28 minute read
The Experiences and Challenges of EM-Bound International Medical Graduates
By Adebisi Adeyeye, MBBS, and Oluwarotimi Vaughan-Ogunlusi on behalf of the SAEM Global Emergency Medicine Academy
Emergency medicine (EM) has grown since its inception, becoming the 4th most popular residency choice amongst senior medical students and thus increasing the competition to match. Interest is not isolated to the United States alone as EM continues to grow internationally. However, there are few international EM training programs available, leaving many international medical graduates (IMGs) searching for opportunities to train in the United States. In this article, we shed light on the experiences and challenges of EMbound students from the perspectives of a United States (U.S.) IMG and non-U.S. IMG trained in medical schools in Europe and West Africa, respectively. This article highlights the plight of IMGs striving for advanced medical training in a specialty that has not historically favored them. Since the 1970s, EM has been recognized as a specialty in the U.S., and over the past 50 years many countries around the world have begun to offer EM residency training. South Africa was the first African country to offer EM residencies in 2004. As of 2017, an additional 11 countries, out of the 54, have introduced emergency medicine residency programs (EMRPs). According to the European Society for Emergency Medicine (EUSEM), 29 European countries recognize EM as a primary specialty. Of those, only 16 meet the European Union ‘Doctors’ Directive’ criteria, which requires training programs of at least five years. Many international medical students and doctors are left without the opportunity to pursue EM in their home countries, particularly in Low- and Middle-Income Countries (LMICs). In Nigeria, EM became a recognized specialty in 2019, and efforts to start a residency at the University College Hospital, Ibadan are underway. As a result, there are currently no EMRPs or formal EM clerkship rotations for Nigerian medical students. Additionally, Nigerian students discover the possibility of pursuing EM late in their education or not at all. The exposure to emergency care is minimal, mostly tending to emergencies whilst on core rotations in surgery, medicine, pediatrics, or ob/gyn. For example, during a 12-week pediatrics rotation, only one week is dedicated to gaining experience in the children’s emergency room. In most cases, the patient has been assessed, resuscitated,
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and stabilized with a working diagnosis in place, limiting student exposure to the core of emergency care. Students in Irish medical schools face similar issues, as access to clinical teaching in the emergency department (ED) is limited. Emergency treatment is covered in didactic lectures, but the principles of the specialty are not taught from an ED perspective unless students seek out international EM electives in their final year of medical school.
IMGs are eager to join the EM community despite the challenges they face. In Nigeria, these include no nationally accepted professional organizations, only four EM-trained physicians in the country, and little to no mentorship opportunities available. A student’s sole option is to join international professional EM organizations for the opportunity to network, participate in scholarly activity, further their knowledge about the specialty, and learn details of the match process.
In 2021, 4,332 applications were submitted to Electronic Residency Application Service (ERAS®) for an EM residency position. Of these, approximately 747 (17%) came from IMGs. In this process, 2,826 applicants successfully matched, of which 178 (6.3%) were IMGs, 143 were U.S. IMGs and the remaining 35 were nonU.S. IMGs. The table below from the NRMP 2021 Match Data illustrates the difference in match rates amongst the most matched specialties. EM not only has a low match rate relative to other specialties, but regularly receives fewer applications from IMGs as well. As the number of residency applications increases, it is likely the declining trend of IMGs matching to EM will worsen. In our view, the following are just a few contributing factors linked to the low success rates IMGs experience in the EM match:
The Standardized Letter of Evaluation (SLOE)
The SLOE is ranked as one of the most important factors in choosing applicants to interview and rank. SLOEs can only be obtained from a rotation done in the United States. The COVID-19 pandemic has thus created difficulty for IMGs due to travel restrictions and institutions’ decisions to limit external clerkship rotators. Additionally, this rotation must be done whilst one is still a medical student, thereby disqualifying many IMGs who have completed their studies from applying to EM.
