DocB,
I think the title of your post and the content of it refer to 2 different things. When you bring up the "soul" of Emergency Medicine, that could mean a lot of things. It has a philosophical connotation, to some maybe even religious. What is going to happen, and what has already happened to the "soul" of Emergency Medicine (and Medicine in general) is a very important question. But I don't think the body of your post really touches on that. I could say alot about whether or not the "soul" of Emergency Medicine (and Medicine in general) live on, but I'll summarize it in a few sentences.
The soul of Emergency Medicine, or your soul as a physician in general, can only be destroyed by one person. That's you. No matter how many heaps of dung politicians, businessmen, and insurance companies heap on you and your patients, and no matter how much harder or miserable they try to make the job, the only person that can allow that flame to be snuffed out is you. Despite the increasing layers of mostly meaningless red tape and other burdens heaped upon your patients and yourself alike, it always boils down to you sitting down with a patient, listening to them, and in some way, with your skills whatever they are and in whatever setting, trying to make that person's life a least a little better, if you can. I know it sounds corny, but it's true. No amout of greed by businessmen, stupidity by administrators or career preserving behavior from a politician can kill that, unless you allow it to. God knows they will try every day, until you and I retire.
Soon decisions will be made about how ED visits will be reimbursed in the future. These will either allow or disallow all the visits for things that really should have been taken care of in a primary care or other outpatient setting. I'm not even talking about the chest pain that turns out to be gastritis (i.e. I'm not talking about the "prudent layperson" concept). I mean the visits for refills, semi-urgent diagnostics, clinic over flow cases and so on.
From where are you getting this prediction? I am as much a doom and gloomer as anyone else, but what has allowed you to conclude this? The politicians know that physician salaries are a tiny percentage of health care costs. They know that widespread physician strikes would be a death knell to anything they wish to accomplish. They also know that playing the "kill the rich, to help the little guy" sales pitch will get them elected, whether they actually follow through, or not.
But they also know that if they don't keep doctors salaries high, especially Emergency Physicians salaries high, their Healthcare House of Legos will crumble. Don't even buy into this BS. Plan on hearing the venom spewed over, and over and over again. But they've done nothing to control doctor's salaries with their 2000 page ACA. Nothing. Salaries will remain strong, and not only that, I predict they will go up. They know that payments to hospitals are massive and much greater than to doctors. Just look at the HOPD facility fees compared to payments to doctors doing the same procedures in their offices. They pay sometimes 5-6 times more for the same service in hospitals. And this past year they increased these HOPD fees even more! Yet at the same time, they drive doctors until the hospital employment model. It proves they really have very little will to actually cut spending, despite their talk. This money will be availible to be payed to attract physicians, as hospitals now need to do. Oh yes, you'll have to fight for it, negotiate for it, and grind through RVUs no matter what specialty you're in, but the money will be there.
They're not going to stop paying for ER visits that are non-urgent. It's not going to happen. I'm calling their bluff. They tried that crap out west a couple of years ago and we had some discussions here about it. You may have to take a weekend off to march on the steps of the capital building every couple of years to prevent it. Even so, so what if they do? You'll quit the crap job that cuts your pay, and work somewhere you get paid a decent wage, and they'll watch those EDs turn into bottomless hell holes. You'll go to a state that hasn't cut the funding, or open a concierge cash-pay urgent care and cut these fool's policies out at the knees.
Don't buy into this political crap-talk. We have a skill and we're going to do what it takes to get paid for it, no matter the setting. I don't care what specialty you're in. It might take relearning the fighting spirit that they tried to snuff out of you in medical school and residency. Are you really going to drain an arm pit abscess at 3am on a holiday
if you're not paid an acceptable wage to do it? I know I'm not. Don't let these fools try to make you think you have to. You're not trapped as much as EMTALA makes you feel.
the system can't survive any longer
I call bullsh-t on this one too. Yes, you keep hearing this. I'm telling you, it's a load of crap. Show me one healthcare "system" that died. Show me one, in any country of the world. What does that even mean, "it won't survive"? It's political panic-speak to motivate people to accept drastic policy changes they wouldn't tolerate otherwise. Sure, they'll have to tweak the system many, many times to get it to survive, but it's not going to die. Regardless, you (and I) don't need to survive forever, do we? We only need it to survive until we retire. That's anywhere from 1-35 years for anyone on this board. Then the next generating can save it for the next 30. You and I can't save all of the future.
