good article about future of FPs

http://www.aafp.org/x42562.xml

good article about future of FPs

http://www.aafp.org/x42562.xml

If the demand were really that high the salaries would be higher. You know, that little thing called "supply and demand."

There may be a shortage of FPs but this is not reflected in the market price.

If the demand were really that high the salaries would be higher. You know, that little thing called "supply and demand."

There may be a shortage of FPs but this is not reflected in the market price.
Here comes Mr. Gloom and Doom again. Panda Bear, are you in practice yet, are you even an FP? It just seems on every FP post you are sure to insert your pessimism. If you are out in practice, thank you for your point of view. If you are just a resident or student, then how could you possibly know what you are talking about. If you don't like FP, you know where the door is.
I AM A practicing FP for 7 years now. True, 150k is the lower end for physicians but how many of your patients would kill for 1/2 of that. It just seems greedy to complain about 150k. Having said that, most FP's, myself included, make considerably more than this. I think 150k is true of employed physicians but if you are willing to take risks, (labs, midlevels, sell your own meds) you can be extremely well off-I know b/c I do this. So instead of students and residents just shooting out the mouth, I am someone in real world practice so I actually know what I am talking about.

If the demand were really that high the salaries would be higher. You know, that little thing called "supply and demand."

There may be a shortage of FPs but this is not reflected in the market price.

http://www.aafp.org/x42562.xml

"While physician compensation was relatively flat in 2004, primary care physicians saw larger gains than specialists for the first time in several years, according to the Medical Group Management Association (MGMA) Physician Compensation and Production Survey: 2005 Report Based on 2004 Data. Primary care physicians' compensation increased 3.13 percent in 2004, while other specialists' compensation increased just 0.18 percent.

Family physicians saw a 2.32 percent increase in median compensation to $156,011; pediatricians saw a 1.47 percent increase to $161,188; and internists saw a 5.36 percent increase to $168,551."

(http://www.allied-physicians.com/salary_surveys/physician-salaries.htm)
These numbers are after 1-2 years, after 3 years, and max

Emergency Medicine $192,000 $216,000 $295,000
FP (with OB) $182,000 $204,000 $241,000
FP (w/o OB) $161,000 $195,000 $239,000
FP - Sports Medicine $ 152,000 $208,000 $363,000
FP - Urgent Care $ 128,000 $198,000 $299,000

I think I can live on that. Check out the difference between FP urgent care and EM after a couple of years of practice. The max for urgent care is actually higher according to this source.

There are FPs making >$500K because the are smart and go learn new procedures, buy equipment for inhouse endoscopy, bone scans, laser hair removal, etc. These are services people pay for and they pay well. The lowest end of the salary curve in primary care are people who haven't bothered to pay attention to the bottom line and how they can improve it.

The people who choose family choose it because they love it and can't see themselves doing anything else. They know they will make less than some docs and that's really okay.

We have to make these decisions as 3rd and 4th year medical students. All you can do is go with your heart. There will always be people like you, Panda Bear, who are dissatisfied with their choice. Fine. Do something else. But honestly, you aren't saying anything new, or anything that all of us haven't already put a lot of thought into.

Panda Bear, are you in practice yet, are you even an FP? It just seems on every FP post you are sure to insert your pessimism.

If memory serves, Panda Bear is an FP intern at Duke who is switching to Emergency Medicine.

There may be a shortage of FPs but this is not reflected in the market price.

There really isn't a "market price" for FPs, because physicians do not operate in a free market economy. Prices for medical services are set by the government and insurance companies. The law of supply and demand does not factor into this. Some would like to see that change.

If memory serves, Panda Bear is an FP intern at Duke who is switching to Emergency Medicine.
Well good riddance! Hope you enjoy the absolute #1 burn out specialty. Thought I read somewhere the average job span of an ER doc was 10 yrs. Enjoy all the lawsuits, drug seekers, absolute scum of the earth patients none of us would touch. Then come back and post about how wonderful your new specialty is. :laugh: :laugh: :laugh:

Well good riddance! Hope you enjoy the absolute #1 burn out specialty. Thought I read somewhere the average job span of an ER doc was 10 yrs. Enjoy all the lawsuits, drug seekers, absolute scum of the earth patients none of us would touch. Then come back and post about how wonderful your new specialty is. :laugh: :laugh: :laugh:

What about EM burns people out so quickly? Is it the fact that EM docs are put in stressful life and death situations that require quick decision making so often?

I personally do not think I could handle EM because I get really nervous in stressful situations where I am put on the spot. I am guessing that EM is not for me. Even though I am not a doc yet, I would think that FM is more easy going and relaxed.

What about EM burns people out so quickly?

Shift work, violence in the ER, infectious disease exposure risks, malpractice litigation, etc. The bottom line as far as burnout is concerned isn't necessarily the stressors themselves, but how the individual manages his/her stress. You can burn out in FM, too...but it's a lot less common.

Well good riddance! Hope you enjoy the absolute #1 burn out specialty. Thought I read somewhere the average job span of an ER doc was 10 yrs. Enjoy all the lawsuits, drug seekers, absolute scum of the earth patients none of us would touch. Then come back and post about how wonderful your new specialty is. :laugh: :laugh: :laugh:

I hope these remarks are made in jest. Otherwise, I hate to see specialty bashing going on. Different specialties fit different personalities. I am sure your comments were made in jest and if so :laugh:

What about EM burns people out so quickly? Is it the fact that EM docs are put in stressful life and death situations that require quick decision making so often?

they arent put in stressful situations. they make lots of phone calls. i dunno why they burn out but probably half of it is because everyone rips on how little thought they put into thier work

they arent put in stressful situations. they make lots of phone calls. i dunno why they burn out but probably half of it is because everyone rips on how little thought they put into thier work
yeah, having 3-4 crashing pts at the same time while you are a solo provider is a piece of cake. in fact coffee breaks during codes are common and expected.....and figuring out which 85 yr old with vague neuro symptoms doesn't need to be admitted is a piece of cake too ( while running the aforementioned 3-4 crashing pts)
what an idiot......

yeah, having 3-4 crashing pts at the same time while you are a solo provider is a piece of cake.

em ppl often talk liek that. they paint this picture where its like theyre ona deserted island and six guys just came in with gunshots to the head, someone is having an mi, and a train crashed nearby. the reality is they immediately call surgery, neurosurg, cardiology, im, and pretty much anyone else who will listen. televsion is nice but real life is a little different, dude.

if someone wanted to test out how great em ppl were just have one day where they werent allowed to make phone calls. i suppose nothing would change right?

