EM Future

[RustedFox]

Yeah i think i remember that thread. I was a 3rd year in early 2015 so had just started to finalize that decision. The idea of a shortage was novel at the time. Every ER doctor you talked to bragged about how they got 50+ emails for jobs and they could get a job posting 300/hr tomorrow if they wanted. EM has been good to me so far. How the tide has changed in just 5-6 years.

I had like, 6 jobs to choose from in one city when I moved to FL.
Now, there's like, 2 jobs in all of FL and they may not be real jobs at all.

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[Cinclus]

What's your number? I relatively new this game, young family soon, and already wondering where my lifeboat is...

I don't know exactly, but I do know that I passed whatever it is. I'm a lucky butthole.

 

[deleted6669]

Know an EM doc who did a sports medicine fellowship to get out of the ER (realized too late as a resident that he didn't want to practice in the emergency room). I'm sure if he did it all again, he would have just done FM --> sports.

I know an FM guy who did a sports medicine fellowship who now works fulltime in the ED...
He is retiring this year after something like 48 years in medicine.

 

[deleted6669]

That's cool, haha the reverse of what I saw. Person I'm thinking of is in his ~40s and (at least pre-COVID) loved how low stress his work was compared to the ED. Also was an academic attending too for a local MD on the side.

My friend took a long path to the ED: RN to psych RN to MD to FM MD to sports med to acupuncture. Got an MBA and an MPH on the way too. Only been doing EM for the last decade or so and will be 70 this summer.

 

[hector10]

As an intern right now, how exactly am I supposed to be motivated enough to finish ?

What other residency options are available for me after EM?
Do I apply to eras lol? Fml

should I even try and get out now?

 

[southerndoc]

As an intern right now, how exactly am I supposed to be motivated enough to finish ?

What other residency options are available for me after EM?
Do I apply to eras lol? Fml

should I even try and get out now?

It's not as much doom and gloom as we fear, but there will likely be negative effects in the near future.

I still enjoy my job, and will continue to work for less pay. However, I do have a floor that if it drops below that, I will choose another career like many other EM docs. There comes a point where dropping below that floor is not worth the stress of critical patients, stress of backed up waiting rooms/admission holds, malpractice risk, etc.

 

[HemorrhagicShock]

As an intern right now, how exactly am I supposed to be motivated enough to finish ?

What other residency options are available for me after EM?
Do I apply to eras lol? Fml

should I even try and get out now?

I would try to get out now if I were you. It's much harder to go back to training after a few years out than to make the jump during your training. Ideally, during your PGY2 you have electives that you can use to your advantage to explore rotations which will provide you with letter of recommendation opportunities and to check out whether you really want to make the switch or not.

Additionally waiting to finish residency may "use up" those medicare-funded years, and might close doors to other residencies (i.e. can't accept you for their training program because you've already done 3-4 years in a post-graduate program)

This advice is weighted even more if you're in a 4-year program. God help you if you are and decide to finish with EM.

Even a simple switch to IM will give you more flexibility if you don't know exactly what you want to do. IM has the entire menu of subspecialty fellowships, along with the option to do hospitalist shift work (if that was one of the initial reasons that drew you to EM). You can easily decide to do a full outpatient-only practice, and/or do all the other cash-based med spa/botox/infusion that physicians use as bail-out strategies.

 

[Rekt]

It's not as much doom and gloom as we fear, but there will likely be negative effects in the near future.

I still enjoy my job, and will continue to work for less pay. However, I do have a floor that if it drops below that, I will choose another career like many other EM docs. There comes a point where dropping below that floor is not worth the stress of critical patients, stress of backed up waiting rooms/admission holds, malpractice risk, etc.

I think it's funny how docs keep posting this crap in various places. "My job is great. EM is great. Yeah the outlook is bad, but not that bad. Probably. Maybe? Idk. Been at my job for years. It's awesome. EM is awesome"

I'm not sure how you can possibly even for one second think that it's not that bad. People aren't interpreting the numbers correctly.

