a b s t r a c t

Introduction: The 2023 Match saw over 500 unfilled positions in emergency medicine (EM). geographic location is the third most important factor for all United States (US) EM-bound senior medical students when selecting programs to rank and can be affected by political climate. Given the perceived importance of geography on program selection and recent changes to reproductive rights in the US, we sought to evaluate the impact of geography and reproductive rights on unmatched positions among EM programs.

Methods: This was a cross-sectional study assessing Match rates in EM by program US state, region, and degree of reproductive rights. We included all EM programs participating in the 2023 Match year. Our primary outcome was to determine the unfilled programs and positions rate per US state. Secondary outcomes included Match rates by region and by degree of reproductive rights.

Results: We found notable differences in unfilled programs by US state, with the highest percentage of unfilled programs and positions in Arkansas (100%, 56.3%), Nevada (100%, 35.5%), Kansas (100%, 40.0%), Ohio (81.3%,

33.3%), and Michigan (80.0%, (36.8%). Among regions, the highest percentage of unfilled programs (62.5%) and residency positions (26.0%) was East North Central (IL, IN, MI, OH, WI). US states with limited reproductive rights had the highest percent (52.9%) of programs with unmatched positions and the highest percent (20.5%) of unfilled positions.

Conclusion: We identified notable differences in unmatched positions by US state and region, as well as the highest rate of unmatched positions in US states with more limited reproductive rights.

(C) 2023

1. Introduction

The 2022 National Resident Matching Program (NRMP) saw an un- precedented 219 unfilled positions across 69 programs in Emergency Medicine (EM) [1]. A joint statement from EM organizations shortly after the Match noted recently released workforce projections [2], issues around non-physician Scope of practice, continued risks posed by COVID-19, and the corporatization of medicine as possible influencing factors related to unfilled positions [3].

The 2023 Match saw more unfilled positions in EM, with an initial

545 positions open prior to the NRMP Supplemental Offer and Accep- tance Program (SOAP) [4]. A recent survey of EM program directors sug- gested that programs in certain geographic locations may be less likely to fill all of their residency positions in the coming years [5]. This predic- tion is consistent with a 2022 NRMP survey of EM-bound senior medical

* Corresponding author.

E-mail address: [email protected] (A. Mannix).

students in the United States (US), which found that geographic location was the third most important factor when selecting residency programs to rank [6].

The effect of location on program selection is often more complex than US state and region alone and can be impacted by political and temporal factors. On June 24, 2022, the US supreme court overturned Roe v. Wade, a 50-year-old landMark Supreme Course decision protecting legal Access to abortion as a federal right [7]. With this ruling overturned, many US states implemented laws making abortion illegal. Other US states soon followed made abortion illegal, significantly restricted, or very difficult to obtain [8]. Many EM physicians began to re-assess how they provided care to pregnant patients in light of potential legal ramifications [9,10].

Given the perceived importance of geography on program selection,

we sought to evaluate the impact of geography on unmatched positions during the 2023 Match. Additionally, given the recent changes to repro- ductive rights in the US, we sought to determine the impact of US state-level reproductive rights on unmatched programs and positions.

https://doi.org/10.1016/j.ajem.2023.06.045

0735-6757/(C) 2023

1. Methods

We obtained a full list of all EM programs participating in the 2023 US Match from the Association of American Medical Colleges Electronic Residency Application Service directory [11]. We also obtained a list of all unfilled EM residency positions for each program using publicly available data [4]. We excluded programs that did not participate in the Match, were not located in the United States, and those that were combined programs (e.g., EM combined with Internal Medicine or Critical Care).

We conducted a cross-sectional survey of Match rates in EM by pro- gram location and degree of reproductive rights. We adhered to the Strengthening the Reporting of Observational Studies in Epidemiology guidelines [12]. The Institutional Review Board at Rush University granted an exemption for this study. Using the above information, we calculated the number of EM programs and number of residency posi- tions available in the SOAP for each of the 52 geographic areas included (50 US States, District of Columbia, and Puerto Rico). We then combined these numbers at the state and regional, using US Census defined regions [13].

We stratified states by degree of reproductive rights as defined by the Center for Reproductive Rights [8]. Reproductive rights were defined as ‘Expanded’ for states in which the right to abortion is protected and additional laws support access to abortion care;

‘Protected’, where the right to abortion is legally protected; ‘Not Protected’, where abortion may continue to be accessible but would not be protected by law; ‘Hostile’, where lawmakers have expressed a desire to prohibit abortion, and ‘Illegal’, where abortion is banned. For the purposes of our analysis and clarity in presentation, we col- lapsed these categories under three major headers: Progressive Rights (Expanded + Protected), Not Protected, and Limited Rights (Illegal + Hostile). Our primary outcome was the number of unfilled programs and positions by state in the 2023 Match. Our secondary outcome was the number of unfilled programs and positions by geographic region and degree of reproductive rights. Data were combined using Microsoft Excel and presented descriptively.

