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About Michael Gisondi, MD

Associate Professor and Vice Chair of Education
Department of Emergency Medicine
Stanford University
Editor, ALiEM EM Match Advice series

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:

  1. 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.
  2. National Resident Matching Program. 2023 Main Residency Match: Advanced-Data Tables. Published March 17, 2023.
  3. 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.
  4. Pupazan, Ionut MD; Cook, Thomas P. MD. Unfilled Residencies were Newer, Rural. Emergency Medicine News 45(7):p 1,22, July 2023.
  5. National Resident Matching Program. 2022 Main Residency Match: Results and Data. Published May 2022.
  6. National Resident Matching Program. 2023 Main Residency Match By the Numbers. Published March 2023.
  7. National Resident Matching Program. NRMP Program Results 2019-2023 Main Residency Match. Published March 2023.

By |2023-07-16T17:20:33-07:00Jul 17, 2023|Academic, Medical Education, Medical Student|
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The Fall of FOAM

Fork in Road Disappearance of FOAM blog podcast

The landscape of emergency medicine and critical care (EM/CC) blogs and podcasts has changed dramatically over the past 20 years. The number of free, open-access EM/CC blogs and podcasts has plummeted. As reported by Lin and colleagues in JMIR Education (2022), these sites decreased in number from 183 in 2014 to just 109 this year– a drop of 40.1% [1].

via GIPHY

This comes after a period of rapid growth of these educational resources in the late 2000’s [2], with expectations that new sites would continue to come online. It is unclear when the combined number of EM/CC blogs and podcasts peaked, or how recently it declined.

Why do we care in these declining numbers?

The FOAM (free open-access medical education) movement has become an important component of EM curricula at many training programs. Online learning resources such as medical blogs and podcasts have all but replaced traditional textbooks, and research suggests that some trainees use these products as their primary study materials [3]. Therefore, the observed decrease in FOAM sites is alarming, as training programs and trainees have come to rely on their availability.

Featured paper

In our JMIR Medical Education paper, Lin et al. sought to identify active EM/CC blogs and podcasts during a 2-week period in May 2022. The authors found a total of 50 blogs, 25 podcasts, and 34 blogs + podcasts (n=109). The age of these FOAM sites ranged from 1-18 years and most were physician-led. Just over half had leadership teams of 5 or more individuals. Support was identified for approximately 75% of the sites and included advertisements, institutional sponsorship, or the sale of goods and services (though site access remained free).

The Christensen Theory of Disruptive Innovation may explain the recent decline in EM/CC blogs and podcasts. Using this lens, FOAM sites are considered ‘disruptors’ in medical education that quickly gained market share previously dominated by ‘incumbents’ such as medical textbooks, journals, and in-person conferences. Rather than cede their influence, incumbent organizations co-opted the disruptive innovation itself, in this case leveraging their assets to create their own online learning resources, blogs, and podcasts. As these incumbent offerings grew, there was less need for new, independent FOAM sites. Concurrently, FOAM sites continue to generate little-to-no revenue and academic value for the creators, making it difficult for the disruptors to challenge the market dominance of incumbents or to create its own unique, sustainable market space. We theorize that older sites likely succumbed to these financial and academic opportunity costs as well as high user expectations for design and functionality.

What is the future of FOAM?

Though EM/CC blogs and podcasts changed the landscape of medical education in fundamental ways, they will likely not endure as independent entities without new business models for sustainability. A recent study suggests that the costs of FOAM might be offset by advertising or other revenues [4]. Based on our observations of current practices on existing FOAM sites, this might include at least incorporating any/all of the following:

  1. Inserting advertisements
  2. Creating products for sale such as books, courses, swag, or consulting services
  3. Developing partnerships
  4. Soliciting for donations

In the meantime, we posit one of 3 potential futures of new and existing blogs and podcasts: hybridization, disappearance, and new-market independence.

future of foam christensen

  1. Hybridization strategy: Incumbents partner with or create their own blogs/podcasts. This loss of independence, which was part of the initial appeal of FOAM grassroots efforts, is traded for more stability and infrastructure. Already 44% of EM blogs are officially affiliated with a sponsoring institution.
  2. Continued disappearance of sites: Progressively fewer independent, free blogs/podcasts because of site demise, merging of sites, or conversion to paid subscription model
  3. Independent sustainability: Growth of independent, free blogs/podcasts as its own new-market endeavor, separate from the incumbent market space, only achievable with better return on investments (academically and financially) for bloggers/podcasters. Once FOAM efforts are no longer a major opportunity cost, educators may even be able to pivot their careers towards this primarily, rather than as a side project.