"em ppl often talk liek that. they paint this picture where its like theyre ona deserted island and six guys just came in with gunshots to the head, someone is having an mi, and a train crashed nearby. the reality is they immediately call surgery, neurosurg, cardiology, im, and pretty much anyone else who will listen. televsion is nice but real life is a little different, dude."

THEN ALL THE CONSULTANTS WAIT 40 MIN TO CALL YOU BACK AND SAY THEY WILL BE IN 45 MIN FROM NOW AND GUESS WHAT? YOU STILL MANAGE THE CRASHING PTS BY YOURSELF UNTIL THEY SHOW...AND WHEN THEY DO YOU BETTER HAVE THEM FULLY WORKED UP(ALL OF THEM).......
dude, I have worked in em for 19 years...this doesn't happen every day but often enough to be stressful.......remind me again, are you an ms3 or an ms4......

THEN ALL THE CONSULTANTS WAIT 40 MIN TO CALL YOU BACK AND SAY THEY WILL BE IN 45 MIN FROM NOW AND GUESS WHAT? YOU STILL MANAGE THE CRASHING PTS BY YOURSELF UNTIL THEY SHOW...AND WHEN THEY DO YOU BETTER HAVE THEM FULLY WORKED UP(ALL OF THEM).......
dude, I have worked in em for 19 years...this doesn't happen every day but often enough to be stressful.......remind me again, are you an ms3 or an ms4......

wow yu talk big. im glad all the er patients are all fully worked up and all everyone has to do is walk down there and smile. like i said, you need to stop watching reruns of 'er' lets ask everyone how many crashing patients are sitting around in their er?

wow yu talk big. im glad all the er patients are all fully worked up and all everyone has to do is walk down there and smile. like i said, you need to stop watching reruns of 'er' lets ask everyone how many crashing patients are sitting around in their er?
SO THAT WOULD BE MS 3 THEN...
EVER HEARD OF "NO AVAILABLE INPT BEDS....."
WE BOARD ICU TYPE PTS IN THE ER ALL THE TIME AND THE INTERNIST WON'T SEE THEM UNTIL THEY GO TO THE FLOOR....GUESS WHO MANAGES THEIR DRIPS, ETC FOR 8 HRS UNTIL A BED IS AVAILABLE.....GUESS WHO STARTS THEIR CENTRAL LINE IN HALLWAY BED 6?
I WORK IN A 100K+ ER PTS/YR FACILITY....WHERE HAVE YOU DONE YOUR 1ST FEW MS 3 ROTATIONS.....

SO THAT WOULD BE MS 3 THEN...
EVER HEARD OF "NO AVAILABLE INPT BEDS....."
WE BOARD ICU TYPE PTS IN THE ER ALL THE TIME AND THE INTERNIST WON'T SEE THEM UNTIL THEY GO TO THE FLOOR....GUESS WHO MANAGES THEIR DRIPS, ETC FOR 8 HRS UNTIL A BED IS AVAILABLE.....GUESS WHO STARTS THEIR CENTRAL LINE IN HALLWAY BED 6?
I WORK IN A 100K+ ER PTS/YR FACILITY....WHERE HAVE YOU DONE YOUR 1ST FEW MS 3 ROTATIONS.....

wow no available inpt beds. thats like the er version of a code, right? then they all look at thir algorithms and say oh this is where we go on divert. problem solved! :laugh: by the way you dont really manage drips if you ask other ppl which drips to put patients on and how to titrate them. just so you know

wow no available inpt beds. thats like the er version of a code, right? then they all look at thir algorithms and say oh this is where we go on divert. problem solved! :laugh: by the way you dont really manage drips if you ask other ppl which drips to put patients on and how to titrate them. just so you know
hello... divert only applies to ambulances...people still walk in and are brought in by their families......with aaa's, mi's, gsw's, screwdrivers stuck in the neck, ruptured ectopics, etc.....
and guess who teaches all the internists how to run codes...oh yeah, the er docs...ever seen an internist run a code...what a cluster...."call anesthesia, call a pharmacist, call the er doc to come and start a central line....where my pocket guide to acls?"
you still haven't answered my question about your level of training.....ms1...ms2....premed?

What the hell happened to this thread. EMEDPA, leave doughnut alone. We all respect you here, know EM works hard, and value your input. I say leave the troll alone and attempt to get this thread back on topic.

hello... divert only applies to ambulances...people still walk in and are brought in by their families......with aaa's, mi's, gsw's, screwdrivers stuck in the neck, ruptured ectopics, etc.....
and guess who teaches all the internists how to run codes...oh yeah, the er docs...ever seen an internist run a code...what a cluster...."call anesthesia, call a pharmacist, call the er doc to come and start a central line....where my pocket guide to acls?"
you still haven't answered my question about your level of training.....ms1...ms2....premed?

see how its like ' yeah were on divert and yet there are still about sixteen people coming in with aaa's, mi's, gsw's, screwdrivers in the neck, zzz, and then the second minute of my shift occurs. by the way has anyone ever seen or heard anyone consult an er doc to start a central line? anyone? was that before or after the er doc did a stat endovascular repair and then broke up with that chick in season 2?

leave the troll alone

out of curiosity did yu notice how nasty emedpa got towards internists? kinda shows you what he/she really thinks about them but thats not trolling right? :rolleyes:

out of curiosity did yu notice how nasty emedpa got towards internists? kinda shows you what he/she really thinks about them but thats not trolling right? :rolleyes:

I think you just fired him/her up. I'm sure he/she respects internists as much as I do.