Every job will be full by 2030 with a surplus of 10,000 docs. You think it's okay for 10,000 people who spent 11-12 years getting to this place to be unemployed? Not even just that, these people, us, losing jobs to people who got a participation certificate online and can practice "healthcare" after observing some rural FM doc 1 day a week for a month, now staffing an ER killing patients.

Another slide said that we need to cut 1100 spots to get to a slim margin steady state of jobs vs retirement. Acep is to busy deciding if we should increase EM to 4 years or just "open more rural or telehealth opportunities" before even thinking to even cut a single spot.

You can also bet acep tried to make all these numbers look as pretty as possible.

I don't blame the guy above you. If I was an intern or incoming intern I'd be immediately firing up eras to apply to a different specialty. Start getting LORs from contacts from your med school. You'll probably have a better chance at a job even in pathology or rad onc than EM soon. Keep in mind it's not going to go from 0 unemployed to 10k all at once. It's already going to start happening within the next couple years. And 2030 seems far, but it's really only 8 years.

 

[sylvanthus]

I second going into IM, loads of options and can do CC if you really like the critical patients. Even better, lateral into an EM/IM program or EM/IM/CC.

 

[miacomet]

Any field in which HCA (and also CommonSpirit) can open residencies is going to be flooded. I

People should choose a field where they can open their own shop fairly easily (IM) or, better, that is hard to outsource to APPs and controls its slots (neurosurgery, ENT, and all other subspecialty surgery).

EM, Anesthesia are going to be flooded.

It's interesting that HCA hasn't opened any rads residencies....

 

[maxxor]

Any field in which HCA (and also CommonSpirit) can open residencies is going to be flooded. I

People should choose a field where they can open their own shop fairly easily (IM) or, better, that is hard to outsource to APPs and controls its slots (neurosurgery, ENT, and all other subspecialty surgery).

EM, Anesthesia are going to be flooded.

It's interesting that HCA hasn't opened any rads residencies....

Residents don’t speed us up. You can’t prospectively assess a given scan for complexity, unlike CRNAs in Anesthesia or ER acuity levels for fast track vs main ER.

The only “workflow” value is overnight coverage but telerads serve that niche well enough for these hospitals.

There are basically no HCA hospitals in my area, but have they even started getting greedy enough to go after rad pro fees via direct employment? I feel like they are starting to crush the pathologists. Perhaps the rads will be next.

 

[RustedFox]

@miacomet

I'm not sure if it was in this thread that you summarized the ACEP clown's suggestions for the future workforce; but it was :

1.) Rural spots (okay, PLPs are doing this, and ACEP itself says that PLP/FP/IM can do it for cheaper.)

2.) Telehealth (this is the antithesis of what we're trained to do.)

3.) Correctional medicine (so, go work for a jail... Okay, those ads all list "IM preferred" right in the requirements section of the description.)

4.) "Proceduralist" (Lol. This doesn't exist.)

So, thanks for nothing there, ACEP.

 

[Spikebd]

Residents don’t speed us up. You can’t prospectively assess a given scan for complexity, unlike CRNAs in Anesthesia or ER acuity levels for fast track vs main ER.

The only “workflow” value is overnight coverage but telerads serve that niche well enough for these hospitals.

There are basically no HCA hospitals in my area, but have they even started getting greedy enough to go after rad pro fees via direct employment? I feel like they are starting to crush the pathologists. Perhaps the rads will be next.

Path has outlets like transfusion medicine/blood banking, forensics, and even a lot of corporate biotech jobs hire paths. Flexibility helps a lot imo.

 

[Fox800]

@miacomet

I'm not sure if it was in this thread that you summarized the ACEP clown's suggestions for the future workforce; but it was :

1.) Rural spots (okay, PLPs are doing this, and ACEP itself says that PLP/FP/IM can do it for cheaper.

2.) Telehealth (this is the antithesis of what we're trained to do)

3.) Correctional medicine (so, go work for a jail... Okay, those ads all list "IM preferred" right in the requirements section of the description)

4.) "Proceduralist" (Lol. This doesn't exist.)

