About Carl Preiksaitas, MD

Medical Education Fellow
Department of Emergency Medicine
Stanford University School of Medicine

Mismatch: Why were there so many unfilled emergency medicine residency positions in 2023?

The Study

In an Annals of Emergency Medicine paper, Preiksaitis et al. sought to identify program factors associated with unfilled post-graduate year 1 (PGY-1) emergency medicine (EM) positions in the 2023 Match [1]. The authors completed a cross-sectional, observational study using National Residency Matching Program (NRMP) data and examined 9 variables as potential predictors of unfilled PGY1 positions using regression analyses [2].

The Findings

The authors identified 6 program characteristics associated with unfilled EM PGY-1 positions in the 2023 Match:, smaller program size (< 8 residents), Mid-Atlantic or East North Central location in the United States, prior accreditation by the American Osteopathic Association, unfilled positions in the 2022 Match, and corporate ownership structure. Program type, length, proximity to other programs, and first accreditation year were not predictive characteristics. Many of these findings were similar to a study of the 2022 EM Match results by Murano et al., as well as an analysis of the 2023 Match by Pupazan and Cook in Emergency Medicine News [3,4].

Match 2023, mismatch, emergency medicine residency programs unfilled positions

Match Data

The unprecedented numbers of unfilled PGY-1 EM residency training positions in the NRMP Match results shocked the specialty these last two years. In 2022, unfilled PGY-1 positions totaled 219 (7.9%), and 554 (18.4%) positions were unfilled in 2023 [2,5]. In contrast, the greatest number of unfilled PGY-1 positions in the last decade was 30 (1.2%) in 2019 [6]. A staggering 131 (47%) EM residency programs had unfilled PGY-1 positions among in 2023 [7].

What does this mean for the future of EM?

Who knows? We can’t make such predictions based on data from only 1 Match cycle. We need to closely follow these numbers in the coming years to fully understand trends in student behavior and program expansion. EM was once considered a competitive specialty, but the current supply/demand mismatch of positions to applicants now suggests otherwise. Without a significant influx of additional applicants, the high unfilled rate for EM is likely to continue for the next several years. This has implications for the composition of the EM physician workforce and its adequacy to meet the rising demand for emergency services.

Is student disinterest the problem?

Many have focused on changes to specialty preferences by students as the major driver in these dramatic Match results. However, the decrease in applicants to EM programs may not be the whole story. 2021 was an unusual outlier in the EM Match, likely fueled by the unique circumstances surrounding the COVID pandemic. Comparison of today’s applicant numbers to data from 2021 gives a false impression of applicant numbers. In fact, the average number of applicants between 2015-2020 and 2022-2023 were relatively similar, with the latter demonstrating 122 more applicants (2,801 vs 2,923). However, between 2015 and 2023, the number of available EM positions grew, with an annual addition of 149 PGY1 positions. Although the establishment of new EM programs is often cited as the source of this growth, anywhere from 25-50% of these new positions were due to the expansion of existing residency programs over several different years. With these data in mind, it makes sense to consider the program factors associated with unfilled residency positions and ensure that we don’t exclusively focus on improving recruitment.

What can residency programs do in this upcoming Match cycle?

Programs that have one or more of the characteristics identified in this study are at risk of being unfilled in the Match once again in the next cycle. Many of these characteristics are immutable. Deliberate actions are required to mitigate the risk:

- Interview more candidates
- Submit a longer Rank Order List
- Optimize program website and digital presence
- Broaden online recruitment efforts to target students in other regions of the country
- Enhance marketing efforts for medical students at nearby schools
- Improve the ‘brand experience’ for visiting students and applicants on interview day

What can we do to help recruitment for our specialty?

Excerpted from the paper, “The most impactful elements of student recruitment to our specialty remain unchanged: student mentorship and exposure to the elements of emergency medicine that make for a rewarding career.”

Mentor pre-clinical medical students to build early interest in the field
Describe your love for the specialty during ED shifts with students
Remain positive when interacting with students
Don’t role model burnout on shift
Explain the limitations of recent EM workforce projections

Conclusion

In conclusion, the landscape of the EM Match is shifting, evidenced by the startling numbers of unfilled PGY-1 positions in recent years. Our deep dive into the factors contributing to these outcomes shed light on several program characteristics associated with unfilled positions. It’s important, however, not to let these figures contribute to a panic regarding the future of EM.

Sure, the increase in vacant spots seems unnerving at first glance, but there’s context to be considered. The surge in EM positions and the relatively steady number of applicants speaks volumes about the supply-demand dynamics at play, something that will require a detailed exploration in its own right. Data points like these do not exist in a vacuum. They’re part of a larger, interconnected system influenced by myriad factors — from medical school experiences to external forces like the pandemic, the changes in the employment structure of many emergency departments, and the current landscape of the healthcare system in general.

