Avoiding the same fate as emergency medicine

[Redpancreas]

I’m sure many of you are probably aware of the **** show that emergency medicine has devolved into over the past decade, with the ACEP meeting on the EM workforce today indicating that there will be an estimated surplus of 9000 EM docs by 2030. This is of course attributed to a mixture of CMG takeovers, residency expansion, and increased reliance upon mid level providers. As recently as 2 or 3 years ago many people in emergency medicine continued to insist that the future was bright and that these employment concerns were massively overblown. At this point there is essentially irrefutable data showing that their field will suffer throughout the next decade. Clearly, a number of factors that made emergency medicine vulnerable to these changes are also present in anesthesiology. While I hope that the actions of those in EM leadership positions to mitigate this issue can be used as groundwork for what we will need to do in anesthesia to avoid the same fate, I was curious if anyone felt there were any changes that could be advocated for now in order to avoid a similar outcome.

Not data or technicalities to back this up but I will say this. People have been talking about CRNAs, Death of Anesthesia, etc. for 30 years. Anesthesia remains strong. Additionally there's pain fellowship, etc. unlike EM which is limited to lesser paying fellowships and admin positions.

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[chocomorsel]

Ocala Hospital

Our full-service hospital offers a range of services, including a 24/7 emergency room, cardiac care and a Level II Trauma Center.

ocalahealthsystem.com

If you do not think HCA and the CMGs will not flood all hospital based specialties to drive down pay, then just look at this. One of many HCA anesthesia residencies. What a stellar group of med students they got. Much easier group to mold, setting the pay bar low. Actually brilliant of them. 4 yrs of low pay residents. Watch them match these programs with large CRNA programs, another cheap work force.

I found about 10 Anesthesia programs, watch these grow and filled by the caribbean mecca schools.

Like EM, you guys better make your money soon because these 100 per year hungry residents will soon be 500/yr.

I was actually offered a job there in ICU. Almost took it. And down the street where UF is they had started one too.

 

[chocomorsel]

indentured servitude seems a bit harsh, I mean I know groups you are describing that are paying those indentured servants a total package of $500K per year for < 50 hours of work per week. I mean they make a lot more once they become a partner but it isn't like they are suffering until then.

Really? Where are these groups? Or do you gotta know the right people? Or be stellar applicant? Or some other BS. Are they advertising?

 

[PainDrain]

Really? Where are these groups? Or do you gotta know the right people? Or be stellar applicant? Or some other BS. Are they adverting?

Would love to know as well because those aren’t jobs I have heard of or seen. I only know one guy who got that type of number as a new hire and it was an “eat what you kill” model.

 

[VA Hopeful Dr]

indentured servitude seems a bit harsh, I mean I know groups you are describing that are paying those indentured servants a total package of $500K per year for < 50 hours of work per week. I mean they make a lot more once they become a partner but it isn't like they are suffering until then.

There's a private group in my town not too dissimilar to that. I'm FM so can't speak to exact money,. But my kids are in the same class as two of the partners' kids. Judging by when they came to town and when we came back and knowing they were partners by then I think it is just a two-year thing.

Judging by the houses they bought and the things they do, the pre-partner pay had to be pretty good.

All guess work of course.

 

[anbuitachi]

Ocala Hospital

Our full-service hospital offers a range of services, including a 24/7 emergency room, cardiac care and a Level II Trauma Center.

ocalahealthsystem.com

If you do not think HCA and the CMGs will not flood all hospital based specialties to drive down pay, then just look at this. One of many HCA anesthesia residencies. What a stellar group of med students they got. Much easier group to mold, setting the pay bar low. Actually brilliant of them. 4 yrs of low pay residents. Watch them match these programs with large CRNA programs, another cheap work force.

I found about 10 Anesthesia programs, watch these grow and filled by the caribbean mecca schools.

Like EM, you guys better make your money soon because these 100 per year hungry residents will soon be 500/yr.

this is terrible.

 

[Test Boy]

this is terrible.

Some USMD’s there. Surprised someone from UCSD ended up there.

 

[chessknt]

Surgeon's think they are safe? More fine Caribbean dominated hungry residents coming to flood the market.

