Every spring, medical students count down the minutes to Match Day, when they learn where they’ll do their residency training. It’s a critical moment of transition for newly minted doctors — the culmination of years of hard work and sacrifice. For the rest of us, it’s a bellwether for the desires and plans of the next generation of doctors, those people we’ll be counting on to care for ourselves and our children.
And this year, we’re stunned that over 550 of the roughly 3,000 residency spots in emergency medicine went unfilled. There were 219 unfilled spots last year and only 14 spots left open in the 2021 match.
How could this be? For years, emergency medicine was a competitive specialty, highly sought after by medical students. Historically it has drawn a special pool of talent — those excited to manage a hemorrhaging trauma patient or fibrillating heart while also embracing the social justice mission of caring for anyone at any hour.
But it’s not just emergency medicine that is struggling to recruit students. Dr. Francis Deng, a neuroradiologist at Johns Hopkins, created a chart from public data to reveal trends in medical student residency applications. He found that the specialties growing in popularity include diagnostic radiology (despite the threat of AI!), dermatology, and physical medicine and rehabilitation. The specialties increasingly shunned by students include emergency medicine, family medicine, and pediatrics.
What is driving these changes? We can point to various incentives. Money, for example. The average medical student graduates with $200,000 in debt, not including undergraduate loans, so it makes sense that they’d look to lucrative specialties to pay it back. Another is lifestyle. The flexible hours of physical medicine or the peace and quiet of the radiology suite might be preferable to the night shifts and chaos of an unsafe, understaffed emergency room.
A position statement published on the American College of Emergency Medicine website mentions possible factors that steered applicants to other specialties this year. They include increasing clinical demands, workforce projections, emergency department crowding, the impact of the pandemic, and the increasing corporatization of medicine. But these pressures speak to a deeper trend.
The specialties losing talent are ones that address the whole patient, not just a single organ or system. They require doctors to sit with suffering and uncertainty — to engage with the messy reality of multiple narratives, integrating the biological and social into a tentative, coherent whole. The healing power of these specialties comes in the form of medications, yes, but also in the act of asking the right questions, of comforting people in times of pain, in being available. This takes time and presence, which is nearly impossible in an assembly line system that allots only 15 minutes per primary care appointment. A recent study showed that primary care doctors would need 27 hours in a day to provide the care recommended by medical guidelines.
The type of healing we’re describing is also not easily coded or billed for — and therefore not valued by payers, which prefer to reimburse for things they can measure. Some primary care doctors, fed up by this fact, have unplugged from The System completely and tried a “direct patient care” model, which bills patients not by procedure or encounter but by month, similar to a gym membership or cell phone bill. But the model struggles to compete with an entrenched, multibillion-dollar health insurance industry that profits off disease and intervention.
Further, there is a cultural problem. Both within and without the halls of medicine, this comprehensive way of caring for people is increasingly viewed as “below” doctors, who are more useful for their technical skills like scoping or stenting or operating. But what about efforts to understand a particular patient’s habits and stresses and possibly prevent the need for a cardiac stent? Or to figure out when the ER patient’s stomach pain is complicated by mental health challenges or loneliness? The system doesn’t incentivize us to deal with these questions.
But here’s the paradox. Often these messy moments when we’re honoring a patient’s struggle and easing their path forward, rather than reducing their experience to a problem list, are the moments when we’re reminded of why we went into medicine in the first place. Inherent in the challenge of human complexity is the meaning that we gain from our careers.
We need talented physicians who can read MRI scans and operate on the delicate structures of the spine. But we must also value those who can get to the heart of a patient’s story.
As a society, we claim we want holistic and compassionate care. We notice our doctors are distracted, or callous, or incapable of seeing us in the ways we most want to be seen. We see an orthopedist for our knee, a dermatologist for our skin, a neurologist for our headaches. We try to piece together the advice we receive. We crave a more integrated whole.
But the Match Day results show us we are getting farther from that vision, not closer to it. If we don’t find a way to capture value in holistic care, to supply doctors with the time and resources they need to practice the art of medicine, to incentivize students to shoulder the responsibility of the entire patient and not just one body part, health care’s crisis will only deepen.
Emily Silverman is an internal medicine physician in San Francisco; assistant volunteer professor of medicine at the University of California, San Francisco; and creator of the medical storytelling live show and podcast The Nocturnists.
Jay Baruch is an emergency physician, professor of emergency medicine, and director of the medical humanities and bioethics scholarly concentration at the Alpert Medical School of Brown University. He is the author of “Tornado of Life: Constraints and Creativity in the ER.”