I think you just fired him/her up. I'm sure he/she respects internists as much as I do.

oh so when i make a remark about em docs thats trolling. but when he/she makes a remark about im docs thats just me firing him/her up. that souds very fair.

good article about future of FPs

http://www.aafp.org/x42562.xml

:laugh:

:laugh:


:laugh:

:laugh:

:laugh:

good article about future of FPs

http://www.aafp.org/x42562.xml
very interesting.....I see an ever expanding role for fp docs as hospitalists, solo docs and as part of multispecialty practices.the increasing #s of outpt procedures done by fp at this point(sigs, treadmills, vasectomies, derm procedures, etc ) can make this quite a rewarding career for someone willing to take full advantage of their training.
I have only the utmost respect for fp folks and would probably go that route at this point if I went back to school.

see once he gets his composure back its back to how everyone respects everyone else. group hug, right

http://www.qfever.com/issues/20020206/erdocs.html

get a load of that complex decision tree

http://www.qfever.com/images/issues/20020206-1/erflow.jpg

dont worry once his shift is over hes out the door too. funny stuff. i like the one about his daughter.

There really isn't a "market price" for FPs, because physicians do not operate in a free market economy. Prices for medical services are set by the government and insurance companies. The law of supply and demand does not factor into this. Some would like to see that change.

By change you mean a system where you can charge whatever you want with no restraint from the the market.

Sorry.

No profession including medicine is immune from market forces. Insurance companies and the government do not "set" the price, rather they "bid" for medical services. If they set the price then they would set it at at zero or next to nothing because this makes the most sense for them economically.

Of course, if they bid too low then they will have no takers. Consequently between you, me, and the invisible hand of the market we have all arrived at a price for medical services which is exactly what those services are worth.

By what they're worth I mean what someone (the government or the insurance company) is willing to pay and what you are willing to accept. You do not have to do business with either the government or the insurance companies if you don't want to. Some physicians operate on a strict "cash only" basis and I understand they do very well. Most physicans make the rational decision that what they lose in price per piece they will make up somewhat in volume and bite the proverbial bullet.

Biting the bullet is part of market economics. I think some of you are confused and think that the market doesn't work because it is constantly trying to minimize your salary. Actually, my friends, this how it's supposed to work.

By the same token nobody is going to operate for long at a loss so even though an insurance company or the government can screw you by bidding down the price of medical services, eventually a point will be reached where no one but the zealots will work (for the Glory of the Motherland, naturally).

In socialist or communist countries where the low price is fixed arbitrarily the market responds by creating scarcity as there is no longer an incentive (except at gunpoint) for anyone (except the zealots once again) to produce. This is why health care is more-or-less rationed in the UK and Canadians who can afford it flock across the border from their socialist utopia to purchase health care.

When you read that hospitals are hot for Family Practice physicians your natural question would be "how hot?" In other words, are they putting their money where their mouths are? Well, 150K is certainly a decent salary. And I don't believe that anybody said that Fmaily Physicians will be flocking to the unemployment office. On the other hand what hospitals want is to maximize their profit.

The assertion that primary care is a big money-maker for a hospital is laughable and typical Duke style Family Medicine propaganda. What the hospital wants is a primary care physician who can send them as many customers as possible. They are not interested in how well you are controlling Mr. Jone's cholesterol or that you have delivered every one of Mrs. Smith's children.

Although I would never accuse any hospital adminstrator of wishing for this, for his bottom line it would be better if there was no primary care as keeping someone out of the hospital also shuts down his revenue stream.

The hospital will get their gate-keeper for the lowest possible price that they can factoring in costs of doing business such as legal liability and competition from other hospitals with better customer service. Currently the FP is the cheapest option for the hospital which explains both the demand and the relative inelasticity of the bid price.

When NP and PAs start admitting patients then the bid price is going to go down to a new level, in this case to what a PA or an NP with a third of the human capital invested as you and none of the debt will take.

Economics is not rocket science.

Well good riddance! Hope you enjoy the absolute #1 burn out specialty. Thought I read somewhere the average job span of an ER doc was 10 yrs. Enjoy all the lawsuits, drug seekers, absolute scum of the earth patients none of us would touch. Then come back and post about how wonderful your new specialty is. :laugh: :laugh: :laugh:

The reports of "burnout" are greatly exaggerated. There is nothing particularly stressful about Emergency Medicine compared to other specialties. The hours are certainly better (both in residency and practice) and you can currently work in as busy or as buccolic an Emergency Department as you wish.

Trauma and critcial care are only stressful to the extent that you don't know how to handle them. As an intern my stress level was pretty high on the few codes that I have had to run (before the code team arrived, naturally) but with experience these things become routine and I have rarely seen one of my EM attendings being anything but unflappable in the direst of medical emergencies.

...drug seekers, absolute scum of the earth patients none of us would touch...




I know you don't mean this. At Duke Family Medicine if you even breathed this sentiment you would be sent to sensitivity training.

I happen to like the scum of the earth and have a pretty good rapport with most of 'em. I certainly prefer a drunk crack-head who cut his hand slapping one of his biaches to some sixty-year-old professor's wife with "fibromyalgia," a thirty year addiction to percocet, and the expectation that I want to spend thirty minutes listening to her non-medical problems.

I also want to point out that matching into EM is by no means a sure thing. I think my odds are better than fifty-fifty but I'd hesitate to say how much better. The match is not kind to retreads.

em ppl often talk liek that. they paint this picture where its like theyre ona deserted island and six guys just came in with gunshots to the head, someone is having an mi, and a train crashed nearby. the reality is they immediately call surgery, neurosurg, cardiology, im, and pretty much anyone else who will listen. televsion is nice but real life is a little different, dude.




Well no, not really. Only one percent of all hospital visits take place at an academic medical center. At a typical community ED the nearest specialist is at home in bed and nowhere near being readily available.

And it is not even true that every EM residency program is at a big academic hospital. Several where I interviewed had a definite "cowboy" feel to them.

Economics is not rocket science.

It's a lot more complicated than you're making it out to be, though.

By change you mean a system where you can charge whatever you want with no restraint from the the market.

No, I didn't say that. If you just want to argue against a straw man, there's little point in my continuing to participate in the discussion.

Only one percent of all hospital visits take place at an academic medical center.

ok lets assume thats true. then you can also say that 0% of traumas are going to most hospitals since many are not accredited trauma centers. people with aaas will either go to places where they can have vascular intervention or basically die when they rupture and em docs arent saving them. people with mis are getting treatments with thrombolytics if theres no cardiologist and ct surgeon on site. and so on. so you tell me how many crashing patients you can truthfully say that em docs are juggling as portrayed by empadoc.

ok lets assume thats true. then you can also say that 0% of traumas are going to most hospitals since many are not accredited trauma centers. people with aaas will either go to places where they can have vascular intervention or basically die when they rupture and em docs arent saving them. people with mis are getting treatments with thrombolytics if theres no cardiologist and ct surgeon on site. and so on. so you tell me how many crashing patients you can truthfully say that em docs are juggling as portrayed by empadoc.