Ocala Hospital

Our full-service hospital offers a range of services, including a 24/7 emergency room, cardiac care and a Level II Trauma Center.

ocalahealthsystem.com

The radiologist who thought it would be hard to start a rad residency? Say hello to yesterday. 1st pilot one likely to have many more to follow

Diagnostic Radiology Residency Program | MountainView Hospital

Read more about the training, benefits and highlights provided by our Diagnostic Radiology Residency in Las Vegas, NV.

mountainview-hospital.com

Orthopedics - Got them too filled with bunch of caribbean grads

You think Dermatology is hard to get into. Wait 10 yrs when there are 50 HCA derm programs

Graduate Medical Education Programs at HCA Healthcare

With 300+ residency and fellowship programs across 16 states, HCA Healthcares GME program offers extensive training for the next generation of physicians.

medicalcityhealthcare.com

You think anyone is safe? HCA has the vast majority of specialties covered and I am quite sure more to come.

Graduate Medical Education Programs at HCA Healthcare

HCA offers innovative, high-quality graduate medical education programs.

hcahealthcare.com

wow you weren’t kidding. People staffing these programs should be ashamed. I see 5 faculty listed for 16 residents? Wtf?

 

[anbuitachi]

Some USMD’s there. Surprised someone from UCSD ended up there.

saw that as well. equally surprised

 

[Katheudontas parateroumen]

saw that as well. equally surprised

Could be residents that SOAP from another specialty

 

[Status Sciaticus]

indentured servitude seems a bit harsh, I mean I know groups you are describing that are paying those indentured servants a total package of $500K per year for < 50 hours of work per week. I mean they make a lot more once they become a partner but it isn't like they are suffering until then.

Where are these groups paying 500K/year for pre-partner pay?

 

[emergentmd]

wow you weren’t kidding. People staffing these programs should be ashamed. I see 5 faculty listed for 16 residents? Wtf?

Now do you see how the PGY 2-4 has 4 residents but PGY1 has 8? Another 4 yrs and that number likely will be 20 PGY1s.

Make your money while it is good b/c its all going downhill for all.

I wonder if those caribbean schools have a kickback agreement with HCA to accept a large portion of them. Seems like a win win on both side. HCA gets low level docs who are just happy to match and Carribean to spout how they match a large amount of specialists.

Glad I am out of this rat race to the bottom.

 

[nimbus]

Ocala Hospital

Our full-service hospital offers a range of services, including a 24/7 emergency room, cardiac care and a Level II Trauma Center.

ocalahealthsystem.com

If you do not think HCA and the CMGs will not flood all hospital based specialties to drive down pay, then just look at this. One of many HCA anesthesia residencies. What a stellar group of med students they got. Much easier group to mold, setting the pay bar low. Actually brilliant of them. 4 yrs of low pay residents. Watch them match these programs with large CRNA programs, another cheap work force.

I found about 10 Anesthesia programs, watch these grow and filled by the caribbean mecca schools.

Like EM, you guys better make your money soon because these 100 per year hungry residents will soon be 500/yr.

Wow. Ocala has a population of 60000 and Marion county has a population of 350000. What kind of cases could they possibly get there? I wonder how they make their case numbers. I always thought inadequate variety and volume of cases would be a barrier to new training programs being created. What am I missing?

 

[nimbus]

saw that as well. equally surprised

Maybe warm weather was his top priority

 

[nimbus]

Ocala Hospital

Our full-service hospital offers a range of services, including a 24/7 emergency room, cardiac care and a Level II Trauma Center.

ocalahealthsystem.com

If you do not think HCA and the CMGs will not flood all hospital based specialties to drive down pay, then just look at this. One of many HCA anesthesia residencies. What a stellar group of med students they got. Much easier group to mold, setting the pay bar low. Actually brilliant of them. 4 yrs of low pay residents. Watch them match these programs with large CRNA programs, another cheap work force.

I found about 10 Anesthesia programs, watch these grow and filled by the caribbean mecca schools.

Like EM, you guys better make your money soon because these 100 per year hungry residents will soon be 500/yr.

From their program director:


“The Anesthesiology Residency Program is committed to training physicians in the science and practice of Anesthesia and Perioperative Medicine. In this context, we will train our colleagues in delivering evidence-based, high quality medical care in which unwarranted variation is extinguished, and in which patient and family satisfaction is optimized. Excellence, collegiality, compassion, and integrity in patient care are the core tenets of our Program Education.”


Isn’t residency the time to try a little “unwarranted variation” for learning purposes? Sounds like a very protocolized cookbook environment.

 

[sloh]

I had no idea HCA residencies were proliferating unabated like this....for so many specialties. And to add insult to injury, when you visit their website the wording does not make it sound like anything nefarious is going on. Ugh. SDN always has the first finger on the pulse.

 

[maxxor]

I had no idea HCA residencies were proliferating unabated like this....for so many specialties. And to add insult to injury, when you visit their website the wording does not make it sound like anything nefarious is going on. Ugh. SDN always has the first finger on the pulse.