No Home EM Experience
For many potential candidates, rotating in the U.S. may be the only chance for an EM rotation at all, removing the chance for IMGs to complete graded EM clerkships that can be used to obtain other letters of recommendations for ERAS applications. Even those students who have secured a U.S. EM clerkship have the additional concern of being perceived as less competitive when compared to their American
Specialty
EM
Surgery (categorical)
Pediatrics (categorical)
Family Medicine
Internal Medicine
Total Number of Applications
4332
IMG Applicants Total Matched Applicants IMG Matched
747 2826 178 (6.3%)
5,329 1,961 1,564 156 (9.97%)
5,685
12,422 2,713
7,708 2,860
4,472 552 (19.3%)
1224 (27.3%)
24,788 13,375 8,632 3416 (39.6%)
Medical Graduate (AMG) counterparts who may have done more clerkships.
Generating a Competitive ERAS
Not having a home EM program or opportunities contributes to the overall perception of IMG candidates being less competitive. Opportunities for EM research, mentorship, membership, and leadership in EM-based organizations help create rich applications for many AMGs but are not replicated in the IMG experience. These challenges constitute a series of hurdles that IMGs must overcome to match. With that in mind, we have compiled a few strategies that have been proven effective for IMG applicants:
Join a Professional EM Organization
Joining professional organizations can be advantageous for students preparing to match into EM. Organizations like SAEM, ACEP, and AAEM offer student memberships, which can be fruitful places for students to get involved with EM, attend conferences, and form important connections. Although beneficial, these networks are based in the U.S. and can be inaccessible to IMGs. This may be caused by travel and financial restrictions or difficulty attending meetings with time zone differences. In our experience, online networks for medical students pose a superior alternative. Networks, such as Advocates for IMGs and TheIMGJourney on Twitter, are creating spaces for IMGs to share information, connect, and network.
U.S.-Based Mentors
Mentorship is one of the most useful tools a medical student can utilize in preparing for their career; however, EM-specific mentorship can be difficult to come by in countries where it is not a recognized specialty and there are few physicians in the field. Students can benefit from connections with U.S.-based EM physicians, in particular other IMGs who have matched to the U.S. Developing these connections can be helpful in many ways, from finding clerkship opportunities to having support with the various aspects of the ERAS process. IMGs pursuing EM training in the U.S. work exceptionally hard to be competitive in the current residency application landscape. For some, chasing their dreams means leaving behind their home, which is a significant sacrifice. And, of those interested in EM, few actualize this dream and overcome the aforementioned challenges. The unfortunate reality is that the challenges faced by IMGs overshadow their strengths; namely their dedication to the specialty and unique point of view posed by training in different health systems and working with diverse populations. IMGs increase the diversity of the EM workforce, which has been linked to improved patient outcomes. In many cases, IMGs are qualified doctors who bring valuable patient care experience that supplements the U.S. medical workforce. An IMG perspective brings benefits ranging from promoting improvement in residency training to supporting new outputs in global health and international EM. EM is a dynamic specialty that is constantly changing and progressing. As the specialty advances, the tides will turn for EM-bound IMGs and we expect to see an improvement in perceptions and opportunities for IMGs.
ABOUT THE AUTHORS
Adebisi Adeyeye, MBBS, is a graduate of the College of Medicine, University of Lagos, Nigeria. She is currently undergoing her housemanship at a general hospital in Lagos State, Nigeria. She currently serves as president of the Emergency Medicine Interest Group in Nigeria and as a co-vice-president of the African Federation for Emergency Medicine (AFEM) Student Council. Oluwarotimi Vaughan-Ogunlusi is a fourth-year medical student at the Royal College of Surgeons in Ireland (RCSI). He currently serves as the president of the RCSI Emergency Medicine Interest Group. @timi_von
About GEMA
The Global Emergency Medicine Academy (GEMA) focuses on improvement of the worldwide delivery of emergency medical care. Joining GEMA is free! Just log in to your member profile. Click “My Account” in the upper right navigation bar. Click the “Update (+/-) Academies and Interest Groups” button on the left side. Select the box next to the academy you wish to join. Click “save.”