Not at all. There is no such thing as an "accredited Trauma center." Any ED which is staffed by a physician who is presumably qualified for the job can expect to recieve trauma (and critically ill) patients.

My hometown in Louisiana of about 25,000 has a fairly large Parish (what you call County) hospital which is essentially deserted of physicians at night except for the ED staff. Since the nearest level one trauma center is about ninety miles away they get plenty of trauma through their doors, albiet MVA blunt trauma and farm accidents rather than the usual urban knife and gun club stuff.

It is also true that they life-flight many patients to the regional trauma center but they stabilize the patient first which is kind of the job description of Emergency Medicine.

As to how many trauma patients the on-duty EM physician in Ruston, Louisana juggles I can't say. He may go a few nights with no serious trauma or he may have four or five from the same motor vehicle accident. The ambulance service in our parish does not routinely make the ninety mile drive to Shreveport.

An EM physician is perfectly qualified to administer thrombolytics if they are indicated and there are no absolute contraindications. Certainly this is a judgement call but I would note that even the cardiologists here at Duke, one of the World's cardiology powerhouses, are extremely cautious with thrombolytics and in a month of cardiology I never had a patient on whom they had been used even if there use would have been indicated.

...another decent discussion turned into an SDN boys club pi$%ing contest...

Maybe I should go hang out with the cool chicks on OBGYN again....

Not at all. There is no such thing as an "accredited Trauma center."

really? the american college of surgeons and the hospitals designated as level 1-4 in america disagree.

An EM physician is perfectly qualified to administer thrombolytics if they are indicated and there are no absolute contraindications.

its not hard to administer (give) thrombolytics. its the 'if they are indicated and no contraindications' part that throws the ed. or are you saying that at duke they dont consult cardiology?

really? the american college of surgeons and the hospitals designated as level 1-4 in america disagree.



its not hard to administer (give) thrombolytics. its the 'if they are indicated and no contraindications' part that throws the ed. or are you saying that at duke they dont consult cardiology?

Designation as a particular level is not the same as being "accredited." The level indicates the availibilty of sub-specialty support and things like an ICU. Even a Level IV trauma center, presumably the base level ED, has the facilities to evaluate, stabilize, and transport all sorts of trauma. You don't have to be at the Mayo Clinic to do the "ABCDs," cardiovert, start a central line, push fluids, do a tracheostomy, intubate, put in a chest tube, or any number of invasive and dangerous procedures.

"Accredited" is a meaningless term.

As to thrombolytics, I'm talking about spending a month on the Duke cardiology service and just pointing out that it's not just ED physicians who are reluctant to administer thrombolytics.

Designation as a particular level is not the same as being "accredited."

actually it is since you have to demonstrate/prove that you have the facilities and services to qualify for a designation as a level x trauma center. you dont just say 'i am one', which means you are being accredited either by the acs or the state.

just how many major traumas do you know of that are being handled by ed docs?

As to thrombolytics, I'm talking about spending a month on the Duke cardiology service and just pointing out that it's not just ED physicians who are reluctant to administer thrombolytics.

i didnt say people administered them without caution and for good reason. but how many people requiring thrombolytics are being treated by ed docs without consultation to cardiology? at duke or anywhere else?

actually it is since you have to demonstrate/prove that you have the facilities and services to qualify for a designation as a level x trauma center. you dont just say 'i am one', which means you are being accredited either by the acs or the state.

just how many major traumas do you know of that are being handled by ed docs?



i didnt say people administered them without caution and for good reason. but how many people requiring thrombolytics are being treated by ed docs without consultation to cardiology? at duke or anywhere else?

But that's the point. Risk aversion is not unique to any specialty. At the same time I do know personally one of the physicians who worked at our parish hospital's ED (a moonlighting internist) and he has administered thrombolytics. And your point is well taken about consultations because he told me that he did call LSU Shreveport to talk to a cardiologist before he pushed them on several occasions.

If you want to talk about the most risk averse specialty it would have to be FP, at least at my program, because we punt everything that is remotely complicated.

At Baton Rouge, the program where I hope to match, he EM residents manage all the traumas as there is no in-house anything except for medicine and OB-Gyn. At some of the other programs where I interviewed the EM residents alternate days with the surgery residents. I was told that since the EM residents rotate on the trauma service, the trauma resident is often-times an EM resident.

If you are working in the ED at a small community hospital then you are going to run the trauma by default as there is no one else.

I think we can agree that the majority of cases seen in most EDs are not trauma but acute medical problems which range from the serious to the silly. Still, to say that EM physicians don't manage traumas would be a stretch.

I don't know what you mean by a major trauma. A gunshot wound is pretty major to some people but jsut another day at the office to others.

Risk aversion is not unique to any specialty.

thats true but theres a difference. with other specialties you weigh the risk and then you do something or not. with the ed its more like you call someone else to have them take the risk for you. true or false ed docs call other specialities to clear patients to leave? if an ed doc did what they say they do then id have respect but its silly to say they 'handle crashing patients' when theyre more like third-party players in the entire situation. if the ed wants more respect then they need to take more responsibility for their patients but its more like they want it both ways on everything. they excuse their superficial 'work-up' by saying their job is not to diagnose on one hand then they brag about how they 'did everything' for the admitting team. which is it? they say that one of the pluses of the field is that it allows you a great lifestyle but then they get offended when you comment on their shiftwork. which is it?

thats true but theres a difference. with other specialties you weigh the risk and then you do something or not. with the ed its more like you call someone else to have them take the risk for you. true or false ed docs call other specialities to clear patients to leave? if an ed doc did what they say they do then id have respect but its silly to say they 'handle crashing patients' when theyre more like third-party players in the entire situation. if the ed wants more respect then they need to take more responsibility for their patients but its more like they want it both ways on everything. they excuse their superficial 'work-up' by saying their job is not to diagnose on one hand then they brag about how they 'did everything' for the admitting team. which is it? they say that one of the pluses of the field is that it allows you a great lifestyle but then they get offended when you comment on their shiftwork. which is it?

