Number of EM residency spots have grown by over 17% in just 4 years and are growing ever faster

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Brahnold Bloodaxe

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I was perusing the match data from 2017 and came across these numbers.
http://www.nrmp.org/wp-content/uploads/2017/04/Main-Match-Results-and-Data-2017.pdf

In 2013, there were 1,743 PGY1 EM positions, which itself was a historically high number resulting from prior extremely rapid growth in residency spots. By 2017, that number has jumped to 2,047.

Frankly, increasing spots by 17% in just 4 years is ridiculous. What's worse is that rather than slowing down, the rate of growth is increasing!

Increase in PGY1 spots from previous year:
2014: 43
2015: 36
2016: 74
2017: 152(!)

This is madness, and it's not even accounting for whatever is happening with DO residencies. At this rate, by the time I hypothetically were to finish my EM residency years from now, the total number of spots will be nearly double what it was for attendings who finished training prior to 2015.

Thoughts?

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Doctors and EPs are terrible businessmen. As un-ethical as it sounds we should be limiting the supply of emergency physicians coming on the market, in order to keep our salaries and demand high. Once the shortage ends, the CMGs are going to start colluding (price-fixing) and tightening the screws on our practice environment. Anyone at this point who goes into academics to work for a CMG is to blame to train new residents.

I give it about 5 years before the "golden age" of reimbursement is over. Better save up now!
 
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It's also interesting to note the following:

In 1990, there were 20,101 PGY1 positions across all specialties. In the 20 years from 1990 to 2010, that number rose to 22,809, an increase of a paltry 2,800 spots. But between 2010 and 2017, the total number of spots rose by an incredible 6040.

To put that into perspective, it took 34 years to increase spots by 6000 from 16,000 in 1976 to 22,000 in 2010, but after that, only 7 years to add another 6000 by 2017!

It almost seems to me like there has been a concerted effort to do to physicians what has been done to lawyers and programmers: flood our job market and make us fight tooth and nail for even the crappiest, poorly paid positions, prostrating ourselves to our empty suit overseers .

Can it be just a coincidence that this massive, unprecedented growth in residency spots that started in 2010 also happens to correspond to the time when the transformation of medicine from a profession of small business owners to corporate wage slaves was well underway? Medicine as a field driven by professionals owning their own practices did not want to see residency spots expanded because it meant more competition and lower earning power. Medicine as a field driven by MBAs and other value-transference parasites wants as many residency spots at possible, in order to reduce the cost of labor and allow them to skim ever bigger slices of the revenue generated by physicians.

The most terrifying thing is that this recent massive expansion in residency spots has not even begun to play out yet. If I increase spots from 22,000 to 28,000, that will result in a net gain of 18,000 over the first 3 years, but the effect grows larger the more time passes, even if the number of spots stays fixed at 28,000 (which it won't, of course). After 15 years, the expansion will result in a net gain of 90,000, and so on. Since the expansion happened so recently, we literally haven't yet begun to feel its repercussions. Today's medical labor market is a function of ~20,000 PGY1 spots. We are yet to experience what it will look like once 28,000 spots make their way through the chronological pipeline.
 
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Also, don't forget that some of those is going to be AOA programs that are converting to ACGME. Those spots have been there (some for a while, some new), just not accessible to MDs.
 
Also, don't forget that some of those is going to be AOA programs that are converting to ACGME. Those spots have been there (some for a while, some new), just not accessible to MDs.

Has this started happening yet? I thought 2020 was when they were going to implement that?
 
Has this started happening yet? I thought 2020 was when they were going to implement that?
2020 is when it has to be implemented by, and even that has an asterisk (programs that fail to convert by 2020 are allowed to stay open to graduate current residents, but they are unable to take new residents). The programs are already converting and already participating in the ACGME match. All the programs on the following link that say "initial accreditation" are AOA programs that can participate in the ACGME match. Since a lot of them are being forced to convert to 3 years, they have to go all in on the ACGME match (all AOA programs are 4 years, but you have to actually require a reason to be a 4 year ACGME program).

https://apps.acgme.org/ads/Public/Reports/ReportRun?ReportId=18&CurrentYear=2016&SpecialtyId=10
 
