AEM Education and Training最新文献

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 understa

With every shift in the emergency department (ED), I am reminded that each of us is only one or two steps from being extremely vulnerable.

My difficult moments have not been as colored by patient stories as by their stories being lost and misconstrued; spun and respun to maintain distance between staff for whom it's another “day on the job” and patient for whom it may be the worst day or era of their life. The protective barrier transforming an individual in need of help into a problem to be dealt with.

My difficult moments have not been as colored by patient stories as by the ways that another “day on the job” for health care workers can easily become either the worst day or worst era of their life. Sometimes that protective barrier can make us feel more safe.

It wasn't the woman who arrived obtunded after ingesting an unknown substance in an attempt to end her life, but the disgruntled complaints that she not only needed resuscitation, but had also “sh*t herself.” The sighs of exasperation when she soiled herself again.

It wasn't the process of uncovering what medication had been overingested, but watching the nurse meticulously wipe the dried, pressed fecal matter from the completely unconscious patient who hours ago had decided this life was not worth living.

It wasn't the survivor of gun violence who repeatedly screamed in pain when the leg the bullet had lodged in was poked and prodded. It was staff rolling their eyes as she continued to vocalize and emote. The disbelief that she could be in so much pain against the belief that she shouldn't have been “out in the streets.”

It wasn't seeing a leg swell up with such tension that it might burst, but watching a resident rush out of the room in tears with the patient's scratch marks across her abdomen.

It wasn't the teenage survivor of sex trafficking who was brought to the ED against her will because she lacked a safe place to sleep. It was hearing the passing of her story from EMS to nursing to residents about how “difficult” she was and “good luck dealing with her.” That she had “probably spent every night with a new man, ‘getting some.’”

It wasn't the physician returning disappointed after being unable to appease a teenage survivor of sex trafficking. It was hearing her say that the patient had called her a “bitch” and watching her remove herself from the care team.

I ask you to reflect with me. What is more frightening?

The “agitated” patient who might raise their voice and threaten or losing the ability to recognize a desperately frightened human staring back?

Losing compassion for a desperately scared human staring back or being another survivor of workplace violence?¹

Resuscitating someone who has attempted to end their life or being comfortable publicly humiliating them in their most vulnerable moment as they are being pulled back from the brink of death?