A rant on corporate emergency medicine

[southeastwizards]

This is a throwaway of someone who posts somewhat routinely...

Much of what Birdstrike writes has significant insight, but one statement in particular rings especially true: even if you have a near ideal job, it can all change at the drop of a hat.

Within the last few years, our group was taken over by a large CMG. Metrics were, of course, emphasized before, but now it's gone crazy. All that matters is door to greet time. Seriously, that's it. Whether you show up with chest pain or medication refill, you need to be seen instantaneously. All resources in our department are directed toward this one goal, with minimal flexibility. If this number starts to creep above a certain number of minutes, you'd think a nuclear strike was incoming. Every administrator within a 30 mile radius is paged and questions start getting asked. We have a frigging giant flat screen TV solely dedicated to displaying this number and a graph that plots it over time -- this has taken precedence over an actual patient tracker.

So the strategy to meet this metric, you ask? Having PAs/NPs at triage screening EVERY single patient, excepting ambulance traffic (and even them at times!). And how does this work in practice? The midlevel gets 1 minute with a patient, shotguns orders, then sends them to the main ER where they won't be seen for another 2-3 hours. By the time I'm able to see the patient, they either had an over-workup that makes me shake my head (frequent unnecessary head CTs on peds; IVFs on all vomiting peds; d-dimer on every chest pain) or the opposite (missed or minimized neurologic deficits; no UA/UPT on female abdominal pain; no pain medication for fractures). Either the patient gets unnecessary treatment, or they're delayed when I need to do a second round of testing. Part of this is that MLPs do the initial ordering, yes, but the majority of it is that they have minimal time to see the patient and are forced to order indiscriminately.

You can imagine that this has decreased morale. It has. Many docs and MLPs have left because it's simply miserable. In their place, we have a bunch of locums docs just passing through, and a bunch of new MLPs who've never worked in an ER before.

This brings me to the second part of my rant: please don't be lazy and actively try to destroy our profession. Because of this mess, there's minimal leadership or oversight on the physician side. Most of the locums docs have taken to coercing the MLPs into doing all their work, including calling admissions and consultations on even the sickest patients. I find myself fuming when double-covered with a locums as he's texting on his phone, drinking a coffee, reading ESPN, and barking orders at the midlevel: "start some meds for the NSTEMI and call the cardiologist; can you call the surgeon for that obstruction?; just admit them to the hospitalist; why don't you try the LP first and call me; I have a lac I need you to do; just start some antibiotics and get them admitted to the ICU." This immediately reminds me of the anesthesia/CRNA fiasco, and it worries me for our future.

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[EctopicFetus]

This is what happens when you have docs who have no investment in the practice at that location. Lets be honest, in an ideal world you are committed to the group, to the hospital system and the patient. Much of this is being slowly wittled away and the locums guys just want to collect a paycheck while doing as little as possible.

 

[GeneralVeers]

Interesting take on locums. As a locums for the last year (working at the same hospital during that time), myself and my locums friends outperform all of the "full timers" on every metric they have.

 

[southeastwizards]

Interesting take on locums. As a locums for the last year (working at the same hospital during that time), myself and my locums friends outperform all of the "full timers" on every metric they have.

This wasn't meant to be a dis on locums in general. I should have mentioned: the remaining full time docs are RVU based, and the locums are straight hourly. Thus the discrepancy. (To add to the bitterness, their hourly rate is significantly above even the top performing full time doc.)

 

[EctopicFetus]

This is a bad mix. while many of us take our personal performance seriously everyone knows the lazy docs. My group is interesting as we have no RVU/productivity portion to our compensation. We have a decent amount of variability. Since we are all owners I feel like I have to do my best. I worked my tail off when I worked for a CMG as a moonlighter. I feel like I have to give my best. Others know the CMGs are desperate and feel like ultra part time docs, they just dont care about the place or the job.

 

[Birdstrike]

This is a throwaway of someone who posts somewhat routinely...

Much of what Birdstrike writes has significant insight, but one statement in particular rings especially true: even if you have a near ideal job, it can all change at the drop of a hat.

Within the last few years, our group was taken over by a large CMG. Metrics were, of course, emphasized before, but now it's gone crazy. All that matters is door to greet time. Seriously, that's it. Whether you show up with chest pain or medication refill, you need to be seen instantaneously. All resources in our department are directed toward this one goal, with minimal flexibility. If this number starts to creep above a certain number of minutes, you'd think a nuclear strike was incoming. Every administrator within a 30 mile radius is paged and questions start getting asked. We have a frigging giant flat screen TV solely dedicated to displaying this number and a graph that plots it over time -- this has taken precedence over an actual patient tracker.

So the strategy to meet this metric, you ask? Having PAs/NPs at triage screening EVERY single patient, excepting ambulance traffic (and even them at times!). And how does this work in practice? The midlevel gets 1 minute with a patient, shotguns orders, then sends them to the main ER where they won't be seen for another 2-3 hours. By the time I'm able to see the patient, they either had an over-workup that makes me shake my head (frequent unnecessary head CTs on peds; IVFs on all vomiting peds; d-dimer on every chest pain) or the opposite (missed or minimized neurologic deficits; no UA/UPT on female abdominal pain; no pain medication for fractures). Either the patient gets unnecessary treatment, or they're delayed when I need to do a second round of testing. Part of this is that MLPs do the initial ordering, yes, but the majority of it is that they have minimal time to see the patient and are forced to order indiscriminately.

You can imagine that this has decreased morale. It has. Many docs and MLPs have left because it's simply miserable. In their place, we have a bunch of locums docs just passing through, and a bunch of new MLPs who've never worked in an ER before.