Addressing Tobacco Use in the Emergency Department? If Not, Maybe You Should Be!
By Nicholas Pettit, DO, PhD, on behalf of the SAEM Oncological Emergencies Interest Group
Tobacco use is common among emergency department (ED) patients, as ED patients have higher smoking rates compared to the general public. Around 5% of all ED visits are due to tobacco related illnesses, and tobacco use leads to many preventable chronic diseases. Promotion of tobacco cessation is easy and addressing tobacco use during the ED visit has the potential to address many health disparities related to tobacco use. Tobacco cessation is not routinely taught in emergency medicine education, but it is easy to learn and can be performed by nearly any member of the health care team.
ED patients frequently experience inequities in health care, such as equitable access to primary care and primary/secondary preventions. Millions of smokers utilize the ED every year, and thus the ED represents a desirable location to offer tobacco cessation interventions, especially for hard-toreach populations. Feasibility and efficacy for initiating tobacco cessation in the ED has been demonstrated by a 2019 systematic review and metaanalysis of randomized controlled trials. It has been said that getting low-acuity patients to engage in smoking cessation would likely be far more impactful for their health than nearly any other intervention available to them during their ED visit. These interventions need only take 60 seconds to perform and are both cost effective and sustainable to getting patients to stop smoking. There are various strategies available for tobacco cessation in the ED, many of which can be self-taught, however official training certificates are available. If someone is interested in quitting, physicians have both pharmacotherapy and behavioral interventions at their disposal. The simplest intervention that can be performed at the bedside is a referral to the tobacco Quitline (1-800-QUIT-NOW) which offers nearly every available tobacco cessation resource for all patients. The typical model for addressing tobacco cessation in the ED is known an SBIRT (Screening, Brief Intervention, and Referral to Treatment). Pharmacotherapy is considered the mainstay therapy for tobacco cessation for nonpregnant adults, and various
options exist including varenicline, bupropion, and nicotine replacement therapy (NRT). Varenicline and bupropion are uncommon prescriptions in the ED physician’s toolkit but are safe and acceptable prescriptions. More commonly offered to patients from the ED is NRT, which can include gum, patch, lozenges, inhalers, and sprays. Each of these therapies has specific dosing based on the patient’s individual tobacco use and several are available over the counter. Many resources are available instructing physicians and patients on how to use each of the various NRT modalities. For pregnant patients, children, and patients not interested in pharmacotherapy, behavioral therapy is the mainstay of treatment.
Tobacco use affects millions of Americans every day and EDs are uniquely situated to offer tobacco cessation interventions. Intervening with ED smokers can be easy, quick, and has the benefit of “meeting patients where they are.” Patients are more likely to sustain from tobacco use if they have a team “in their corner,” thus physicians should also discuss tobacco cessation with those that accompany the patient during the ED visit.
Health systems should encourage opportunities to engage patients in tobacco cessation and that includes offering tobacco cessation during an ED visit. You are sure to encounter a tobacco user on your next shift — consider addressing tobacco cessation with that patient.
ABOUT THE AUTHOR
Dr. Pettit is an assistant professor of emergency medicine, Indiana University School of Medicine, and chair of the SAEM Oncological Emergencies Interest Group. @DrNickDr
The 2021 Sex and Gender Health Education Summit and Steps for Inclusion of Sex and Gender Transformative Educational Content
By Mehrnoosh Samaei, MD, MPH, on behalf of the Sex and Gender in Emergency Medicine Interest Group
The 2021 Sex and Gender Health Education (SGHE) Summit was a threeday summit, held virtually, November 12-14 2021. The SGHE summit brought together educators from institutions around the United States and internationally to advance sex- and gender-specific health education across a multiprofessional network.