Well, I love shift work and absolutely despise call, probably more than most people despise it which is saying a lot. It is my fondest hope to never have to take call again (well, after repeating intern year next year if all goes well).

I think overnight call is stupid. Yeah. Yeah. I know. You learn a lot by admitting patients but I think a night float system would be just as effective for this and lets everybody get a good night's (or day's) sleep.

I did serve for eight years in the Marines as an infantryman, doing the military equivalent of "hard time." I have paid some dues in life, enough to know that there is no reward for getting screwed out of sleep and time off.

I have worked on several codes in the ED with EM residents so I can say with authority that they were managing a crashing patient.

It's a lot more complicated than you're making it out to be, though.

Sure it is. But SDN is a hobby, not a career and I don't have the time or the inclination to write a treatise on economics.

The fundamentals of economics aren't really that hard ot grasp. It's just that people can't get past their emotional reaction to what they view as the unfairness of the market.

Well, I love shift work and absolutely despise call

who likes call? but other specialties do it. the er can decide not to have any because there is little to no commitment to patient care. at the end of their shift they just sign out. and thats because really there are other physicians who are taking care of the patient even if they are physically in the er in many cases. all you need to do as an er doc is to make sure you actually know who is taking care of that patient, in other words youre like a nurse.

I have worked on several codes in the ED with EM residents so I can say with authority that they were managing a crashing patient.

not really. they may have been initiating a code on a patient but i can guarantee 100% that another group of physicians managed the patient. they either took over after a mnute of the code or at the very least they took the patient at the end of the code, but actually ive never seen an ed doc complete an entire code in isolation. have you? and to say that coding a patient consists of 'managing' them is false. if you say that you 'manage' a gsw to the head, as ed docs and empadoc say, thats fairly different from starting a code as you call the trauma team and neurosurgery. dont get me wrong im not saying that the ed should be managing a gsw to the head, but neither should they be pretending they do. they dont. thats just plain and simple. do they manage mis? no cardiology does. do they manage broken bones? no ortho does. what does the er really manage? theyre triage nurses. tell the trueth, how quickly is another physician called by the er on any patient? and dont say there are patients who are down in the ed for 16 hours without a consult because then usually the consultant comes down and sees that nothing has been done for the patient and they have just been sitting around for 16 hours. i mean how much is actually done by er docs other than drawing up the same labs on every patient and maybe throw in an imaging study at random?

The fundamentals of economics aren't really that hard ot grasp. It's just that people can't get past their emotional reaction to what they view as the unfairness of the market.

My original post stated that healthcare does not operate in a free market economy. You said a lot of things in your reply, but nothing was really germain to what I originally wrote. The free market is defined as "business governed by the laws of supply and demand, not restrained by government interference, regulation or subsidy." With rare exceptions (e.g., a doctor who only accepts cash), medicine in the U.S. operates almost exclusively under the umbrella of regulation. The free market law of supply and demand is not a factor.

Insurance companies and the government do not "set" the price, rather they "bid" for medical services. If they set the price then they would set it at at zero or next to nothing because this makes the most sense for them economically.

Private insurers set their fee schedules according to Medicare. Medicare rates are determined using a formula based on the gross national product (GNP), not the actual costs of providing healthcare. Again, not a free market.

The insurance industry itself operates in something more akin to a free market, with insurers negotiating rates with employers based on market forces in their particular geographic area. However, these rates have little bearing on the fee schedules that are offered to physicians. Insurers typically use fee schedules to grow their network of providers as they see fit. With rare exceptions, physicians have little leverage when negotiating fee schedules. The "negotiations" usually amount to little more than "Here's what we pay, take it or leave it." In many locales, one or two carriers now insure the majority of covered lives. If you choose not to accept those plans, you lose access to a significant chunk of your patient population. Again, not a free market from the physicians' standpoint.

My original post stated that healthcare does not operate in a free market economy. You said a lot of things in your reply, but nothing was really germain to what I originally wrote. The free market is defined as "business governed by the laws of supply and demand, not restrained by government interference, regulation or subsidy." With rare exceptions (e.g., a doctor who only accepts cash), medicine in the U.S. operates almost exclusively under the umbrella of regulation. The free market law of supply and demand is not a factor.

There is not a single business that is not regulated to one extent or another by the government. I was in the manufacturing sector for many years and we were beset by all kinds of OSHA and environmental regulations.

The medical industry is probably the most regulated of any but it's just a question of degree. If the criteria is that only unfettered capitalism results in free markets then I guess there is no such thing as free market.

As long as you are able to choose how you will work and what you will charge for your services, the market is free. The "freeness" of the market has nothing to do with whether your offered price is accepted. You can practice a cash only business. You can also require your patients to file their own insurance claims but nobody wants to do this because the consumer expects a low price and no responsibilty to pay for thier health care except that they pay part of their premium.

I repeat, if the government or an insurance company could set the price for your services and you had no choice but to accept this price, they would set the price at zero minimizing their cost in the process.

The price they have arrived it is high enough to entice doctors to accept it. Your confusion results from not correctly identifying the health care consumer. Since most Americans have either private or governement health insurance, the health care customer is the insurance company, not the patient, and it is this relationship that responds to market forces.

People do make money accepting medicare, medicaid, and private insurance. Like most industries the low bid price is offset by increased volume which is why family medicince doctors only spend a measley five or ten minutes with most patients.

Private insurers set their fee schedules according to Medicare. Medicare rates are determined using a formula based on the gross national product (GNP), not the actual costs of providing healthcare. Again, not a free market.

The insurance industry itself operates in something more akin to a free market (which is why it's such a profitable industry), with insurers negotiating rates with employers based on market forces in their particular geographic area. However, these rates have little bearing on the fee schedules that are offered to physicians. With rare exceptions, physicians have little leverage when negotiating fee schedules with payers. The "negotiations" typically amount to little more than "Here's what we pay, take it or leave it." In many locales, one or two carriers now insure the majority of covered lives. If you don't accept those plans, you lose access to a significant chunk of your patient population. Again, not a free market from the physicians' standpoint.

You are confused. How the buyer determines what he is willing to pay is irrelevant to the operation of the market. The only important thing is whether his offer is accepted. It doesn't matter if the price was calculated using a GDP-based formula or astrology.