This brings me to the second part of my rant: please don't be lazy and actively try to destroy our profession. Because of this mess, there's minimal leadership or oversight on the physician side. Most of the locums docs have taken to coercing the MLPs into doing all their work, including calling admissions and consultations on even the sickest patients. I find myself fuming when double-covered with a locums as he's texting on his phone, drinking a coffee, reading ESPN, and barking orders at the midlevel: "start some meds for the NSTEMI and call the cardiologist; can you call the surgeon for that obstruction?; just admit them to the hospitalist; why don't you try the LP first and call me; I have a lac I need you to do; just start some antibiotics and get them admitted to the ICU." This immediately reminds me of the anesthesia/CRNA fiasco, and it worries me for our future.

I think your point was not to bash Locums but more along the lines of, "I thought my job was good, but it changed on me. What happens if I leave to chase the next great job, and it flip flops on me again, and again..?"

Frustration with lack of control over practice environment...

Not wanting to job chase for an entire career...

Feeling trapped..

If so, I get the frustration.

(Thanks for the shout-out, by the way).

 

[NinerNiner999]

This sounds an awful lot like HCA and Emcare, who are in bed with each other and run their ED's like tyrants. Take heed - there is only one way we can collectively change this culture - Don't work for them.

This model will eventually implode because a) nobody wants to work for a hospital that pushes metrics, pages administrators, and forces their directors to drive in at 4am and miraculously "fix" their systemic problems that can't be culturally changed, and b) nobody wants to work for and be loyal to a contract group that encourages metrics "in the name of the contract" and pays locums $300- $600/hr as mercenaries to keep a warm body in the department. HCA and EMCare are boxing themselves in to a market that will only attract two types of people - new grads who don't know better, and seasoned locums - who don't care about long-term loyalty, and won't accept the pauper's pay of the loyal full time physician. Eventually, the new grads won't want to work for them anymore (or ever again), and their recruiting pool will dry up. Eventually, their locum pay will be unsustainable and their locum pool will go elsewhere that pays the same rates and doesn't force metrics like they do. Who will staff their ER's when that happens?

Emcare by itself isn't bad, and like all CMG's, has it's pluses and minuses. HCA by itself is no different than any other hospital corporation - same metrics, same profit goals. Combining the two is a recipe for synergistic evil that exploits the worst of both sides and taints the practice of emergency medicine.

 

[EctopicFetus]

This sounds an awful lot like HCA and Emcare, who are in bed with each other and run their ED's like tyrants. Take heed - there is only one way we can collectively change this culture - Don't work for them.

This model will eventually implode because a) nobody wants to work for a hospital that pushes metrics, pages administrators, and forces their directors to drive in at 4am and miraculously "fix" their systemic problems that can't be culturally changed, and b) nobody wants to work for and be loyal to a contract group that encourages metrics "in the name of the contract" and pays locums $300- $600/hr as mercenaries to keep a warm body in the department. HCA and EMCare are boxing themselves in to a market that will only attract two types of people - new grads who don't know better, and seasoned locums - who don't care about long-term loyalty, and won't accept the pauper's pay of the loyal full time physician. Eventually, the new grads won't want to work for them anymore (or ever again), and their recruiting pool will dry up. Eventually, their locum pay will be unsustainable and their locum pool will go elsewhere that pays the same rates and doesn't force metrics like they do. Who will staff their ER's when that happens?

Emcare by itself isn't bad, and like all CMG's, has it's pluses and minuses. HCA by itself is no different than any other hospital corporation - same metrics, same profit goals. Combining the two is a recipe for synergistic evil that exploits the worst of both sides and taints the practice of emergency medicine.

I think the supply of docs is endless. Emergency medicine has become almost fully commoditized. At some point they will make the job easier so they dont have to pay $300/hr.

 

[Birdstrike]

This sounds an awful lot like HCA and Emcare, who are in bed with each other and run their ED's like tyrants. Take heed - there is only one way we can collectively change this culture - Don't work for them.

This model will eventually implode because a) nobody wants to work for a hospital that pushes metrics, pages administrators, and forces their directors to drive in at 4am and miraculously "fix" their systemic problems that can't be culturally changed, and b) nobody wants to work for and be loyal to a contract group that encourages metrics "in the name of the contract" and pays locums $300- $600/hr as mercenaries to keep a warm body in the department. HCA and EMCare are boxing themselves in to a market that will only attract two types of people - new grads who don't know better, and seasoned locums - who don't care about long-term loyalty, and won't accept the pauper's pay of the loyal full time physician. Eventually, the new grads won't want to work for them anymore (or ever again), and their recruiting pool will dry up. Eventually, their locum pay will be unsustainable and their locum pool will go elsewhere that pays the same rates and doesn't force metrics like they do. Who will staff their ER's when that happens?

Emcare by itself isn't bad, and like all CMG's, has it's pluses and minuses. HCA by itself is no different than any other hospital corporation - same metrics, same profit goals. Combining the two is a recipe for synergistic evil that exploits the worst of both sides and taints the practice of emergency medicine.

Great post.

 

[Birdstrike]

I think the supply of docs is endless.

Disagree.

Emergency medicine has become almost fully commoditized.

Agree.

At some point they will make the job easier so they dont have to pay $300/hr.

Agree, but not until there's critical shortages, sentinel events leading to hospital lawsuits and bad publicity, physician strikes or having to close their doors due to lack of staff.

 

[WilcoWorld]

Agree, but not until there's critical shortages, sentinel events leading to hospital lawsuits and bad publicity, physician strikes or having to close their doors due to lack of staff.