Absolutely, the key mission of EM – providing quality care to everyone, at any time – stays constant even as we face these challenges. Remember, even though there were 554 unfilled positions from the 2023 Match, an impressive 90.4% (501 positions) were filled during the Supplemental Offer Acceptance Program (SOAP) [5]. For now, the current workforce and pipeline of new emergency physicians appears stable.

While it’s important to understand and address the dynamics of recruitment, our main goal should always be the training of new doctors. Right now, there are 2,957 interns just starting out who need our guidance and support. They’re the future of our specialty, and our priority should be to help them become the best emergency physicians they can be. Despite the ups and downs of the Match process, let’s not lose sight of our most important job: training the next generation of EM physicians.

References:

Preiksaitis C, Krzyzaniak S, Bowers K, Little A, Gottlieb M, Mannix A, Gisondi MA, Chan TM, Lin M. Characteristics of Emergency Medicine Residency Programs With Unfilled Positions in the 2023 Match. Ann Emerg Med. 2023 Jul 11:S0196-0644(23)00429-8. PMID: 37436344.
National Resident Matching Program. 2023 Main Residency Match: Advanced-Data Tables. Published March 17, 2023.
Murano T, Weizberg M, Burns B, Hopson LR. Deciphering a Changing Match Environment in Emergency Medicine and Identifying Residency Program Needs. West J Emerg Med. 2023;24(1):1-7. PMID: 36735008.
Pupazan, Ionut MD; Cook, Thomas P. MD. Unfilled Residencies were Newer, Rural. Emergency Medicine News 45(7):p 1,22, July 2023.
National Resident Matching Program. 2022 Main Residency Match: Results and Data. Published May 2022.
National Resident Matching Program. 2023 Main Residency Match By the Numbers. Published March 2023.
National Resident Matching Program. NRMP Program Results 2019-2023 Main Residency Match. Published March 2023.

By Carl Preiksaitas, MD|2023-07-16T17:20:33-07:00Jul 17, 2023|Academic, Medical Education, Medical Student|

A bottle of nail glue and timolol eye drops (reproduced with permission from BMJ Publishing Group Ltd [1])

You are working a busy shift in your department’s fast track area and sign up for a patient with a complaint of “eye pain.” The patient is a fan of glue-on nails and mistook her nail glue bottle for her eyedrops. Now she is unable to open her eyelid for the exam and you struggle to open it yourself. You want to avoid cutting the adhered eyelashes and wonder if there’s a better solution.

Background rise of artificial, press-on nails

Artificial acrylic or “press-on” nails were first invented in the 1950s; however, they did not gain in popularity until the 1980s as nail art became a trend [2]. Shortly thereafter, they fell out of style until a resurgence occurred with the COVID pandemic forcing the closure of nail salons. Compared to pre-pandemic values, Google searches for “press on nails” increased 300% [3]. Application of most nails requires nail glue, which often contains a mixture of alcohol, cyanoacrylate (superglue), or photo-bonded methacrylate [4].

Nail glue complications

Use of nail glue at home can result in adverse exposures with the most common location being the eye [5]. Because nail glue is often packaged in small containers identical to eye drop bottles, patients can mistake the nail glue for ophthalmic drops — especially those with visual impairment [6]. This exposure was first described in the medical literature in 1982 and has been described many times since despite repeated calls for manufacturers to modify the bottles to be safer [1].

In the presence of water, cyanoacrylate rapidly polymerizes, leading to the bonding effect [5]. If the glue gets into a person’s eye, reflexive blinking pushes the glue to the eyelid margins resulting in the eyelashes or eyelid margins sticking together [5], also known as inadvertent tarsorrhaphy. Methods to open the eyelids include removal of glue with forceps, removal or cutting of the eyelashes, or soaking the eye for hours to days with a moist gauze [1, 6, 7].

Although the most successful solvent to dissolve dried glue is acetone, this can cause corneal and conjunctival injuries [8]. The effectiveness of other solvents has been debated in the literature with mixed reports of efficacy [9].

Trick of the Trade: Apply petroleum-based topical antibiotic ointment

Our personal experience managing several of these cases suggests that a petroleum-based topical antibiotic ointment, such as Bacitracin, can help loosen the glue bond. It is an inexpensive option with minimal harm to fix inadvertent eyelid adhesion from nail glue (or other superglue). It is worth trying before attempting more aggressive techniques.

eyelid nail glue adhesion inadvertent tarsorrhaphy ointment

Before and after application of topical antibiotic ointment to remove inadvertent nail glue causing eyelid adhesion

Materials Needed

Bacitracin ointment (1-2 tubes)
Cotton-tipped applicatiors (Q-tips)

Technique

Apply the topical ointment liberally to the affected eye.
Let rest undisturbed for 15-20 minutes.
Gently pull the eyelids and eyelashes apart.
- Be careful not to massage the area too vigorously onto the eye itself, as any residual local glue can result in corneal trauma.
- You can use cotton-tipped applicators to help gently tease the lid margins apart.
Copiously irrigate the eye.
Perform an eye exam to assess for ocular injury.
Consider obtaining an ophthalmology consult.