It remains to be seen whether FOAM can withstand market and academic pressures or whether it is destined to be assimilated by better-resourced incumbent organizations.

What is the future of ALiEM?

We hope to stick around and hope the rest of the FOAM community will evolve with us.

Comments?

Join the interesting discussion on Twitter. We are thrilled to bring this conversation to the forefront.

https://twitter.com/M_Lin/status/1582021848958500864?s=20&t=nBcJtrRvgML2QMRNnZkwwA

References

  1. Lin M, Phipps M, Yilmaz Y, Nash CJ, Gisondi MA, Chan TM. A Fork in the Road: Mapping the Paths of Emergency Medicine and Critical Care Blogs and Podcasts. JMIR Medical Education. 2022 (preprint available: https://doi.org/10.2196/39946)
  2. Cadogan M, Thoma B, Chan TM, Lin M. Free Open Access Meducation (FOAM): The rise of emergency medicine and critical care blogs and podcasts (2002-2013). Emerg Med J. 2014;31(e1):e76-e77. doi:10.1136/emermed-2013-203502
  3. Branzetti J, Commissaris C, Croteau C, et al. The Best Laid Plans? A Qualitative Investigation of How Resident Physicians Plan Their Learning [published online ahead of print, 2022 May 24]. Acad Med. 2022; doi:10.1097/ACM.0000000000004751
  4. Lee M, Hamilton D, Chan TM. Cost of free open-access medical education (FOAM): An economic analysis of the top 20 FOAM sites. AEM Educ Train. 2022;6(5):e10795. Published 2022 Sep 9. doi:10.1002/aet2.10795
By |2022-10-18T22:59:19-07:00Oct 19, 2022|Academic, Emergency Medicine, Medical Education, Social Media & Tech|
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How I Educate Series: Michael Gisondi, MD

This week’s How I Educate post features Dr. Michael Gisondi, the  Vice Chair of Education at Stanford University. Dr. Gisondi spends approximately 80% of his shifts with learners which include emergency medicine residents, off-service residents, medical students, and physician assistant students. He describes his practice environment as a busy, high-acuity, university-based, suburban hospital with an annual ED census of 85,000. One-third of the patients speak a language other than English and one-third are without health insurance. Below he shares with us his approach to teaching learners on shift. 

Name 3 words that describe a teaching shift with you.

Direct observation & autonomy

What delivery methods do use when teaching on shift?

Hypothetical questioning

What learning theory best describes your approach to teaching?

Relational autonomy

What is one thing (if nothing else) that you hope to instill in those you teach?

Patients deserve comprehensive evaluations. That doesn’t mean sending every test on every patient, but it does mean considering broad differentials and testing when appropriate.

How do you balance your flow with on-shift teaching? Does this come at the expense of your documentation?

Every interaction is teaching, though perhaps it isn’t signposted as such. For instance, how much time I spend with one patient relative to another speaks volumes to those who are paying attention.

What is your method for reviewing learners’ notes and how do you provide feedback on documentation?

I read them all, and I point out errors of omission or misstatements that need correction.

Do you feel departmental flow and metrics adversely affect teaching? What is your approach to excelling at both?

Absolutely not. Being efficient is one of the most important learning outcomes during emergency medicine training. Metrics are measures of these learning outcomes and are not at odds with training in any way. Residents must learn how to excel as attendings and operational metrics are part of their future.

It can be difficult to sit back and let senior learners struggle what is your approach to not taking over prematurely?

I’ve learned to give a long leash to the senior residents. I stalk the board constantly and read all the notes, both from physicians and nursing. I sneak in to examine patients when the residents aren’t looking. I know what’s happening on my team and can gauge how much autonomy to give my residents.

Do you start a teaching shift with certain objectives or develop them as a shift unfolds?

I let the shift play itself out.

Do you typically see patients before or after they are presented to you?