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2020 is when it has to be implemented by, and even that has an asterisk (programs that fail to convert by 2020 are allowed to stay open to graduate current residents, but they are unable to take new residents). The programs are already converting and already participating in the ACGME match. All the programs on the following link that say "initial accreditation" are AOA programs that can participate in the ACGME match. Since a lot of them are being forced to convert to 3 years, they have to go all in on the ACGME match (all AOA programs are 4 years, but you have to actually require a reason to be a 4 year ACGME program).

https://apps.acgme.org/ads/Public/Reports/ReportRun?ReportId=18&CurrentYear=2016&SpecialtyId=10

Thanks. It definitely makes me feel better to find out that the explosive growth in EM spots is largely due to reclassification of existing positions rather than the creation of real de novo slots.
 
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Before we get too carried away by training ourselves out of jobs, consider that the number of ERs and ER employment opportunities are also growing.
In my county, and the adjacent one down here in FL, they're building three new ERs this year.
I don't know which is the rate-limiting one (the appearance of new employment positions or the creation of "new" residency spots), but there's also a number of "doc loss" that needs to be counted in there as well.
People retire, they go work somewhere else doing something else, they go do "administrative things", etc.
 
Before we get too carried away by training ourselves out of jobs, consider that the number of ERs and ER employment opportunities are also growing.
In my county, and the adjacent one down here in FL, they're building three new ERs this year.
I don't know which is the rate-limiting one (the appearance of new employment positions or the creation of "new" residency spots), but there's also a number of "doc loss" that needs to be counted in there as well.
People retire, they go work somewhere else doing something else, they go do "administrative things", etc.

Also true. Just in Vegas they have opened one full acute care hospital, 3 freestandings, with two more in the works. That means openings for ~ 20 full time physicians in a market with a shortage.

At some point though, the freestanding EDs will be legislated out of existence, or they will reach market saturation. It is that point where supply will catch up and begin to exceed demand.
 
Also true. Just in Vegas they have opened one full acute care hospital, 3 freestandings, with two more in the works. That means openings for ~ 20 full time physicians in a market with a shortage.

At some point though, the freestanding EDs will be legislated out of existence, or they will reach market saturation. It is that point where supply will catch up and begin to exceed demand.
But those patients will still need to go somewhere and the hospital based EDs will be understaffed for the volume.
 
But those patients will still need to go somewhere and the hospital based EDs will be understaffed for the volume.

True, however one could argue that most of the freestanding EDs are overstaffed for the volume. It's not uncommon for sites to have 1 pt/hour and still make a profit. Many are low-acuity and could be seen by an NP or urgent care. Most hospital-based EPs see around 2 pt/hour.
 
And yet I spent 5 hours waiting in the ER last week..lol.
 
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The number of EM spots has been 'growing' because of the number of AOA (DO) residencies that have recently merged with ACGME. overall there has been not too much expansion of actual residency slots due to no significant increase in governmental funding for residency training.

Some DO programs will be closing, but these are the more 'mentorship' type of residencies such as urology. most of the DO programs easily became ACGME. so more doors are open for US graduates, DO or MD, and less spots open to FMGs.

The job market is still pretty good it appears for EM. I get at least 15 emails a day from recruiters looking for candidates. How long it will be before the job market is not in our favor I think has to do with whether we will become more along the lines of midlevel managers, and increase our midlevel supervision rather than competition with each other in the future.
 
Well the scary thing is that EM is such a young field that a very small percentage of docs are retiring each year. For a field like Ortho, more than half of their docs are 55 or older and so their labor market is more or less in equilibrium: for every 700 orthos that finish training each year and enter the labor force, there is roughly that same number retiring.

With EM? They have 2000+ grads entering the job market each year and probably only a fraction of that number retiring. So each year you have to find jobs for 1000 or more docs. There may be a shortage right now, but we're plugging that shortage to the tune of 1000+ docs a year, so I hope it's really, really big.
 
Are the new ones CMG run? They certainly have an incentive to start programs.

Depends. On one hand residents are cheap doctors for CMGs. On the other hand, screw EMCare with a rusty pole based on how they've treated my residency program.
 
