated our nation’s underlying health inequities. EM health policy needs to respond to these gaps in healthcare access.

Over the next decade we should expect the scope of practice for EM physicians to include population health as a paradigm of care. Not all of what we do during our EM shifts are critical resuscitations. Much of our time is spent managing chronic disease and lower acuity health concerns. As a result, EM physicians will be increasingly incentivized to work towards improving patients’ overall health outcomes and well-being. This can take many forms, such as coordinating care with outpatient team members (therapists, social workers, and primary care physicians), to having an awareness about the financial implications of ED care on underinsured patients, to advocating for better out-of-hospital social programs that provide equitable health resources to all individuals. EM trainees are well-positioned to provide an informed view of barriers to care for society’s most vulnerable patients.

One such mechanism for reducing barriers to care is telehealth. Telehealth practice rapidly expanded during the COVID pandemic.⁶ Now that more patients have grown accustomed to this health care interaction, it is likely that it will remain a part of our practice after the pandemic has ended. However, in order to make its use a reasonable expectation for EM providers, future health policy and advocacy work will be needed to ensure adequate reimbursement. There is also an imperative to determine what exactly defines a “high quality” telehealth encounter. Finally, we must promote policies that mitigate disparities and ensure that all people—including those that are low-income and low-resourced—have meaningful access to these innovations. 

EM physicians should also be prepared to focus more on value-based care metrics rather than the current fee-for-service model. The Affordable Care Act of 2010 and The Medicare Access and CHIP Reauthorization Act of 2015 are further transforming healthcare reimbursement into a value-based care model. Until now, EM has been relatively shielded from these changes, but there has been an increasing push to focus more on quality process measures, such as time-to-doctor and time-to-disposition metrics, through payment incentives.⁷ An increasing number of EM employment contracts are starting to reflect this shift, requiring EM physicians to agree to productivity and quality-based incomes rather than flat hourly rates or annual salaries.

Lesson 3: The COVID-19 pandemic exposed how mentally and emotionally difficult this field can be. To prevent burnout, EM physicians have to find what fuels their passion.

There is a growing literature base showing that high levels of burnout exist within EM. Surveys suggest that about 65% of EM physicians will experience burnout, and the specialty often ranks within the top five of most burned-out specialties in medicine.^8,9 The expert panel discussed that the clinical demands of working through COVID-19 have had substantial mental health effects on EM providers, and the added layer of uncertainty for secure job placement only further adds to mental strain. The panelists advised that trainees should seek roles where they feel they are thriving in an environment that fits their personality and future goals. Financial compensation should not be the sole consideration. Applicants should also think about the following when assessing whether a position is the right fit for them: a) Does the job have an employment model (democratic group, contract management group, etc.) that you find acceptable to your clinical practice preferences?; b) What is the employer’s governance model and how are decisions made for the group?; c) What are the market trends in the job’s location (e.g, whether or not the Medicaid expansion took place, patient demographics, ancillary support services, wellness initiatives); and d) Does the department have a vision that aligns with your own passions and interests? 

The expert panel also recommended cultivating a set of interests outside of clinical EM in an effort to maintain work-life balance. Therefore, when agreeing to a job, candidates should speak candidly with future employers about the details of protected time to ensure that interests outside of clinical work can be completed as part of the contract. For example, if someone expresses an interest in quality improvement research, they should seek out positions that can offer protected time or funding to complete these tasks. Alternatively, individuals with an interest in medical education should seek out departments that have this as a core mission. To be compensated for a passion project, it must align with the values of the department. 

TAKE-HOME POINTS
In conclusion, the COVID-19 pandemic challenged the field of EM and its trainees at every level, ranging from strained clinical environments to enhanced uncertainty about the existence of future employment opportunities. The expert panel provided key lessons that helped provide reassurance and guidance for EM residents as they approach the job market.

• Graduating EM residents have the skillset to work both internally within the hospital’s administration and externally with policymakers and advocacy groups to help inform policy decisions that affect some of society’s most vulnerable patients.
• We can provide needed insight for broader advocacy efforts aiming to make this challenging work environment a more sustainable setting for mitigating burnout, which fundamentally has the effect of improving the quality of care delivered to patients.
• While being equipped with these important historical lessons regarding EM and the trajectory of the specialty’s workforce, there is great promise in our collective ability to shape the future of this specialty in a way that enhances the quality of care for our patients and preserves the workforce to take on this critical social challenge.

REFERENCES

1. Hartnett KP, Kite-Powell A, DeVies J, et al. Impact of the COVID-19 Pandemic on Emergency Department Visits — United States, January 1, 2019–May 30, 2020. MMWR Morb Mortal Wkly Rep. 2020;69(23):699-704.
2. ACEP Surveys Members About COVID-19. ACEP Now. https://www.acepnow.com/article/acep-surveys-members-about-covid-19/. Published 2020. Accessed January 5, 2021.
3. Beeson MS, Ankel F, Bhat R, et al. The 2019 Model of the Clinical Practice of Emergency Medicine. J Emerg Med. 2020;59(1):96-120.
4. Emergency Medicine Residents’ Association. Life After Residency: Contracts, Careers, Pay, and Policy. https://www.emra.org/be-involved/events--activities/acep/acep20-on-demand/ao-n-hpc-on-demand/. Accessed January 4, 2021.
5. Haas MRC, Hopson LR, Zink BJ. Too Big Too Fast? Potential Implications of the Rapid Increase in Emergency Medicine Residency Positions. AEM Educ Train. 2020;4(S1):S13.
6. Nelson LS, Keim SM, Ankel FK, et al. American Board of Emergency Medicine Report on Residency and Fellowship Training Information (2019-2020). Ann Emerg Med. 2020;75(5):648-667.
7. Russi CS, Heaton HA, Demaerschalk BM. Emergency Medicine Telehealth for COVID-19: Minimize Front-Line Provider Exposure and Conserve Personal Protective Equipment. Mayo Clin Proc. 2020;95(10):2065–2068.
8. Medford-Davis L, Marcozzi D, Agrawal S, et al. Value-Based Approaches for Emergency Care in a New Era. Ann Emerg Med. 2017;69(6):675-683.
9. Stehman CR, Testo Z, Gershaw RS, Kellogg AR. Burnout, drop out, suicide: Physician loss in emergency medicine, part I. West J Emerg Med. 2019;20(3):485-494.
10. Shanafelt TD, Boone S, Tan L, et al. Burnout and satisfaction with work-life balance among US physicians relative to the general US population. Arch Intern Med. 2012;172(18):1377-1385.