I try to see as many patients with residents as possible. There are so few direct observation opportunities in training that I try to create them as much as possible. It helps me give better feedback to residents and it improves efficiency.

How do you boost morale amongst learners on shift?

Everyone gets a meal break. I try to help chart or disposition patients when busy. I liken myself to a good second-year resident.

How do you provide learners feedback?

Again, I’m giving feedback constantly, whether it is signposted or not. Simply agreeing with a plan is feedback. I find that I don’t have much to say on end-of-shift feedback forms because I’ve been teaching and giving feedback throughout the shift.

What tips would you give a resident or student to excel on their shift?

Stop for 3 minutes after every patient and write the H&P in the chart. It will save so much time later in your shift. Similarly, complete your entire note before calling report. It saves you and the admitting team a lot of time on the phone.

Are there any resources you use regularly with learners to educate during a shift?

Equianalgesic opioid dosing charts.

What are your three favorite topics to teach during a shift?

Running a code, motivational interviewing, and how to remove an ingrown toenail

What techniques do you employ when teaching on shift?

Relational autonomy, direct observation, The Feedback Formula.

What is your favorite book or article on teaching?

Fostering the Development of Master Adaptive Learners: A Conceptual Model to Guide Skill Acquisition in Medical Education

Who are three other educators you’d like to answer these questions?

Holly Caretta-Weyer, Abra Fant, Sara Krzyzaniak

 

How I Educate Series logo

Read other How I Educate posts for more tips on how to approach on-shift teaching.

 

By |2022-07-29T09:06:43-07:00Aug 3, 2022|How I Educate, Medical Education|
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EM Match Advice 37: EM Program Directors Reflect on the 2022 Match

EM Match Advice 10 year table residency match

In this 37th episode of EM Match Advice, we discuss the results of the 2021-22 EM Residency Match with lots of shocking numbers and surprises to review. The table above lists the trends and data since 2014, extracted from the National Resident Matching Program (NRMP) site [1]. Could this have been foreseen? What does this mean for the 2022-23 EM Match season? In this podcast, Dr. Mike Gisondi and Dr. Michelle Lin host the following esteemed panel of 3 program directors to review this juicy table and discuss the future:

  • Dr. Abra Fant (Northwestern University)
  • Dr. Sara Krzyzaniak (Stanford University)
  • Dr. Bonnie Kaplan (Denver Health)

More Numbers from ERAS/AAMC by Program

emergency medicine EM Match Advice ERAS table

EM Match Advice Podcast

 

Read and Listen to the Other EM Match Advice Episodes

Blog posts: https://www.aliem.com/em-match-advice-series/

 

References and Additional Reading

  1. National Residency Match Program: Data and Reports
  2. Pelletier-Bui AE, Schnapp BH, Smith LG, et al. Making Our Preference Known: Preference Signaling in the Emergency Medicine Residency Application. West J Emerg Med. 2021;23(1):72-75. Published 2021 Dec 17. doi:10.5811/westjem.2021.10.53996. PMID 35060866
  3. Preference/Program Signaling (PS) in Emergency Medicine. CORD website, 2022.
By |2022-05-28T09:30:51-07:00May 11, 2022|EM Match Advice, Podcasts|
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EM Match Advice 36: It’s Time to Make Your Rank List

Now that interview season for residency match has concluded, our residency director panel tackles the hot topic of making your rank list, which includes “love letters” to programs and second look visits. In this podcast, Dr. Mike Gisondi and Dr. Michelle Lin host an esteemed panel of 3 program directors, Dr. Emily Fisher (University of Oklahoma), Dr. William Paolo (SUNY Upstate), and Dr. Michael Van Meter (University of Texas Health Science Center at Houston) to discuss these issues. Good luck to everyone in the match this year!

EM Match Advice Podcast

Read and Listen to the Other EM Match Advice Episodes

Blog posts: https://www.aliem.com/em-match-advice-series/

By |2022-04-26T16:24:10-07:00Feb 9, 2022|EM Match Advice, Podcasts|
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EM Match Advice: Where did all the jobs go, and did the applicants follow?