Obviously the government's bid is high enough or nobody would accept it. You continuously point out the princely sums to be made by Family Medicince physicians so in your sector, at least, the market is working. The fact that it is not working to your satisfaction because you are making less than you think you are worth is immaterial.

My worry about FP is actually that the government's bid price will continue to decrease as less expensive options, NPs for example, move into your market to undersell you.

Every free market has automatic downward pressure to reduce the bid price to the lowest possible level at which the "economic profit" is zero. Once again, below this price only the zealots will work as every other rational person will look for a job where he does not lose money.

I repeat. Nobody will work for free or if they are taking a loss.

"Take it or leave it" is valid free market concept. We do this all the time in real life. I shop at Wal Mart, for example, because I will not "take" Food Lion's asking price for a can of corn which is 40 cents higher than I am willing to pay.

Does Food Lion decry the lack of a free market from their point of view? Of course not. Setting the price high or low is just a function of what the market will bear.

"The actual cost of providing health care" is a meaningless concept. What you mean here is that you'd like to be paid more for your part of providing health care.

..but actually ive never seen an ed doc complete an entire code in isolation...


Captain Obvious strikes again. Nothing at a major academic medical institution happens in isolation. On my last MICU rotation the MICU resident was part of the code team and his only job was to put in the central line. (which was usually a femoral line and not really a central line if you want to get technical) People came form all over the hospital and Upper-level floor resident on the ward that called the code was in charge.

It's kind of embarrassing having "Family Medicine" on my ID badge in a code because the assumption was that I couldn't put in the line.

When a patient "codes" in the ED, they do not call a hospital-wide code. The EM residents run the code with the usual cast of characters. Like most things if you are timid somebody else is going to take charge and if this is the trauma chief who happens to be seeing a patient in your ED than he is going to do it.

"The actual cost of providing health care" is a meaningless concept.

I think we'll just have to agree to disagree. Have a nice day.

Don't they teach anything other than Marxist economics at universities any more?

I think we'll just have to agree to disagree. Have a nice day.

Well, this thread is kind of confusing to me too. On one hand the premise is that Family Medicine salaries are going up responding to the increased demand from a normally functioning market. On the other hand family medicine salaries blow because the eee-vil gubmint' and the insurance companies have colluded to keep your salaries down to fast-food levels.

Is the salary picture good or bad?

Then you all tell me that EM blows because it has a high burnout rate secondary to treating all of those critically ill and seriously injured patients only to tell me several posts later that EM physicians don't actually treat any seriously ill patients but immedietely pass them on to real doctors.

Captain Obvious strikes again. Nothing at a major academic medical institution happens in isolation. On my last MICU rotation the MICU resident was part of the code team and his only job was to put in the central line. (which was usually a femoral line and not really a central line if you want to get technical) People came form all over the hospital and Upper-level floor resident on the ward that called the code was in charge.

It's kind of embarrassing having "Family Medicine" on my ID badge in a code because the assumption was that I couldn't put in the line.

When a patient "codes" in the ED, they do not call a hospital-wide code. The EM residents run the code with the usual cast of characters. Like most things if you are timid somebody else is going to take charge and if this is the trauma chief who happens to be seeing a patient in your ED than he is going to do it.

This is exactly why no one should train at an opposed residency for family medicine, "prestigious" or not. It's just not worth it, and the kinds of docs these programs turn out are the kind that people too often associate with FPs: fine for the clinic but incompetent at everything else.

The complete opposite is often true of FPs from solid unopposed programs like Ventura and JPS.

As for the NP debate...let's just sit back and watch. I doubt the doomsdayists are going to be proven correct on this one.

This is exactly why no one should train at an opposed residency for family medicine, "prestigious" or not. It's just not worth it, and the kinds of docs these programs turn out are the kind that people too often associate with FPs: fine for the clinic but incompetent at everything else.

The complete opposite is often true of FPs from solid unopposed programs like Ventura and JPS.

As for the NP debate...let's just sit back and watch. I doubt the doomsdayists are going to be proven correct on this one.

You are so right. I would have gotten better training at the E.A. Conway program in little old Monroe, Louisiana than I am getting here at Duke (for Family Medicine, I mean).

It is just too easy to punt everything to a specialist. Not to mention that since our clinic is somewhat "volume driven" being a money-making practice the teaching suffers.

Well, this thread is kind of confusing to me too. On one hand the premise is that Family Medicine salaries are going up responding to the increased demand from a normally functioning market. On the other hand family medicine salaries blow because the eee-vil gubmint' and the insurance companies have colluded to keep your salaries down to fast-food levels.

Is the salary picture good or bad?

Then you all tell me that EM blows because it has a high burnout rate secondary to treating all of those critically ill and seriously injured patients only to tell me several posts later that EM physicians don't actually treat any seriously ill patients but immedietely pass them on to real doctors.

i dont agree with that about EM. i think you do treat and manage well critically injured patients, and pass on when its nec. but their is alot of stress and burnout, but thats in evfery field.

On my last MICU rotation the MICU resident was part of the code team and his only job was to put in the central line.

and yet the point is that someone who was a member of the micu team did everything. obviously in a code one person is the leader and everyone else has designated tasks but that is not to say that the team as a whole is not acting independently and in isolation. it is quite different in the ed because they may initiate a code but most certainly one of their initial steps is to notify someone else to come to aid them. obviously captain obvious was not obvious enough for you.

and yet the point is that someone who was a member of the micu team did everything. obviously in a code one person is the leader and everyone else has designated tasks but that is not to say that the team as a whole is not acting independently and in isolation. it is quite different in the ed because they may initiate a code but most certainly one of their initial steps is to notify someone else to come to aid them. obviously captain obvious was not obvious enough for you.


In community/private hospitals if someone codes the ER docs are the ones called to the floor to run it right?

In community/private hospitals if someone codes the ER docs are the ones called to the floor to run it right?

Right. And let me reiterate that they do not call a "hospital wide code" if a patient codes in the ED. Presumably the assumption is that the EM physicians with their staff in the ED can handle it.

and yet the point is that someone who was a member of the micu team did everything. obviously in a code one person is the leader and everyone else has designated tasks but that is not to say that the team as a whole is not acting independently and in isolation. it is quite different in the ed because they may initiate a code but most certainly one of their initial steps is to notify someone else to come to aid them. obviously captain obvious was not obvious enough for you.


