Emergency medicine (EM) resident Rafay Khan, DO, faced an onslaught of COVID-19 patients when he worked in the intensive care unit at Lehigh Valley Hospital in Allentown, Pennsylvania, in December and January. He was constantly intubating patients, dashing to crises, and having to share devastating news with families. “Imagine explaining to a wife in her 30s that her husband just died,” he says. “It was excruciating and exhausting.”
But when Khan went home, he didn’t rest much. Instead, he would turn to his quest to find a job for when he graduates this spring. He would spend hours scouring online jobsites, reaching out to recruiters, cold-calling employers, and contacting alumni, attendings, and anyone else he thought could help.
And he still couldn’t find anything.
His new rotation is less intense, yet his stress continues. “I’ve been working so hard, and now my future is unknown. It feels just awful.”
At a time when the raging pandemic highlights how desperately doctors are needed, EM residents have been struggling mightily to find future employment.
“It used to be your phone would blow up with calls from recruiters from all over the country,” says RJ Sontag, MD, president of the Emergency Medicine Residents Association. “Now residents can’t even get them to call back.”
Although there’s no hard data on how many EM residents haven’t been able to find jobs, experts agree the change has been dramatic.
“Typically, the vast majority of EM residents would have already accepted a position by the winter,” says Mark Reiter, MD, MBA, director of the EM residency program at the University of Tennessee Health Science Center (UTHSC) College of Medicine in Nashville. “In January this year, I’d estimate over a quarter nationwide were still looking for a position.”
“They spent four years in residency, and now they’re faced with the prospect of unemployment. This has never happened in the history of emergency medicine, and it’s difficult to see a way out.”
RJ Sontag, MD
President of the Emergency Medicine Residents Association
Many medical fields have been hit hard during the pandemic as patients have avoided hospitals and doctor’s offices. For example, physician recruiting requests to the health care search firm Merritt Hawkins plummeted 30% in the months after COVID-19 struck — the biggest drop in the firm’s 33-year history.
But EM has suffered more than most, experts say. That’s largely because of how EM hiring works and how significantly emergency department (ED) volumes have dropped overall despite sometimes large numbers of COVID-19 patients.
Many emergency departments have slashed staff to trim costs. In fact, 83% reduced physicians’ hours during the pandemic, according to an American College of Emergency Physicians (ACEP) survey.
Now, EM residents are scrambling to find alternatives, including taking temporary work or grabbing jobs in remote regions where they have no friends or family. And many worry whether the trend will continue for months — or even years.
“These are people who dedicated their entire adult lives to the pursuit of medicine. They spent four years in residency, and now they’re faced with the prospect of unemployment,” Sontag notes. “This has never happened in the history of emergency medicine, and it’s difficult to see a way out.”
The factors fueling the phenomenon
Why have EM residents’ job prospects dried up so dramatically? Much of the answer comes down to simple economics, experts say.
For one, the U.S. health care system has been hemorrhaging money during the pandemic.
COVID-19 shut down many elective procedures that generate revenue — while also increasing expenses for items like ventilators and personal protective equipment. The American Hospital Association reports that hospitals and health systems lost $200 billion in the second quarter of 2020. And federal aid packages, “though crucial, came nowhere near to covering the losses,” explains AAMC Chief Health Care Officer Janis Orlowski, MD.
“Many hospital emergency departments reported decreases in patients of 40% or more early in the pandemic.”
Mark Rosenberg, DO, MBA
President of the American College of Emergency Physicians
Emergency departments were struck particularly hard. Visits declined as patients avoided them for fear of contracting the coronavirus, and car accidents were down as people ventured out less. In addition, some EDs were packed with COVID-19 patients who were being “boarded” there until beds became available on overrun hospital floors. That meant long waits to get into the ED, driving some patients to leave before being seen.
“Many hospital emergency departments reported decreases in patients of 40% or more early in the pandemic,” says ACEP President Mark Rosenberg, DO, MBA. “Although there’s been some improvement, patient volume is still down 20% in some communities.” And that’s in a field that usually experiences upticks every year.
Volume matters more in EM than in other medical specialties, experts say. Emergency departments don’t perform high-cost procedures — compare stitching up a scraped knee to performing brain surgery — so they rely on numbers to generate revenue.