Yep - if the CMG's are making good money with the current model, why would they change it unless they are forced to by something like the above? Well, if they figure out a way to make more money by making the job better for the docs, I suppose they would…but it wouldn't be because they thought those docs were such swell guys and gals.

 

[@JackShephard]

This is a throwaway of someone who posts somewhat routinely...

Much of what Birdstrike writes has significant insight, but one statement in particular rings especially true: even if you have a near ideal job, it can all change at the drop of a hat.

Within the last few years, our group was taken over by a large CMG. Metrics were, of course, emphasized before, but now it's gone crazy. All that matters is door to greet time. Seriously, that's it. Whether you show up with chest pain or medication refill, you need to be seen instantaneously. All resources in our department are directed toward this one goal, with minimal flexibility. If this number starts to creep above a certain number of minutes, you'd think a nuclear strike was incoming. Every administrator within a 30 mile radius is paged and questions start getting asked. We have a frigging giant flat screen TV solely dedicated to displaying this number and a graph that plots it over time -- this has taken precedence over an actual patient tracker.

So the strategy to meet this metric, you ask? Having PAs/NPs at triage screening EVERY single patient, excepting ambulance traffic (and even them at times!). And how does this work in practice? The midlevel gets 1 minute with a patient, shotguns orders, then sends them to the main ER where they won't be seen for another 2-3 hours. By the time I'm able to see the patient, they either had an over-workup that makes me shake my head (frequent unnecessary head CTs on peds; IVFs on all vomiting peds; d-dimer on every chest pain) or the opposite (missed or minimized neurologic deficits; no UA/UPT on female abdominal pain; no pain medication for fractures). Either the patient gets unnecessary treatment, or they're delayed when I need to do a second round of testing. Part of this is that MLPs do the initial ordering, yes, but the majority of it is that they have minimal time to see the patient and are forced to order indiscriminately.

You can imagine that this has decreased morale. It has. Many docs and MLPs have left because it's simply miserable. In their place, we have a bunch of locums docs just passing through, and a bunch of new MLPs who've never worked in an ER before.

This brings me to the second part of my rant: please don't be lazy and actively try to destroy our profession. Because of this mess, there's minimal leadership or oversight on the physician side. Most of the locums docs have taken to coercing the MLPs into doing all their work, including calling admissions and consultations on even the sickest patients. I find myself fuming when double-covered with a locums as he's texting on his phone, drinking a coffee, reading ESPN, and barking orders at the midlevel: "start some meds for the NSTEMI and call the cardiologist; can you call the surgeon for that obstruction?; just admit them to the hospitalist; why don't you try the LP first and call me; I have a lac I need you to do; just start some antibiotics and get them admitted to the ICU." This immediately reminds me of the anesthesia/CRNA fiasco, and it worries me for our future.

Great post. And very important on the end. The docs abusing MLP by having them do all the work while reading ESPN with a cup of coffee - that's terrible.

I believe that topics like this are going to have to be handles on a national level (with organizations like ACEP or others). The corporations will continue to expand until the money is gone - and they don't have their employees interests in mind.

 

[exsanguination]

Disagree.

Why? Seems like BC/BE MDs and DOs are being produced at a rate larger than what is needed and new programs are opening up every year..

 

[Birdstrike]

This sounds an awful lot like HCA and Emcare, who are in bed with each other and run their ED's like tyrants. Take heed - there is only one way we can collectively change this culture - Don't work for them.

This model will eventually implode because a) nobody wants to work for a hospital that pushes metrics, pages administrators, and forces their directors to drive in at 4am and miraculously "fix" their systemic problems that can't be culturally changed, and b) nobody wants to work for and be loyal to a contract group that encourages metrics "in the name of the contract" and pays locums $300- $600/hr as mercenaries to keep a warm body in the department. HCA and EMCare are boxing themselves in to a market that will only attract two types of people - new grads who don't know better, and seasoned locums - who don't care about long-term loyalty, and won't accept the pauper's pay of the loyal full time physician. Eventually, the new grads won't want to work for them anymore (or ever again), and their recruiting pool will dry up. Eventually, their locum pay will be unsustainable and their locum pool will go elsewhere that pays the same rates and doesn't force metrics like they do. Who will staff their ER's when that happens?

Emcare by itself isn't bad, and like all CMG's, has it's pluses and minuses. HCA by itself is no different than any other hospital corporation - same metrics, same profit goals. Combining the two is a recipe for synergistic evil that exploits the worst of both sides and taints the practice of emergency medicine.

"Meet the new boss. Same as the old boss."- The Who, Won't Get Fooled Again

Read ninerniner's post again. You should expect this synergistic combination to spread, and become the norm, for one very simple and unstoppable reason:

Money.

It's the most profitable formula out there today (the one outlined by ninerniner and southeastwizards). Expect it to become the rule, not the exception. Follow the money, and this is where you'll be led, if you're not there already. (You think you're on a protected island? Think again). My only disagreement with niners post is that "nobody wants to work" in such scenarios. Many people work in such systems. They're sold a bill of goods and once they're held by the ---s, they're trapped, or they blindly jump at the next "bill of goods."

Right now, everyone is flocking towards hospital based specialties and hospital-employees positions. You should be heading in the exact opposite direction. Once they've got the majority of doctors within their grasp the vice will be tightened so much tighter. Wait and see what happens with physician morale then.

Flock towards outpatient Medicine, non-EMTALA based environments, where there is little if any call, and little if any night/weekend/holiday work. This is the only safe haven, and the only ground where a physician will have any control over his practice life at all. Mark my words.

