How much time do we have?

[cyanide12345678]

As of today, plenty of job options. The going is back to being good, for the time being.

How many more years do you guys think we have before we are all walking on egg shells where we can be replaced by the numerous number of new grads willing to take any job because they can’t find employment? At what point, if at all, do you think that a decent number of new grads will not be able to find adequate employment?

I personally think we have 5 more years, i don’t think the market would be able to handle 10k new graduates and a lot of new grads will be doing fellowships because they otherwise couldn’t find employment.

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[Major]

My first instinct answer 5 years as well.

Fml

 

[PikminOC]

With midlevels, do you think it may be sooner? https://www.npr.org/sections/health-shots/2023/02/11/1154962356/ers-hiring-fewer-doctors

 

[bravotwozero]

ah well. Nobody can predict the future, but we'll see. Still possible in five years to build a six to seven figure net worth, especially if one is halfway there. Then, can transition to a lower paying but sustainable and circadian friendly job, and prolong one's retirement horizon, or enter semi-retirement. In states where physician owned FSEDs are legal, may have more wiggle room to transition to lower volume and lower pay jobs where nights are less brutal.

 

[NYEMMED]

3-5 years

 

[Mount Asclepius]

The book answer: 2030. The on-the-ground answer: 2023. Hope for the best, prepare for the worst. Find as solid a SDG as you can and ride out whatever good years remain. Best case scenario CMGs come and go with med students realizing how hard EM is driving up demand for those still in the pit.

 

[Pudortu]

I think 5 years is optimistic but I’m a pessimist at heart. I think in 2-3 years we will reach an equilibrium and then it will start getting much harder to find a job. I really hope that I am wrong and there’s a huge exodus with retirees.

 

[GonnaBeADoc2222]

The sky has been falling on the house of medicine for the past fiftyeleven years and nothing has happened. Y'all are a little ridiculous.

 

[Rekt]

The sky has been falling on the house of medicine for the past fiftyeleven years and nothing has happened. Y'all are a little ridiculous.

There’s still 3000 EM graduates every year. Probably more on the horizon as I stopped researching new residencies. If anything the acep report findings will be pushed back a year or two max, although they theoretically counted for attrition.

 

[Torsion]

The last report I saw in one of the EM periodicals suggested that the workforce report severely undercounted our attrition rate as a specialty which is closer to 5% per year. We are losing a ton of docs. Interest in the field from students has clearly waned. If there is some proactiveness about closing bad HCA and private equity residencies the ship could be righted.

 

[Old_Mil]

I personally think we have 5 more years, i don’t think the market would be able to handle 10k new graduates and a lot of new grads will be doing fellowships because they otherwise couldn’t find employment.

I would say it's no longer than that. I suspect that ten years from now you're going to see EM as a field and dominated by FMGs and midlevels. I suspect the lull right now is veterans getting out, and if you're a medical student right now you'd be nuts to go into this field.

If there is some proactiveness about closing bad HCA and private equity residencies the ship could be righted.

In the field most heavily dominated by the corporate practice of medicine, it's all a question of reducing "provider" reimbursement to the point that it's just above the cost of liability.

 

[Major]

There’s still 3000 EM graduates every year. Probably more on the horizon as I stopped researching new residencies. If anything the acep report findings will be pushed back a year or two max, although they theoretically counted for attrition.

Acgme keeps approving and allowing new EM
Residencies to open. I hear about it all the time with the EMRA emails.

I also have it on good authority that usacs is even trying to open their own EM residency in Cincinnati. Wtf

 

[RustedFox]

Someone post this thread over at r/emergencymedicine.

That place is full of naïve MS-2s that are "set on EM".

 

[finalpsychyear]

We will be lucky to get to 2030 in most fields that are non surgical. I am working harder than ever as I have slowly seen where i work not hire an MD in 5 years. Allowing this mid level crap to get this far in an industry where costs are a major concern has set us up for large pay cuts and less job stability. Work more NOW, save more NOW, and invest more NOW as at best we get a few more years.

 

[Old_Mil]

Going forward you're either going to have to specialize, or go into something like IM/FP that will allow you to have a cash or concierge practice as this increasingly goes towards medicare for all.

 

[PikminOC]

You're not worried about midlevels taking over? Just about other physicians? Midlevels are a bigger risk imo.

 

[PikminOC]

The sky has been falling on the house of medicine for the past fiftyeleven years and nothing has happened. Y'all are a little ridiculous.