No. The MICU resident was the "line" person and did just that. The ward resident who called the code ran the code.

But at other hospitals the MICU staff is also part of the code team but they do not respond to codes in the ED.

actually it is since you have to demonstrate/prove that you have the facilities and services to qualify for a designation as a level x trauma center. you dont just say 'i am one', which means you are being accredited either by the acs or the state.

just how many major traumas do you know of that are being handled by ed docs?



i didnt say people administered them without caution and for good reason. but how many people requiring thrombolytics are being treated by ed docs without consultation to cardiology? at duke or anywhere else?

Perhaps things are different because I practice at a rural institution (but I believe Panda made the point that the majority of care occurs at non academic centers so perhaps this is relevant). Traumas are handled by our EM physicians (unfortunately some of them are not EM trained and this is a problem--ideally we would have an 100% EM trained/boarded ED we're working on it) with Peds traumas managed by Peds & EM. We stabilize and ship (fly if the weather permits which is a little less than 50% of the time on average) but sometimes it's the things that are done in the first hour that make the difference.

As far as thrombolytics in ACS the standard of care with STEMI is cath lab in <2 hours or thrombolytics (providing no contraindications) and ship. We do not have cardiology at our institution so the thrombolytics decisions are made by either EM or medicine on call. I feel that part of being EM competent requires comfort with thrombolytic therapy the indications and contraindications. For the most part the EM trained cadre of our providers have this competency some of our non EM trained are not competent in this arena and the case diverts to the medicine on call. [But in these cases I feel that this is a deficiency in our ED physician. I'm not saying its something I'm not comfortable/competent with or shouldn't be, because it is and I am. However, I think that it delays care if the decision is turfed to me, but you have to do the right thing for the patient so I will see and stabilize and ship these patients. In these cases we usually ship ED to ED and I basically function as if I was an EM provider (and when we get an 100% EM trained ED I'll be glad to opt out)]

In community/private hospitals if someone codes the ER docs are the ones called to the floor to run it right?

you gotta be kidding me.

No. The MICU resident was the "line" person and did just that. The ward resident who called the code ran the code.

again as i said in any code there is by definition according to acls protocols a team leader and other people with designated jobs. doing a job as part of the code team is different from having the code team take over.

In community/private hospitals if someone codes the ER docs are the ones called to the floor to run it right?

you gotta be kidding me.

Right. And let me reiterate that they do not call a "hospital wide code" if a patient codes in the ED. Presumably the assumption is that the EM physicians with their staff in the ED can handle it.

Ideally at community hospitals the physicians do a better job of checking their egos and attitudes at the door than you three seem to have today. That said, in our community rural hospital if there is a code on the floor and it is the middle of the night our ED physician may be the only physician in house. They will run the code until the attending on call arrives in house. I admit that this made me uncomfortable at first as I was used to residency where there were multiple physicians in house and the idea of driving in from home for a code seemed quite honestly frightening. You adapt to your practice to the resources you have to practice with and the situation and I make it a point to make rounds before heading out the door and the nurses are trained to call sooner rather than later knowing that we can be 10 minutes away. So far in my short tenure I haven't had the experience of truly coming in for a code. I have come in for near codes and was fortunate to still be in my office the night that one of my colleagues patients got sent to the floor with saturations in the 70s on 50% venti mask by one of our less competent EM providers (don't slam EM he isn't EM trained perhaps that is part of the problem) the RT got him on 100% with marginal saturations (low 90s) and the nurses called me and I came over and intubated. My patient who self extubated at 3AM was considerate enough to do it on the morning of one of my worst weekend calls and I was still on the medical floor completing my final H&P so I could just cruise back over to the ICU and reintubate. (Had I not been in house depending on patient condition the ED physician might have been asked to attempt reintubation---some of our ED physicians would be challenged by that request another reason we need EM trained providers).

As far as ED codes as we are a single staffed department with some non EM trained providers our ED codes do "go overhead". I have been the airway or access physician while the ED physician ran the code or vice versa. We try to work together to do what is right for the patient. With pediatric alerts the ED nurses often contact the pediatrician on call even before letting the ED physician know (partly because we may not be in house).

They will run the code until the attending on call arrives in house.

nobody ever said ed docs cant code people. i said and you just reiterated that ed docs are strictly temporizing agents at best. certainly at academic centers even this is debatable as it is barely disputable that they are essentially triage nurses. but ok if you want to focus on small isolated community centers that does not change things.

Well good riddance! Hope you enjoy the absolute #1 burn out specialty. Thought I read somewhere the average job span of an ER doc was 10 yrs. Enjoy all the lawsuits, drug seekers, absolute scum of the earth patients none of us would touch. Then come back and post about how wonderful your new specialty is. :laugh: :laugh: :laugh:

This is a very troubling attitude from anyone, but especially an attending. You are a physician, not God, I challenge you to take a deep breath and meet your patients where they are and attempt to move forward. I hate to break it to you but addiction, mental illness, and lack of responsibility or compassion are not exclusive to patients presenting to the ED. Unfortunately you have demonstrated some of those qualities in your response now.

nobody ever said ed docs cant code people. i said and you just reiterated that ed docs are strictly temporizing agents at best. certainly at academic centers even this is debatable as it is barely disputable that they are essentially triage nurses. but ok if you want to focus on small isolated community centers that does not change things.

Well if I'm five minutes away to be honest the die is likely well cast (based largely on the care provided by the ED physician) by the time I arrive. Sure I can attempt to swoop in and save the day but it may not be possible at that point. You seem to have a real hang up with EM providers, please do your patients a favor and get over it.