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Market forces and supply and demand. Currently Demand is much greater than supply.

FSED outweighs any midlevels/increased residency spot/low retirement. This will continue to be the case where each FSED that opens up takes 5 docs out of the market. FSEDs are not slowing down and expanding to other states.

Supply will be greater than demand if FSEDs are not viable. So all ED docs should be in favor of FSEDs.

Take this away and income will plummet by 1/3. I remember when FSEDs were not in existence and EM docs in texas was taking $125-150/hr job. We all will be fighting for the $150/hr job when there are 5 docs apply for each opening in nice cities.

I am sure FSEDs will eventually die, that is when the house of cards will fall.

Once the dominoes falls, SDGs will be nonexistent. CMGs will come to hospitals and give sweet deals that hospitals can not refuse as they are paying EM docs (their largest expense) 1/3-1/2 of the current rates.
 
The number of EM spots has been 'growing' because of the number of AOA (DO) residencies that have recently merged with ACGME. overall there has been not too much expansion of actual residency slots due to no significant increase in governmental funding for residency training.

Some DO programs will be closing, but these are the more 'mentorship' type of residencies such as urology. most of the DO programs easily became ACGME. so more doors are open for US graduates, DO or MD, and less spots open to FMGs.

The job market is still pretty good it appears for EM. I get at least 15 emails a day from recruiters looking for candidates. How long it will be before the job market is not in our favor I think has to do with whether we will become more along the lines of midlevel managers, and increase our midlevel supervision rather than competition with each other in the future.

This is simply not true.

Here’s a list of ACGME emergency medicine residency programs that have opened since 2010:

- University of Washington - Seattle, WA
- University of Missouri - Columbia, MO
- Dartmouth University - Lebanon, NH
- Hackensack Health - Hackensack, NJ
- Brookdale Hospital - NYC, NY
- Hofstra Staten Island - NYC, NY
- Crozer Chester - Upland, PA
- Jackson Memorial - Miami, FL
- Adventura Health - Miami, FL
- Kendall Hospital - Miami, FL
- UCF Osceola - Kissimmee, FL
- UT Nashville - Nashville, TN
- UT Memphis - Memphis, TN
- Carilion Roanoke - Roanoke, VA
- Grand Strand - Myrtle Beach, SC
- USC Greenville - Greenville, SC
- Kaweah Delta - Vistalia, CA
- Kaiser San Diego - San Diego, CA
- Riverside Community - Riverside, CA
- UT San Antonio - San Antonio, TX
- UT Austin - Austin, TX


*The above list does not include the 18 new AOA emergency medicine residency programs that have started since 2010 that are currently applying for ACGME accreditation.
 
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The number of EM spots has been 'growing' because of the number of AOA (DO) residencies that have recently merged with ACGME. overall there has been not too much expansion of actual residency slots due to no significant increase in governmental funding for residency training.

Some DO programs will be closing, but these are the more 'mentorship' type of residencies such as urology. most of the DO programs easily became ACGME. so more doors are open for US graduates, DO or MD, and less spots open to FMGs.
Not based reality at all. The DO to MD wave hasn't really happened yet. Lots of hospitals have come to the realization that residents are cheaper than midlevels, so they have started creating more and more slots. CMS money dried up nearly 20 years ago.
Well the scary thing is that EM is such a young field that a very small percentage of docs are retiring each year. For a field like Ortho, more than half of their docs are 55 or older and so their labor market is more or less in equilibrium: for every 700 orthos that finish training each year and enter the labor force, there is roughly that same number retiring.

With EM? They have 2000+ grads entering the job market each year and probably only a fraction of that number retiring. So each year you have to find jobs for 1000 or more docs. There may be a shortage right now, but we're plugging that shortage to the tune of 1000+ docs a year, so I hope it's really, really big.
Even less based in reality. The number of doctors working in EM that aren't board certified is pretty large. And many of them are retiring. It's not like nobody was working in EDs back in the 80s. Trust me, there are plenty of jobs out there, and that isn't changing anytime soon.
I would be more worried about CMG takeovers. I'm not as worried about the FSEDs going away. It can't happen. Ambulatory surgery centers happened, and the only thing that happened to them was the facility fee was dropped, but not removed altogether. And there's a bill getting started to remove the ridiculous law created by Obamacare that doesn't let physicians own hospitals (and work at them).
 