Nothing has happened? Midlevels aren't replacing physicians?

 

[GonnaBeADoc2222]

Lord.

Y'all have this crazy defeatist chicken little attitude.

I'm tired of this whining of "midlevels can just switch specialties and we are stuck." You're a physician, you can do whatever you want. You need to get out of the "employee" mindset though. You can go out on your own and open up whatever cash only concierege type set up you want. Its a risk, and you might not get revenue for a few months though.

Work more? Nah. My goal is to work as little as possible to achieve a reasonable lifestyle.

ERs not hiring physicians? My shop just hired 7.

 

[GonnaBeADoc2222]

Nothing has happened? Midlevels aren't replacing physicians?

Not where I work. We keep increasing physician staffing and cutting midlevel staffing.

What do you think the absolute worst case scenario end game is of the physician vs midlevel issue? It's not that physicians go away. Its that physician pay decreases and midlevels forced out, since why would you pay a midlevel when you can now get a physician for the same price? Dont get me wrong, that would blow, but you'll have a job.

 

[PikminOC]

Not where I work. We keep increasing physician staffing and cutting midlevel staffing.

What do you think the absolute worst case scenario end game is of the physician vs midlevel issue? It's not that physicians go away. Its that physician pay decreases and midlevels forced out, since why would you pay a midlevel when you can now get a physician for the same price? Dont get me wrong, that would blow, but you'll have a job.

Physicians malpractice etc costs more too. They are held to physician standards. So it would be less pay than midlevels. https://www.npr.org/sections/health-shots/2023/02/11/1154962356/ers-hiring-fewer-doctors

 

[PikminOC]

Lord.

Y'all have this crazy defeatist chicken little attitude.

I'm tired of this whining of "midlevels can just switch specialties and we are stuck." You're a physician, you can do whatever you want. You need to get out of the "employee" mindset though. You can go out on your own and open up whatever cash only concierege type set up you want. Its a risk, and you might not get revenue for a few months though.

Work more? Nah. My goal is to work as little as possible to achieve a reasonable lifestyle.

ERs not hiring physicians? My shop just hired 7.

Midlevels are also setting up private practices. And with the dnp they call themselves doctors. And patients don't know the difference.

 

[RustedFox]

Lord.

Y'all have this crazy defeatist chicken little attitude.

I'm tired of this whining of "midlevels can just switch specialties and we are stuck." You're a physician, you can do whatever you want. You need to get out of the "employee" mindset though. You can go out on your own and open up whatever cash only concierege type set up you want. Its a risk, and you might not get revenue for a few months though.

Work more? Nah. My goal is to work as little as possible to achieve a reasonable lifestyle.

ERs not hiring physicians? My shop just hired 7.

PLP: I know all the medicinez, I can work by myselfslolz.
Physician: I know enough to know that I don't know enough medicine to do this correctly and responsibly.

Bro.

 

[HemorrhagicShock]

Midlevels are also setting up private practices. And with the dnp they call themselves doctors. And patients don't know the difference.

Truth.

The concierge and DPC practice models are accessible by mid-levels and at least around here (PNW) it's a trendy way to "bail out." They're all starting their primary-care-health-spa-cosmetics-ketamine-you-name-it practices, and patients have ZERO clue regarding their ability to deliver on any real long-term health promise.

The cash pay world is all about customer satisfaction and to some extent "results." The fortunate thing for these NPPs is that the placebo effect and power of suggestion is perhaps the most potent thing we have in medicine, and they're unyielding and merciless with its application without even realizing that's what they're selling.

It's only a matter of time until the term "Doctor" is no longer protected as profit-centered interests chip away at rules and regulations, and then all bets are off.

Physicians malpractice etc costs more too. They are held to physician standards. So it would be less pay than midlevels. https://www.npr.org/sections/health-shots/2023/02/11/1154962356/ers-hiring-fewer-doctors

Our PAs carry the same exact malpractice/limits as the physicians in our group. It's exactly the same (1m/3m).

 

[PikminOC]

Truth.

The concierge and DPC practice models are accessible by mid-levels and at least around here (PNW) it's a trendy way to "bail out." They're all starting their primary-care-health-spa-cosmetics-ketamine-you-name-it practices, and patients have ZERO clue regarding their ability to deliver on any real long-term health promise.

The cash pay world is all about customer satisfaction and to some extent "results." The fortunate thing for these NPPs is that the placebo effect and power of suggestion is perhaps the most potent thing we have in medicine, and they're unyielding and merciless with its application without even realizing that's what they're selling.

