Emergency physicians who left or seriously considered leaving emergency medicine attributed their decisions to structural failures, moral injury, and rigid career paths, according to a qualitative study published in JAMA Network Open.
The findings come amid mounting concern about the emergency medicine workforce. In the study introduction, researchers noted that emergency physician attrition exceeds 5% annually and peaked at 9% in 2020, compared with 3.5% to 4.9% across other specialties. Emergency medicine also ranks among the specialties with the highest rates of burnout, at nearly 70%. Female emergency physicians stop practicing, on average, 12 years earlier than their male colleagues.
In the national study, researchers conducted semistructured video interviews with 46 board-certified or board-eligible emergency physicians from August 8, 2024, to April 11, 2025. Participants had either left clinical emergency medicine or seriously contemplated leaving clinical practice. Most participants, 74%, no longer practiced emergency medicine, whereas 19% practiced emergency medicine part time and 6% remained in full-time emergency medicine practice.
The study was conducted in 2 phases: first enrolling physicians who had left full-time emergency department work with no intention of returning, then enrolling physicians who had seriously contemplated leaving but continued practicing. Researchers said this approach was intended to identify factors associated with attrition as well as factors that may support retention.
Of 125 eligible physicians who completed screening, 95 were invited to participate and 46 completed interviews. Researchers recruited participants through social media, residency alumni networks, and snowball sampling, and used purposive sampling by gender, practice setting, region, and years in practice. They used iterative thematic analysis to identify major themes associated with attrition and possible retention strategies.
Participants described a widening mismatch between rising emergency department demands and available staffing and resources. Many reported that inadequate physician, nursing, and ancillary staffing interfered with their ability to provide safe, high-quality care. Emergency department boarding, overcrowding, and caring for patients in hallways or waiting rooms were commonly cited as sources of distress.
Participants also described institutional pressure to prioritize throughput, efficiency metrics, and patient satisfaction scores over clinical outcomes and patient safety. Several characterized emergency medicine as a “dumping ground” for broader health system problems, with emergency physicians expected to manage upstream failures without sufficient resources or institutional support.
Workplace violence, disrespect, and interpersonal conflict were also recurring themes. Participants described verbal abuse from patients and coworkers, physical assaults against nurses, hostility from consultants, and a sense that emergency physicians had become “everybody’s punching bag” for system failures.
Burnout was common, but researchers emphasized that many participants framed their experiences more specifically as moral injury: the conflict between professional duty and an inability to meet that duty within resource-constrained systems. In the discussion, researchers noted that burnout may be eased by rest, whereas moral injury may fracture professional identity and make leaving clinical practice feel like the only sustainable option.
That distinction also shaped participants’ views of wellness initiatives. Several described resilience programs, wellness events, yoga apps, and similar interventions as inadequate or counterproductive when staffing shortages, boarding, and operational pressures remained unaddressed.
Mental health support emerged as another concern. Participants described insomnia, fatigue, depression, anxiety, and depersonalization, but some also reported fear that seeking treatment could affect licensure or employment. The researchers identified confidential, affordable, and timely mental health care, along with standardized state medical board language to reduce stigma, as potential retention strategies.
Work-life integration and career flexibility also emerged as major themes. Participants described difficulty balancing shift work with caregiving responsibilities and reported limited options to adjust clinical workloads across career stages. Some participants said traditional emergency medicine career paths required the same intensity of night, weekend, and high-volume shifts regardless of age, family needs, or evolving professional goals.
Women more frequently described caregiving conflicts, inadequate parental leave, insufficient support for pregnancy and lactation, and gender inequities in advancement as factors in decisions to leave or consider leaving emergency medicine. Women physicians also identified greater representation of women in leadership as a potential retention strategy.
Participants suggested several approaches to improve retention, including increased physician and nurse staffing, less emphasis on throughput and satisfaction metrics, expanded mentorship, more flexible scheduling, confidential mental health support, opportunities for professional growth, and gender equity in promotion and leadership.
In an invited commentary, Mira Mamtani, MD, of the University of Pennsylvania Perelman School of Medicine, and Chinezimuzo Ihenatu, MD, also of the University of Pennsylvania Perelman School of Medicine, wrote that solutions should address individual, institutional, and national contributors to emergency physician attrition.
At the individual level, the editorialists highlighted professional development and individualized coaching as possible supports for physicians seeking careers aligned with their values and life stage. They noted that coaching may also help physicians identify an alternative clinical practice, including at another location or in another type of clinical setting, that could help prevent attrition from clinical practice altogether.
At the institutional level, the editorialists called for policies that support work-life integration, including paid parental leave for the nonbirthing parent, lactation policies that do not penalize physicians for pumping time, flexibility to reduce clinical hours for caregiving responsibilities, and transparent, equitable compensation.
The editorialists also cited specific scheduling strategies, including avoiding night shifts for emergency physicians older than 50 years or for pregnant physicians after 27 weeks of gestation. They noted that some interventions may be cost-neutral, such as a night-shift market that allows physicians to exchange a night shift for a day shift with an associated compensation exchange.
At the national level, the commentary emphasized emergency department boarding and overcrowding as contributors to moral injury and attrition. Boarding occurs when admitted patients remain in the emergency department because of insufficient inpatient beds or staffing. Although emergency physicians and patients experience boarding most directly, the editorialists noted that emergency physicians often have limited control over the upstream and downstream factors that cause overcrowding.
Potential national strategies included expanding access to care outside the emergency department through programs such as hospital at home, restructuring reporting to better capture emergency department boarding, and realigning financial incentives to prioritize emergency department patients and safe care.
The study had several limitations. Women, academic physicians, and physicians from coastal regions were overrepresented, which may limit generalizability. Recruitment through social media and snowball sampling may have introduced selection bias. The sample focused on physicians who had left or seriously considered leaving emergency medicine, so the findings may not reflect the experiences of physicians who remain satisfied in long-term practice. Researchers also noted possible recall and negativity bias, did not conduct member checking, did not recruit physicians who left and returned to emergency medicine, and did not distinguish between participants who transitioned to nonclinical careers and those practicing in non–emergency medicine clinical settings.
“Our findings suggest that leaving clinical practice is a rational response to untenable systems bound by resource constraints, devaluation of work, and rigid career structures,” wrote first study author Serena Hua, MD, of Stanford University School of Medicine, and colleagues. “Understanding why emergency physicians leave is a critical first step toward designing environments where they want to stay.”
Disclosures: The study was supported by a Stanford University Department of Emergency Medicine Seed Grant. Richelle J. Cooper, MD, reported unrelated research funding from the National Heart, Lung, and Blood Institute; the National Institute of Neurological Disorders and Stroke; and the Patient-Centered Outcomes Research Institute, as well as a stipend from the American College of Emergency Physicians for editorial services unrelated to the study. Michelle P. Lin, MD, reported receiving grants from the Stanford University Department of Emergency Medicine during the conduct of the study and outside grants from the National Institute on Aging, National Heart, Lung, and Blood Institute, Agency for Healthcare Research and Quality, and Emergency Medicine Foundation. No other disclosures were reported. The commentary authors reported no conflicts of interest.
Source: JAMA Network Open