 

[Birdstrike]

Why? Seems like BC/BE MDs and DOs are being produced at a rate larger than what is needed and new programs are opening up every year..

Show me data that indicates we are anywhere near an oversupply of BC/BE EPs. They wouldn't be hiring midlevels at this clip if we were anywhere close.

I haven't worked a traditional EM shift in almost 3 years and my landline, mobile and inbox overflow daily with recruiting requests to come work all over the country, despite always saying, "No." When that stops, I'll let you know. When people I know stop being pressured to always work more shifts than they want despite exhaustion, I'll let you know.

I wish there was an over supply of EPs. If there was, I wouldn't have been pressured to always work more than I wanted, and still would probably be happy doing what I used to do (ED pit doc).

(Note: Saturated job markets, in perfect locations don't count.)

 

[@JackShephard]

Why? Seems like BC/BE MDs and DOs are being produced at a rate larger than what is needed and new programs are opening up every year..

Well, I believe we can either have lots of physicians or the MLPs will start becoming increasing important.

I've worked with great and not so great MLPs. So I'm neutral to them. But it seems like having a healthy supply of physicians is a good thing. There will be rumblings about tough job markets when it happens (as we hear in the other specialties).

In general, the entire idea to suppress the # of practioners to in some way protect income and job security seems like a bad idea. Our best weapons against dropping incomes and employment is to have better skills, better efficiency and strong national organization / political presence.

 

[EctopicFetus]

Disagree.



Agree.



Agree, but not until there's critical shortages, sentinel events leading to hospital lawsuits and bad publicity, physician strikes or having to close their doors due to lack of staff.

As the number of residents graduating increases and jobs in urban centers fill up what will the new grads do? They will take some crap cmg job leave in 1-2 years and be replaced by another resident.

IMO CMGs know this, want to drive investor profits at all costs. You may be the best, smartest, prettiest, most handsome and skilled ER doc but if you leave that group or hospital will survive.

 

[EctopicFetus]

Show me data that indicates we are anywhere near an oversupply of BC/BE EPs. They wouldn't be hiring midlevels at this clip if we were anywhere close.

I haven't worked a traditional EM shift in almost 3 years and my landline, mobile and inbox overflow daily with recruiting requests to come work all over the country, despite always saying, "No." When that stops, I'll let you know. When people I know stop being pressured to always work more shifts than they want despite exhaustion, I'll let you know.

I wish there was an over supply of EPs. If there was, I wouldn't have been pressured to always work more than I wanted, and still would probably be happy doing what I used to do (ED pit doc).

(Note: Saturated job markets, in perfect locations don't count.)

I get those same emails. I will say this, where are those jobs, what do they pay etc. I have gotten hit hard for the same 4-5 jobs over the last few weeks. what I know, they are in the middle of nowhere and/or the pay sucks.

I dont see any big cities on my recruiting emails. The ones that are are the CMGs with garbage pay. Where are the SDGs going. Thats the real shame.

BTW i got an email about spending my summer in the US Virgin Islands. My job is great and flexible so I was like... hmm ill ask about this thing.

Pay? 110/hr.. Uhh no thanks. You have to be kidding me. Hawaii pay sucks, SD is full, most of Cali in the big cities is full. Phoenix is full, denver well you know thats super tough, portland and seattle the same.

Now I obviously know more about the west coast market but I will say this, I am glad I was looking for a job when I did because the market is very tight for what I would consider a half-decent job in the west coast.

 

[EctopicFetus]

Oh and I have spoken to recruiters about other jobs. I moonlit with emcare and they ask if I would work for them. I say yes, then throw out a high number. They dont seem to be calling me back which leads me to the conclusion that they are getting people cheaper. I will just say that the number I throw out is significantly less than I make at my "real" job. Hence my fear/concern/distaste for CMGs.

 

[Birdstrike]

I get those same emails. I will say this, where are those jobs, what do they pay etc. I have gotten hit hard for the same 4-5 jobs over the last few weeks. what I know, they are in the middle of nowhere and/or the pay sucks.

I dont see any big cities on my recruiting emails. The ones that are are the CMGs with garbage pay. Where are the SDGs going. Thats the real shame.

BTW i got an email about spending my summer in the US Virgin Islands. My job is great and flexible so I was like... hmm ill ask about this thing.

Pay? 110/hr.. Uhh no thanks. You have to be kidding me. Hawaii pay sucks, SD is full, most of Cali in the big cities is full. Phoenix is full, denver well you know thats super tough, portland and seattle the same.

Now I obviously know more about the west coast market but I will say this, I am glad I was looking for a job when I did because the market is very tight for what I would consider a half-decent job in the west coast.

Again, big cities and places everyone wants to be, don't count. They are saturated in every specialty, every profession, always. Not being able to snap your fingers and get a "great job" in a "great location" does not equal a problem with a specialty being over saturated. It includes a cool city being over saturated, and the best jobs being over saturated. The problem of a BC/BE EP "not being able to find a job," any job, due to there being too many EPs, basically doesn't exist. It might mean someone wants great pay in a great location and they're checking several jobs off there list they don't dream about, or seem less than ideal. But that's a self imposed unemployment, not a sign there aren't jobs.

Are there really any EM attendings on here, that don't have a job?

 

[Old_Mil]

"Meet the new boss. Same as the old boss."- The Who, Won't Get Fooled Again
."

Right now, everyone is flocking towards hospital based specialties and hospital-employees positions. You should be heading in the exact opposite direction. Once they've got the majority of doctors within their grasp the vice will be tightened so much tighter. Wait and see what happens with physician morale then.