It's only a matter of time until the term "Doctor" is no longer protected as profit-centered interests chip away at rules and regulations, and then all bets are off.



Our PAs carry the same exact malpractice/limits as the physicians in our group. It's exactly the same (1m/3m).

Yes but the standard the midlevels are held to versus physicians is different.
And you're in a group. Out in private practice land, the nurses aren't paying the same for insurance as I am.

 

[PikminOC]

Truth.

The concierge and DPC practice models are accessible by mid-levels and at least around here (PNW) it's a trendy way to "bail out." They're all starting their primary-care-health-spa-cosmetics-ketamine-you-name-it practices, and patients have ZERO clue regarding their ability to deliver on any real long-term health promise.

The cash pay world is all about customer satisfaction and to some extent "results." The fortunate thing for these NPPs is that the placebo effect and power of suggestion is perhaps the most potent thing we have in medicine, and they're unyielding and merciless with its application without even realizing that's what they're selling.

It's only a matter of time until the term "Doctor" is no longer protected as profit-centered interests chip away at rules and regulations, and then all bets are off.



Our PAs carry the same exact malpractice/limits as the physicians in our group. It's exactly the same (1m/3m).

And result wise midlevels in my field give people what they want, not what they need.

 

[Tenk]

So many of these big PE CMGs are so deep in the red they won’t survive what’s coming. We got longer than five years. They don’t.

 

[JacobMcCandles]

The things that I've learned throughout my life is that we typically don't know nothin'. Things that seem so obvious turn out to be wrong. Things that seem impossible end up happening. I don't see EM being a specialty of FMG and midlevels. The expectations of Americans and American healthcare is too high for that to happen. I do think that part of the solution is just outlasting CMGs. When private equity money dries up, as it's starting to now, they can't fall back on their bloated operations. I do think there will be some opportunities for some docs to create their own SDG. I think it might be pretty lean for SGDs for the next few years but I think the long term outlook is brighter than it was.

 

[emergentmd]

If and when CMGs fold, the Er will be run by employed ER docs. SDG days other than rural areas are a thing of the past. It is almost impossible to get the new gen EM docs to take on business risks and work associated with a CMG. Most just want to punch the clock and have freedom outside of medicine.

The old EM docs that used to work large hours are being replaced by docs who want to work 120hrs/month.

Something will have to give. If payments continue to go down, the CMGs will not survive so its going to be hospital employees or single payer government employees. Unless carriers have a change of heart and increase payments, SDGs are just not viable.

 

[JacobMcCandles]

If and when CMGs fold, the Er will be run by employed ER docs. SDG days other than rural areas are a thing of the past. It is almost impossible to get the new gen EM docs to take on business risks and work associated with a CMG. Most just want to punch the clock and have freedom outside of medicine.

The old EM docs that used to work large hours are being replaced by docs who want to work 120hrs/month.

Something will have to give. If payments continue to go down, the CMGs will not survive so its going to be hospital employees or single payer government employees. Unless carriers have a change of heart and increase payments, SDGs are just not viable.

I don't know about the hospital systems you're familiar with but the ones I'm familiar with have shown absolutely zero interest in employing EM docs. I would be somewhat surprised if these hospital systems all of a sudden change their tune and start employing EM docs.

 

[emergentmd]

I don't know about the hospital systems you're familiar with but the ones I'm familiar with have shown absolutely zero interest in employing EM docs. I would be somewhat surprised if these hospital systems all of a sudden change their tune and start employing EM docs.

Its all about money and if the headache is worth it. Currently, most large hospital systems do not want the headaches of employing ER docs, Anesthesiologist, radiologist, etc because the margins are too thin. Better to get someone like TH/EMcare to do it and not deal with a low margin/big headache business and as decreased payments has shown, a potentially money losing business.

Once the CMGs start to fold or demand stipends, then it may be worth it to employ docs. There are systems in Texas that essentially employs most of their docs/specialists and you will see more of this once the CMGs fold. If Emcare folds and gives back hundreds of contracts to the hospital, what are their choice? Find another CMG/SDG/management group who will take on a money losing contract? I doubt it.

The hospitals will eventually have to employ the docs b/c no one will run a money losing contract. We ran our SDG in its hayday and the margin was already thin and we had minimal administrative expenses. No way can a top heavy CMG make money when insurance companies balk at the outrageous bills which is happening now.