You seem to have a real hang up with EM providers, please do your patients a favor and get over it.

you seem to be full of pap. youre one of those people who think that as long as you put 'do your patients a favor' or 'this will benefit your patients' in front of a statement that makes it unassailable despite the fact that the two thoughts are completely disconnected. in other words you have been trained well to be a sheep. and before you get mad at what i say, put your patients first. :laugh:

you seem to be full of pap. youre one of those people who think that as long as you put 'do your patients a favor' or 'this will benefit your patients' in front of a statement that makes it unassailable despite the fact that the two thoughts are completely disconnected. in other words you have been trained well to be a sheep. and before you get mad at what i say, put your patients first. :laugh:

When you are unable to have a professional working relationship with your colleagues in another specialty patient care suffers. Hence growing up and putting patient care before trashing someone else (which seems to be the jist of the majority of your posts) would be beneficial. Perhaps how you conduct yourself in real life is vastly disparate from your conduct on the message board. If that is the case then good for you (and is life really so boring that you feel the need to flame and troll on a message board?). Otherwise please grow up. I've been told that you are no longer allowed to be actively involved in the practice of medicine and are disgruntled as a result of the situations and actions that led to that. If this is indeed the case then my sympathies and I wish you the best of luck in addressing your own issues in due time.

When you are unable to have a professional working relationship with your colleagues in another specialty patient care suffers ...please grow up.

that hardly sounds professional. does that mean your working relationship with collegaues is suffering? :laugh: or do you only give out advice and solliliquisms without following them? see the thing is that people like you like to talk like youre these very mature and compassionate people who are adults. but then you pick and choose when that needs to occur. in the middle of lecturing me about understanding and getting along you started trying to do some shots in the dark that are frankly fairly low blows hoping to yank my chain. but that contradicts your own message. and if i say that then you get all angry and start blustering some more because you dont like faceing the facts.

the fact that you couched your words in a backhanded pretense of sympathy doesnt make them more mature. if i said to you 'i apologzie that you are so ignorant and hope youre able to improve yourself as you grow in life' would you find that to be an acceptable message since it is the same way you speak?

you gotta be kidding me.


I believe the Physician who works in a small hospital pretty much backed up my statement that ER docs run the codes on the floor. In the middle of the night who else is gonna run it, the janitor? I know for a fact even in large private hospitals ER is responsible for ALL floor codes. So I guess no, I'm not kidding you...

I know for a fact even in large private hospitals ER is responsible for ALL floor codes. So I guess no, I'm not kidding you...

for about two minutes. so yes you are kidding me.

I believe the Physician who works in a small hospital pretty much backed up my statement that ER docs run the codes on the floor. In the middle of the night who else is gonna run it, the janitor? I know for a fact even in large private hospitals ER is responsible for ALL floor codes. So I guess no, I'm not kidding you...


Right, and guess who is running the ER (and thus the codes) in those small hospitals? Your friendly neighborhood jack or jill of all trades family doc. :)

for about two minutes. so yes you are kidding me.


You think the attending is gonna make it out of bed and to the hospital in two minutes? Are you even in medical school?

Right, and guess who is running the ER (and thus the codes) in those small hospitals? Your friendly neighborhood jack or jill of all trades family doc. :)

So let me get this straight. A Family Physician who spends his day dealing with chronic health care issues and treating other non-acute complaints can run a code but an EM physician whose job description includes stabilzing horrifically injured or seriously ill patinets cannot?

I wil grant you that every physician is ACLS certified but isn't it possible that an EM physician might have a little more practical experience than an FP?

You can't cast such a wide net on the hospitals, EM's or FM docs. It will be different in almost every hospital you go to. If I'm in house, I'll run the code. But at 2 am I'm in bed and the ED doc runs the code if no other doc is in the hospital. They'll call me if the patient is coming out of it and I will stabilize the patient after I haul A@@ to the hospital.

You can argue all you want about who is right and wrong. Chances are you all are both right and wrong.


PS This thread is worthless at this point.

PS This thread is worthless at this point.

It is still serving the very important purpose of entertaining me.

So let me get this straight. A Family Physician who spends his day dealing with chronic health care issues and treating other non-acute complaints can run a code but an EM physician whose job description includes stabilzing horrifically injured or seriously ill patinets cannot?

I wil grant you that every physician is ACLS certified but isn't it possible that an EM physician might have a little more practical experience than an FP?

ACLS is basically the epitome of cookbook medicine (but this isn't bad because the cookbook is grounded in evidence and updated in a timely fashion) so yes I think FP can run codes, IM can run codes, Med-Peds can run codes, EM can run codes. Sadly being comfortable comes from doing it frequently. Procedural prowess with intubations and central access plays into your success somewhat as well (but this goes back to experience the more you do the better you are within reason). Experience varies by institution, I know where I trained FP residents never carried code pagers and the IM code team coded their patients for them. (I think this did them an educational disservice but that is another topic). They did not have unit privileges so they did not do lines or intubate. Other residency programs at other institutions may have similar problems.

In our institution as a pediatrician I'm more comfortable with pediatric acute care than all but one of our ED physicians (but again we don't have 100% EM trained providers in our ED :( ) and I have had our ED physicians step back and let me (and even ask me to please) run the code in the ED with adults. The point is that we all have our strengths and weaknesses and you must adapt to practice within the resources of the health care system you find yourself in. The goal should be having EM trained providers in rural EDs (but if that isn't reality then it is even more critical that your IM, FP, and Peds doctors be comfortable with critical care).

ACLS is basically the epitome of cookbook medicine (but this isn't bad because the cookbook is grounded in evidence and updated in a timely fashion) so yes I think FP can run codes, IM can run codes, Med-Peds can run codes, EM can run codes. Sadly being comfortable comes from doing it frequently. Procedural prowess with intubations and central access plays into your success somewhat as well (but this goes back to experience the more you do the better you are within reason). Experience varies by institution, I know where I trained FP residents never carried code pagers and the IM code team coded their patients for them. (I think this did them an educational disservice but that is another topic). They did not have unit privileges so they did not do lines or intubate. Other residency programs at other institutions may have similar problems.

In our institution as a pediatrician I'm more comfortable with pediatric acute care than all but one of our ED physicians (but again we don't have 100% EM trained providers in our ED :( ) and I have had our ED physicians step back and let me (and even ask me to please) run the code in the ED with adults. The point is that we all have our strengths and weaknesses and you must adapt to practice within the resources of the health care system you find yourself in. The goal should be having EM trained providers in rural EDs (but if that isn't reality then it is even more critical that your IM, FP, and Peds doctors be comfortable with critical care).

Well said.

I matched into EM, by the way.

Well said.

I matched into EM, by the way.

:thumbup: Congratulations! [And if you have any interest in relocating to a rural ED in 3 years let me know ;)]