Flock towards outpatient Medicine, non-EMTALA based environments, where there is little if any call, and little if any night/weekend/holiday work. This is the only safe haven, and the only ground where a physician will have any control over his practice life at all. Mark my words.

This is maybe the best advice that anyone in medical school now could get.


Sent from my Z10 using Tapatalk

 

[exsanguination]

Oh and I have spoken to recruiters about other jobs. I moonlit with emcare and they ask if I would work for them. I say yes, then throw out a high number. They dont seem to be calling me back which leads me to the conclusion that they are getting people cheaper. I will just say that the number I throw out is significantly less than I make at my "real" job. Hence my fear/concern/distaste for CMGs.

What I wonder about for those in my position (about to start residency), are there even going to be SDGs left when we get out???

Despite being in a west coast residency, seems like my options are to work outside of nicer places for fair pay or to get beaten up by a CMG in a more "desirable" location.

 

[exsanguination]

What are urgent care jobs paying on the west coast? Are these even jobs available to BC/BE EPs? I have no debt going into residency (had a career before starting medical school), so my future salary isn't that big of a concern. Like Birdstrike said above, I'm looking for an outpatient, non-emtala, no call option as a BC/BE EP.

 

[@JackShephard]

Now I obviously know more about the west coast market but I will say this, I am glad I was looking for a job when I did because the market is very tight for what I would consider a half-decent job in the west coast.

Interesting. I haven't heard this yet.

Maybe we are overproducing EPs? I guess there will always be space in the smaller cities though.

 

[@JackShephard]

Right now, everyone is flocking towards hospital based specialties and hospital-employees positions. You should be heading in the exact opposite direction. Once they've got the majority of doctors within their grasp the vice will be tightened so much tighter. Wait and see what happens with physician morale then.

Flock towards outpatient Medicine, non-EMTALA based environments, where there is little if any call, and little if any night/weekend/holiday work. This is the only safe haven, and the only ground where a physician will have any control over his practice life at all. Mark my words.

I agree with the thesis of your argument - but what are the outpatient based environments with little call and night/weekend/holiday work that are safe?

Cardiology? Radiology? Pathology? These have all been hit pretty hard? Surgery? They have their own challenges. Family Medicine? Certainly not the holy grail of medicine. I mean, sure we can name 3-5 specialties that are the most competitive in medicine and say they are great, but what about the other 90% of specialties?

I guess there are things like Reproductive Endocrinology or Allergy, Derm, etc. But those are a small minority of physicians. By your estimations, we are all screwed.

There seem to be many people happy with EM. I know it's not the most coveted spot in the world, but physicians in general are paid well and have good job security compared to other fields. And EM is good compared to most other fields in medicine...

 

[EctopicFetus]

Again, big cities and places everyone wants to be, don't count. They are saturated in every specialty, every profession, always. Not being able to snap your fingers and get a "great job" in a "great location" does not equal a problem with a specialty being over saturated. It includes a cool city being over saturated, and the best jobs being over saturated. The problem of a BC/BE EP "not being able to find a job," any job, due to there being too many EPs, basically doesn't exist. It might mean someone wants great pay in a great location and they're checking several jobs off there list they don't dream about, or seem less than ideal. But that's a self imposed unemployment, not a sign there aren't jobs.

Are there really any EM attendings on here, that don't have a job?

I agree. you can find a job. It might require an hour commute for whatever money. Now that being said how does one define whatever money is the question. IMO a job at $150-180/hr isnt hard to find. They might be hard (or impossible) in locations but if Emcare ran all the EDs in say San diego, or any other desireable location they could pay crap and still get a ton of docs. I imagine most people arent like I spent 7 post undergrad years getting ready to take a job with crap pay in a crap location.

I dont believe this problem exists in other specialties quite as bad. My point is that Emcare will have an endless supply of residents willing to work with them at $150/hr in a semi crappy city and in a semi crappy work environment.

There is a reason some very high percentage of Em docs change jobs in the first 2-3 years. That factoid there is why emcare will always fill their jobs esp as more residents are produced.

 

[EctopicFetus]

What are urgent care jobs paying on the west coast? Are these even jobs available to BC/BE EPs? I have no debt going into residency (had a career before starting medical school), so my future salary isn't that big of a concern. Like Birdstrike said above, I'm looking for an outpatient, non-emtala, no call option as a BC/BE EP.

If you want that why bother going into EM? Do an FP residency and work in an urgent care.

 

[EctopicFetus]

Interesting. I haven't heard this yet.

Maybe we are overproducing EPs? I guess there will always be space in the smaller cities though.

Thats my point. Want to work 2 hours outside of SD or Phoenix or LA or SF or Denver there are jobs. Within those cities. Not so much... at least for decent jobs.

 

[EctopicFetus]

I agree with the thesis of your argument - but what are the outpatient based environments with little call and night/weekend/holiday work that are safe?

Cardiology? Radiology? Pathology? These have all been hit pretty hard? Surgery? They have their own challenges. Family Medicine? Certainly not the holy grail of medicine. I mean, sure we can name 3-5 specialties that are the most competitive in medicine and say they are great, but what about the other 90% of specialties?

I guess there are things like Reproductive Endocrinology or Allergy, Derm, etc. But those are a small minority of physicians. By your estimations, we are all screwed.

There seem to be many people happy with EM. I know it's not the most coveted spot in the world, but physicians in general are paid well and have good job security compared to other fields. And EM is good compared to most other fields in medicine...

Agreed. I can name some others.. endocrinology, pain etc.

 

[MSmentor018]

This sounds an awful lot like HCA and Emcare, who are in bed with each other and run their ED's like tyrants. Take heed - there is only one way we can collectively change this culture - Don't work for them.