 

[Arcan57]

Barring another COVID-scale drop in patient volume, I don't see the system collapsing by year 20xx. Instead, jobs are going to bifurcate as desire to make the money we made at our peak diverges from the desire not to have every shift be like hooking your genitals up to a car battery.

Docs that need to be making that bank are going to be supervising 3-4 midlevels or they're going to be charging into 3 pph shifts to try and keep their earnings steady.

Docs that can't/won't tolerate those conditions will look like academics used to in the 00's. Solidly middle upper class and your choice of putting 1 of your kids into a great school or two into good state schools without a scholarship. Tough work, decently high malpractice exposure, not soul destroying.

 

[johhnybgood]

Barring another COVID-scale drop in patient volume, I don't see the system collapsing by year 20xx. Instead, jobs are going to bifurcate as desire to make the money we made at our peak diverges from the desire not to have every shift be like hooking your genitals up to a car battery.

Docs that need to be making that bank are going to be supervising 3-4 midlevels or they're going to be charging into 3 pph shifts to try and keep their earnings steady.

Docs that can't/won't tolerate those conditions will look like academics used to in the 00's. Solidly middle upper class and your choice of putting 1 of your kids into a great school or two into good state schools without a scholarship. Tough work, decently high malpractice exposure, not soul destroying.

This is awesome post. And on point

 

[xaelia]

The hospitals will eventually have to employ the docs b/c no one will run a money losing contract.

Who knows exactly how hospitals will staff the EDs, though. A lot of hospitals are operating significantly in the red right now, so their appetite to subsidise a money-losing tire fire can't be high. They are struggling with their accounts receivable/cash on hand just as much as any CMG would with collections.

 

[Arcan57]

Who knows exactly how hospitals will staff the EDs, though. A lot of hospitals are operating significantly in the red right now, so their appetite to subsidise a money-losing tire fire can't be high. They are struggling with their accounts receivable/cash on hand just as much as any CMG would with collections.

Hospitals that have a choice strictly limit NPs in the ED both for quality reasons and their penchant for upsetting consultants who bring in significant revenue to the hospital. Your point that they may not have a choice is fair though.

 

[ScepticSkeksis]

The job market seems to have temporarily rebounded especially in Texas. I see many advertised rates of $275 or more before negotiation. Hopefully this continues for at least 5 more years so can save up enough to do something else if things get bad. What will really be interesting is what happens to physician supply when Envision/TeamHealth/USACS tries to implement national wage controls. The unintended consequence might be thousands of physicians opting out of clinical work altogether, which may push wages back up.

 

[emergentmd]

Who knows exactly how hospitals will staff the EDs, though. A lot of hospitals are operating significantly in the red right now, so their appetite to subsidise a money-losing tire fire can't be high. They are struggling with their accounts receivable/cash on hand just as much as any CMG would with collections.

No matter what, economics matter and hospitals will do whatever they need to stay profitable. If CMGs can't make a profit and go bankrupt, then what choice do hospitals have other than Employing docs or making them IC. We very well could be going to the 4:1 or worse Anesthesiology model. I mean what other choice do new er docs have?

 

[emergentmd]

The job market seems to have temporarily rebounded especially in Texas. I see many advertised rates of $275 or more before negotiation. Hopefully this continues for at least 5 more years so can save up enough to do something else if things get bad. What will really be interesting is what happens to physician supply when Envision/TeamHealth/USACS tries to implement national wage controls. The unintended consequence might be thousands of physicians opting out of clinical work altogether, which may push wages back up.

How can the CMGs legally implement national wage controls? Even if it passes the legal muster, it would take them years to have enough supply of docs to work at depressed wages.

 

[ScepticSkeksis]

How can the CMGs legally implement national wage controls? Even if it passes the legal muster, it would take them years to have enough supply of docs to work at depressed wages.

Collusion between big players in an industry isn't unheard of. The two or three biggest players could agree behind the scenes to all have a standard rate they won't go over.

 

[HemeOncHopeful19]

Collusion between big players in an industry isn't unheard of.

I mean what are salary surveys if not collusion between the big players to make sure they don’t pay too much.

 

[xaelia]

Not really that unusual or bizarre, except when contrasted with the prior context and expectations set for our health system.

See:

WA Country Health Service - Emergency Telehealth Service

Western Australia’s Emergency Telehealth Service – a global leader in virtual emergency care.

www.wacountry.health.wa.gov.au

 

[emergentmd]

Collusion between big players in an industry isn't unheard of. The two or three biggest players could agree behind the scenes to all have a standard rate they won't go over.

