“We have been seeing really, really sick people,” he said. He had firsthand experience with the novel coronavirus, too — he caught it in March and recovered after a few feverish days.
Despite all that, the 29-year-old doctor cannot find a company in his hometown of Houston ready to hire him when he graduates next year. Durrani has searched since the summer, “getting on calls with recruiters and hospitals and whatnot,” he said. “And I haven’t locked anything down.”
Like him, many in this class of emergency medicine physicians — young doctors, called residents, who are training in this specialty — are struggling to find full-time employment, even while they work on the front lines treating covid-19 patients.
The dearth of jobs is the result of a domino effect: Many people stayed away from hospital emergency rooms this past year, wary of contracting the virus. As patient numbers dropped, emergency departments brought in less money. As a result, cash-strapped employers stopped recruiting new doctors.
“We’re putting our own lives at risk, our family’s lives at risk,” said emergency medicine physician R.J. Sontag, the president of the Emergency Medicine Residents’ Association. “We’re in, frankly, a financially precarious position with a ton of debt and limited income. And the fact of the matter is that employers just aren’t hiring.”
The pandemic exposed many perplexing vulnerabilities in the American medical system — as varied as critical staffing shortages of nurses and inadequate stocks of protective equipment. This is another one. Fewer places can afford newly minted emergency medicine doctors during a crisis in which it would seem they should be in high demand.
“Calling it a paradox is exactly right,” said Janis Orlowski, the chief health-care officer at the Association of American Medical Colleges. “There’s a need for more physicians. And yet we find ourselves in this situation.”
New contracts have vanished with the “significant shortfall” in hospital and physician practice dollars, she said. The result is that after four years of medical school and up to four years of residency, some new doctors have no place to go.
“It’s by far the tightest job market in emergency medicine that I’ve ever seen,” said Mark Reiter, the chief executive of the consulting group Emergency Excellence and director of the emergency medicine residency program at the University of Tennessee Health Science Center in Nashville. By his conservative estimate, at least a quarter of residents are having trouble finding work.
About 2,500 new emergency medicine doctors enter the workforce each year, Sontag said. They do so heavily in debt, he said, with half of them owing more than $200,000 in school loans, and one-fourth owing over $300,000.
Many of the newest crop have had contracts altered, if not rescinded. “I have a good friend who signed a contract, bought a home, moved his wife across the country,” Sontag said, “and then he lost his contract after he’d already moved.”
The Emergency Medicine Residents’ Association does not have a tally of how many members are without jobs. But a survey from the American College of Emergency Physicians found that 20 percent of emergency medicine group practices laid off doctors this year, almost one-third furloughed them and more than half cut hours or wages.
“What we’re watching now is frightening for the residents,” said Mark Rosenberg, the American College of Emergency Physicians’ president.
Sontag, who attended the UT Health San Antonio residency program, said that only one of 12 final-year residents there has secured a job. In a typical year, all of them would have contracts by now.
Patients stay away for fear of covid-19
It wasn’t unusual for Angela Cai, a physician in her final year of residency at SUNY Downstate’s Kings County Hospital in Brooklyn, to treat patients with strokes. But one man stood out — because he had waited nearly a day last April to call an ambulance.
“If people come in with strokes very early, ideally within three hours, there are some treatments you can offer to reverse the symptoms,” she said. “But that was totally out of the question for him. He wasn’t able to walk.”
She asked the man why he had delayed. “He said he was watching everything on the news and he was afraid,” she said.
That fear of catching the coronavirus fueled a sharp drop in visits to emergency departments. They plummeted by 40 percent in March and April, as reported by the Centers for Disease Control and Prevention’s surveillance program, and children were kept away at even greater levels.
Although emergency departments in coronavirus hot zones are gateways to a flood of covid-19 patients, those zones have been distributed unevenly in time and space. Even in virus hotspots, Reiter pointed out, the pandemic can congest emergency rooms — some patients with covid-19 are kept in emergency department beds, which reduces capacity and causes waiting room delays.
The number of emergency department patients overall is 15 percent below last year’s levels, Reiter said.
“In the thick of it, I definitely wasn’t thinking about my job,” Cai said. “I didn’t really make the connection between how this unprecedented drop in [emergency department] volume would affect my job market.” Cai is still finalizing her plans for what she will do after graduation.
A ‘golden ticket’ no longer
Before the coronavirus, new emergency medicine doctors could expect to receive multiple offers in the last year of their residency programs.