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This is simply not true.

Here’s a list of ACGME emergency medicine residency programs that have opened since 2010:

- University of Washington - Seattle, WA
- University of Missouri - Columbia, MO
- Dartmouth University - Lebanon, NH
- Hackensack Health - Hackensack, NJ
- Brookdale Hospital - NYC, NY
- Hofstra Staten Island - NYC, NY
- Crozer Chester - Upland, PA
- Jackson Memorial - Miami, FL
- Adventura Health - Miami, FL
- Kendall Hospital - Miami, FL
- UCF Osceola - Kissimmee, FL
- UT Nashville - Nashville, TN
- UT Memphis - Memphis, TN
- Carilion Roanoke - Roanoke, VA
- Grand Strand - Myrtle Beach, SC
- USC Greenville - Greenville, SC
- Kaweah Delta - Vistalia, CA
- Kaiser San Diego - San Diego, CA
- Riverside Community - Riverside, CA
- UT San Antonio - San Antonio, TX
- UT Austin - Austin, TX


*The above list does not include the 18 new AOA emergency medicine residency programs that have started since 2010 that are currently applying for ACGME accreditation.

St John's Riverside Yonkers
Rush
UCF - Ocala
UCF - North Florida Regional
Reading Hospital (accredited April, starting '18)
 
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Anecdotally, I know that HCA is opening three EM residencies in the next few years in FL, but based off what I have heard, really only 1 of those locations is warranted. The docs where I scribe at all say the same: HCA is doing this to have cheap labor, but also to make residents buy into their way of EM, and ideally stay on after residency is complete.
 
I think were also forgetting the huge wave of baby boomers who are about to enter the market in peak numbers. Also, until meaningful insurance reform is passed and government regulations become effective, we can expect to treat anyone with critical end of life diseases in this bracket for another 30 years to come. This is why incentives for reducing readmissions is failing - because they keep coming to the ED. Hospitals may be changing their admission options, adding outpatient referral centers, and providing ACO models of system-managed care, but it isn't going to stop the deluge of senior and frail elderly patients who continue to take up our ICU beds and hold volumes. Also, this will increase our insured rate, because they will all have medicare as a minimum.

FSEDs are going to flourish in the short term, but just as easily as they have appeared, their golden reimbursements due to facility fees will eventually fall (read Anthem and Georgia). Also, the rapid expansion of these pop up ER's is going to outpace the capital to build them (read Texas Free Standing Bankruptcy and Hedge Fund) and require massive financial restructuring to secure their operation. CMG's are going to face serious Stark concerns when multiple service lines begin to mix with hospital and non-hospital entities, and eventually a decision will be made regarding enforcement of Stark provisions, or changing of the law in favor of free market economy. Physicians will be called upon to advocate for the patient and common good, and CMG's along with ACEP will be at the lobbying forefront. In short, we will be placed in a checkmate position of having to advocate for the groups that control our ability to practice.

I hate to say it, but if the infiltration of CMGs into our practice, training, and future has any hope of being stopped, it will stem from ACEP distancing itself from the corporations that sponsor their assemblies, leadership training, and clinical policies. Our ACEP directors need to take a stand and take the economics of big business away from the purity of our specialty and their mission to regulate, support, and define a standard of care.

More residency spots are hardly the issue - its the senior emergency physicians and leaders in our own specialty who are giving away our practices.
 
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Doctors and EPs are terrible businessmen. As un-ethical as it sounds we should be limiting the supply of emergency physicians coming on the market, in order to keep our salaries and demand high. Once the shortage ends, the CMGs are going to start colluding (price-fixing) and tightening the screws on our practice environment. Anyone at this point who goes into academics to work for a CMG is to blame to train new residents.

I give it about 5 years before the "golden age" of reimbursement is over. Better save up now!

The CMG's are funding the residencies. It's not a coincidence...the good buisnessmen are running the CMG's (though many aren't doctors)
 
Are there any non biased resources out that that have taken a scientific approach towards analyzing this potential issues?
 
