Director’s Corner: Navigating Staffing Shortage

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As an applicant and director, the pandemic realities have changed the game.

Dear Director,


I have read the findings of the ACEP workforce task force and I am concerned about getting a job in 5 to 10 years.  Why is the job market so tough right now and will it get better?

The ACEP Workforce Taskforce report is certainly concerning when you’re thinking about the job market 10 years from now. When you look at the data on residency growth and the amount of new attendings entering the workforce every year, you do not need to be a rocket scientist to see that there is an increasing supply of emergency physicians, which will result in an excess of qualified emergency physicians based on today’s volume and staffing models.

Prior to COVID-19, the job market was still active. You could get a job as a locum’s doctor, and I knew medical directors of good emergency departments that had open spots.  With the reduction in ED volume that COVID caused, most of us found ourselves being grossly overstaffed in our own departments.  This made it very difficult to change jobs and really froze the job market.


You may have known a new graduate last year who had their starting date delayed or maybe even had their contract broken. As I have spoken to attendings in different residencies this year, it is clear that the job market is very tight.  I have heard of many residents from good programs who do not have jobs lined up while others have decided to stay on to pursue a fellowship.

There were a variety of unanticipated consequences with COVID.  While I know a few doctors who retired because of the pandemic, I also know several people who put off retirement because they felt like they would have nothing to do because of COVID.  They could not travel so they figured they should continue to work and make money instead of staying home and being quarantined.  Because of the volume decline, it also made it harder for doctors to change jobs.

The routine transitions that occur in any department for a number of reasons were not taking place because there were no openings for people to go to.  It is a bit of a domino effect because when there is no movement at one site, no one is being hired from another site to fill that spot. Therefore, the job market was stagnant.

Funny enough, I hired a couple of part-time docs in late 2019.  They had barely made it through credentialing when COVID hit.  Our department went through the bi-annual recredentialing period this month and as I signed off on their credentials, it occurred to me that it will still be many months before I’ll need part-timers again to help fill the schedule.


The Applicant’s Perspective

It is definitely harder to get a job right now.  I have seen EDs that were never fully staffed become popular enough with applicants to now have a waiting list.  This does not mean that you will be unemployed or will not be able to get a job in the immediate future.  It does mean that you will likely need to broaden your search and consider going to outlying suburbs of your desired city or even a different state to find a job.  I live 46 miles from my current ED.  Prior to the pandemic, my commute in the DC area often really stunk.  But it was the right job and living environment for me and my family.  Keep in mind, that the perfect job may not exist.

This may be the time to consider rural areas.  While jobs in metropolitan areas may be scarce, the outlying small towns may need ER docs.  I never thought I’d be driving 30,000 miles a year, but I love the job and where I live so it works. This is the time to consider your basic needs.  There are opportunities to grow professionally in any job you take.  Some jobs may be more challenging or anxiety-provoking than you thought you would desire, but no job is permanent.  It’s certainly more important to have a job then to be unemployed.

When I was a new attending, I wanted to work 18 shifts a month.  I was annoyed when I only got 15 my first month since I had bills to pay.  In your new job, you may find that you are given fulltime hours of 30/week even though you want 35.  Or, when being offered a job by a group that staffs multiple EDs, you may also be asked to split time at multiple sites.  Or you might be given an offer with the actual site (amongst two to three) to be named later.

Many ED groups have also found ways to supplement income by working outside the brick-and-mortar of the ED.  Don’t be surprised if your job responsibilities or opportunities include telemedicine, observation, Freestanding EDs, the ICU or procedure teams.

No matter where you are in your career, while you are looking for a job, it is also the time to be using your professional network.  This may be an old boss, your residency colleagues who were a couple years ahead of you and already in the workforce, or professional societies like your state chapter of ACEP.  Most of the larger companies have talent managers/recruiters and regular communication with them about anticipated openings and your desire to work in a particular location will help.

I also continue to see jobs being posted on some of the social media groups and honestly some of these jobs look pretty good. Just in the last few weeks, I’m also starting to get more emails about job opportunities and locums.  ED volume seems to be returning and that may open up the job market some, but conventional wisdom doesn’t have pre-pandemic volumes returning for another year or more.