So, thanks for nothing there, ACEP.

You forgot proposing to make all EM residencies 4 years long, while NPP's with 500 clinical hours are gobbling up jobs left and right. Sounds super smart, ACEP.

 

[RustedFox]

You forgot proposing to make all EM residencies 4 years long, while NPP's with 500 clinical hours are gobbling up jobs left and right. Sounds super smart, ACEP.

I didn't see that. Didn't watch the "webinar", because I knew it was going to be tone-deaf.
Did they really say that?

 

[Rekt]

I didn't see that. Didn't watch the "webinar", because I knew it was going to be tone-deaf.
Did they really say that?

Gillian said this is her top idea right now.

 

[namethatsmell]

B/C THEY CANT CUT SLOTS...that's true. For as much as people want to bash ACEP, they do know what they are talking about in this--it is absolutely anti-trust. The market flooded b/c HCA and other medical centers planned this. Your academic centers want this--increase supply lowers their physician costs. APP oversupply gives them a new revenue stream and even cheaper labor. Did ACEP enable some of this w/ CMG's..absolutely...CMG's were their top Funders. ACEP has to pay the bills too. Can AAEM fix this? LOL, no--they don't have a quarter of the influence in Washington that DC has. It's naive to think ACEP can fix this...in truth today's EM doctors under 40 were hosed by previous docs (both CMG and SDG's that sold out), hospitals, businesses, academic centers, etc.

Face it everyone here...MEDICINE IS A BUSINESS. Everyone for themselves. Go watch Wall Street or read a business book--no one gives a rip about top quality, they just want affordable and moldable employees so that they can institute algorithm led care for least amount of costs. The only shot you have is to fight business mentality w/ new a better business mentality. The sooner EM physicians realize they have to divorce themselves from hospital-contracts, the better they'll be. Start a DPC w/ other doctor fields, better tele-medicine model, or hell fight Stark and open a physician led hospital. But don't go crying to ACEP, who don't have the power or ability to fight the 1000lb Insurer and Hospital gorillas who now call the shots in Washington.

Quoted for truth.

Going to ACEP with your problems is like going to the schoolyard bully and asking them to feel empathy for those they pray upon. While we have some overlapping goals, ACEP is not our friend.

In this country, medicine is a business and nobody cares about you (until perhaps the time when they inevitably become a patient). IMHO physicians are trapped in the worst kind of Venn diagram space between corporate control and government regulation .

At present, physicians only have 2 professional tasks: 1) care for patients in a way that allows you to sleep at night and 2) look out for yourself and your colleagues. And then the bonus task: do what you can to push back on corporate and governmental factors destroying our profession.

 

[RustedFox]

Gillian said this is her top idea right now.

And what did she say that fourth year will do, besides delay that resident not finding a job when they are thru with that fourth year?

Meanwhile, Jenny McJennyson is working in the ER and screwing up patient care.

 

[Taurus]

It's interesting that HCA hasn't opened any rads residencies....

Lol. 😂 That’s what I keep telling you guys. It’s not that simple to open a radiology residency. You need enough volume and subspecialty expertise for the residents to rotate through, ie, chest, body, neuro, MSK, peds, mammo, IR, nucs, etc. An HCA hospital staffed by 3 radiologists isn’t going to cut it. We have multiple HCA hospitals in my desirable large city and I have radiology privileges at all of them. Even at the largest HCA hospital in town, it’s only staffed by 3 radiologists on-site. We of course have other subspecialty radiologists off-site who read HCA hospital studies as well. Even if all the radiologists were on-site, you probably only need 10 of them to staff daily. Not enough for a residency.

Even the smallest radiology residencies have at least 15-20 radiologists on-site. Could you have the residents rotate at multiple HCA hospitals in multiple cities or states? Yes, but that would be a financial and logistical nightmare for both the program and residents. Even if HCA did this and opened a few radiology residencies, it won’t create a significant increase in the number of radiology graduates to impact the job market. Like I keep saying, the biggest threat to radiology is corporate radiology and Wall Street.