References

Yusuf IH, Patel CK. A sticky sight: cyanoacrylate “superglue” injuries of the eye. BMJ Case Rep. 2010;2010:bcr11.2009.2435. doi:10.1136/bcr.11.2009.2435
Quinn J. Not Your ’80s Press-Ons: Why the Press-On Manicure Trend Is a Must-Try. Sunday Edit. Published June 10, 2022. Accessed October 26, 2022.
Google Trends on “press on nails”. Google Trends. Accessed October 26, 2022.
Brambilla E, Crevani M, Petrolini VM, et al. Exposure to Nail and False Eyelash Glue: A Case Series Study. Int J Environ Res Public Health. 2020;17(12):E4283. doi:10.3390/ijerph17124283
Forrester MB. Characteristics of ocular nail glue exposures reported to the National Electronic Injury Surveillance System during 2000-2019. Clin Toxicol Phila Pa. 2021;59(7):633-638. doi:10.1080/15563650.2020.1834115
Samet A, Li DQ, Al-Qahtani A, Arthurs B, El-Hadad C. Nail glue injuries to the eye: assessment of two cases. Can J Ophthalmol. 2022;57(1):e11-e13. doi:10.1016/j.jcjo.2021.04.026
Cohen J. Super Glued Shut. Brown Emergency Medicine. Published Apr 12, 2017. Accessed February 5, 2023.
Reddy SC. Superglue injuries of the eye. Int J Ophthalmol. 2012;5(5):634-637. doi:10.3980/j.issn.2222-3959.2012.05.18
Prouty H, Adams DS, Heard K. Evaluation of Treatments for Cyanoacrylate Eyelash Adhesion Using an In-Vitro Model. Cutan Ocul Toxicol. 2008;27(1):11-14. doi:10.1080/15569520701856732

By Carl Preiksaitas, MD|2023-02-06T13:59:27-08:00Feb 8, 2023|Ophthalmology, Tricks of the Trade|

It feels like yesterday that we were sheltered-in-place, staring at our computers, wondering, “So now what?”

As COVID-19 paused all in-person educational sessions, the early morning residency conference we used to begrudgingly join quickly became something that we profoundly missed. While we can now be “present” while wearing sweatpants and a button-down shirt, we miss the human connection. Many of us would gladly even suffer through traffic just to be a part of this morning conference tradition.

As educators and innovators, we know what a disruptive force the COVID-19 pandemic has been to the medical community. It has strained our medical and healthcare systems and has irrevocably altered our day-to-day lives. Without a doubt, the pandemic also changed how we delivered educational content to our learners over the past year.

Scholars have written about how likely this pandemic will likely precipitate the much-needed digital transformation of healthcare and health professions education that many of us have expected and hoped for. But while some of these innovations are born out of necessity, they may also inadvertently isolate us from the experiential aspects of education and human interaction that provide meaning to our work. For the ALiEM team, we cherish the opportunity to be part of some of these significant innovative and positive “disruptions,” further aligning our goal of creating an impactful and fulfilling academic life in emergency medicine.

The Backstory

As a remote team working across continents, the ALiEM team has thrived on digital connection for over a decade. With excellent collaborators and volunteers representing different parts of the world, our daily operations require us to stay connected and work asynchronously to achieve our goals and deliverables. When the lockdowns hit, we leveraged its impact on physical distancing and leaned into connecting with each other even more! They say “chance favors the prepared mind,” and there we were, already on Slack and yearning for the opportunity to harness the power of teamwork using our shared passions, individual creative strengths, and enthusiastic and supportive emojis. There were moments of creating, moments of celebration, and moments of simply being with each other – often through an evening #WifiAndWine.

By the Ides of March 2020, an auspicious time indeed, we knew we were at a turning point. Our friends and work families had been working on the front lines combating the pandemic locally, gathering PPE, and studying the effects of a virus we knew next to nothing about. New information was coming in daily, and the signal-to-noise ratio was low. In some ways, to escape the disruptions going on all around us, we banded together to focus our unique energies toward creating something as novel as the virus itself in the realm of free open-access medical education.

