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A Historically Bad Job Market for Emergency Physicians

2021; Elsevier BV; Volume: 77; Issue: 6 Linguagem: Inglês

10.1016/j.annemergmed.2021.03.004

1097-6760

Maura Kelly,

Healthcare Policy and Management

In the fall of 2019, an emergency physician in his last year of residency started his search for a job. He wanted a position in the Midwest town where he and his wife had grown up. At the time, the job market for emergency physicians was strong, as it more or less always had been since the specialty began to emerge in the United States in the 1970s. The resident—who we’ll call Frederick to maintain his anonymity—had his pick of offers. After careful consideration, he decided to join a private democratic practice that would give him a say in departmental matters. “I wanted a long-term fit,” he said. He signed a contract with the group. That spring, he and his wife moved back to their hometown (approximately 600 miles from Frederick’s residency) so they could settle in before his job began. Meanwhile, coronavirus disease 2019 had flooded the country. Just as Frederick and his wife were about to close on a house, the pandemic rerouted their future. His new employer’s recruiter called to tell him that the firm was rescinding Frederick’s job offer; the emergency department was no longer getting enough traffic to justify the hire. Too many would-be patients were avoiding the hospital out of fear that they would be exposed to the novel coronavirus. “The recruiter was apologetic,” Frederick said. “He explained it was an incredibly difficult decision and offered to help me find other employment, but in reality, there wasn’t a lot they could do.” Frederick contacted employers whom he had turned down the previous fall, but by then, they had no openings. Until very recently, a situation like Frederick’s would have been unheard of. Emergency physicians were all but guaranteed jobs after residency. But the coronavirus and the economic havoc it has wreaked played a significant role in changing that. Contrary to what many anticipated, the pandemic actually reduced volumes in EDs; an American College of Emergency Physicians (ACEP) poll found that nearly a third of Americans were so worried about getting sick that they delayed or avoided emergency care during the pandemic.1New poll: nearly a third are delaying or avoiding medical care due to COVID-19 concerns. American College of Emergency Physicians.https://www.emergencyphysicians.org/press-releases/2020/4-28-20-new-poll-nearly-a-third-are-delaying-or-avoiding-medical-care-due-to-covid-19-concernsGoogle Scholar Coronavirus disease 2019 also scared the population into forgoing services ranging from cancer screenings to elective procedures2Lerman C. Op-ed: the danger in postponing cancer screenings during the pandemic.https://www.latimes.com/opinion/story/2020-09-28/cancer-screening-down-covid-pandemicGoogle Scholar; a June report by the American Hospital Association found that outpatient numbers decreased by more than a third and inpatient numbers decreased by 19.5% from 2019 to 2020.3New AHA report: losses deepen for hospitals & health systems. American Hospital Association.https://www.aha.org/press-releases/2020-06-30-new-aha-report-losses-deepen-hospitals-health-systemsGoogle Scholar The slowdown created a strained financial situation system-wide: according to the American Hospital Association,4New analysis shows dramatic impact of COVID-19 on hospital & health system financial health. American Hospital Association.https://www.aha.org/press-releases/2020-07-21-new-analysis-shows-dramatic-impact-covid-19-hospital-health-systemGoogle Scholar hospitals and health systems lost an estimated $203 billion between May 2020 and June 2020 alone and likely lost an estimated $20 billion per month from July 2020 through December 2020, resulting in estimated losses of $323 billion for the year. With less money coming in, all sorts of health care groups, from large hospitals to small practices, looked for ways to cut costs. “Many emergency medicine employers aren’t hiring,” said RJ Sontag, MD, president of the Emergency Medicine Residents’ Association. Data from a number of sources have suggested that this is a particularly difficult time to be looking for work in emergency medicine. The official online career center for ACEP and Emergency Medicine Residents’ Association, emCareers.org, found that between May and November 2020, the number of job postings were reduced by more than 25% compared to that in the same period in 2019.5Interactive Jobs Map. emCareers.org.https://www.healthecareers.com/ACEP/search-jobs/Google Scholar The site simultaneously saw a spike in the number of job seekers; during 2020, the number of users who signed