 

[partypantss]

So how do I, as a rising PGY1, go about jumping ship? Do I lowkey go talk to people in my hospital's IM/ radiology program? Or start doing research and hope I can land a CCM fellowship? CCM seems right up my alley so maybe that's my best bet.

 

[miacomet]

So how do I, as a rising PGY1, go about jumping ship? Do I lowkey go talk to people in my hospital's IM/ radiology program? Or start doing research and hope I can land a CCM fellowship? CCM seems right up my alley so maybe that's my best bet.

CCM is a tight market right now, although nothing like EM. Do you think your program could set up a combined EM-IM residency for you?

 

[maxxor]

Lol. 😂 That’s what I keep telling you guys. It’s not that simple to open a radiology residency. You need enough volume and subspecialty expertise for the residents to rotate through, ie, chest, body, neuro, MSK, peds, mammo, IR, nucs, etc. An HCA hospital staffed by 3 radiologists isn’t going to cut it. We have multiple HCA hospitals in my desirable large city and I have radiology privileges at all of them. Even at the largest HCA hospital in town, it’s only staffed by 3 radiologists on-site. We of course have other subspecialty radiologists off-site who read HCA hospital studies as well.

Even the smallest radiology residencies have at least 15-20 radiologists on-site. Could you have the residents rotate at multiple HCA hospitals in multiple cities or states? Yes, but that would be a financial and logistical nightmare for both the program and residents. Even if HCA did this and opened a few radiology residencies, it won’t create a significant increase in the number of radiology graduates to impact the job market. Like I keep saying, the biggest threat to radiology is corporate radiology and Wall Street.

If they really wanted to do it, they could, especially in Florida.

But I don’t think it really helps them operationally. They already get the technical component. The professional component isn’t worth it (yet).

The reason HCA wants residents in various specialties is two fold:
1. Decrease NPP usage as residents are cheaper. This is my personal vindication of “I goddamn told you so” when attendings would say they lose money on residents.

2. Long term depress employed physician salaries through oversupply.

Radiology (yet) isn’t a problem as they are already pretty bare bones. We don’t use mid levels like Anesthesia or ER, and the only real workflow use for residents is overnight coverage which teleradiology serves more than adequate.

 

[sylvanthus]

So how do I, as a rising PGY1, go about jumping ship? Do I lowkey go talk to people in my hospital's IM/ radiology program? Or start doing research and hope I can land a CCM fellowship? CCM seems right up my alley so maybe that's my best bet.

Remember, there are gonna be alot of you guys thinking of jumping into ccm fellowship. I can see that route becoming pretty competitive in a few years.

 

[Lawpy]

How likely will SLOEs be dropped after this news? @gamerEMdoc

 

[partypantss]

Remember, there are gonna be alot of you guys thinking of jumping into ccm fellowship. I can see that route becoming pretty competitive in a few years.

Yeah this is what I'm worried about

 

[Lawpy]

Remember, there are gonna be alot of you guys thinking of jumping into ccm fellowship. I can see that route becoming pretty competitive in a few years.

Is it better to go IM/pulmCC route over EM? Because that's what i'm thinking especially since EM has this SLOE obsession that can badly backfire if SLOEs suck and IM doesn't really have away requirements.

 

[miacomet]

CCM is a tight market right now, although nothing like EM. Do you think your program could set up a combined EM-IM residency for you?

Going into another hospital-based specialty is not much of a solution.

 

[Fox800]

As an new attending, my biggest decision is whether to look to fleeing the US for another country, or trying to wiggle my way into a fellowship. Non-clinical jobs (UR) seem to want at least five years of experience.

 

[turkeyjerky]

Is it better to go IM/pulmCC route over EM? Because that's what i'm thinking especially since EM has this SLOE obsession that can badly backfire if SLOEs suck and IM doesn't really have away requirements.