At a time where everyone was feeling alone, we asked ourselves how we could support the joy of learning from and with each other? In truly whirlwind fashion, the first ALiEM Connect conference went from idea to execution in less than 2 weeks, a record-breaking time even for ALiEM. Thank especially to the American Board of Emergency Medicine for sponsoring these events.

We recently made it to the semi-finals at the CORD/ACEP Innovator of the Year competition, where we shared the below video capturing the fun, collaboration, and innovative outcome of our efforts. Oh, and the familiar ratatat of Slack.

Making this a Multiple Win

The secret sauce of the ALiEM team is that we have a diverse group of people, each of whom brings their own perspective and that we are able to share with one another liberally. Dr. Michelle Lin encouraged an environment that is psychologically safe and supportive since the inception of the ALiEM enterprise. It is out of this space that our diverse team was able to successfully bring a massively successful project to fruition amid a global pandemic. What started as a small brainstorming session blossomed into ALiEM Connect – 3 distinct remote conferences featuring nationally-recognized educators and thought leaders enjoyed by residents across the country.

It’s difficult to express as a linear narrative, but looking back, it seems as though our team divided into unique roles without a second thought. Just like a production company, we had the front and back of the house. Those in the front made sure to help get people in the seats to watch; stage managers and coordinators ensured that every part of each of the ALiEM Connect experiences was phenomenally smooth. We had talented individuals who acted as hosts and speakers to ensure that each of these experiences was top-notch and engaging. In the back, Drs. Mary Haas, Yusuf Yilmaz, and Teresa Chan sprung quickly into action to create a program evaluation strategy for our ALiEM Connect program, including a formal institutional review board exemption! All the while, testing and vetting platforms and methods to distribute the material were ongoing. We built upon each technological skill, learned new platforms, and trialed different features. We had barely decided on an open, free, and accessible platform (which was, in fact, no individual platform but an amalgamation of many!) before sending out the invites.

But the fun didn’t stop there! We’re the “academic” life in emergency medicine! How could we not also share our results with the traditional academic community? Within days of finishing our first ALiEM Connect experience, our program evaluation team generated the scaffolding of a manuscript to put together our thoughts and analyze the evaluation data collected. We harnessed the power of metrics from social media platforms (YouTube, Slack, Twitter), website analytics, and end-user experiences. Harnessing all of these analytics and communicating the right message with our academic medicine community was important to inform and help others to replicate similar approaches to their residents. Our team used ready to use metrics which came from YouTube analytics. But we did not stop there as we needed more reports of how the residents and programs interacted during the Connect events in the backchannel, Slack. We developed Python supported software to export and analyze all the messages happening in separate channels. We developed a “Emoji Cloud” to see how the reactions happened, and closely analyzed the messages during the event.

Given the true novelty of the experience, we figured we might as well shoot for the moon, as they say, by submitting our innovation description paper to Academic Medicine. After all, even if they didn’t accept it, we might get some constructive reviews, to say the least. As innovators, we are comfortable with the possibility of failure. We understand the value of the saying, “You miss 100% of the shots you don’t take,” and were prepared to accept “no” as an answer. With that, we took a calculated risk, making use of the same collaborative strategy to craft a manuscript, and clicked submit.

…And we’re glad we took that shot! We are excited to share that what we sent was indeed accepted and express our gratitude for the chance to share our low-cost approach to a large-scale, nationwide residency conference! You may read the Published Ahead-of-Print version of our paper.

Moral of the story…

You might be asking yourself, “What’s the moral of the story here? Of course, with enough academics and experts, yeah, you got a paper published. Cool…” But the papers aren’t the point. In fact, during the COVID-19 pandemic, more papers have been published than ever before – more research is being done, and our whole field is changing. The point is… this is how we got to ENJOY the academic life during a pandemic! We made lemonade (and several other desserts!) out of the lemons we were handed. New knowledge comes from thinking big and trying new things. Turns out, sometimes you also have to write about those experiences and share them with others.

As emergency physicians, we know we’re good in a crisis. But this experience reminded us that by surrounding ourselves with amazing people, we could get a surprising amount of work done (at record speed) and have a fantastically memorable time along the way. The moral of this story is that when you bring great people together and give them a chance to get to know each other, magic happens. ALiEM Connect happens. And we impact more people than we can possibly meet at the touch of our keyboards. We are so grateful for the chance to work alongside all the wonderful people at each of our institutions every day. Still, also, we are indebted to those who are our digital family. Thank you to all of you who make initiatives like ALiEM Connect possible. Academic life in emergency medicine is all about bringing a great team together.

So is the ALiEM team.

By Carl Preiksaitas, MD|2021-04-23T11:02:57-07:00Apr 26, 2021|Academic, Beyond the Abstract, Education Articles, Medical Education, Professional Development, Social Media & Tech|