I’m sure this will be controversial (mostly to some of your pocketbooks) but it’s disgusting that FM / IM is allowed in this specialty with BCEM unemployment on the horizon.
It’s time for FM / IM to get out of this specialty
- Thread starter skougess
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I think that problem will sort itself out, with the oversupply of EPs. You are going to have wages that are going to go to a race to the bottom, to the point where mid levels, and physicians will all have the same pay. When that happens, why would any employer pick an IM/FP/low level provider over an EP?
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''disgusting'' is probably a strong word
FM and IM docs in the ED are by and large who started Emergency medicine in the first place, and they filled a role when there werent enough of us in departments across the country.
that being said, 43 years on there is no reason why an ED should be staffed by non-em trained physicians. No other specialty does this en masse.
FM and IM docs in the ED are by and large who started Emergency medicine in the first place, and they filled a role when there werent enough of us in departments across the country.
that being said, 43 years on there is no reason why an ED should be staffed by non-em trained physicians. No other specialty does this en masse.
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I wonder if NPP wages will go down too. Maybe instead of 240/hr docs and 140/hr NPP well have 140/hr docs and 60/hr NPPs
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My 0.2 as a graduating resident. I think we should make it so non BCEM docs can only work in CAH. Totally agree that at this point with EP oversupply we should be phasing out IM/FP/Etc. From what I have experienced non EP docs are more likely to not be up to date on recent literature, are more likely to shot gun workups, and are less likely to be comfortable with procedures.
For MLPs we should be lobbying for patient safety. Leadership has failed for too long to protect our specialty.
For MLPs we should be lobbying for patient safety. Leadership has failed for too long to protect our specialty.
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If an NP/PA can do it, why not a FM/IM doc? Hell why have EM at all?
D
deleted6669
Where are EM NPPs making 140/hr? As an EMPA for over 25 years at the top of the pay scale everywhere I work, practicing at the top of my license and experience I make nowhere near that.
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"I passed muster, if you will, as the first non-physician, full-time, sole provider here as an NP working in the ER alongside the docs," he says. "It was so successful that we ultimately eliminated all the docs here and replaced them all with nurse practitioners or physician assistants."
www.healthleadersmedia.com
Effective April 1, 2020, all seven urgent care clinics of the Edward-Elmhurst Health System will replace physicians with nurse practitioners. At least 15 physicians have been eliminated, and physicians will no longer provide patient care or medical direction in the urgent care clinics. The hospital system indicates its business model will provide lower acuity care at a lower cost.
epmonthly.com
Nurse Practitioner Elected Medical Staff President
A high-achieving nurse practitioner who was elected to the influential position of medical staff president with more than 50% of the all-physician vote explains his unusual rise through the ranks.
www.healthleadersmedia.com
Effective April 1, 2020, all seven urgent care clinics of the Edward-Elmhurst Health System will replace physicians with nurse practitioners. At least 15 physicians have been eliminated, and physicians will no longer provide patient care or medical direction in the urgent care clinics. The hospital system indicates its business model will provide lower acuity care at a lower cost.
The Horse is Out of the Barn | Emergency Physicians Monthly
Care Crisis — Physicians terminated from all Edward-Elmhurst Health System clinics replaced by APPs. https://youtu.be/FFx-44zpHY0 Effective April 1, 2020, all seven urgent care clinics of the Edward-Elmhurst Health System will replace physicians with nurse practitioners. At least 15 physicians...
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D
deleted6669
Isn't this happening anyway, aside from the FM docs who are about to retire? At my last several urban trauma ctr jobs, every time an FM/IM doc left for any reason they were replaced by a residency trained and boarded EM physician.
D
deleted6669
Not a fan of this model. I agree with the vast # of posters here that every ED should have ED physicians working in the depts and acting as the directors."I passed muster, if you will, as the first non-physician, full-time, sole provider here as an NP working in the ER alongside the docs," he says. "It was so successful that we ultimately eliminated all the docs here and replaced them all with nurse practitioners or physician assistants."