In this episode of EM Match Advice, our panel takes on the tough issues of 2021. Specifically we discuss the American College of Emergency Physicians (ACEP) Workforce Study [1] that projects fewer jobs for emergency physicians and the hot-off-the-press ERAS data showing a drop in the number of EM residency applicants, compared to 2 years ago. Did one cause the other? In this podcast, Dr. Mike Gisondi and Dr. Michelle Lin host an esteemed panel of 3 program directors, Dr. Cassandra Bradby (East Carolina University), Dr. Adam Kellogg (Baystate Health), and Dr. Craig Krausz (Saint Louis University).

The Numbers

  • The ACEP Workforce Study projects a whopping 7,845 excess of emergency physicians in 2030 who could be left without jobs. And our very smart medical students have been eyeing those numbers carefully.
  • While EM is still an attractive specialty for many medical students, some enter this year’s residency application season with a trepidation that hasn’t been seen before. And a good deal of  students clearly chose a specialty other than EM, with approximately 200 fewer applicants projected this cycle, compared to 2 years ago. Most of that drop came from students at LCME-accredited medical schools. [Silver lining: These numbers may make for a buyer’s market that greatly favors the students in the upcoming Match.]
  • Below is a summary of the ERAS data, pulled from their downloadable Excel data. Note that these data were collected on October 3 of each year and only summarize data from EM-only residencies (not EM/IM or EM/FM).
Characteristic2016-172017-182018-192019-202020-21*2021-22
Number of EM residency applicants3,2203,3303,3383,601x3,408
Average number of submitted applications in EM49.153.3557.8659.75x61.23
Average of applications received per EM program883.3866.6850.82874.58x772.82
AAMC’s ERAS data for 2016-2022 for the specialty of Emergency Medicine, collected on October 3 of each year
(* Because of the pandemic, the 2020-21 season’s timeline was shifted later by about 1 month, resulting in non-comparable data.)

EM Match Advice Podcast

Additional Resources

Read and Listen to the other EM Match Advice Episodes

Blog posts: https://www.aliem.com/em-match-advice-series/

References

  1. Marco CA, Courtney DM, Ling LJ, et al. The Emergency Medicine Physician Workforce: Projections for 2030 [published online ahead of print, 2021 Aug 2]. Ann Emerg Med. 2021; doi: 10.1016/j.annemergmed.2021.05.029. Epub ahead of print. PMID: 34353653.
By |2021-10-27T09:50:17-07:00Oct 30, 2021|EM Match Advice, Podcasts|
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Stanford’s INFODEMIC Conference on COVID-19 Misinformation: Open-access podcasts

In July 2021, Dr. Vivek Murthy became the first U.S. Surgeon General to declare health misinformation a public health crisis. Specifically, COVID-19 vaccine misinformation and disinformation on social media greatly affects vaccination rates in certain populations. Rapid increases in reliable health information about COVID-19 can be overshadowed by the spread of even greater amounts of misinformation, leading to an ‘infodemic.’

The World Health Organization defines an infodemic as:

“… too much information including false or misleading information in digital and physical environments during a disease outbreak. It causes confusion and risk-taking behaviours that can harm health. It also leads to mistrust in health authorities and undermines the public health response. An infodemic can intensify or lengthen outbreaks when people are unsure about what they need to do to protect their health and the health of people around them.”

INFODEMIC Conference on Social Media and COVID-19 Misinformation

On August 26, 2021, Stanford University’s Department of Emergency Medicine and Ethics, Society, and Technology Hub co-sponsored a unique conference to address this issue, “INFODEMIC: A Stanford Conference on Social Media and COVID-19 Misinformation.” Speakers presented virtually from around the world including experts in social media, health policy, ethics, and medicine. The conference focused on the causes of COVID-19 misinformation and mitigation strategies. Vaccine Confidence, Vaccine Hesitancy, and Vaccine Equity were among the main topics of the meeting. INFODEMIC also featured representatives from Facebook, Google, and Twitter, as well as physician influencers, to discuss the role of social media companies to address misinformation online.

Below are recordings of each of the INFODEMIC conference presentations, presented as podcasts. Video recordings of these presentations are also available to view online. The conference agenda and featured speakers are listed on the Stanford INFODEMIC website.

Podcasts

By |2021-10-06T19:40:30-07:00Oct 8, 2021|Academic, COVID19|
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