This model will eventually implode because a) nobody wants to work for a hospital that pushes metrics, pages administrators, and forces their directors to drive in at 4am and miraculously "fix" their systemic problems that can't be culturally changed, and b) nobody wants to work for and be loyal to a contract group that encourages metrics "in the name of the contract" and pays locums $300- $600/hr as mercenaries to keep a warm body in the department.

with the new 2014 cms measures to "treat the clock" instead of the patient, isn't all hospitals going to push to keep up with the measures? chest pain or sprained ankle....it's all the same when the clock's running and some bean counter is watching

 

[Birdstrike]

with the new 2014 cms measures to "treat the clock" instead of the patient, isn't all hospitals going to push to keep up with the measures? chest pain or sprained ankle....it's all the same when the clock's running and some bean counter is watching

What's do you mean by this, the "two midnight rule"?

 

[WilcoWorld]

What's do you mean by this, the "two midnight rule"?

An admission that doesn't last through two midnights will only be covered as an observation.

Admit at 1159pm on the 1st, nd discharge at 1201 on the 3rd - you're good.
Admit at 1201 on the 2nd and discharge at 10am on the 3rd - even though the patient was there for 10 hours longer, it's only an "Obs".

 

[Birdstrike]

An admission that doesn't last through two midnights will only be covered as an observation.

Admit at 1159pm on the 1st, nd discharge at 1201 on the 3rd - you're good.
Admit at 1201 on the 2nd and discharge at 10am on the 3rd - even though the patient was there for 10 hours longer, it's only an "Obs".

I know, but I was wondering if the "CMS treat the clock" he was talking about was something else....

 

[MSmentor018]

sorry I should have cleared it up, I was responding to the comment about emcare/hca and how they push docs to see pt to meet the metrics. I was specifically pointing towards the "door to doc time". the previous post stated to not to work for the tyrants but with CMS hammering these measures isn't all ED's going to bend to this? no hospital is going to take a hit because the ER group can't produce the numbers it wants.

I get it, it makes sense to rapidly triage to identify medical emergencies. but i think the spirit of that is lost when med refills, suture removal, sprains/strains, is seen before a chest pain. eventually triage doesn't really matter....it's about treating the clock.

 

[TrumpetDoc]

Door to doc is a "metric" and that is all. It is of no more use than a marketing ploy...number to put on billboard to advertise wait time.
When it is insanely busy and the ED is full...I am not providing better care to anyone by beating myself to say hi to pts within 30 min. Even when I do see a true sick person there, if the ED is full of holds and psych pts, that's all there is to it. There will still be bad outcomes of pts waiting in the waiting room, only now, a "provider" will have "seen" them.

 

[Arcan57]

Door to doc is a "metric" and that is all. It is of no more use than a marketing ploy...number to put on billboard to advertise wait time.
When it is insanely busy and the ED is full...I am not providing better care to anyone by beating myself to say hi to pts within 30 min. Even when I do see a true sick person there, if the ED is full of holds and psych pts, that's all there is to it. There will still be bad outcomes of pts waiting in the waiting room, only now, a "provider" will have "seen" them.

Unless your charge nurses are completely unmotivated, there is some value in identifying what a provider thinks is a sick patient. Is it the same as them being able to go straight back to a room where there are actual resources automatically assigned to the patient? No, but they can move ahead of some of the BS ESI level 2 patients (I'm looking at you 35yo chest pain with a nl EKG) or maybe even bump out to a hallway. Also, at least at our shop when we're full of holds the docs usually aren't busy because there aren't new patients coming back to be seen.

I will completely agree that using a door to doc metric that doesn't take into account patient acuity and is actually set as faster than I wait to see my kids' pediatrician is stupid and will lead to widespread gaming of the system without significant improvement in patient outcomes (any British physicians on this forum?).

 

[Birdstrike]

Door to doc is a "metric" and that is all....
When it is insanely busy and the ED is full...I am not providing better care to anyone by beating myself to say hi to pts within 30 min.

The busier, more chaotic, and overwhelmed an ED gets, is the extent to which achieving such an arbitrary metric becomes increasingly unobtainable, yet is also exactly the extent to which the administrators will push even harder for you to obtain it.


Misguided + Sadistic + Unrealistic = Soul Crushing.

 

[TrumpetDoc]

Unless your charge nurses are completely unmotivated, there is some value in identifying what a provider thinks is a sick patient. Is it the same as them being able to go straight back to a room where there are actual resources automatically assigned to the patient? No, but they can move ahead of some of the BS ESI level 2 patients (I'm looking at you 35yo chest pain with a nl EKG) or maybe even bump out to a hallway. Also, at least at our shop when we're full of holds the docs usually aren't busy because there aren't new patients coming back to be seen.

I will completely agree that using a door to doc metric that doesn't take into account patient acuity and is actually set as faster than I wait to see my kids' pediatrician is stupid and will lead to widespread gaming of the system without significant improvement in patient outcomes (any British physicians on this forum?).

This, though, is not in any way changed by having door to doc measures. Part of training is owning the WR and knowing what is out there.

I don't know about any of you, but I know every pts complaint, vitals, and most likely past history as they are in the WR (a fav benefit of EMRs).

My thing is, if you are not busy, it's a non issue, an if you are busy (really busy/full) it is a non issue as far as the "metric" goes.

Do you actually still get to use hallway beds? We cannot. Thought JC banned the used of those?