1. Results

We identified 274 participating programs, with 129 programs par- ticipating in the SOAP. Forty-five US states had EM programs participat- ing in the 2023 Match, with 26 US states having programs participating in the SOAP. The median number of programs per US state was 2 (inter- quartile range: 1-5) and the median number of positions per US state was 26 (interquartile range: 16-61). The five US states with the highest percentage of unmatched programs were Arkansas (100%), Nevada (100%), Kansas (100%), Ohio (81.3%), and Michigan (80%) (Table 1). The five US states with the highest percentage of unmatched positions

Table 1

Summary of residency programs participating in the SOAP and available residency positions available in the SOAP during 2023 Match.

State	Number of Unmatched Programs out of total state programs(%)	Number of unmatched positions out of total state positions (%)	Region	Reproductive Rights Status
Alabama	1/2 (50%)	1/16 (6.3%)	East South Central	Limited Rights
Arizona	2/5 (40%)	5/49 (10.2%)	Mountain	Limited Rights
Arkansas	2/2 (100%)	9/16 (56.3%)	West South Central	Limited Rights
California	7/24 (29.2%)	22/288 (7.6%)	Pacific	Progressive Rights
Colorado	0/1 (0%)	0/17 (0%)	Mountain	Progressive Rights
Connecticut	0/2 (0%)	0/37 (0%)	New England	Progressive Rights
Delaware	1/2 (50%)	6/18 (33.3%)	South Atlantic	Progressive Rights
District of Columbia	0/2 (0%)	0/21 (0%)	South Atlantic	Progressive Rights
Florida	9/22 (40.9%)	48/234 (20.5%)	South Atlantic	Progressive Rights
Georgia	0/5 (0%)	0/61 (0%)	South Atlantic	Limited Rights
Illinois	2/12 (16.7%)	9/140 (6.4%)	East North Central	Progressive Rights
Indiana	0/1 (0.0%)	0/21 (0%)	East North Central	Limited Rights
Iowa	0/1 (0.0%)	0/9 (0%)	West North Central	Limited Rights
Kansas	1/1 (100.0%)	4/10 (40.0%)	West North Central	Progressive Rights
Kentucky	0/2 (0.0%)	0/25 (0%)	East South Central	Limited Rights
Louisiana	0/4 (0.0%)	0/35 (0%)	West South Central	Limited Rights
Maine	0/1 (0.0%)	0/10 (0%)	New England	Progressive Rights
Maryland	0/2 (0.0%)	0/23 (0%)	South Atlantic	Progressive Rights
Massachusetts	1/5 (20.0%)	2/72 (2.8%)	New England	Progressive Rights
Michigan	20/25 (80.0%)	92/250 (36.8%)	East North Central	Progressive Rights
Minnesota	0/3 (0.0%)	0/32 (0%)	West North Central	Progressive Rights
Mississippi	2/3 (66.7%)	9/27 (33.3%)	East South Central	Limited Rights
Missouri	3/5 (60.0%)	11/49 (22.5%)	West North Central	Limited Rights
Nebraska	0/1 (0.0%)	0/9 (0%)	West North Central	Limited Rights
Nevada	3/3 (100%)	11/31 (35.5%)	Mountain	Progressive Rights
New Jersey	7/12 (58.3%)	27/144 (18.8%)	Mid Atlantic	Progressive Rights
New Mexico	0/1 (0.0%)	0/12 (0.0%)	Mountain	Not Protected Rights
New York	19/31 (61.3%)	83/371 (22.4%)	Mid Atlantic	Progressive Rights
North Carolina	4/7 (57.1%)	22/71 (31.0%)	South Atlantic	Limited Rights
Ohio	13/16 (81.3%)	56/169 (33.3%)	East North Central	Limited Rights
Oklahoma	4/5 (80.0%)	8/24 (33.3%)	West South Central	Limited Rights
Oregon	0/1 (0.0%)	0/11 (0%)	Pacific	Progressive Rights
Pennsylvania	14/22 (63.6%)	78/237 (32.9%)	Mid Atlantic	Limited Rights
Puerto Rico	1/2 (50.0%)	1/17 (5.9%)	Territory	Not Protected Rights
Rhode Island	1/2 (50.0%)	3/22 (13.6%)	New England	Progressive Rights
South Carolina	2/5 (40.0%)	4/55 (7.3%)	South Atlantic	Progressive Rights
Tennessee	1/5 (20.0)%	5/36.9%)	East South Central	Limited Rights
Texas	4/15 (26.7)	13/165 (7.9%)	West South Central	Limited Rights
Utah	0/1 (0.0%)	0/8 (0.0%)	Mountain	Limited Rights
Vermont	0/1 (0.0%)	0/6 (0%)	New England	Progressive Rights
Virginia	4/6 (66.7%)	13/62 (21.0%)	South Atlantic	Not Protected Rights
Washington	0/1 (0.0%)	0/24 (0%)	Pacific	Progressive Rights
West Virginia	1/2 (50.0%)	3/22 (13.6%)	South Atlantic	Limited Rights
Wisconsin	0/2 (0.0%)	0/0 (0%)	East North Central	Limited Rights

were Arkansas (56.3%), Kansas (40.0%), Michigan (36.8%), and Nevada (35.5%).