There is a growing recognition of the importance of sex and gender considerations in health outcomes, however, the incorporation of sex and gender differences into the health education has not uniformly and adequately happened. While sex- and gender-based medicine (SGBM) principles are directly related to all health care settings across all specialties including acute care, emergency medicine (EM) residents do not typically receive dedicated and structured education in this area. The SGHE Summit provided the opportunity to highlight innovative and sustainable curriculum methods for teaching sex- and gender-specific health. Participants learned about the “sex and gender integrative educational toolkit” to help educators assess and modify their content to become sex and gender transformative. The toolkit includes the following five steps:
Step 1
Assess the status of the current educational content which could fall into one of the following five categories: Sex and gender biased. • Stigmatizing, reinforcing stereotypes, wrong use of language Sex and gender blind. • Ignores sex and gender differences Sex and gender sensitive. • Acknowledges the differences in sex and gender without mentioning the mechanisms or contributing factors Sex and gender specific. • Acknowledges the differences
• Discusses the reasons or contributing factors or knowledge gaps • Doesn’t discuss how this information could be applied to clinical settings Sex and gender transformative. • Acknowledges the differences • Considers gender norms, roles, and relations for people of all genders • Discusses contributing factors or mechanisms of the differences or the knowledge gap • Includes knowledge translation strategies to improve patient care
Step 2
Use a checklist to identify what’s not accurate, what’s missing, and what could be improved in education materials. The checklist is derived from the book “How Sex and Gender Impact Clinical Practice”
Step 3
Identify existing resources. The following resources are examples of some that are free, available, and easy to use: • Sexandgenderhealth.org for slides and videos that can be inserted into existing presentations. • Relevant chapters from the book,
“How sex and Gender impact Clinical
Practice” • The sexandgenderhealth.org PubMed search tool for the most recent data
Steps 4 & 5
Use the resources to then edit the educational materials and reassess the modified content per steps one and two.
Additionally, the Summit aimed to increase awareness of the intersectionality of sex, gender, race, and social determinants of health to include a panel discussion focused on “Intersectionality and LGBTQ+ Health Education.’’ Emergency physicians observe the inequities experienced by underrepresented and marginalized communities during each shift. To promote health equity and reduce systemic disparities, EM trainees need to learn how to apply an intersectionality lens to clinical context and to develop conceptual framework for considering social determinants of health during each patient encounter.
The exclusive event of the Summit was the special screening of the documentary “Ms. Diagnosed”, a film that followed the stories of real women, often through the lens of emergency department care, who suffered from being misdiagnosed, and whose lives and families have been significantly affected by sex- and genderbased health care inequities. (Official trailer of the movie)
The recordings of the Summit and all the materials are still available for anyone interested in enhancing interprofessional education through a sex and gender approach. (Registration link).
ABOUT THE AUTHORS
Dr. Samaei is a research fellow in the division of sex and gender in emergency medicine, department of emergency medicine, Warren Alpert Medical School of Brown University.
About SGEM
The Sex and Gender in Emergency Medicine (SGEM) Interest Group works to raise consciousness within the field of emergency medicine on the importance patient sex and gender have on the delivery of emergency care and to assist in the integration of sex and gender concepts into emergency medicine education and research. Joining SGEM is free! Just log into your member profile. Click “My Account” in the upper right navigation bar. Click the “Update (+/-) Academies and Interest Groups” button on the left side. Select the box next to the academy you wish to join. Click “save.”
The Resident Dashboard: Creating a Virtual Interface for Trainees
By Ryan LaFollette, MD and Robbie Paulsen, MD on behalf of the SAEM Virtual Presence Committee
Throughout the COVID pandemic, emergency medicine (EM) programs have needed to intermittently move to remote learning, remote feedback, and remote relationships. These times underscore the importance in keeping a holistic look at resident performance as well as maintaining a rigorous process of feedback. While Milestones 2.0 created behaviorally-anchored data points to report performance over time, program leadership are increasingly awash in a world of qualitative and quantitative metrics and the need for a way to summarize and translate these to their residents. At this intersection of resident-sensitive quality metrics and big data comes a potential dream for residents and program leadership to have a visual dashboard that gives a more complete look at real time resident performance.