I would definitely go IM over EM if CCM is your goal. They run the majority of the fellowships, and as more and more EM grads try to jump ship it's going to get increasingly competitive. Plus then you'll have Pulm as an exit, or can jump ship before fellowship if it looks like the market for CCM goes down the same road as EM.

 

[namethatsmell]

So how do I, as a rising PGY1, go about jumping ship? Do I lowkey go talk to people in my hospital's IM/ radiology program? Or start doing research and hope I can land a CCM fellowship? CCM seems right up my alley so maybe that's my best bet.

A great question and I'm not sure there's a one-size-fits-all guide. But in a nutshell: think a bit about what field you want to migrate to, start quietly reaching out to potential mentors/PDs in that space, and approach your most supportive PD/aPD.

Assuming that there are two fields you find equally as interesting/appealing, pick the one with the most favorable opportunity cost for you. Unless said field is highly procedural, I would be very wary of entering a specialty that basically locks you into having to work for a hospital/precludes you from owning up your own practice (after all, that's why you're considering leaving EM).

A 3rd yr med student I've been advising recently reached out with new doubts about going into EM after I gave a painfully honest overview of the professional landscape they'd likely be walking into around the time they'd be expected to finish residency (same spiel I'd already given them last year, but I guess they finally heard the same thing from other sources). This student, who could match into any field they wanted, is now deciding between FM and psych. I think psych is a better fit for the person, but the reality is that both are excellent choices for docs who want to help patients while being their own boss and control their destiny (this wise student's ultimate goal...at least for the time being lol). My point is not that you shouldn't go into rads or ccm...but if you're going to go to the effort of finding a new field make sure it meets your wants for both day-day doctor responsibilities but also fits with your mid and longer-term life goals. And if you're really not sure of a field, err on the side of picking something allows you to practice in a wide array of settings.

 

[jw3600]

Yeah volume wise we're back to normal. APP even went back to their pre-covid staffing hours/ratios at all of our sites.

You mean midlevels?. Come on bro. Read the room.

 

[turkeyjerky]

As an new attending, my biggest decision is whether to look to fleeing the US for another country, or trying to wiggle my way into a fellowship. Non-clinical jobs (UR) seem to want at least five years of experience.

The way I see it, unless you're a current partner at a stable SDG, we're all screwed. Even if you're cool with making 140/hr, the future will entail zero job security and miserable conditions (and by future I mean 5-10 years, after that it'll probably be even worse as we basically become amazon bots used to carry out the EMR recommended interventions, and that's if we're lucky...)

 

[miacomet]

A great question and I'm not sure there's a one-size-fits-all guide. But in a nutshell: think a bit about what field you want to migrate to, start quietly reaching out to potential mentors/PDs in that space, and approach your most supportive PD/aPD.

Assuming that there are two fields you find equally as interesting/appealing, pick the one with the most favorable opportunity cost for you. Unless said field is highly procedural, I would be very wary of entering a specialty that basically locks you into having to work for a hospital/precludes you from owning up your own practice (after all, that's why you're considering leaving EM).

A 3rd yr med student I've been advising recently reached out with new doubts about going into EM after I gave a painfully honest overview of the professional landscape they'd likely be walking into around the time they'd be expected to finish residency (same spiel I'd already given them last year, but I guess they finally heard the same thing from other sources). This student, who could match into any field they wanted, is now deciding between FM and psych. I think psych is a better fit for the person, but the reality is that both are excellent choices for docs who want to help patients while being their own boss and control their destiny (this wise student's ultimate goal...at least for the time being lol). My point is not that you shouldn't go into rads or ccm...but if you're going to go to the effort of finding a new field make sure it meets your wants for both day-day doctor responsibilities but also fits with your mid and longer-term life goals. And if you're really not sure of a field, err on the side of picking something allows you to practice in a wide array of settings.

This is really wise counsel.
Also, and I hate to say this, but think of where advice is coming from. PDs have the goal of matching the best students in their specialty and marketing is a big part of the job; while their jobs and salaries are not as secure as they think, many are not aware of this and their immediate goal is to recruit people into their specialties.