Nurse Practitioner Elected Medical Staff President
A high-achieving nurse practitioner who was elected to the influential position of medical staff president with more than 50% of the all-physician vote explains his unusual rise through the ranks.
That is not to say that PAs/NPs can't work there too, but the leadership and direction of emergency medicine has to be coordinated by emergency physicians.
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Exactly. As much as I want to jump on board with the OP's sentiments, we just have so much less in common with the more specialized specialties. After all, our specialty was born out of a hodge podge of specialists all working in the ED. Surgeon's, IM, FM, OB, hell I've even worked with cards and ENT who were EPs. After all, anybody could easily do 90% of what we treat in the ED. It's only the 10% that we have specialized training to handle and I would say that most specialists could pick that up with enough experience. How many of us can handle 90% of what a cardiologist does? What about 90% of an OB? 90% of ENT?...No takers? That's my point. We're generalists and we don't specialize enough to sufficiently make ourselves or our contributions to the pts care...unique. So much of what we do is plain FM/IM which is why most FMs can handle 90% of EM and then they do a few courses, get some experience, practice on a few cadavers and pick up the other 10%.
If the goal of all this is to take back our specialty, then I think it's a laudable and idealistic effort but ultimately.... impractical and likely to fail unless the market is flooded with a surplus of unemployed EM docs where they start to vastly outnumber the FM/IM guys. At which point the salaries will be so low that FM/IM starts to drift back towards their original career path because nobody else is going to want to put up with the stress/liability/hours for less pay than what they could make as a hospitalist or PCP.
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There is a difference between being able to do something and doing it well. Hospitalist/FP we could definitely do but we probably wouldn’t do it well which is exactly my point.
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Not anywhere I have been. Mostly in the 65-80$ range.
D
deleted6669
exactly. I make a bit more than that, but not much.
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I think anybody can do something well given enough time, interest and experience. My SO is an FM trained NP and was a bad ass in the ED after enough experience. Then she switches to FM and yes...it was several months of pain, stress and learning but now she's a badass in FM. I just think there's a tremendous amount of overlap between our specialties and it's really just dependent on the individual. Don't get me wrong...EM trained docs are superior out of residency in the ED. However, it's not a sustainable superiority throughout their career once you factor in experience among other generalists that choose to work in the ED. How does anybody plan on pushing out all these IM/FM guys with 20 years experience who can do everything the new grads can do...and with better efficiency? The only prayer is to lower salaries to where they don't want to do it anymore...or get hospitals to create bylaws requiring ABEM to work in the ED. If salaries are so low that IM/FM doesn't want to do it, what quality of medical students are going to be applying for EM as one of the lowest paid, highest stress specialties? At that point we'll probably be reaching the bottom of the barrel in quality of applicants.
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deleted6669
ORLANDO, Fla. -- A study by Duke University Medical Center researchers has shown that
physician assistants, with proper training can successfully perform cardiac catheterizations.
"Under the careful supervision of experienced attending cardiologists, trained physician
assistants can perform diagnostic cardiac catheterization, including coronary angiography, with
procedural times and complication rates similar to those of cardiology fellows. This is the first
large study that demonstrates that this is a safe practice," said Dr. Richard Krasuski, a Duke
cardiology fellow who led the study which was presented Wednesday at the 50th Annual
Scientific Session of the American College of Cardiology.
Physician assistants (PAs), who originated at Duke in the 1960s, work with physicians to provide
diagnostic and therapeutic patient care in virtually all medical specialties and settings. Cardiac
catheterization involves threading a thin catheter through a patient's arteries until it reaches the
heart. X-ray dye is then injected to determine if the arteries are blocked.