They probably took their experience with the few academic hospitals they’ve purchased and generalized to all their random sites.

Really the only thing remaining to stop this is to have RRCs across the board raise requirements. The Radiology requirements are imo far too low but that’s been ok because most programs far exceed them.

 

[okayplayer]

High quality groups (those that still exist) still want people who trained at outstanding residency programs. These won’t fly for those groups.

Now getting a job at USAP/Envision/etc on the other hand....

 

[PainDrain]

High quality groups (those that still exist) still want people who trained at outstanding residency programs. These won’t fly for those groups.

Now getting a job at USAP/Envision/etc on the other hand....

Can you perhaps imagine a scenario where these graduates have a series of bad outcomes working for a PE backed AMC and the hospital drops the company in favor of a safer model?

 

[OTCAwesome]

Surgeon's think they are safe? More fine Caribbean dominated hungry residents coming to flood the market.

Ocala Hospital

Our full-service hospital offers a range of services, including a 24/7 emergency room, cardiac care and a Level II Trauma Center.

ocalahealthsystem.com

The radiologist who thought it would be hard to start a rad residency? Say hello to yesterday. 1st pilot one likely to have many more to follow

Diagnostic Radiology Residency Program | MountainView Hospital

Read more about the training, benefits and highlights provided by our Diagnostic Radiology Residency in Las Vegas, NV.

mountainview-hospital.com

Orthopedics - Got them too filled with bunch of caribbean grads

You think Dermatology is hard to get into. Wait 10 yrs when there are 50 HCA derm programs

Graduate Medical Education Programs at HCA Healthcare

With 300+ residency and fellowship programs across 16 states, HCA Healthcares GME program offers extensive training for the next generation of physicians.

medicalcityhealthcare.com

You think anyone is safe? HCA has the vast majority of specialties covered and I am quite sure more to come.

Graduate Medical Education Programs at HCA Healthcare

HCA offers innovative, high-quality graduate medical education programs.

hcahealthcare.com

What's wrong with Caribbean grads?

 

[deleted126335]

Can you perhaps imagine a scenario where these graduates have a series of bad outcomes working for a PE backed AMC and the hospital drops the company in favor of a safer model?

I can imagine it. Just feel that it is unlikely. Easier to lower standards and expectations. Rotate some individual marginal players out and keep the same model.

 

[emergentmd]

What's wrong with Caribbean grads?

Nothing but when a large portion are Caribbean then that is a big red flag.

Nothing wrong w driving a Prius but I rather buy a Tesla. Sure the Prius may end up having 500k with not issues and the Tesla a lemon but I’ll take my chances w a Tesla.

 

[emergentmd]

High quality groups (those that still exist) still want people who trained at outstanding residency programs. These won’t fly for those groups.

Now getting a job at USAP/Envision/etc on the other hand....

Idealistic but very naive way of thinking.

High flying group needs 5 new grads. Partners want more profit and insurance companies tightening payment.

Group knows there are 100 HCA grads coming out so do they offer last yrs 500k packet or the new 300k packet.

These groups are money 1st quality 2nd. History does not lie.

So guess who is going to fill the 300k? Yup HCA grads.

Next yr they will offer 250k and as the market is oversupplied there will be 10 application for each spot.

Next yr they will drive that down to 200k and all partners will make 800k working half the tim

 

[GassYous]

Nothing but when a large portion are Caribbean then that is a big red flag.

Nothing wrong w driving a Prius but I rather buy a Tesla. Sure the Prius may end up having 500k with not issues and the Tesla a lemon but I’ll take my chances w a Tesla.

Not related to the thread but I've heard of a few issues with brand new teslas lately and really poor customer service.

 

[okayplayer]

Idealistic but very naive way of thinking.

High flying group needs 5 new grads. Partners want more profit and insurance companies tightening payment.

Group knows there are 100 HCA grads coming out so do they offer last yrs 500k packet or the new 300k packet.

These groups are money 1st quality 2nd. History does not lie.

So guess who is going to fill the 300k? Yup HCA grads.

Next yr they will offer 250k and as the market is oversupplied there will be 10 application for each spot.

Next yr they will drive that down to 200k and all partners will make 800k working half the tim

Not how groups in my part or the country work. There is one contract everyone gets. Same buyin. Same terms.

The better groups only offer interviews to folks from “name” programs.

 

[PainDrain]

Not related to the thread but I've heard of a few issues with brand new teslas lately and really poor customer service.

Yah. Elon just won’t return my calls regarding the technical issues I am having.

 

[emergentmd]

Not how groups in my part or the country work. There is one contract everyone gets. Same buyin. Same terms.