“The residents had their pick of where they wanted to go,” Rosenberg said. If a particular hospital didn’t need more emergency staff, it was often the case another one nearby did.
Hospitals, outside of academic centers, rarely hire emergency doctors outright. Most medical centers instead have contracts with physician provider groups. Those can be small, doctor-run companies, or large corporations, backed by private-equity firms, that employ thousands of doctors who work at hundreds of hospitals.
More than half of the emergency doctors in the United States are employed by investment-firm-owned companies, Reiter said, and those companies have generally been “more aggressive” when cutting back doctors’ hours amid the pandemic.
In the past, recruiters representing employers flocked to residency programs, offering salary advances or to pay moving expenses.
“Residency-trained emergency medicine doctors, for a couple of decades, have had the golden ticket,” said Michael Belkin, a vice president at the physician-recruiting firm Merritt Hawkins. “They could call their shots; they could demand high dollars.”
Since 2008, the number of emergency doctors in the United States has grown from 40,000 to almost 50,000; there are fewer of these specialists per person, though, particularly at rural hospitals. In that same period, the number of doctors enrolled in emergency residency programs grew from about 4,500 to nearly 8,000.
That growth has also increased the competition for jobs, Reiter said.
One doctor in a Midwestern city, a recent graduate of an emergency residency program who spoke on the condition of anonymity to avoid potential career harm, described a fraught path to employment: Last fall, several clinician groups offered the doctor a job. The physician decided to join a small, doctor-run firm.
In the late spring, the emergency department where the doctor was completing a residency began to cut back shifts as non-covid-19 patients stopped coming. The doctor received a call from the new employer, expecting to hear the company was reducing hours, too.
Instead, the firm withdrew the job offer, exercising a 90-day termination clause in the contract. The doctor asked the other groups, whose offers the physician had declined in the fall, for work. None hired the doctor, who has more than $300,000 of student debt.
The doctor found a temporary position at a hospital where, during the first wave of the pandemic, few people visited the emergency department. Now, though, that city is experiencing a surge in patients from the pandemic.
“The acuity of illness has gone up quite a bit in the past few months, particularly with respiratory complaints related to the coronavirus,” the doctor said. “Our census within the hospitals has skyrocketed to pretty much 100 percent capacity.” Amid this rise, the original firm agreed to hire the doctor to begin early this year.
Some residents have opted to apply for emergency medicine fellowships, which provide additional expertise in toxicology, ultrasounds, wilderness medicine or other subjects at academic centers.
“All fellowships have become more competitive this year,” Sontag said. Opting for a fellowship also has financial consequences; the pay in a fellowship is closer to a resident’s salary — an average of about $59,000 — than it is to a full-time attending physician’s salary, an amount in the six figures.
A rough road to recovery
U.S. hospitals — many of them operating on thin margins before the pandemic — lost $50 billion per month in the period from March through June, not including government relief money, according to an estimate by the American Hospital Association. A drop in emergency patients was not the only factor. Scheduled and elective surgeries, previously consistent revenue streams, were canceled. Health-care providers also had to spend money on protective gear and ventilators.
“Cash conservation is probably key for most of these places,” said Kayla Cline, an expert in hospital finances at Texas A&M University.
Congress offered $175 billion of financial relief to the health-care system as part of the massive coronavirus aid packages passed earlier last year. But “often the money didn’t trickle down as it was intended” to practice groups that employ physicians, Sontag said. At least $1.5 billion of interest-free loans went to hospitals and staffing companies owned by well-funded investment firms, according to a Bloomberg News analysis.
One consequence of the pandemic, though, may work to the advantage of new doctors seeking jobs: Some emergency medicine doctors are retiring sooner than they otherwise might have.
The crisis has made a difficult job more challenging. “There’s a lot of depression, PTSD, suicide and the like,” Rosenberg said. “And a couple of things that people like to do after a long shift — maybe go out for a beer, hug a friend, cry on a shoulder — we can’t do any of them now.”
Doctors who work in emergency departments are more susceptible to burnout than average physicians. “There’s only so much trauma and so much — I don’t know how else to say it, but — patient loss that one can handle,” Belkin said.
Orlowski said that when elective surgeries were allowed to resume over the summer, with the drop in coronavirus cases, doctors told her “things were just going gangbusters.” She predicted that patients will similarly return to emergency departments as vaccines against the novel coronavirus become more widely available.
But the job market’s recovery could be slow.
“It’s going to take hospitals two, three, four years to get beyond the financial problems that will occur from this year,” Orlowski said. Until that happens, she said, she expects employers to be more conservative in hiring.