"With cardiac catheterizations increasing more than 300 percent during the last 10 years,
physician assistants have begun performing more of these procedures under the supervision of
cardiologists. However, there was insufficient evidence before this to support whether this was a
safe practice," Krasuski said.
The Duke study compared 929 diagnostic cardiac catheterizations performed by PAs with
supervision by a cardiologist to 4,521 catheterizations performed by cardiology fellows.
Cardiology fellows are physicians receiving three to four years of advanced training in cardiology
after completing an internal medicine residency. The procedures were performed at Duke
between July 1998, when PAs were first given approval by the institution to perform the
procedure, and April
2000. The patients in the two groups were of similar demographics.
The study showed that the incidence of major complications, such as myocardial infarction (heart
attack), stroke, arrhythmia requiring defibrillation or pacemaker placement, pulmonary edema
requiring mechanical ventilation and vascular complications requiring surgical intervention, were
nearly identical in both groups. For PAs, the complication rate was
0.54 percent as compared to a
0.58 percent complication rate for cardiology fellows.
Additionally, the cases performed by the PAs were done more quickly (
70.2 minutes versus
72.6 minutes by the cardiology fellows), and used less fluoroscopic time (
10.2 minutes as compared to
12.2 minutes). Krasuski noted that the time and fluoroscopic differences were most likely due to
the fact that the patients treated by the fellows were slightly sicker.
"We are not saying that PAs should replace doctors in performing cardiac catheterizations or
should be stand-alone operators. What this study shows is that this is a skill that can be learned
and successfully performed by PAs, thus permitting cardiologists to become more efficient in the
cath lab while maintaining excellent patient care," Krasuski said.
Krasuski added that with the involvement of PAs, cardiologists are freed up to interpret data
generated by the catheterization, plan the patient's follow-up care and even consult with
referring physicians while the case is still going on.
PAs must receive approximately one year of specialized training to properly perform the
procedure. Additionally, they must have advanced life support training, remain up-to-date on the
latest techniques and information on catheterization and be approved by cath lab directors and
faculty to perform catheterizations. Furthermore, cardiologists must be present in the
catheterization suite supervising the PAs and be ready to take over the case should
complications arise.
Joining Krasuski in the study were Dr. John Warner, Dr. Andrew Wang, Dr. J. Kevin Harrison,
John Bolles, Erica Moloney, Carole Ross, Dr. Thomas Bashore and Dr. Michael Sketch Jr.
physician assistants, with proper training can successfully perform cardiac catheterizations.
"Under the careful supervision of experienced attending cardiologists, trained physician
assistants can perform diagnostic cardiac catheterization, including coronary angiography, with
procedural times and complication rates similar to those of cardiology fellows. This is the first
large study that demonstrates that this is a safe practice," said Dr. Richard Krasuski, a Duke
cardiology fellow who led the study which was presented Wednesday at the 50th Annual
Scientific Session of the American College of Cardiology.
Physician assistants (PAs), who originated at Duke in the 1960s, work with physicians to provide
diagnostic and therapeutic patient care in virtually all medical specialties and settings. Cardiac
catheterization involves threading a thin catheter through a patient's arteries until it reaches the
heart. X-ray dye is then injected to determine if the arteries are blocked.
"With cardiac catheterizations increasing more than 300 percent during the last 10 years,
physician assistants have begun performing more of these procedures under the supervision of
cardiologists. However, there was insufficient evidence before this to support whether this was a
safe practice," Krasuski said.
The Duke study compared 929 diagnostic cardiac catheterizations performed by PAs with
supervision by a cardiologist to 4,521 catheterizations performed by cardiology fellows.
Cardiology fellows are physicians receiving three to four years of advanced training in cardiology
after completing an internal medicine residency. The procedures were performed at Duke
between July 1998, when PAs were first given approval by the institution to perform the
procedure, and April
2000. The patients in the two groups were of similar demographics.
The study showed that the incidence of major complications, such as myocardial infarction (heart
attack), stroke, arrhythmia requiring defibrillation or pacemaker placement, pulmonary edema
requiring mechanical ventilation and vascular complications requiring surgical intervention, were
nearly identical in both groups. For PAs, the complication rate was
0.54 percent as compared to a
0.58 percent complication rate for cardiology fellows.