I was perusing the match data from 2017 and came across these numbers.
http://www.nrmp.org/wp-content/uploads/2017/04/Main-Match-Results-and-Data-2017.pdf

In 2013, there were 1,743 PGY1 EM positions, which itself was a historically high number resulting from prior extremely rapid growth in residency spots. By 2017, that number has jumped to 2,047.

Frankly, increasing spots by 17% in just 4 years is ridiculous. What's worse is that rather than slowing down, the rate of growth is increasing!

Increase in PGY1 spots from previous year:
2014: 43
2015: 36
2016: 74
2017: 152(!)

This is madness, and it's not even accounting for whatever is happening with DO residencies. At this rate, by the time I hypothetically were to finish my EM residency years from now, the total number of spots will be nearly double what it was for attendings who finished training prior to 2015.

Thoughts?
A big part of this (75 of the spots in 2017, literally half of the "increase") are DO programs that are newly ACGME accredited. 9 AOA EM programs received initial accreditation and entered the match last year, and 4 entered the match the year before that. Your "the sky is falling" nonsense is eyeroll-inducing.
 
Well the scary thing is that EM is such a young field that a very small percentage of docs are retiring each year. For a field like Ortho, more than half of their docs are 55 or older and so their labor market is more or less in equilibrium: for every 700 orthos that finish training each year and enter the labor force, there is roughly that same number retiring.

With EM? They have 2000+ grads entering the job market each year and probably only a fraction of that number retiring. So each year you have to find jobs for 1000 or more docs. There may be a shortage right now, but we're plugging that shortage to the tune of 1000+ docs a year, so I hope it's really, really big.
The big problem with EM at the moment is that the vast majority of EM providers outside of cities still aren't EM residency trained. So there's plenty of room for the next 15-20 years for all these grads. But moving beyond that, I think there will be a saturation point that is hit.
 
**Cue arguments as to whether an EM-PA is better or worse than an IM/FM trained physician for those roles.**

Drink!
 
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Not based reality at all. The DO to MD wave hasn't really happened yet.

Yes it has, its already happened. There's been a significant number of AOA programs that have gained ACGME accredidation, maybe 30, and the second you do, all residents that graduate are considered ACGME, not just new ones that match. Programs have been getting acredited for 2 to 3 years now. There are several AOA programs that have graduated two classes now as ACGME classes eligible for the ABEM board.
 
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Yes it has, its already happened. There's been a significant number of AOA programs that have gained ACGME accredidation, maybe 30, and the second you do, all residents that graduate are considered ACGME, not just new ones that match. Programs have been getting acredited for 2 to 3 years now. There are several AOA programs that have graduated two classes now as ACGME classes eligible for the ABEM board.
So far as I know, only 13 have been recently accredited. There's a lot of places still in the process, but there'll be a big changeover in the next year or two. Most programs are expected to gain full accreditation, as EM is one of the better controlled osteopathic specialties, and there are several dozen of them out there.
 
This is simply not true.

Here’s a list of ACGME emergency medicine residency programs that have opened since 2010:

- University of Washington - Seattle, WA
- University of Missouri - Columbia, MO
- Dartmouth University - Lebanon, NH
- Hackensack Health - Hackensack, NJ
- Brookdale Hospital - NYC, NY
- Hofstra Staten Island - NYC, NY
- Crozer Chester - Upland, PA
- Jackson Memorial - Miami, FL
- Adventura Health - Miami, FL
- Kendall Hospital - Miami, FL
- UCF Osceola - Kissimmee, FL
- UT Nashville - Nashville, TN
- UT Memphis - Memphis, TN
- Carilion Roanoke - Roanoke, VA
- Grand Strand - Myrtle Beach, SC
- USC Greenville - Greenville, SC
- Kaweah Delta - Vistalia, CA
- Kaiser San Diego - San Diego, CA
- Riverside Community - Riverside, CA
- UT San Antonio - San Antonio, TX
- UT Austin - Austin, TX


*The above list does not include the 18 new AOA emergency medicine residency programs that have started since 2010 that are currently applying for ACGME accreditation.
That's 21 programs in 7 years, or three per year on average. Given an average program size of 8 residents, that accounts for 24 or so of the new match positions per year (or 30 if we're being generous and assuming initial classes of 10). The extra in the past couple of years is partially AOA programs switching over (such as the over 70 positions I noted to have transitioned last year alone).
 