The better groups only offer interviews to folks from “name” programs.

You don’t understand economics. I don’t want to be dismissive but this has never been proven in history or realm or reality.


Your group does it now bc there is more demand than supply.

Wait until this flips, insurance cut payment, cmg comes in, or partners want to hit the lottery.

New meat will be the first to fall. Why would a partner pay 500k if the cmg down the road just started at 300k and had lines of oversupplied HCA docs wanting the job?

Oh wait. That is what happened to my private group 7 yrs ago when HCA said sell out or get taken over.

All hospital based practices have zero leverage and zero pts. You are just a widget right now and if they find a cheaper widget you will be replaced

 

[okayplayer]

You don’t understand economics. I don’t want to be dismissive but this has never been proven in history or realm or reality.


Your group does it now bc there is more demand than supply.

Wait until this flips, insurance cut payment, cmg comes in, or partners want to hit the lottery.

New meat will be the first to fall. Why would a partner pay 500k if the cmg down the road just started at 300k and had lines of oversupplied HCA docs wanting the job?

Oh wait. That is what happened to my private group 7 yrs ago when HCA said sell out or get taken over.

All hospital based practices have zero leverage and zero pts. You are just a widget right now and if they find a cheaper widget you will be replaced

We don’t “pay” anything. You earn your wage through your production and you pay a buyin for 2 years.

I understand things fine.

 

[emergentmd]

We don’t “pay” anything. You earn your wage through your production and you pay a buyin for 2 years.

I understand things fine.

You are missing the point but ok. Your group is a unicorn where nothing will change

 

[chocomorsel]

We don’t “pay” anything. You earn your wage through your production and you pay a buyin for 2 years.

I understand things fine.

Read your first sentence. Tell us it doesn’t sound contradictory.

 

[Twiggidy]

Really? Where are these groups? Or do you gotta know the right people? Or be stellar applicant? Or some other BS. Are they advertising?

AMCs that have been mentioned on here

 

[emergentmd]

Pawns but without them they would never be a specialist. When they are done no one will care where they came from.

 

[Twiggidy]

We don’t “pay” anything. You earn your wage through your production and you pay a buyin for 2 years.

I understand things fine.

And this is exactly how it should be

 

[okayplayer]

Read your first sentence. Tell us it doesn’t sound contradictory.

My group’s buy in is 100k over two years. I guess we could eliminate that? I don’t think that would push the needle much.

It’s the same buy in my partners paid 15 years ago.

This is also a high quality group in a nice part of the country that has never needed to recruit and hires from top tier programs regionally and nationally. We still don’t have issues with staffing.

 

[Twiggidy]

Pawns but without them they would never be a specialist. When they are done no one will care where they came from.

There's truth here. These places not only have anesthesiology residencies but also surgery, ortho, etc. All these grads will get employment somewhere, but that's part of the problem. Simple economics. Increase the supply and market forces drives the demand down. The demand becomes so low that 'specialist' are no longer specialist because surgeons, anesthesiologist, radiologist, and ER docs are growing on trees. Now you need something that really sets you apart (whispers: fellowship) and then hope there's a demand for your subspecialty.

 

[ucladoc2b]

sad to say but they were likely in the bottom decile of their class and are just happy they matched somewhere in anesthesiology.

sad that these Caribbean grads are essentially being used as pawns by HCA.

Well, I can personally confirm that this is not the case.

 

[OTCAwesome]

Nothing but when a large portion are Caribbean then that is a big red flag.

Nothing wrong w driving a Prius but I rather buy a Tesla. Sure the Prius may end up having 500k with not issues and the Tesla a lemon but I’ll take my chances w a Tesla.

I totally get what you're saying. However, I would skim the cream of the crop, hard working Caribbean grad any day of the week over an entitled, middle of the pack US grad. That's how many mid tier residency programs get amazing residents.

 

[nimbus]

sad to say but they were likely in the bottom decile of their class and are just happy they matched somewhere in anesthesiology.

sad that these Caribbean grads are essentially being used as pawns by HCA.

No. Switched out of a good program in a more competitive specialty.

 

[chocomorsel]

My group’s buy in is 100k over two years. I guess we could eliminate that? I don’t think that would push the needle much.

It’s the same buy in my partners paid 15 years ago.

This is also a high quality group in a nice part of the country that has never needed to recruit and hires from top tier programs regionally and nationally. We still don’t have issues with staffing.

Why the need to get so defensive? I just stated that your statement was contradictory, that is all.
“There is no buy in, but there is a buy in.”
Edit.. never mind I probably misunderstood.