Competency Based Medical Education (CBME) and associated Entrustable Professional Activities (EPAs) have been a transformational grounding of specialty-specific metrics which create an Accreditation Council for Graduate Medical Education (ACGME)derived data set for each resident that can be trended over time. These are generated from supervising physicians after clinical exposure and may be prone to a halo effect that may homogenize
data. There have been recent efforts within medicine, including EM, to move to Observable Practice Activities (OPAs) that map to EPAs to objectively quantify micro skills of residency training (Warm et al. 2014). While these can demonstrate a resident’s progression toward entrustment and reveal potential programmatic weaknesses when viewed in aggregate, they do not necessarily ensure adequate patient and/or procedural exposure.
Resident Sensitive Quality Metrics (RSQM), which are patient-centered outcomes that can be attributed to a resident’s care, are a critical aspect of resident feedback. These are specialityspecific and have been derived and visualized well in radiology (Durojaiye et al). In broad medical specialties like internal medicine and pediatrics, RSQM have been made through Delphi-derived EMR-based metrics, but these have yet to be meaningfully defined and applied in EM. In their absence, institutional morbidity and mortality triggers, or national quality metrics such as doorto-balloon times, can be used, though these metrics involve work-intensive chart review, lack context, and are not solely within the resident’s control.
Operational metrics such as patientsper-hour, door-to-disposition time, and admission rates are easily available within Electronic Medical Records (EMRs) and are used to assess attending physician performance in academic and community settings. These metrics are already being integrated into many residency reviews, showing improved satisfaction with feedback without creating quantitative change. Potentially, other expansion of EMR quantitative data may include a resident’s case-mix by chief complaint or diagnosis to ensure adequate coverage of the American Board of Emergency Medicine (ABEM) model of clinical practice throughout training. 360-degree assessments have been used extensively in industry but are newer in medicine. Quantitative and qualitative multisource feedback from nurses, patients, and learners can provide essential bottom-up feedback to trainees, particularly on communication and professionalism skills. It can be a challenge to collect sufficient data from these often-untrained evaluators, however these assessments can serve as another perspective on a comprehensive resident dashboard.
Ideally, each of these data points could be combined into a comprehensive transparent dashboard. The dashboard can illustrate how each resident is performing, individually or compared to their current or historical peers, and can be used to identify specific clinical and behavioral metrics to which they may target performance improvement. An excellent framework is described by Epstein et al who present a residentcentric model of dashboard generation and management in a Canadian EM residency, which includes a model of performance metrics, quality data, as well as quantitative and qualitative integrated feedback. This breadth of information and new integration of big data can create a holistic sense of resident performance that embraces a growth mindset, is learner-centric, and generates actionable feedback. As graduate medical education (GME) and future employers are likely to continue trends towards accountability in care, having these dashboards and quality metrics will be critical to defining how the specialty of emergency medicine defines its own quality and feedback mechanisms in this data-driven and virtual world.
REFERENCES
- Phillips RL Jr, George BC, Holmboe ES, Bazemore AW,
Westfall JM, Bitton A. Measuring Graduate Medical
Education Outcomes to Honor the Social Contract. Acad
Med. 2022 Jan 11. - Warm et al. Entrustment and Mapping of Observable
Practice Activities for Resident Assessment. J Gen Intern
Med 29(8):1177-82.
ABOUT THE AUTHORS
Dr. LaFollette is an associate professor of emergency medicine at the University of Cincinnati and assistant program director and former chair of the SAEM Virtual Presence Committee
Dr. Paulsen is an associate professor of emergency medicine at the University of Cincinnati and assistant program director in charge of resident assessment and evaluation
Understanding the Effects of the COVID-19 Pandemic on All Categories of EM Providers
By Richard Wolfe, MD; León D. Sánchez, MD, MPH; and Al’ai Alvarez, MD, on behalf of the SAEM Wellness Committee
The long and devastating effects of the COVID-19 pandemic on the wellness of the different categories of emergency medicine (EM) staff raises questions about postpandemic consequences. Each pandemic wave has added to the stress, sense of powerlessness, and isolation of health care workers, especially those of us in EM. Each wave has caused variable degrees of dysfunction at a systemslevel, preventing consistent delivery of safe care, and putting staff at risk for contagion and moral distress.