“To keep an emergency department open 24/7 — keep the lights on, have all the necessary machines — is very expensive, but it’s reimbursed based on volume,” says Sontag. “So when numbers drop, employees often wind up getting cut.”
What’s more, who makes the decision to cut employees tends to be different in emergency medicine. Often, EDs are staffed by outside contracting companies rather than directly by the hospital, Orlowski notes. “These groups are run more like a business, so they’re more likely to cut contracts.”
Some wonder whether the growing supply of EM residents could be another factor at play. The number of EM programs increased from 82 in 1990 to 239 in 2018, and residency slots rose by more than 700 from 2016 to 2020, for a total of 2,665.
Orlowski doesn’t think those numbers are driving employment woes, though. “Programs have indeed proliferated,” she says. “But there seemed to be a real need because every year the number of people going to emergency rooms continued to increase. So the proliferation was not a problem — until this year.”
Facing the unknown
In the past, EM residents would be wooed by employers with fine dinners and plump signing bonuses, Sontag says. This year, many residents are instead grappling with tremendous uncertainty.
And the change is threatening to upend many aspects of their lives.
Residents may not know if they can get a job near ill parents, he explains. “Others have spouses who aren’t going to be able to be in the same city, or they can stay together but one simply can’t find a job.”
What’s more, residents searching for jobs face the fear of being unable to repay student loans. In 2020, medical school graduates with debt owed a median of $200,000, according to AAMC data. With that much debt, “to be in a position where you’re having a hard time finding work — or you’re finding work for less hours than you need — is very difficult,” says Reiter.
“These are residents who have been working hard on the front lines during COVID-19 and making tremendous sacrifices. That makes all this so disheartening.”
Rafay Khan, DO
Emergency medicine resident at Lehigh Valley Hospital
For those residents who are fortunate enough to land a contract, life still isn’t worry-free. They know that an offer can be revoked, which happened in the spring when emergency departments were hurting even more.
“Last year, one resident from my program signed with a job in Florida. She bought a house and did everything to get ready to move, and then they rescinded her contract,” Khan says. “I’ve heard that happening to other people, too.
“These are residents who have been working hard on the front lines during COVID-19 and making tremendous sacrifices,” he adds. “That makes all this so disheartening.”
Finding a way forward
Given the slim job prospects, EM residents have been piecing together alternatives.
Some are deciding to expand their job searches far beyond where they had hoped to live.
“I began looking for a position in Philadelphia to be near my friends and family,” says Joe Adams, who prefers to use a pseudonym. “That quickly changed to being OK with a two-hour commute. Then, I expanded to being within two hours of an airport, so I could fly home. I’ve been looking in states far away and in cities I’ve never even heard of.”
Another strategy is working in an urgent care clinic until EM positions materialize. But that option comes with two downsides: a steep salary cut and less complex tasks than these doctors are trained to do.
Other EM job seekers are eyeing positions in facilities considered less than ideal for a newly minted provider.
“It’s notoriously hard in emergency medicine to keep your skills up,” says Trevor Kauffmann, MD, a resident at the UTHSC College of Medicine in Nashville. “So you want to avoid your first job being somewhere that doesn’t have the volume of patients you need to stay fresh. A lot of openings I saw were in places with maybe 6,000 patients a year and my current program has almost 100,000.”
There’s also the possibility of pursuing a fellowship — one or two more years of specialty education — to delay entering the workforce. Of course, that entails additional training residents didn't necessarily plan to get. Plus, it involves waiting longer to bring in a substantial salary. “Many of my classmates have kids and mortgages, and they need to start earning a real income already,” Khan explains.
As they look ahead, some EM residents worry that the situation may not improve anytime soon. “People are worried about pent-up demand for jobs,” says Sontag.
Orlowski predicts that EM job opportunities will pick up — though it may take some time. “I think this is very transient,” she says. “I don’t have a crystal ball, but I could see life returning to normal next winter and emergency room volumes going back up.”
Meanwhile, Sontag hopes the landscape will improve for those still searching. He points to the unique rewards of his chosen field. “I believe in the reason I went into emergency medicine. I believe in the social justice mission of being the only specialty that takes care of every patient regardless of their ability to pay. I’m glad we’re set up to handle a pandemic or a mass casualty in the middle of the night on a Tuesday. I love that.”