Additionally, the cases performed by the PAs were done more quickly (
70.2 minutes versus
72.6 minutes by the cardiology fellows), and used less fluoroscopic time (
10.2 minutes as compared to
12.2 minutes). Krasuski noted that the time and fluoroscopic differences were most likely due to
the fact that the patients treated by the fellows were slightly sicker.
"We are not saying that PAs should replace doctors in performing cardiac catheterizations or
should be stand-alone operators. What this study shows is that this is a skill that can be learned
and successfully performed by PAs, thus permitting cardiologists to become more efficient in the
cath lab while maintaining excellent patient care," Krasuski said.
Krasuski added that with the involvement of PAs, cardiologists are freed up to interpret data
generated by the catheterization, plan the patient's follow-up care and even consult with
referring physicians while the case is still going on.
PAs must receive approximately one year of specialized training to properly perform the
procedure. Additionally, they must have advanced life support training, remain up-to-date on the
latest techniques and information on catheterization and be approved by cath lab directors and
faculty to perform catheterizations. Furthermore, cardiologists must be present in the
catheterization suite supervising the PAs and be ready to take over the case should
complications arise.
Joining Krasuski in the study were Dr. John Warner, Dr. Andrew Wang, Dr. J. Kevin Harrison,
John Bolles, Erica Moloney, Carole Ross, Dr. Thomas Bashore and Dr. Michael Sketch Jr.
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Did you miss that big part? That’s what makes every midlevel outcome study garbage—they’re all done under the supervision of physicians. Essentially midlevels and physicians v physicians. Not hard to see why outcomes would be similar. What are midlevels gonna do when s*** hits the fan during a procedure like this? The same thing crnas do, run like hell to get a doctor to save them. Except when there are no more docs around we all know what will happen. Be careful what you wish for. I genuinely don’t understand how someone can have the hubris to risk people’s lives day in and day out and go home and sleep soundly
D
deleted6669
This was 20 years ago. They now hire for interventional cardiology PAs. I believe after the study, the rules were changed to be similar to an anesthesia team model where one MDA oversees X CRNAs in several ORs. One interventional cardiologist could oversee X PAs doing routine diagnostic caths and if a critical stenosis is found they call the cardiologist who comes in and places a stent(s).
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Lol. 9K+ unemployed ER docs and they're going to do our job after a fellowship?
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yeah i lol'd too when I read that..
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Isn’t this like EM people thinking they can do MICU after 1 year of fellowship while most IM docs do 2-3 years of fellowship for the same job? Granted, the same hospitals that would hire an EM doc to work in their MICU are the kind that would hire an IM doc to work in their ED.
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No. Just stop, please.
Where did this clown come from? Has HCA teamed up with Russian hackers to infiltrate this site and sow discord or something?
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Not to the patient..."I passed muster, if you will, as the first non-physician, full-time, sole provider here as an NP working in the ER alongside the docs," he says. "It was so successful that we ultimately eliminated all the docs here and replaced them all with nurse practitioners or physician assistants."
Nurse Practitioner Elected Medical Staff President
A high-achieving nurse practitioner who was elected to the influential position of medical staff president with more than 50% of the all-physician vote explains his unusual rise through the ranks.
Effective April 1, 2020, all seven urgent care clinics of the Edward-Elmhurst Health System will replace physicians with nurse practitioners. At least 15 physicians have been eliminated, and physicians will no longer provide patient care or medical direction in the urgent care clinics. The hospital system indicates its business model will provide lower acuity care at a lower cost.