The first wave was a call to arms that exposed our unpreparedness — evidenced by the limited PPE available. EM frontline workers went to work not knowing if they would contract the infection and expose their families. Many lived isolated from their families for months to try to protect them. This selfimposed isolation compounded existing stressors resulting from the inability to care for patients safely and adequately due to the lack of ventilators and critical care beds. While there was optimism that the pandemic would abate after the first wave, providing much-needed relief, we soon encountered overwhelming workloads due to critical emergency department (ED) crowding —especially during the Delta and Omicron surges. As EM physicians, we are used to sprinting. Like firefighters going into a burning building, we work at 110% capacity and push through until the fire is over. The problem is that while EM physicians were built to be sprinters, we were running a marathon. With the vaccine rollout we thought we were close to the finish line, but we weren’t even halfway there, and instead of a marathon, we found ourselves running an ultramarathon. We faced new challenges of balancing work and home life—remote meetings became the norm and continued to encroach on everyone’s personal time. And, of course, the despair and betrayal from the bipolar attitude of the public towards health care workers was especially demoralizing. In the beginning we were regarded as superheroes; then we became the target of anger and apathy caused by societal polarization and demonization of preventive health care measures. During this crisis, the growing lack of trust in physicians continued on Page 46
WELLNESS & RESILIENCE
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and nurses has been exceptionally unjust and hurtful and undermines the patient-caregiver bond that drives our motivation and professionalism. We are exhausted, and with the latest Omicron surge, we have also found ourselves in the reversed role of patients.
Nurses, Residents, and Attendings
Nurses, residents, and attendings experienced the effects of the pandemic in even different ways. During the first wave, many providers had fears of contracting an unknown disease and spreading it to friends and family. Hospital leadership appropriately imposed rigorous precautions to prevent the spread of infection in the workplace and preserve staff. Still, a side effect was that these isolation requirements contributed to staff anxiety over risk of contagion. Nurses, who had the most significant exposure to this frightening unknown infection, felt abandoned by the shortage of PPE and the unequal application of standards for patient/ nurse ratios and distancing precautions from one part of the hospital to another. Faced with the same salary but better working conditions, EM nurses questioned whether working in limitedresource units versus other parts of the hospital (such as the endoscopy suites) was worth it. This sense of betrayal, which permanently damaged institutional loyalty from this group, continues, a year later, to contribute to the extreme difficulties in retaining experienced nurses.
Attendings
Attendings in the first wave experienced a collapse in the number of emergency department (ED) visits, as the public feared the ED was a source of contracting COVID-19. In some cases, this fear translated to austerity measures, and physicians found themselves concerned for the financial security of their families, even as they were being praised in the press as heroes. Attendings also constantly navigated the moral dilemma of doing the best for their patients while at the same time not being able to provide the best of care due to increasing limitations in essential critical care resources such as ventilators and PPE. Some even had to resort to rationing care.
Residents
Residents experienced sudden isolation during times of stress because of the loss of the in-person activities of residency training. This loss of inperson gatherings came at a time when many residents were experiencing the adjustment of moving to a new city and would have typically been developing the social networks that provide needed support for surviving residency training. The curtailing of personal interactions through work and the loss of routine social activities as the pandemic shuttered society, left many feeling isolated at a time of high stress. Residency training was already isolating and rigorous even without pandemic; with the pandemic, the resolve of residents was constantly tested as previously unappreciated sources of connection, such as journal club meetings and didactic conferences, moved to virtual platforms. Elective time
and away rotations were canceled, and many were asked to volunteer their nonED time to serve in the COVID-19 ICU units. For the graduating residents at the end of 2020, reports of job offers being rescinded were not uncommon.