Now would be a good time to revisit my earlier post on the topic regarding new hospital/ER construction, attrition via retirement/specialization/OtherCareers, and the ever-growing population.
 
The big problem with EM at the moment is that the vast majority of EM providers outside of cities still aren't EM residency trained. So there's plenty of room for the next 15-20 years for all these grads. But moving beyond that, I think there will be a saturation point that is hit.

Stop using the word "provider" when you want the word "physician".
 
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Right. The word you want is "physician".
But that doesn't fit for the PA-only EDs that are so prevalent in rural areas (hence "providers"), a practice that would likely cease if there were enough EM residency trained physicians to reach the saturation point. To use physician would neglect this substantial segment of positions.
 
But that doesn't fit for the PA-only EDs that are so prevalent in rural areas (hence "providers"), a practice that would likely cease if there were enough EM residency trained physicians to reach the saturation point. To use physician would neglect this substantial segment of positions.

You are correct.

I am trying to state that the arrangement of a MLP independently caring for patients in a rural setting is not and should not be considered a solution to the need for physicians, albeit subtlely and inartfully so.
 
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So far as I know, only 13 have been recently accredited. There's a lot of places still in the process, but there'll be a big changeover in the next year or two. Most programs are expected to gain full accreditation, as EM is one of the better controlled osteopathic specialties, and there are several dozen of them out there.

Nope, there's been almost 30 as of this spring. There were originally about 60 AOA EM programs, about 50 applied, and if I counted right, 28 have gained initial accredidation. I've attached the status list of the 50 AOA programs that have gone through the process and where they are at. All ones that have "initial accredidation" are ACGME accreditted and all graduates are eligible to take the ABEM board.
 

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Nope, there's been almost 30 as of this spring. There were originally about 60 AOA EM programs, about 50 applied, and if I counted right, 28 have gained initial accredidation. I've attached the status list of the 50 AOA programs that have gone through the process and where they are at. All ones that have "initial accredidation" are ACGME accreditted and all graduates are eligible to take the ABEM board.
I was talking about as of Match time. If you look at the dates, the majority of those programs were approved too late to be Match-eligible, which would prevent them from affecting the statistics that the OP was concerned about.
 
I was talking about as of Match time. If you look at the dates, the majority of those programs were approved too late to be Match-eligible, which would prevent them from affecting the statistics that the OP was concerned about.

Oh I gotcha. That makes sense. About half of the programs were accredited before the match of this year, and half after.
 
Oh I gotcha. That makes sense. About half of the programs were accredited before the match of this year, and half after.
And many that were accredited before were accredited in January, which is too late for match eligibility. Next year there's going to be a huge jump in spots.
 
But that doesn't fit for the PA-only EDs that are so prevalent in rural areas (hence "providers"), a practice that would likely cease if there were enough EM residency trained physicians to reach the saturation point. To use physician would neglect this substantial segment of positions.

If these rural EDs have gotten away with paying $80/hr to PAs to staff their ED shifts for years or even decades, why would they all of a sudden decide replace them with $200/hr board certified EM docs even if they were available?
 
And many that were accredited before were accredited in January, which is too late for match eligibility. Next year there's going to be a huge jump in spots.

Yes and no. There will be about 15 or so newly eligible programs in the ACGME match from the AOA, but only the ones that went 3 years will likely be matching their spots in the ACGME match. Because if they stayed 4 years, they can match in either match, and I'd imagine most former AOA programs will continue to utilize the AOA match until they no longer can because they don't have to compete with 160 other ACGME programs for candidates. The programs that went 3 years, they have to match all their spots in the ACGME match.

How many went 3 vs 4? I don't know honestly. I've never been able to find that answer anywere, I've even gone as far as looking on programs websites but many weren't updated after they got initial accreditation to state whether they are a 3 or 4 year program. If anyone knows how many of the roughly 30 former AOA programs that got initial acredidation are a 3 vs 4, I'd love to know!
 