Obamacare has committed over $1 Trillion dollars into the system. Yes, they are going to pit various specialties against each other through the AMA RUC fee schedules creating in-fghting to get the dollars, but these doom and gloom scenarios, where the "system won't survive" are crap. Every few years you hear, "Medicare will be bankrupt in 10-15 years, oh no!" and "Social security will be insolvent in 10-15 more years, oh no!" Bulls--t. I'm not even that old, and I've been hearing those predictions for at least 30 years, since my Dad had the TV news blaring when I as a kid. The predictions 30 years ago were, "We'll be bankrupt in 10-15 years." Thirty years later the predictions are still, "We'll be bankrupt in 10-15 years." It's political panic-speak and should be ignored as much as possible. It's just asymptomatic PVCs. Turn on the "ignore" button, and don't allow these fools to manipulate.
Have you looked at an MGMA doctor survey lately? Look at one. Salaries are strong as hell. Every year as an EP the trend was that my salary went up. It's going up this year and my calculations are that it will again next year. Though I don't work in the traditional ER setting currently, I'm still a "doctor. " MGMA supports this for many specialties. I don't know how much inflation corrects down those numbers!(certainly some) but the bottoming out of salaries has not happened as predicted. It won't unless you let it! You're a doctor. You have tremendous skills. Don't assume you have to let some fool tell you you're salary has to drop 50% and take it. If they do, go find someone to pay you a decent wage, that you earned. Somewhere. Or make the opportunity for yourself.
We are expensive and inefficient at managing non-emergent patients.
So what. We're the only people crazy enough to work when everyone else is sleeping, celebrating and take care of the people no one else is willing enough, awake enough, or courageous enough to take care of. This is your best asset. In today's Medicine on Demand culture, Emergency Physicians are ready, willing and able to provide what 300,000 Americans want: Medicine on Demand. Do you think Americans want to give up the ability to get 24-hr medical care on demand? Do you think pcp's that are moving to conceirge care and specialists in cushy niche specialties want to start pulling night shifts in the ED again like they did 40 years ago? If they want to stop paying a premium for this 24 hr on demand care, I'm saying, "I call your bluff. Stop paying for it. Go right ahead." They can go right ahead and see the Armageddon of protests, crying and whining when Medicine on Demand ends, and they can't find anyone to staff their EDs. It's an entitlement now. It's not going away.
I wrote this 2 years ago, and I still feel I was on to something that even I didn't fully grasp then:
http://www.kevinmd.com/blog/2012/12/obamacare-create-normal-medicine.html
I do agree in every way that politicians, administrators and insurance companies are going to be fighting a tug of war back and forth with dollars and their own self intersts and doctors will get caught in the middle. But I really don't see any overall cost containment in any policy changes they've made in any of these recent years, including salaries. Do you? Heathcare spending continues to go up, costs are inflating, physicians salaries remain strong and more and more patients are being churned throught the system. A rising tide lifts all boats, and I think as costs continue to bloat, doctors will do well. That may not get Press Ganey and your C suite off your back, it may not stop the government from heaping on more stupid regulations, Obamacare may continue to have major flaws, and working nights, weekends and holidays won't get any easier. But the opportunities and dollars are going to be there.
You may have to think outside the box of traditional doctor think like "Get the perfect job. Plant roots. Stay with perfect unchanging traditional job for 30 years. Retire." Look a PCPs. They're flipping the whole system on its head and cutting out insurance companies, medicare and medicaid entirely and most seem to love it. The opportunities are going to be there. You've just got to be smart about it, and take control over your own practice life. Count on the fact that you're just as smart, if not smarter than these people.
Whether or not policies have changed the "soul" of the specialty into something entirely different than "Emergency" Medicine or not, and whether they threaten the core of that is another discussion, that I think Mr Hat touched on the best in the "Convenience Department" thread. Also, whether or not increasing regulation and policy changes will make working in an Emergency Department environment itself intolerable, I can't rule out. But economically, the predictors of the bottom falling out on reimbursements and salaries are crying wolf, in my opinion, or they're just repeating the political talk they keep hearing without thinking it through. I think reimbursement and salaries are going up, but only time will tell.
My advice, if you're worried about this stuff, is to diversify. I did a fellowship. I talked to another guy recently who did hyperbarics. He now only has to work two clinical shifts a month unless he wants more. He seemed happy. I talked to another guy recently, who did an EM cardiovascular fellowship. He runs an obs unit and works about 8-10 shifts per month. I talked to another guy recently who's starting some side business selling pain creams and medical equipment. I talked to another guy who's doing some work with wound care. Many have been opening up free standings or urgent cares for a long time now. Think about a direct pay or concierge practice. Don't tell me you don't know how. There's no patient or "chief complaint" you can't handle. All you need is to call an accountant, a healthcare attorney, and go. Diversify, and then if EMTALA and the suits make the hospital-based ED environment or employment model intolerable, you don't have to wear their handcuffs. Or, if you choose to take the traditional path and deal with their crap, I think the salaries are going to be there if you're wiling to adapt. I really do.