up for new accounts increased by 56%, whereas the number of applications for open positions went up by a third. Many temporary gigs that some emergency physicians relied on also disappeared. “Locums options are drying up, so even the idea of flying across the country part of every month for work is off the table,” said Sontag, who is based in Columbus, Ohio. “Residents are turning to urgent cares, hoping that their increased volumes will mean extra shifts.” However, he noted that the work often paid half of what they made in the ED. Moreover, fewer full-time openings are not the only problem. Tightened purse strings also meant job cuts and less lucrative work in the field. According to a recent unpublished ACEP poll—referenced in a letter sent by the college to President Joe Biden6ACEP letter to president-elect Biden on COVID-19American College of Emergency Physicians.https://www.acep.org/globalassets/new-pdfs/advocacy/acep-letter-to-president-elect-biden-on-covid-19-11.24.20.pdfGoogle Scholar—a fifth of those surveyed said that their emergency medicine group had laid off a physician, nearly a third said that their group had furloughed a physician, and more than half said that they had reduced pay. However, the pandemic and the concomitant financial repercussions do not entirely explain the shortage of opportunities. Rather, the bad job market is “the culmination of several trends” according to Tom Florence, Executive Vice President of Merritt Hawkins, a leading physician search firm. He provided some historical context: “Emergency medicine is a relatively new specialty, and for years, hospitals competed for a limited number of physicians certified by the American Board of Emergency Medicine as residency programs ramped up.” In the past, hospitals coped with the shortage by hiring physicians without American Board of Emergency Medicine (ABEM) certification to staff their EDs. But emergency medicine quickly became a popular specialty, and the number of ABEM-certified emergency physicians grew rapidly. A new study of the emergency medicine workforce, published in the December issue of Annals, found that the number of emergency residents increased from 4,565 residents in 145 programs in 2008 to 7,940 residents across 247 programs by 2020.7Bennett C.L. Sullivan A.F. Ginde A.A. et al.National study of the emergency physician workforce, 2020.Ann Emerg Med. 2020; 76: 695-708Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar The burgeoning supply of emergency physicians in recent years means that hospitals have increasingly replaced uncertified physicians covering EDs with ABEM-certified physicians. At the same time, a flurry of hospital closures over the last 10 years has led to reduced opportunities for emergency physicians. The proliferation of urgent care centers—which, in many areas, are staffed with primary care physicians, physician assistants, and nurse practitioners rather than with emergency physicians alone—also contributed. “For a period of at least ten years, emergency medicine ranked among Merritt Hawkins’ top twenty most requested types of searches,” said Florence. “That streak ended in 2019.” Some experts believe that a relatively new player in the field of emergency medicine has exacerbated the situation. “Private equity firms have purchased significant stakes in most of the large national EM contract management groups,” said emergency physician Mark Reiter, MD, MBA, a past president of the American Academy of Emergency Medicine. “These groups have expanded rapidly by purchasing independent groups.” Companies owned by private equity firms now employ more than half of all emergency physicians in the United States. According to Reiter, who is also a professor of emergency medicine at the University of Tennessee in Murfreesboro and Nashville, many of these corporate-minded outfits responded to the pandemic by reducing hours, slashing or delaying pay, and cutting administrative expenses. Private equity also contributed to the number of emergency physicians flooding the job market. “The vast majority of new residency programs are sponsored by large private-equity-backed contract management groups (ie, Envision, TeamHealth) or large for-profit hospital networks (ie, HCA Healthcare), who may have a vested interest in creating an oversupply of emergency physicians,” Reiter noted. “This can put significant downwards pressure on physician salaries, which is their main expense.” Attrition also tends to be lower in an oversupplied market. What is more, said Reiter, is that “many new residencies have opened up in certain geographic areas—like Florida and Texas—that traditionally commanded high salaries, significantly distorting the local job markets, and leading to lower salaries.” What about the $175 billion