 

[Twiggidy]

Why the need to get so defensive? I just stated that your statement was contradictory, that is all.
“There is no buy in, but there is a buy in.”
Edit.. never mind I probably misunderstood.

Yeah. I see where the wording threw you off. His group doesn’t technically “pay” the salary (neither does mine) in as much you earn whatever salary commiserate to how much you work. You do “pay”’a buy in, and there’s various ways that’s is done.

 

[anbuitachi]

There's truth here. These places not only have anesthesiology residencies but also surgery, ortho, etc. All these grads will get employment somewhere, but that's part of the problem. Simple economics. Increase the supply and market forces drives the demand down. The demand becomes so low that 'specialist' are no longer specialist because surgeons, anesthesiologist, radiologist, and ER docs are growing on trees. Now you need something that really sets you apart (whispers: fellowship) and then hope there's a demand for your subspecialty.

until fellowship trained anesthesiologists start growing on trees as well

 

[Status Sciaticus]

My group’s buy in is 100k over two years. I guess we could eliminate that? I don’t think that would push the needle much.

It’s the same buy in my partners paid 15 years ago.

This is also a high quality group in a nice part of the country that has never needed to recruit and hires from top tier programs regionally and nationally. We still don’t have issues with staffing.

Yeah. I see where the wording threw you off. His group doesn’t technically “pay” the salary (neither does mine) in as much you earn whatever salary commiserate to how much you work. You do “pay”’a buy in, and there’s various ways that’s is done.

So if I just pay the buy-in on day 1, do i start making partner salary?

 

[Twiggidy]

So if I just pay the buy-in on day 1, do i start making partner salary?

Theoretically you should

 

[Twiggidy]

until fellowship trained anesthesiologists start growing on trees as well

They already kind of are

 

[okayplayer]

Theoretically you should

Of course nobody ever does that, but if you showed up and said "here's $100k, now quit charging me buy-in," we'd say sure.

Well, might actually be a problem because of pre-tax/post-tax source of money, but whatever.

 

[blue.jay]

Idealistic but very naive way of thinking.

High flying group needs 5 new grads. Partners want more profit and insurance companies tightening payment.

Group knows there are 100 HCA grads coming out so do they offer last yrs 500k packet or the new 300k packet.

These groups are money 1st quality 2nd. History does not lie.

So guess who is going to fill the 300k? Yup HCA grads.

Next yr they will offer 250k and as the market is oversupplied there will be 10 application for each spot.

Next yr they will drive that down to 200k and all partners will make 800k working half the tim

This is exactly what's happening in nephrology from majority of fellows being IMGs with visa issues who have no choice other than take what's offered.

 

[Arch Guillotti]

And that’s where I disagree. If you are having a difficult time recruiting you can totally vote to change the time track.
Why? “Because that’s how we’ve always done it” is most often never a good answer.
Life is about change, and progression. Not stagnation. It’s inevitable.

Nowadays anything more than a two year track is onerous. 3 years at the max, only for a great group. You are right things can change, starting salary can go up, length to partnership can go down. But for those of us still living the private practice "dream", it only changes so much. I didn't get a free ride, why should the next guy get one?

Pick your poison, you can't have it all these days.

 

[maxxor]

Nowadays anything more than a two year track is onerous. 3 years at the max, only for a great group. You are right things can change, starting salary can go up, length to partnership can go down. But for those of us still living the private practice "dream" it, it only changes so much. I didn't get a free ride, why should the next guy get one?

Pick your poison, you can't have it all these days.

Personally, if there’s a longer “track”, I would have been ok with knowing in writing by 2 years whether I was to be partner or not, even if the track were longer. That way if they try and do some sale shenanigans, you have some recourse.

I even would have understood if they’d fired me because they lost the contract but kept up their end of the bargain for the existing associates further along in the track, but firing the prior associates made all of us lose faith that we’d ever make partner.

 

[Man o War]

Personally, if there’s a longer “track”, I would have been ok with knowing in writing by 2 years whether I was to be partner or not, even if the track were longer. That way if they try and do some sale shenanigans, you have some recourse.

I even would have understood if they’d fired me because they lost the contract but kept up their end of the bargain for the existing associates further along in the track, but firing the prior associates made all of us lose faith that we’d ever make partner.

This is what we do. After one year we give you a notice in writing that you have made partner or not. You do have to complete your buy in after that, however. You get voting rights after that one year mark.

 

[PainDrain]

This is what we do. After one year we give you a notice in writing that you have made partner or not. You do have to complete your buy in after that, however. You get voting rights after that one year mark.

This is the honest way to do things and probably one of the best deals I have heard. I commend you guys for having some integrity.