The Horse is Out of the Barn | Emergency Physicians Monthly
Care Crisis — Physicians terminated from all Edward-Elmhurst Health System clinics replaced by APPs. https://youtu.be/FFx-44zpHY0 Effective April 1, 2020, all seven urgent care clinics of the Edward-Elmhurst Health System will replace physicians with nurse practitioners. At least 15 physicians...
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I'm an anesthesiologist. No PA, NP, or CRNA, or whoever, is happy doing routine procedures day in/day out for eternity. They want more. It's human nature. When they realize 'wanting more' means another 8 years of training or so they try and create shortcuts. Their societies tell them and everyone else they're just as good as the MDs. That's the US right now. And the MBAs cut costs at every opportunity to sweeten their bonus pot.
I saw the $60-85 per hour up there and saw you say you make a bit more. CRNAs make twice that. Sometimes more. They still want more. Their representative society, the AANA, fights tooth and nail for more. There is nothing off limits in medicine, no respect for the hierarchy and no feeling that years of sacrifice and hard work should pay off. We're all at the mercy of the MBAs and those wanting more in a society where everyone gets a trophy.
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I will again take this opportunity to remind you that there are emergency room CEOs in rural America who still want and need the hybrid ER/IM and ER/FM doctor who is the ER doc and Hospitalist . They certainly don’t want an EM only doc who is not able to round and manage care of the 2-10 patients in the hospital or consult on their psych ward/ geri psych ward.
I have seen EM docs now rushing to these roles and after a learning curve the EM doc will also be a Hospitalist.
What you really need is your ER groups to stop hiring PAs/NPs to replace your EM docs.
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If an EM NP can go through a bit of a struggle to switch into FM, there's no reason EM docs shouldn't be able to do the same.
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None of what you just said is accurate. Not sure what you're getting at.
MICU requires a 2 year fellowship from EM (just like IM). And there are plenty of excellent hospitals with EM-CCM staffing their MICUs.
As far as the original post, I think disgusting is a pretty strong word. IM/FM and all other specialties paved the way for EM. I don't see why they couldn't do a fellowship and staff an ED. Now it may be tough to get a job in the near future, but still I think they'd be fine. Maybe we could all learn from each other.
D
deleted6669
Most NPs who work in the ED are family nurse practitioners, not ENPs.
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220 000 is the answer.
The reason Fm docotrs in the middle of the biggest FM shortage in the whole wide world choose to work in a different specialty is because for many the balance between pay / responsibility is so bad that they would rather choose EM.
If FM paid 350k than there would've been no shortage of FM physicians and no FM working in the ED...
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We should be paying FM 350k. We should pay docs more to keep people healthy than we pay them to fix things that go wrong. Well in my opinion anyway.
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FM guys in my neck of the woods (SE) are pulling 400K with a busy practice.
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Yep. I'm in the SE. 300k is easy. 400k is doable but does take some hard work.
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How about getting rid of midlevels who are the real people taking your jobs? Don't understand why people worry about the tiny little issues rather than the overwhelming big issues.
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Because we cant. They are cheaper and therefore will stay.
Almost half of the hospitals in the US don't have intensivists in their ICUs...
Intensivists in U.S. Acute Care Hospitals - PubMed
Analyzing the intensivist section of the American Hospital Association Annual Survey database is a novel approach to estimating the numbers of privileged and full-time equivalent intensivists in acute care hospitals with ICU beds in the United States. This methodology opens the door to an...
pubmed.ncbi.nlm.nih.gov
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Problem is NPs are invading the ICUs and working as “hospitalists” also.
I think ICU is only a few years behind the EM deathspiral.
I think ICU is only a few years behind the EM deathspiral.
The difference between the ICU and EM is disposition. The ED always has a disposition, admit vs discharge. The ICU actually has to get the patient well enough to go to the floor*. I can't remember the last time I've seen an NP actually do an SBT/SAT without explicit instructions to do so. Once the vent days and ICU LOS goes through the roof, we'll be back to getting more intensivists.