When analyzed by geographic region, the highest percentage of un- matched programs were East North Central (62.5%) Territory (50%), and Mountain (45.5%), while the lowest was New England (16.7%). The re- gions with the highest percentage of unmatched positions were East North Central (26.0%), Mid-Atlantic (25.0%), and South Atlantic (16.9%), while the lowest was New England (3.3%). Regional data with the US states included are presented in Supplemental Table 2.

When analyzed the data by unfilled programs and positions and by reproductive rights status for each state. Summary of findings can be found in Supplemental Table 3. US states with limited reproductive rights (defined as Hostile or Illegal) had the highest percent (52.9%) of unfilled programs. US states with Progressive reproductive rights (defined as Expanded or Protected) had the lowest percent (46.2%) of unfilled programs. US states with limited reproductive rights had the highest percent (20.5%) of unfilled positions, US states with Not Protected reproductive rights status had the lowest percent (14.0%) of unfilled positions.

1. Discussion

When evaluating unfilled programs and positions by US state, we identified different rates of unfilled programs and positions across US states. The EM programs within the US states of Arkansas, Nevada, Kan- sas, Ohio, and Michigan were most impacted by having unfilled pro- grams and positions during the 2023 Match. There are likely multiple factors contributing to the programs with unfilled positions, including but not limited to US state and regional preferences, political factors, and reproductive rights climate.

Of the 19 US states without unfilled programs or positions, all those US states had 5 or fewer programs and 61 or fewer positions available. While that could suggest that a smaller number of programs and posi- tions could lead to a better Match, that is not supported by our data. The three US states with 100% of programs participating in the SOAP (Arkansas, Nevada, and Kansas) all have 3 or fewer EM programs. While Michigan and Ohio have a higher number of EM programs and positions also participated in the SOAP, suggesting that factors exist beyond the number of programs alone.

A previous survey of program directors in EM also found that the East North Central region had the most unfilled programs and positions and New England had the least unfilled programs and positions [5]. While this study was limited in that it evaluated fewer than half of all EM programs, our results expanded on these findings by including all EM residency programs, and support the findings, as we obtained simi- lar results. While East North Central was noted to have the highest percent of unfilled programs and positions.

Our study suggests that programs in US states with limited repro-

ductive rights were more likely to have unfilled programs and positions during the 2023 Match. US states with limited reproductive rights had the highest percentage of programs with unfilled positions (52.8%), and the highest percentage of unfilled positions (20.5%). These findings are consistent with previous literature, which suggested that the major- ity of medical students would preferentially apply for residency in a US state where abortion access is preserved [10].

It is also possible that additional unmeasured, program-specific fac- tors may have contributed to these findings that were independent of the reproductive rights status. With virtual interviews limiting students’ exposure to EM program locations, they may be more reliant on factors such as weather, political climate, and cost of living. Moving forward, EM program leadership should be aware that these factors may contrib- ute to unfilled residency programs and positions. Additional research is needed to better understand the impact of other factors, including program reputation, resident pay, work hours and scheduling, parental leave policies, program culture, and supervision, among others on unmatched positions.

There are several important limitations to consider for this study. The findings were limited to available data on programs participating in the SOAP process. Additionally, this Match year was the highest rate of open positions within EM since the Match process began, which may have influenced program choices and recruitment efforts com- pared with prior years. Moreover, we were unable to account for potential confounders, including program length, culture, interview experiences, national reputation, and other factors which may also influence applicant decision-making. Finally, the current Match cycle included virtual interviewing, which may also have influenced the Selection process, including number of interviews conducted and ability to visit the program location prior to ranking [14].

1. Conclusion

During the 2023 EM Match, US states had different percentages of unfilled programs and positions. The US states most affected are Arkan- sas, Nevada, Kansas, Ohio, and Michigan. There were regional differ- ences as well, with the East North Central region having the highest percentage of unfilled programs and unfilled positions. Finally, we iden- tified a difference in unfilled programs and positions for US states with limited and progressive reproductive rights. US states with limited reproductive rights had the highest percent of unfilled programs and positions. These data should help inform programs when recruiting and deciding on the number of candidates to interview in the future.

Prior presentations

All authors report no prior presentations.

Financial support

All authors report no financial support.

CRediT authorship contribution statement Alexandra Mannix: Conceptualization, Data curation, Formal analy-

sis, Investigation, Methodology, Project administration, Software, Supervision, Writing - original draft, Writing - review & editing. Amanda Young: Conceptualization, Data curation, Investigation, Writing - original draft. Michael Gottlieb: Conceptualization, Data curation, Investigation, Methodology, Project administration, Resources, Supervision, Writing - original draft, Writing - review & editing.

Declaration of Competing Interest

All authors report no conflicts of interest

Appendix A. Supplementary data

Supplementary data to this article can be found online at https://doi. org/10.1016/j.ajem.2023.06.045.

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