Yes and no. There will be about 15 or so newly eligible programs in the ACGME match from the AOA, but only the ones that went 3 years will likely be matching their spots in the ACGME match. Because if they stayed 4 years, they can match in either match, and I'd imagine most former AOA programs will continue to utilize the AOA match until they no longer can because they don't have to compete with 160 other ACGME programs for candidates. The programs that went 3 years, they have to match all their spots in the ACGME match.

How many went 3 vs 4? I don't know honestly. I've never been able to find that answer anywere, I've even gone as far as looking on programs websites but many weren't updated after they got initial accreditation to state whether they are a 3 or 4 year program. If anyone knows how many of the roughly 30 former AOA programs that got initial acredidation are a 3 vs 4, I'd love to know!
I'm betting most stay 4 years for the hospital labor.

As to "competing with the other ACGME programs," they will likely get higher calibre applicants in the ACGME match, all things considered. Literally every PD I've talked to in every other field has said they withdrew from the AOA match for specifically that reason, as AOA candidates simply aren't as good on average.
 
I'm betting most stay 4 years for the hospital labor.

As to "competing with the other ACGME programs," they will likely get higher calibre applicants in the ACGME match, all things considered. Literally every PD I've talked to in every other field has said they withdrew from the AOA match for specifically that reason, as AOA candidates simply aren't as good on average.

I personally agree, but I don't think its an MD vs DO thing (I don't think that's what you were implying, but wanted to clarify it so no one misunderstands). I want the best candidates, regardless of where they train. When you are a newly accredited community EM program, you aren't getting elite allopathic candidates applying unless they are from your town or unless you open a program in a great place to live. I'd much rather match a top tier DO than an MD who's failed their boards and got mid to low 1/3 SLOEs. But you do get a higher calibre of candidate in the ACGME match, and that's because the best DO candidates usually forgo the AOA match and enter the ACGME match as well.

I disagree though that most will stay "4 years because of the labor". Its the same number of spots. If you are a 6 per 4 or an 8 per 3, it's 24 GME spots regardless. Hospitals budget on the total number of GME spots they are funding altogether, not how many are in each class. So the expense is the same, assuming the number of spots are the same. When we got accreditted, we went from a 6 residents/4 year program to an 8 resident/3 year program. Budget neutral, 24 total spots.

The problem long term with going 4 years. Only 10% or so, maybe less, of ACGME EM programs are 4 years. To be a 4 year program, you can't just decide that's what you want and get it. You have to justify to the ACGME a significant benefit your residents get by doing a 4th year as opposed to graduating via the typical 3 year pathway. You can't just tell the ACGME you want a 4 year program because you need the labor. And many of the AOA programs were in smaller hospitals without significant research opportunity. It's much harder to justify a 4 year program at institutions like that. Look at the current 4 year ACGME programs, the vast majority are located in huge name places. USC, Hopkins, Penn, etc.

That, combined with the fact that 4 year programs are generally less popular amongst most candidates, and the candidates that want a 4 year program are generally doing so because they want to do big time research at a big institution, and aren't going to go to a tiny former AOA program in a small hospital with limited research opportunities, makes staying 4 years unattractive to many. Virtually the only benefit to stay 4 years is to still be eligible to match in the AOA match the next 2 years. After that, those programs that stay 4 years are going to really struggle to be competitive I think.
 
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Knowing that EM has one of the highest burnout rates, I would be willing to bet that the average EM doc's career in medicine is shorter than the above mentioned ortho surgeon or anesthesiologist in full time medicine. I have no evidence to base this on, but food for thought.
 
I disagree though that most will stay "4 years because of the labor". Its the same number of spots. If you are a 6 per 4 or an 8 per 3, it's 24 GME spots regardless. Hospitals budget on the total number of GME spots they are funding altogether, not how many are in each class. So the expense is the same, assuming the number of spots are the same. When we got accreditted, we went from a 6 residents/4 year program to an 8 resident/3 year program. Budget neutral, 24 total spots.

Wouldn't it be slightly budget positive since you no longer have the more expensive PGY4? If, for example the pay was PGY1: 46.5k, PGY2: 48k, PGY3: 50, and PGY4: 52, the difference in pay alone is $23k by eliminating the top step.
 
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