 

[bravotwozero]

As an new attending, my biggest decision is whether to look to fleeing the US for another country, or trying to wiggle my way into a fellowship. Non-clinical jobs (UR) seem to want at least five years of experience.

I've thought about the overseas route myself, many times. Can get some really nice paying EM jobs overseas with a more doctor friendly culture. If I was <5 years from calling it quits, would totally do it. The problem is if/when you decide to come back stateside, you'll have nothing left but a scorched earth job market, so this decision is really a one way street more ideal in the last phases of your career.

 

[bravotwozero]

You mean midlevels?. Come on bro. Read the room.

No, APP as in American Physician Partners..., unless that was a double entendre joke of some sort...

 

[ZX10R]

Lets be real for a second, how could ACEP lower the amount or residency spots without getting stuck in massive lawsuits that lead to no where. They would essentially have to prove physicians graduating from the "sub-par" residencies are not up to some made up standard. If the residents that became attendings are passing the boards at the same %-rate and having the same outcomes what ground do they have to stand on? They cant just got out tomorrow and say you now need X amount of non-simulated crics to meet criteria for a residency program approval, and if you haven't had those numbers in the past X-# of years you will get shut down. There would be massive backlash if that were to happen. Then what do you do with the huge amount of residents that now have no residency? Yes, this would by a short term problem, but if you are ACGME accredited you are required to give those residents a residency position in the same field.

The only solution I can see is to add on more criteria to make the cost of the residency more than the benefit. Expensive SIMs labs, faculty: resident quotas (like 1 full-time faculty (ABEM only) for every 2 ED residents), add in more stringent criteria on who you can consider core faculty, minimum of level 2 trauma center, community outreach programs through EMS, X-number of ultrasound fellowship trained faculty, or only allowing EM-ICC faculty precept in the ICU, I think anesthesia has something similar where they must be observed for X% of the time by an CC-Anesthesiologist. Whatever it is, it has to make the cost more so HCA/Envision arnt able to make millions for hardly any investment. No ****ty ass urgent care shifts, I hear at some programs these are the majority of shifts and that is just pitiful.

Even with all of this, it is only part of the problem. If we somehow cut residency spots in half overnight that would still leave (Im guestimating here) 1000-2000 excess ED docs. We are talking 9,000 here, that just insane. Midlevels will only further expand, and now HCA/Envision is looking into midlevel fellowship expansion to save even more money. It wont be long before a woke Ivory tower makes a damn PA an EM PD. Our profession is a joke.

 

[Groove]

I think the best short and medium term solution is to push for more fellowships and access to traditional IM subspecialty fellowships. Most of our fellowships just suck... or are impractical. Wilderness medicine? Undersea and hyperbaric medicine? Anytime I hear someone doing one of those I immediately associate them with the IM/PEDS people. The residency/fellowship of indecisiveness.... More often than not the Wilderness/ultrasound/hyperbaric peeps are looking for a year to fluff their feathers some more, feed from mom's tit, and psych themselves up to finally cut the attending umbilical.

The IM/PEDS folk kick the adult/peds can down the road a few years so they can finally decide which one they want to do when they grow up. I love asking them how they are going to use their combined residencies and I always get a million answers. When I check back in a few years, 90% of them are adult hospitalists. 10% pediatricians.

Anyway, I say we need better fellowships or better ACCESS to traditional fellowships. I've always been jealous of anesthesia with their solid and varied fellowship options.

 

[bravotwozero]

ACEP says they are now looking for feedback, based on the email I got. Let 'em have it guys.

 

[RustedFox]

I think the best short and medium term solution is to push for more fellowships and access to traditional IM subspecialty fellowships. Most of our fellowships just suck... or are impractical. Wilderness medicine? Undersea and hyperbaric medicine? Anytime I hear someone doing one of those I immediately associate them with the IM/PEDS people. The residency/fellowship of indecisiveness.... More often than not the Wilderness/ultrasound/hyperbaric peeps are looking for a year to fluff their feathers some more, feed from mom's tit, and psych themselves up to finally cut the attending umbilical.

