A recent study commissioned by the American College of Emergency Physicians (ACEP) identified a likely scenario of a surplus of over 7,000 emergency physicians (EPs) in the United States in 2030. This future scenario was based on an estimated 2% annual graduate medical education (GME) growth, 3% annual EP attrition, 20% of ED encounters seen by a nurse practitioner or physician assistant, and an 11% increase in ED visits relative to 2018. This study raised important questions about the future supply of and demand for emergency physicians, including whether to intervene, what are the likely consequences and moral implications of potential actions, and how to implement potential changes.

The future of the workforce in EM depends on balancing the supply with the demand for emergency physicians. We propose that evaluation of potential actions to balance supply and demand should rely on the ethical principles of beneficence (doing good), nonmaleficence (primum non nocere, or “do no harm”), and justice (fair and equitable treatment).

The Supply of Emergency Physicians

GME in emergency medicine is a 3- or 4-year program. Most federal funding comes from the Centers for Medicare & Medicaid Services (CMS) Medicare GME program, which provided as much as $10.3 billion in 2015. With sustained funding and the continuing popularity of the specialty, the number of EM residency programs has expanded dramatically in recent years. The latest data from the Accreditation Council for Graduate Medical Education (ACGME) in 2020-21 show that EM has a total of 276 accredited residency programs, placing emergency medicine on the latest “top five” list of specialties with the greatest increase in programs (+16 programs) since 2016-2017. CMS recently announced plans to fund an additional $1.8 billion over the next 10 years for additional residency slots, specifically for hospitals serving underserved and rural areas.

Emergency medicine continues to be a popular specialty choice among medical graduates. In fact, post-graduate emergency medicine residency slots increased by 27.5% from 2014 (1,786 slots) to 2018 (2,278), according to a report from the American Board of Emergency Medicine and Accreditation Council for Graduate Medical Education. This rapid growth in EM residency programs poses novel ethical issues, including questions about maintaining the quality of emergency medicine residency training, allocating limited graduate medical education funding equitably, and supporting the work life of emergency medical care professionals. To develop and sustain a highly skilled workforce, medical students and residents must have adequate clinical training opportunities. Data have shown that market forces may not always align with high-quality medical training, and residency expansion does not always mirror the demand for medical specialists. If, for example, a large supply of new emergency physicians significantly exceeds demand, new physicians may confront diminished job prospects and significant salary decreases.