If you have been to an ER lately — or if you’ve watched the disturbingly accurate TV show “The Pitt” — you’ve seen scenes that resemble field hospitals more than state-of-the-art medical centers. Waiting rooms have been turned into makeshift care zones. Chairs, cots and cubicles serve as gurneys. Providers eyeball the sick and injured and “shotgun” orders for patients. It feels chaotic and unwelcoming because it is.
This is the new normal for emergency departments in the United States, the result of a dramatic rise in the number of ER beds occupied by patients waiting for a space on a traditional hospital ward. We call them “boarders” and in many emergency departments, they routinely account for half or more of all available care space.
With a fraction of beds in play for new arrivals, waiting room patients — even some arriving by ambulance — are increasingly likely to be seen, examined and treated in the lobby. The consequences are as predictable as they are devastating: worse patient outcomes, fragmented care, longer hospital stays, ballooning costs and rising frustration and anger among staff and patients.
Less visible — but no less harmful — is the toll this takes on young doctors in training.
A recent study led by Dr. Katja Goldflam, a Yale professor, documents the scale of the problem. Nearly three-quarters of the emergency medicine residents she surveyed reported that boarding had highly negative effects on their training. They expressed anxiety and a mounting emotional toll over their diminishing ability to manage patients or handle department surges with confidence, and their growing sense that they could not provide the kind of care they’d expect for their own families.
As emergency medicine educators with a combined six decades of experience, this feels personal to us. We are failing our trainees. We are failing our patients. And we are compromising the future of doctors and patients alike.
The damage is not theoretical. One of us recently experienced it personally, when his father — during the final months of his life — visited two prestigious ERs. Both times, recently trained physicians missed straightforward but life-threatening problems after brief, stopgap-style encounters. Poor clinical judgment is more likely, and more consequential, in a hurried and overwhelmed care environment.
Today, medical education is no longer centered on memorizing facts. With smartphones, decision-support tools and now AI, information is everywhere. What sets a good doctor apart is judgment — the ability to navigate uncertainty, synthesize complex data and make decisive, accurate choices. Building this kind of judgment requires many patient encounters — “reps.”
No amount of classroom learning, reading or podcast listening can replace the formative experience of confronting a clinical puzzle in a patient who has entrusted you with their care. Yet in today’s crowded ERs, physicians in training are losing access to these crucial face-to-face encounters and the skills, competence and confidence they teach.
Shift change “rounds” — once a space for discussion and reflection — now operate more like inventory checks: Here’s a 78-year-old with heart failure, there’s a 35-year-old with appendicitis still awaiting an OR.
Meanwhile, as the waiting room overflows, doctors scatter into the lobby to see new arrivals, hoping to reduce the backlog. “Lobby medicine” — a sanitized term for care delivered in a setting stripped of privacy, dignity and safety — is more than a logistical nightmare. It sends a terrible message to young physicians: that cursory patient assessments, firing off broad-spectrum tests and “moving the meat” is acceptable. It is not.
Why is boarding getting worse?
COVID-19 was the inflection point. While volumes dipped early in the pandemic, they rebounded within a year — and in 2024, according to national hospital metrics, stood at 10% above 2021 levels. In 2023, research showed a 60% increase in boarding and fourfold increase in median boarding times compared with pre-pandemic ERs.
The reasons are complex and systemic: financial pressure to keep hospital beds full (every open space is lost revenue), an aging population with greater needs, dwindling access to primary care and a collapsing system of rehab, skilled nursing or home health options. Hospitals are boxed in, forced to provide basic care while waiting days, sometimes weeks, for aftercare services to become available. It is not uncommon for a third or more of the patients in a hospital to be on hold pending an appropriate discharge destination. The bottleneck trickles down: Wards become holding areas, the ER becomes a de facto ward and the lobby becomes the ER.
So, what’s the fix?
The simple answer — just end boarding — has been the rallying cry of well-intentioned efforts for decades. Nearly all have failed. Why? Because emergency department crowding is not the root problem. It’s the canary in the coal mine of a dysfunctional healthcare delivery system riddled with misaligned incentives and priorities.
Real change will require collective outrage that spills beyond the ERs, into the inboxes and onto the agendas of hospital administrators, insurance executives and elected officials.
Consider air travel. Imagine if Los Angeles International Airport shut down three of its four runways, forcing all takeoffs and landings onto one. Travelers would revolt. The Federal Aviation Administration would intervene. The system would be made to fix itself — because it’s unsafe, ineffective and unsustainable.
But when the same thing happens in healthcare, some patients may bark in anger and frustration at the multi-hour waits, but most simply shrug, grateful, finally, for an exhausted ER doc’s time.
Enough.
If we want better healthcare it means investing more — adding beds, staffing and aftercare capacity. It means creating primary care options other than a default trip to the ER. It means reclaiming the ER not just as a place for healing, but as a place for learning. A place where doctors are taught not in disaster zones, but in environments that allow for connection and understanding of our patients and their diseases. Finally, it means recognizing that designing and investing in better systems and in medical education is crucial to public safety.
Training a great doctor is like training a great athlete. You can’t learn to sink a three-pointer by watching YouTube. You have to step onto the court. In medicine, that means standing in front of a patient and deciding: What now?
That experience — raw, real and imperfect — is irreplaceable. And we’re losing it.
How we care for patients today will define how we all will be cared for tomorrow.
Eric Snoey is an attending emergency medicine physician in Oakland. Mark Morocco is a Los Angeles physician and professor of emergency medicine.