I have made huge cases out of sick pts in the WR but psych holds CANNOT be moved around unless there is one to one and nursing security available. And psych holds are prob the main reason we over crowd at my shop. Admits on a good day take 2 hours to get upstairs and if hospital full they have to stay put.
Septic, abnormal EKGs, dislocations, you name it we cannot get them to a room any faster if I see them in 5 min versus 45. Cannot make a room or manifest an extra nurse out of thin air. I wish I were able to do it.
I/we bring this up constantly with admin and the argument by admin ALWAYS is they cannot afford nursing to make more space and if we would just put another doctor on shift we could just magically see an discharge people instead of them holding for admits (this is a paraphrase from two separate meetings over the year).
And no they will not make an OBs unit, just OBS status on the EMR and stay interior ED bed.
As long as the hospitals take mo accountability in this we, with these metrics, are simply whipping boys that can be targeted and blamed. Simple.

EPs should look out for the WR pts REGARDLESS!

 

[Birdstrike]

...
I/we bring this up constantly with admin and the argument by admin ALWAYS is they cannot afford nursing to make more space ...
As long as the hospitals take mo accountability in this we, with these metrics, are simply whipping boys that can be targeted and blamed. Simple.
!

As far as not being able to "afford" nurses?

BS.

You know it as well as I do. Real answer is: "My CEO bonus is tied to hospital profits. Adding staff decreases that, therefore I don't want to add another nurse. It is much better for me to have you, and her, work harder and faster for not a dollar more."

As far as EPs being the whipping boys: This is where ACEP needs to take a formal stand and accept formal complaints, anonymous if needed from EPs and investigate, to protect their members. They then need to censure and publish ethical charges against hospitals that abuse such "metrics". They need to make it clear with an official statement saying EDs are not the same as outpatient offices handling non-emergencies, they're not like ORs stacking 10 elective surgeries in a row and that "efficiency" is profoundly different in the ED. EPs should not be prodded, threatened, or judged based on factors that are largely out of their control (nurse staffing, beds available, 15 patients piling in an ED in 5 minutes, unlike occurs anywhere else in any healthcare setting) and using such metrics to brow-beat EPs equals an

ETHICAL VIOLATION

that should be known, shunned and shamed.

As far as I'm concerned it's abusive, and EM leadership needs to take a stand against it. This stuff damages the specialty, decreases morale, and physician job satisfaction. I also think there is a case to be made that it harms patient care by pressuring doctors to "greet" non-emergencies before true emergencies. To the extent we and our leaders put up with this kind of madness, is the extent to which we feed the monster. This applies not only to EM, but all specialties in Medicine, where we've allowed businessmen, insurance companies and the government to poison the well.

 

[TrumpetDoc]

As far as not being able to "afford" nurses?

BS.

You know it as well as I do. Real answer is: "My CEO bonus is tied to hospital profits. Adding staff decreases that, therefore I don't want to add another nurse. It is much better for me to have you, and her, work harder and faster for not a dollar more."

As far as EPs being the whipping boys: This is where ACEP needs to take a formal stand and accept formal complaints, anonymous if needed from EPs and investigate, to protect their members. They then need to censure and publish ethical charges against hospitals that abuse such "metrics". They need to make it clear with an official statement saying EDs are not the same as outpatient offices handling non-emergencies, they're not like ORs stacking 10 elective surgeries in a row and that "efficiency" is profoundly different in the ED. EPs should not be prodded, threatened, or judged based on factors that are largely out of their control (nurse staffing, beds available, 15 patients piling in an ED in 5 minutes, unlike occurs anywhere else in any healthcare setting) and using such metrics to brow-beat EPs equals an

ETHICAL VIOLATION

that should be known, shunned and shamed.

As far as I'm concerned it's abusive, and EM leadership needs to take a stand against it. This stuff damages the specialty, decreases morale, and physician job satisfaction. I also think there is a case to be made that it harms patient care by pressuring doctors to "greet" non-emergencies before true emergencies. To the extent we and our leaders put up with this kind of madness, is the extent to which we feed the monster. This applies not only to EM, but all specialties in Medicine, where we've allowed businessmen, insurance companies and the government to poison the well.

By golly I have always loved your posts but this makes me just cry tears of joy!

And I/we know exactly what they are peddling with their not cost effective crap. Published green zone profit of over 2 billion...come on!

I WISH, WISH, WISH, our entities would do just what you ahe said.

Unfortunately ACEP, the body with the actual muscle (if any at all) just promotes corporate interests in EM (evident as many of the contributors to their articles (ACEP monthly) and leadership are CMG big wigs.
It is so overwhelmingly against the Finacial interests of CMGs to even voice disapproval if such metrics that we are screwed.

Same as LOS and such. Name me an EP who wouldn't like to clear the damn dept...
But to grade EPs on things like this is repugnant.

Bird and like minded folks, perhaps a collaborative venture to shed some light on this would be nice?? Perhaps an open mic at ACEP with flash mob-style participation into the discussion. Some anarchy at an ACEP conv may be in order. lol

 

[TooMuchResearch]

By golly I have always loved your posts but this makes me just cry tears of joy!

And I/we know exactly what they are peddling with their not cost effective crap. Published green zone profit of over 2 billion...come on!

I WISH, WISH, WISH, our entities would do just what you ahe said.

Unfortunately ACEP, the body with the actual muscle (if any at all) just promotes corporate interests in EM (evident as many of the contributors to their articles (ACEP monthly) and leadership are CMG big wigs.
It is so overwhelmingly against the Finacial interests of CMGs to even voice disapproval if such metrics that we are screwed.

Same as LOS and such. Name me an EP who wouldn't like to clear the damn dept...
But to grade EPs on things like this is repugnant.

