Caring for Patients Anywhere, Anyhow: How Emergency Department Crowding and Boarding Shapes Professional Identity in Emergency Medicine Training

Introduction: Emergency department (ED) boarding is a well-documented crisis associated with adverse patient outcomes, healthcare worker burnout, and moral injury. Although prior work has documented operational and educational impacts, including reductions in resident productivity and procedural exposure, less is known about how sustained boarding shapes professional identity formation. We sought to explore how sustained ED boarding shapes the learning experiences and professional identity formation of emergency medicine (EM) residents, as perceived by both residents and the attending physicians who train them. Methods: Using a constructivist paradigm, we conducted a qualitative study using semi-structured interviews with residents and attending physicians from a 4-year EM residency program with rotations across 5 clinical sites, between July and August 2025. Two researchers independently coded transcripts and iteratively refined a shared codebook, continuing until additional interviews were unlikely to add new insight, guided by the concept of information power. We used reflexive thematic analysis, treating researchers’ clinical and analytic judgment as a resource for identifying patterns of meaning, and prioritized participants’ own construction of meaning over the frequency of any single idea, consistent with an interpretive phenomenological approach. Results: We interviewed 13 emergency physicians: 6 residents and 7 attending physicians (range: 1–30+ years after residency). Three overarching themes emerged: (1) Educational challenges and opportunities—boarding fragments diagnostic ownership, narrows the acuity spectrum, and limits authentic undifferentiated encounters, although attending physicians adapt through structured hypotheticals and micro-teaching); (2) Shifts in the clinical environment—operational and structural adaptations create educational dead space, constrain the therapeutic alliance, and generate role ambiguity around boarded patients); and (3) Moral strain and suffering—moral injury and combined suffering is not peripheral to training but embedded within it, shaping how residents interpret professional responsibility and integrity. The three themes exist in a triangular relationship, with suffering at the foundation. Conclusion: Boarding appeared to function as a formative context for professional identity formation, not merely a disruptive one. Residents described learning systems-level practice, advocacy, and emotional regulation, often through loss and moral injury, alongside attending physicians navigating the same. These findings suggest that recognizing boarding as a structural condition of training may reorient the responsibility of graduate medical education: formalizing adaptive teaching strategies, creating structured opportunities to process moral strain, and committing to advocacy that treats boarding as the educational crisis it is.