Subsequent waves of the pandemic have added to the problem in new ways. The vaccine roll out at the end of 2020, and declining infection rates by spring, offered a period of hope which quickly waned due to the public’s resistance to health care recommendations and vaccinations. The growing hostility of a significant part of the population toward the efforts needed to prevent the spread of the infection has been a new experience for physicians and nurses who have traditionally been among the most trusted and respected professionals. The seemingly unending course of this pandemic forced residents to realize that every component of their training, from the bedside to the classroom, was being impaired.
New Variants Expose Staff Shortages
Latter waves, due to new variants, exposed a shortage in most categories of providers, which further disrupted the patient flow and added to the workload of those who continued to staff the ED. This was amid already not having a readily available pool or hiring up to unburden the already tired and frustrated caregivers. Experienced EM nurses have left their home institutions in unheardof numbers to work in less stressful environments or find better opportunities as traveling nurses. Some have left health care altogether. This mass exodus of health care workers also comes during an unprecedented need for staffing the ED.
The wellness of attendings, residents, and nurses has never faced a more significant challenge. Ensuring the mental health of the workforce to mitigate the long-term effects on retention and performance needs to start immediately. However, to be most effective, we still need to understand the specific causes for each provider category and design interventions that prioritize sustainability and well-being. There is a paucity of randomized controlled trials for COVID-19 and burnout and even less data on granular interventions to match the specific problems linked to residents versus attendings versus nurses. With extensive vaccination and mutation of the virus to more contagious but less lethal variants, it is hoped that the pandemic will slowly morph into a milder endemic and allow the return into something close to the conditions that existed before 2020.
An informal survey of the chairs in emergency medicine through the Association of Academic Chairs of Emergency Medicine (AACEM) listserv has shown that burnout experiences are common. All report evidence of burnout in attendings, residents, and advanced practice providers. It is no surprise that EM and critical care rank the highest in burnout and depression across medical specialties. Unlike our community physician colleagues, academic centers may also have been insulated from the most severe economic challenges. Regardless, to date, there have been very few physician departures or resignations from EM—evidence of strong resilience that seems part of our specialty. In most academic centers, we have witnessed significant departures of experienced nurses. Equally important, we see shortages in all types of clerical and support staff, with a worsening trend inverse to one’s total compensation.
The ethics and resilience seen in the physician workforce may mask long-term instability as many may have suffered sufficient damage to impair the quality of their work and cause them to leave clinical medicine in the future when faced with a new stressor.
As we look deeper, the most significant difference from pre-2020 to now is that we have been exposed to a higher level of sustained trauma. By now, many of us are surrounded by colleagues who are, in ways, traumatized and even broken. While we may have a sense of responsibility to keep forging ahead, once this pandemic cools off, do we continue, or just like other professions, will we find respite in changing careers or even enjoying early retirement? How do we prepare ourselves for the next novel pandemic? It is critical to address these questions to prepare us for the postpandemic reality. To achieve this, we must prioritize the wellness needs of the workforce now.
We cannot afford to wait while the residue of trauma and moral injury continues to accumulate. As academic EM physicians, we must band together to investigate which interventions are available to effectively address the damage created by COVID-19 and study how they can be implemented within the constraints of the pandemic — with the scarcity of time, funding, and continued social distancing. If we do not invest in our people now, we may face outcomes — that could have been prevented — later.
ABOUT THE AUTHORS
Dr. Wolfe is chief of emergency medicine, Beth Israel Deaconess Medical Center, and associate professor of emergency medicine, Harvard Medical School, Boston, MA.
Dr. Sánchez is chief of emergency medicine, Brigham and Women’s Faulkner Hospital, and associate professor of emergency medicine, Harvard Medical School, Boston, MA.
Dr. Alvarez is director of wellbeing and clinical assistant professor, department of emergency medicine, Stanford University School of Medicine, Stanford, CA. @alvarezzzy