Almost every business has this collusion. There is a reason car rental and airline flights typically are the same. But supply and demand wins out. There is a monetary threshold where both sides are satisfied, I don't think collusion will materially change this.

Imagine if EMCARE/TH colluded (illegal) to set rate in Dallas at $100/hr. They could not find docs to fill, does a terrible job, HCA balks at the ER situation. EMCARE or TH will blink and raise rates. Or HCA will give the contract to another CMG who will then move towards a better rate.

 

[BicepsTriceps]

No matter what, economics matter and hospitals will do whatever they need to stay profitable. If CMGs can't make a profit and go bankrupt, then what choice do hospitals have other than Employing docs or making them IC. We very well could be going to the 4:1 or worse Anesthesiology model. I mean what other choice do new er docs have?

Can't this be solved with immunity to the doctor supervising APP?

If I was given federal/ state immunity from lawsuits for the APP cases I supervised I wouldn't mind personally to supervise whatever number of APP needed. As the long as the hospital/ CMG group take the liability and I stay out of it I'll supervise whoever and whatever.

Otherwise you wouldn't find me touching an APP chart with a 10 foot pole.

 

[EctopicFetus]

With midlevels, do you think it may be sooner? https://www.npr.org/sections/health-shots/2023/02/11/1154962356/ers-hiring-fewer-doctors

I called it before. summer of 2027 people wont be able to find a normal job.

 

[finalpsychyear]

I called it before. summer of 2027 people wont be able to find a normal job.

Incoming new attendings or existing attendings?

 

[PianoMedic]

I don't know about the hospital systems you're familiar with but the ones I'm familiar with have shown absolutely zero interest in employing EM docs. I would be somewhat surprised if these hospital systems all of a sudden change their tune and start employing EM docs.

If they can’t find any group to take the contract to staff the department, they will have to start employing EM docs or stop taking CMS payments. EMTALA means they have to have an ER of some kind, and after what happened to Cleveland Clinic when they hid their ER, it has to be visible, clearly marked, and staffed 24/7. Most hospitals can’t survive without CMS payments, so they’ll do whatever is necessary to keep that money coming in.

 

[bravotwozero]

If they can’t find any group to take the contract to staff the department, they will have to start employing EM docs or stop taking CMS payments. EMTALA means they have to have an ER of some kind, and after what happened to Cleveland Clinic when they hid their ER, it has to be visible, clearly marked, and staffed 24/7. Most hospitals can’t survive without CMS payments, so they’ll do whatever is necessary to keep that money coming in.

There’s always locums groups. They can still be an option for lots of hospitals.

 

[PianoMedic]

There’s always locums groups. They can still be an option for lots of hospitals.

Hadn’t considered that. I think that would quickly become unsustainable from a cost standpoint, providers would probably be getting National average salary, but the charge to the hospital has to cover the company’s overhead too.

 

[JacobMcCandles]

If they can’t find any group to take the contract to staff the department, they will have to start employing EM docs or stop taking CMS payments. EMTALA means they have to have an ER of some kind, and after what happened to Cleveland Clinic when they hid their ER, it has to be visible, clearly marked, and staffed 24/7. Most hospitals can’t survive without CMS payments, so they’ll do whatever is necessary to keep that money coming in.

It'll still be much, much easier to have someone else do it. For many hospitals, employing EM docs would be the last resort. It takes a lot to completely run and manage an ED. There will always be somebody willing to take on a contract.

 

[EthylMethylMan]

You're not worried about midlevels taking over? Just about other physicians? Midlevels are a bigger risk imo.

We need to figure out how to market ourselves to patients better. There's ample evidence on poorer outcomes and increased resource utilization with midlevels. If most reasonable people knew that with midlevels they'd have to sit through more tests and have lower odds of doing well, they'd want a doc.

 

[RustedFox]

We need to figure out how to market ourselves to patients better. There's ample evidence on poorer outcomes and increased resource utilization with midlevels. If most reasonable people knew that with midlevels they'd have to sit through more tests and have lower odds of doing well, they'd want a doc.

Patients want tests and pills.
Admins want tests and cheap labor; they don't care about the actual medicine.
PLPs want to order ALL the tests, because "look at me, I can do the medicines".

Then, they hand the hot mess that they created to us once they get results and have no idea what they're looking at and say: "*Giggle* now do your job."