Directors’ perspective

As a director, I would rather be a little bit over staffed than understaffed.  I have been a director for the last 15 years and prior to COVID-19, I cannot remember the last summer where I was fully staffed.  When you are understaffed during the summer, you are either on vacation or working a ton and no one is happy.

Being over staffed also meant that if a doc left the group unexpectedly, I was not so desperate in my own search to replace them.  When I think of hiring physicians that ultimately were not a good fit for my site, I often realize that I have hired them off kilter from the regular recruiting cycle when I am usually a little bit more desperate to fill a spot.

With that said, from a director’s point of view, there is an excessive supply of well-qualified emergency physicians looking for work right now.  I am much less likely to make a mistake in hiring because I have more people to choose from. Directors may also use some of this time to thin the ranks of their underperformers.  Most directors will tell you that they have at least one physician who is not a good fit for the department.

These docs either underperform in metrics or create problems with nurses, the hospitalist, etc.  I have long said that directors were better off trying to rehabilitate under-performers then to go out and try to look for the perfect replacement.  Replacing someone takes time and money and there is certainly no guarantee the new hire will be a star.  However, the calculus on this changes a little bit when there are so many well-qualified physicians looking for a job.

Previously, I may have put an underperforming doctor on a six-month performance improvement plan, recognizing that I do not really want to replace them, but hopefully getting the message across to them that they need to improve.

Given the overall staffing conditions now, I do think directors are more likely to put people on a shorter, perhaps three-month, performance improvement plan with the intent of terminating them at the end of the 90 days.  Again, with the volume decreased, many sites are overstaffed and we can afford to be less tolerant of underperforming providers.

I really regret never taking an economics course in college.  However, I have enough understanding of the supply and demand curve to be concerned about future pay.  The market will drive our pay and while I am hopeful we will not take a pay cut, I am not optimistic that our pay will continue to increase at the rate it has done the last 5 to 10 years.

One thing I do expect to happen, is a significant decline in the amount of dollars being paid for signing bonuses for new hires.  This bonus has had tremendous escalation in the recent past and given the availability of people looking for jobs, I suspect these will decrease dramatically, if not go away.


I started volunteering in emergency department in 1986 and one of my responsibilities was to assist the physician’s assistant who was sewing up lacerations.  In every hospital I have worked at since finishing residency, APPs have been a critical part of the patient care team.  I wrote extensively about the role of APPs in the emergency department in a two-part column last year, outlining the pros and cons of the financial aspects, integration and credentialing.

I generally do not see them going away.  They are an important part of the care team and a critical component of how groups budget for physician salaries.  If anything, I’ve seen significantly more utilization of APPs throughout the hospital over the last 10 years, whereas before, they primarily worked in the ED, OR and OB. I recognize and share the concerns that many have on how APPs may disrupt and/or impact the emergency physician workforce down the line, whether it regards independent practice or replacing emergency physicians.


As normal emergency department volume returns, we actually will not be as over staffed as we have been for the past 15 months.  Although I’m optimistic that the job market will improve in the near future, it’s still likely to be tight for the next several years as we fully recover lost volume and incorporate all of the new attendings who are finishing residency and fellowship the last couple of cycles into our work force.

COVID-19 has taught us how to expand our services outside of the ED, but it will take years to fully develop these programs.  I anticipate we will see some of the routine departures that were put on hold this past year as the market begins to open up again. If you are going to be in the job hunt, now is the time to be casting a broad net as to what kind of job might be acceptable for you.

Being flexible is a personality trait most emergency physicians have, and it will be critical for the next two years.  Finally, if you are feeling comfortable in a job but below average in job performance, you should probably be worrying.  Your metrics and job performance matter now more than ever. When there is such a great supply of well-qualified emergency physicians, all of us are easier to replace if we are not keeping up with the pace.



EXECUTIVE EDITOR Dr. Silverman is Chairman of Emergency Medicine at the Virginia Hospital Center. He also serves as the Director of the Alteon-Mid Atlantic Leadership Academy. Dr. Silverman’s practical wisdom is available in an easy-to-use reference guide, available on Amazon. Follow on Twitter @drmikesilverman

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