*This is a reflection of the different expectations of the job, not a flex on EM. Most patients aren't going to be better for a change in dispo after 3-4 hours.
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Just have intensivists on during the day, NP coverage at night with intensivist backup? Wouldnt be surprised to see this happen across the country.
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That's the model where I live. Patients are essentially abandoned to substandard care after 5pm all across our city. Need a procedure or intervention done? Beg the ER doc to do it or have the ICU attending do in the morning. Truly shameful.
That's why tele-ICU is booming. All big health systems like Emory, Cleveland clinic, Advocate Aurora have tele-ICU intensivists covering 2-3 hospitals with NPs running the show. Just like ACT anesthesia model.
The community hospital of one of these big hospitals where I work is not even staffed by APP after 5pm. It's run by ICU nurses and tele-ICU (which at times is also a NP).
If these health systems want to save money but cutting MD cost and hiring more NPs under one tele-ICU MD I think they will do it.
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Someone has said this before, but I think a better path forward than what OP is saying is allowing docs to be more interchangeable like midlevels already are. For example, EM/IM/FM can get double-boarded in any of the 3 by doing 3 years of a full, core residency plus 1 year in the other.
Look, the market is being flooded by midlevels regardless. I’d rather have larger physician numbers vying for spots together. Pay is going down whether we like it or not, but I think the floor is higher with the model above.
Look, the market is being flooded by midlevels regardless. I’d rather have larger physician numbers vying for spots together. Pay is going down whether we like it or not, but I think the floor is higher with the model above.
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I respect the training of my EM colleagues and understand the desire to exclude FM/IM trained docs out of the ED. However, it works both ways, and my impression is that this is helping to solidify a reciprocal feeling amongst FM/IM physicians that EM docs need to stay out of hospitalist and outpatient work.
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It is disheartening, I'll admit, to see the contrast in boards here. In the FM board they couldn't be more accommodating and helpful to EM people looking to change into outpatient or to get out of the ED. Over here, we have a thread dedicated to why they should get out of "our" specialty.
I don't honestly see any reason an IM/FM trained doc would not make a great EM physician with maybe a 2 year fellowship in a busy ED. I don't think 1 year would cut it but I don't have any evidence to support this, just anecdotal experience. Neither do I think an EM trained person could enter the outpatient world and just know how to do it well because we see sick patients. I think it'd take probably 2 years to do that well also.
I would be all for these fellowships to exist, and welcome FM/IM into the ED. The question is why would any of them want to spend the time doing that, with the projections and saturation we're looking at?
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You did. Some of the PA's I work with at a local site have complained that they call tele-ICU and get an NP who seems to know less than they do. If you dig into some of the tele-ICU notes written overnight (b/c they have to document too apparently) you'll see they're mostly templates of ICU checklist stuff or recitation of practice guidelines for the patient's admitting diagnosis without any real thought put into what's going on (i.e. is that admitting diagnosis even correct?).Did I read that correctly? Tele-ICU which is ALSO an NP?
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I work at multiple rural hospitals, and I'm usually the only BCEM physician. The vast majority are FM docs. Some decent, some scary. Since ACEP is in bed with CMGs, they can just lobby them to hire only BCEM physicians as the market becomes more saturated. That alone will eliminate a good chunk of future unemployment issues. The problem becomes, how many EM docs are willing to travel and staff these hospitals? If you don't do it, someone else will, probably cheaper.
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You worry about a few IM and FM docs while NPs gonna take your job. This will be controversial, but you get what you deserve
These are not mutually exclusive. NPs need to leave our specialty too.
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Yeah, but you've wasted your efforts against the wrong enemy
The fact is EM is a specialty that you guys need to bail from. It will be ran over by NP because the patients go to the next line of defense, hospitalists. It will take a long time until it becomes obvious admissions are inappropriate and hospitals are wasting money. You'll be old by then