spent on coronavirus disease relief, money that Congress kicked over to the health care system? Shouldn’t some of that aid money have trickled down to emergency physicians to protect them from the bad economy? Reiter explained that much of the money earmarked for emergency medicine groups “went directly to the large national private equity-backed staffing companies—Envision, TeamHealth, et cetera.” Indeed, a Bloomberg news report found that at least $2.5 billion of the relief money ended up in the hands of well-funded investment firms, in the form of bailout grants and loans, by way of the hospitals and staffing companies they own.8Willmer S. A Wall Street Giant Tapped $1.5 Billion in Federal Aid for Its Hospitals.https://www.bloomberg.com/news/articles/2020-09-14/a-wall-street-giant-tapped-1-5-billion-in-federal-aid-for-its-hospitalsGoogle Scholar These large corporations did not always distribute these funds to their physician employees. Rather, they used the funds to service debt, cover administrative costs, and, in some cases, keep businesses profitable. Job shortage is tough for emergency physicians of all ages looking for work. But in at least one way, it is particularly stressful for those at the beginning of their careers: a quarter of graduates will leave residency with more than $300,000 in their outstanding loans, whereas half will owe more than $200,000. “It’s really bleak out there,” said Sontag. “Residents are calling employers and simply being told they’re not hiring this year or that they’ll re-evaluate hiring decisions in the spring [of 2021]. Residents are in a holding pattern, expanding their job search wider and wider, hoping that someone is hiring.” “It’s a very tight job market for graduating residents,” says ACEP President Mark S. Rosenberg, DO, MBA, FACEP, who is also chair emeritus of emergency medicine at St. Joseph's Health in Paterson, NJ. One way to help address the problem, he says, is through sub-specialty fellowships like those he has developed at St. Joseph’s—in geriatrics emergency medicine, emergency department palliative care, faulty development, emergency department administration, and acute pain and addiction management. These create more, and more flexible, opportunities for new doctors and their employers—because sub-specialty fellowships “work financially for the hospital, the department, and for the fellow,” Rosenberg notes. “My residents have to be paid according to ACGME [Accreditation Council for Graduate Medical Education] guidelines and very similarly to the rest of the residents in the institution,” he explains. “My attendings get paid based on standards in the industry of how much a physician with so much training should get paid. My fellows in these non-ACGME fellowships are paid with a method that is best described as a hybrid.” They earn significantly more as a fellow than they would as a resident and also receive a generous amount of Continuing Medical Education money. The fellow also works a defined number of clinical hours as an attending as part of their fellowship responsibilities. “If I had an attending working that clinical shift, it would cost me significantly more,” says Rosenberg. Even after paying for a faculty member to serve as mentor and program director, his net cost is zero. Meanwhile, his fellows get paid well and improves their CV that “make the fellow a much stronger candidates in a tight job market.” according to Rosenberg. What’s more, he adds, “If the volume comes back, I already have someone working for me and I can offer them a full-time position.” And Rosenberg believes there's reason for optimism. “We expect the job market for emergency physicians to rebound as the virus gets under control, patient volumes get closer to ‘normal’ levels, and vaccines become more widely available,” he says. “The pandemic continues to open the eyes of hospitals and health systems to the value of emergency physicians. We will weather this storm.” How did things turn out for Frederick? He landed a job at a “less-than-desirable” hospital near his hometown. However, a month after starting that position, the staffing organization that hired him decided not to renew their agreement with the hospital. Frederick was given the option to stay on at the hospital, although with a different group that would be running the department. However, before he could make up his mind about what to do, he got a call from the practice that had rescinded his top-choice offer several months prior. “Volumes had returned and the group had acquired new sites,” Frederick said. “They were able to offer me a job again. I decided to take a chance and accept.” He will start his new position in the spring of 2021. “I’m excited for the future and ready for some stability for me and my family.”