Emergency medicine (EM) has plummeted in popularity, with the highest unfilled position rate (18.3%) of any specialty in the 2023 Match (asamonitor.pub/3X3WYwS). This occurred while simultaneously facing a 10% decrease in applicants compared to the year prior. Anesthesiology applicants, on the other hand, increased by 10% as medical students fled the ERs and flocked to the ORs (asamonitor.pub/3X3WYwS). What happened to emergency medicine?

“While EM clings to the hope of recovery, akin to anesthesiology’s success after its nadir in the 1990s, anesthesiology should remain vigilant, as some of the factors that contributed to the decline of interest in EM could be in anesthesiology’s future.”

In 2021, an article titled “The Emergency Medicine Physician Workforce: Projections for 2030” estimated an oversupply of 7,845 physicians in 2030 (Ann Emerg Med 2021;78:726-37). Between 2014 and 2023, there was a 30% increase in emergency medicine residency programs and a 46% increase in PGY-1 positions (asamonitor.pub/48TW22Z). Between 2001-2021, the proportion of for-profit-affiliated EM residency programs increased by over 1,129% (AEM Educ Train 2022;6:e10786). Despite increases in ER visits, 20% of encounters are now seen by nurse practitioners or physician assistants (Ann Emerg Med 2021;78:726-37). This trend was concerning enough that Indiana passed legislation in 2023 requiring that a hospital with an ER have a physician on site, on duty, responsible for the emergency department at all times it is open (asamonitor.pub/3tRX0xO).

This is not the first time published workforce projections may have influenced the popularity of a specialty. In 1994, ASA released a report, “Estimation of Physician Work Force Requirements in Anesthesiology,” that projected a 30% oversupply of residents (Abt Associates Inc 1994). In certain scenarios, demand could still be met even if zero anesthesiologists were trained for the next 16 years! (ASA Newsl 2004;68:20-1). This was partially due to increased pressure by managed care organizations to reduce surgical volume and increased utilization of CRNA staffing models (asamonitor.pub/420X0b8). In 1995 and 1996, anesthesiology categorical and advanced positions went 54% and 66% unfilled, respectively (Anesth Analg 2018;126:568-78).

Figure 1: Time-Lagged Comparison of Increasing EM & Anesthesiology Residency Programs (Data sourced from NRMP).

Figure 1: Time-Lagged Comparison of Increasing EM & Anesthesiology Residency Programs (Data sourced from NRMP).

Even the popular press picked up on the plight of anesthesiologists with a 1995 article in the Wall Street Journal called “Numb and Number: Once a Hot Specialty, Anesthesiology Cools As Insurers Scale Back” (asamonitor.pub/420X0b8). The article shared the challenges of Dr. Patrick Kwan, who traveled up and down California to work locum tenens jobs just to make ends meet (asamonitor.pub/420X0b8). Many anesthesiologists work as locum tenens today, but for very different financial reasons!

Figure 2: Time-Lagged Comparison of Increasing EM & Anesthesiology Residency Positions (Data sourced from NRMP).

Figure 2: Time-Lagged Comparison of Increasing EM & Anesthesiology Residency Positions (Data sourced from NRMP).

Despite increased interest in anesthesiology residency – which has become almost as competitive as radiology, orthopedic surgery, or dermatology, with a 0.16% unfilled rate in Match 2023 – interest in anesthesiology fellowship training has decreased (asamonitor.pub/3X3WYwS). In February 2018, “The Pediatric Anesthesiology Workforce: Projecting Supply and Trends 2015-2035” study predicted an oversupply of pediatric anesthesiologists (Anesth Analg 2018;126:568-78). In 2019, the pediatric anesthesiology fellowship unfilled rate doubled to 16.7%, from 8.1% in 2017 (asamonitor.pub/47JdxBQ). In 2023, the unfilled rate more than quadrupled compared to 2017, at 36.3% (asamonitor.pub/3X3WYwS). Conversely, despite decreased interest in EM residency, interest in EM fellowship training has increased (asamonitor.pub/4aUDJMU).

While physician workforce projections are “sticky,” the effect of the publications themselves on the pipeline as a self-defeating prophecy should not be underestimated (ASA Monitor 2021;85:14-5). In EM, anesthesiology, and pediatric anesthesiology, oversupply projections in 2021, 1994, and 2018 were followed by precipitous drops in program match rates. While EM clings to the hope of recovery, akin to anesthesiology’s success after its nadir in the 1990s, anesthesiology should remain vigilant, as some of the factors that contributed to the decline of interest in EM could be in anesthesiology’s future. One factor common to both specialties is the corporatization of health care, which has contributed to the increased numbers of residency programs and positions in both fields. In fact, growth in anesthesiology programs and positions parallels and overlaps entirely with the EM trajectory when shifted by six years. Will anesthesiology ultimately face the same crisis as EM five years from now in 2029? Perhaps that depends on the next workforce projection or subsequent news media publication.