Bird and like minded folks, perhaps a collaborative venture to shed some light on this would be nice?? Perhaps an open mic at ACEP with flash mob-style participation into the discussion. Some anarchy at an ACEP conv may be in order. lol

AAEM is the organization that is more likely to advocate for this stuff.

 

[TrumpetDoc]

Agree...but ACEP has the numbers ($) and power, as well as people in influential positions not only bending over to these things, but gaining from them.

 

[deleted206819]

Agree...but ACEP has the numbers ($) and power, as well as people in influential positions not only bending over to these things, but gaining from them.

Maybe it's time to drop ACEP membership en masse and move over to AAEM.

 

[NinerNiner999]

Door to doc is a "metric" and that is all. It is of no more use than a marketing ploy...number to put on billboard to advertise wait time.
When it is insanely busy and the ED is full...I am not providing better care to anyone by beating myself to say hi to pts within 30 min. Even when I do see a true sick person there, if the ED is full of holds and psych pts, that's all there is to it. There will still be bad outcomes of pts waiting in the waiting room, only now, a "provider" will have "seen" them.

It's also just an average, that should be evened out by rapidly discharging the BS dental pain, med refill, etc. ASAP. For every 2 discharges in less than 10 minutes, a provider can open the equivalent of 10 patient rooms in a one hour period. Put another way, if it takes 5 patients 10 minutes to be seen (door to Doc), 5 more can be seen in 50 minutes for the same "average" time of 30 minutes per patient. This is the LEAN motivation to see patients as quickly as possible. It keeps the department open to accommodate the sick (even if you are seeing the not-so-sick first, but rapidly).

This, like the Bible, the Torah, and many other well known large tomes of text resembling the thickness of the ACA, is often taken to the literal extreme by administrators who wait with baited breath for the first violation of 31 minutes to pick up the phone. If every patient came in at the same frequency, with the same complaint, same workup, same process time, same diagnosis, and same disposition then there would be an application for such quality control measures. The problem is that we aren't making widgets in this "factory" and the basic concepts of business efficiency do not apply. I personally would try my hardest NOT to work for the factories that are run like a sweat shop in this regard.

 

[WilcoWorld]

Admits on a good day take 2 hours to get upstairs and if hospital full they have to stay put.
Septic, abnormal EKGs, dislocations, you name it we cannot get them to a room any faster if I see them in 5 min versus 45. Cannot make a room or manifest an extra nurse out of thin air. I wish I were able to do it. I/we bring this up constantly with admin and the argument by admin ALWAYS is they cannot afford nursing to make more space and if we would just put another doctor on shift we could just magically see an discharge people instead of them holding for admits (this is a paraphrase from two separate meetings over the year).
And no they will not make an OBs unit, just OBS status on the EMR and stay interior ED bed.

Translation: It's more profitable to whip the providers than it is to hire enough nurses.

 

[TrumpetDoc]

It's also just an average, that should be evened out by rapidly discharging the BS dental pain, med refill, etc. ASAP. For every 2 discharges in less than 10 minutes, a provider can open the equivalent of 10 patient rooms in a one hour period. Put another way, if it takes 5 patients 10 minutes to be seen (door to Doc), 5 more can be seen in 50 minutes for the same "average" time of 30 minutes per patient. This is the LEAN motivation to see patients as quickly as possible. It keeps the department open to accommodate the sick (even if you are seeing the not-so-sick first, but rapidly).

This, like the Bible, the Torah, and many other well known large tomes of text resembling the thickness of the ACA, is often taken to the literal extreme by administrators who wait with baited breath for the first violation of 31 minutes to pick up the phone. If every patient came in at the same frequency, with the same complaint, same workup, same process time, same diagnosis, and same disposition then there would be an application for such quality control measures. The problem is that we aren't making widgets in this "factory" and the basic concepts of business efficiency do not apply. I personally would try my hardest NOT to work for the factories that are run like a sweat shop in this regard.

Oh I know...but it is what you state later...that as soon as we start to tickle the line...the damm alarms go off and it actually interferes with my MDM on current patients because I have to go to a "huddle" and talk about it.

Wilco....exactly.

 

[TrumpetDoc]

Unfortunately, looks like all shops are heading this way. Ran away from it, moved to different part of country. Initially this was not an issue,,, but all it took was time.
Instead of tackling problems, real problems (psych holds, boarders) D2D, LOS, and patient satisfaction are what we are focused on. Unfortunately not outcomes or saves.


Corporate EM/CMG presentations to hospitals is PORN for administrators.

 

[MSmentor018]

Translation: It's more profitable to whip the providers than it is to hire enough nurses.

the beatings will continue until moral improves

 

[Birdstrike]

as soon as we start to tickle the line...the damm alarms go off and it actually interferes with my MDM on current patients because...

Yes, exactly. And that's where annoying crosses the line to unethical, in my opinion. Such policies are therefore, bad for patients for this exact reason.

 

[RustedFox]

Oh I know...but it is what you state later...that as soon as we start to tickle the line...the damm alarms go off and it actually interferes with my MDM on current patients because I have to go to a "huddle" and talk about it.

When we tickle the line, the "surge protocol" gets initiated, and all the docs on their days off get phone calls to "come in and help". They first incentivized it with "time-and-half pay", but then they played this game where they tried to justify not paying you the bonus if "not more than X patients were seen in Y time and the surge wasn't really needed".

That pissed a lot of people off, and they (we?) all just quit coming in. Now "surge" is useless because nobody comes to help. Several docs have either quit or changed jobs; and you know that it was a motivating factor. We got into EM because we don't want to be "on-call", but when those stuff noses and work notes pile up.... dear lord.... better call in reinforcements!