The IM/PEDS folk kick the adult/peds can down the road a few years so they can finally decide which one they want to do when they grow up. I love asking them how they are going to use their combined residencies and I always get a million answers. When I check back in a few years, 90% of them are adult hospitalists. 10% pediatricians.

Anyway, I say we need better fellowships or better ACCESS to traditional fellowships. I've always been jealous of anesthesia with their solid and varied fellowship options.

Give me access to a FM fellowship that will let me be BE/BC, and I will take it.

 

[Groove]

Give me access to a FM fellowship that will let me be BE/BC, and I will take it.

Or even call it say....an "Outpatient Medicine" fellowship. It can be a 1-2 years and prepare EM for outpatient IM/FM medicine. OM fellowship. Something that allows us to set up shop and practice outpatient medicine like our FM/IM colleagues. I would totally do something like that. I think it's ridiculous that we have no real viable way to practice generalist outpatient medicine other than an urgent care.

 

[Dr.Bruh]

Anybody know the utility of Admin/MedEd fellowship (possible MBA) for someone who would literally rather go back to bartended than ever to an IM residency lol.

 

[RustedFox]

Or even call it say....an "Outpatient Medicine" fellowship. It can be a 1-2 years and prepare EM for outpatient IM/FM medicine. OM fellowship. Something that allows us to set up shop and practice outpatient medicine like our FM/IM colleagues. I would totally do something like that. I think it's ridiculous that we have no real viable way to practice generalist outpatient medicine other than an urgent care.

I daresay that I could do more good medicine out of the ER than I could inside the ER.

 

[RustedFox]

Anybody know the utility of Admin/MedEd fellowship (possible MBA) for someone who would literally rather go back to bartended than ever to an IM residency lol.

That's how you end up a congressperson.
Solid career path, if you ask me.

 

[clibby]

Lets be real for a second, how could ACEP lower the amount or residency spots without getting stuck in massive lawsuits that lead to no where. They would essentially have to prove physicians graduating from the "sub-par" residencies are not up to some made up standard. If the residents that became attendings are passing the boards at the same %-rate and having the same outcomes what ground do they have to stand on? They cant just got out tomorrow and say you now need X amount of non-simulated crics to meet criteria for a residency program approval, and if you haven't had those numbers in the past X-# of years you will get shut down. There would be massive backlash if that were to happen. Then what do you do with the huge amount of residents that now have no residency? Yes, this would by a short term problem, but if you are ACGME accredited you are required to give those residents a residency position in the same field.

Yes, this is exactly part of the solution. There will be a backlash no matter what you do. 35 intubations (all of which could be in the OR) is a joke. 10 chest tubes is a joke. 20 CVLs is not enough. 45 adult resuscitations and 15 pediatric resuscitations? Is this intern year? Raising these standards is a must and even some established programs may have trouble, but that is a GOOD thing for our future. Some quality programs will have to absorb residents over the next few years, but they won't all close at once. They will close when their review from the RRC comes up and that will be staggered just like when they opened.

The only solution I can see is to add on more criteria to make the cost of the residency more than the benefit. Expensive SIMs labs, faculty: resident quotas (like 1 full-time faculty (ABEM only) for every 2 ED residents), add in more stringent criteria on who you can consider core faculty, minimum of level 2 trauma center, community outreach programs through EMS, X-number of ultrasound fellowship trained faculty, or only allowing EM-ICC faculty precept in the ICU, I think anesthesia has something similar where they must be observed for X% of the time by an CC-Anesthesiologist. Whatever it is, it has to make the cost more so HCA/Envision arnt able to make millions for hardly any investment. No ****ty ass urgent care shifts, I hear at some programs these are the majority of shifts and that is just pitiful.

This is another part to it. I mean look at this new gem founded by a past president of CORD: Emergency Medicine Residency Program | UHS SoCal MEC

The main hospital is 140 beds and is not a comprehensive stroke center nor a trauma center that only sees 45,000 patients per year. The secondary site has an impressive 122 beds and sees 49,000/year according to the GME website (hospital website says 30,000). The tertiary site for peds is a site with a whopping 120 beds for adults (no inpatient peds) and 50,000 patients/year combined but they are there for peds. (how that combines to 160,000 I have no idea!). I can't imagine enough variety and acuity per resident with these numbers and lack of tertiary/quaternary services nevermind do so for 10 residents per year.

This is a type of program that likely could not survive an increase in standards such as EMS involvement (not just ride alongs), more stringent ICU requirements on the number of beds in the ICU/patients per resident across all specialties/variety of patients, requiring the main site to be a trauma/STEMI/Sroke center, and strict faculty/resident and patient/resident ratios. These sites could get ultrasound faculty as there are tons graduating now. I also don't think sim lab requirements are that onerous for these hospitals given the benefits long term of a residency. You won't see state of the art sim centers, but many programs only have mediocre sim labs now.

 

[RustedFox]

CMGs have demonstrated that they have no problems closing residencies. Anyone remember what happened to SUMMA ... ?

 

[namethatsmell]

The only solution I can see is to add on more criteria to make the cost of the residency more than the benefit. Expensive SIMs labs, faculty: resident quotas (like 1 full-time faculty (ABEM only) for every 2 ED residents), add in more stringent criteria on who you can consider core faculty, minimum of level 2 trauma center, community outreach programs through EMS, X-number of ultrasound fellowship trained faculty, or only allowing EM-ICC faculty precept in the ICU, I think anesthesia has something similar where they must be observed for X% of the time by an CC-Anesthesiologist. Whatever it is, it has to make the cost more so HCA/Envision arnt able to make millions for hardly any investment. No ****ty ass urgent care shifts, I hear at some programs these are the majority of shifts and that is just pitiful.

Precisely. The most effective way to fight corporate entities is by meaningfully targeting their pocketbooks. And in this case, the idea that increased/targeted spending on a training program would yield improved outcomes passes the face validity test.

 

[sylvanthus]

Is it better to go IM/pulmCC route over EM? Because that's what i'm thinking especially since EM has this SLOE obsession that can badly backfire if SLOEs suck and IM doesn't really have away requirements.

Ya I think it likely is a better route. More options if CC becomes crazy competitive, and also have pulm clinic as a backup.

 

[miacomet]

Precisely. The most effective way to fight corporate entities is by meaningfully targeting their pocketbooks. And in this case, the idea that increased/targeted spending on a training program would yield improved outcomes passes the face validity test.

Insane about the urgent care shifts.
Will the RRC and ACGME actually go against corporate medicine?
I doubt it....

 

[namethatsmell]

Insane about the urgent care shifts.
Will the RRC and ACGME actually go against corporate medicine?
I doubt it....

Great question.

In the days when there were literally no docs to work in rural EDs, I could understand the rationale of allowing for somewhat laxed program accrediting guidelines. Times have certainly changed though. Given that the projected surplus of EM-trained docs by the end of this decade will be more than 2x higher than the number of neurosurgeons in the US (yes, the # of jobless EM docs alone will be >2x higher than all the brain surgeons we have), it absolutely makes sense from the patient-safety perspective to adjust the requirements to make sure we only produce extremely well-trained EM docs going forward.

Here's a list of the ACGME's current EM RRC members:

Emergency Medicine

Maybe a good starting point, and potentially low hanging fruit, would be for people to take a look and see if they know any of these folks well enough to grab a coffee/beer with them. You could ask their rationale for how they determine the residency accreditation criteria, what they think of the current EM workforce situation, and if they think it makes sense to set the bar higher for new/continuing program accreditation since many EM residents in the near-future will be more likely to obtain unemployment benefits following graduation rather than a full time EM job.

 

[miacomet]

It seems like this situation has been brewing for years. Once the Texas market imploded, I knew this was inevitable. Why are students still picking EM, a dead field? And what are PDs doing with unemployed grads?