r EM physicians relatively underpaid?

[Painter1]

for the amount of work, including procedures done, being knowledgable in pretty much every field, and dealing with a large volume of patients--the going hourly rate of attending EM docs seems woefully low when compared to radiologists, anesthesiologists, etc.

what's the deal?

i'm not greedy, just curious.

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[EctopicFetus]

Actually some studies have been done and unfortunately i cant find the link but per hour EM docs are in the top 5-10.

 

[EctopicFetus]

now of course I wouldnt complain if we made more money!

 

[DropkickMurphy]

now of course I wouldnt complain if we made more money!

Good....now I don't have to question your sanity Fetus.....

 

[EctopicFetus]

Good....now I don't have to question your sanity Fetus.....

Bottom line for what we deal with we are probably underpaid but I think this holds true for most specialties that arent Derm, Rads etc.

I mean an IM doc or a FP doc might see 40-50 people in a day.

Obviously there are differences but we make 40-60K more than they do.

Then again the Peds docs (who I am biased towards) make like 120K or some bs when they deal with "difficult" patients all day. I mean counseling parents can take a lot of time (we do a little of this in the ED as well).

Thats my bit.. In the end I think its not that EM is underpaid as certain fields are OVERPAID.. a little more balance in salaries is in order in my opinion...

IMO No doc should make over 1 mil per yr and most shouldnt make more than 500K and none should make under 200K.. This is my fantasy and im sticking to it...

 

[EctopicFetus]

Now those of you who have been on here a while you know im a staunch supporter of free markets.. since health care is not even close to a free market my ideals are sticking..

 

[macdaddy23]

After getting spit at by another psych patient last night and reading another survey yesterday about how shift work and jet lag will lower your life expectancy yes I do believe we are underpaid. However, would I do anything else? No.

 

[NinerNiner999]

I wouldn't say we are underpaid, I think "underreimbursed" is a more appropriate word. If we actually collected 1/2 of what we billed, we would top some of the "highest paid" specialties. If our collection rates were close to say, the average surgeon who treats patients with private insurance (or even basic insurance for that matter), we would be on top. But, if ifs and buts were candy and nuts, oh what a Christmas it would be...

 

[mfleur]

I wouldn't say we are underpaid, I think "underreimbursed" is a more appropriate word. If we actually collected 1/2 of what we billed, we would top some of the "highest paid" specialties. If our collection rates were close to say, the average surgeon who treats patients with private insurance (or even basic insurance for that matter), we would be on top. But, if ifs and buts were candy and nuts, oh what a Christmas it would be...

Wait a minute...I have to bill patients? Thought we were all hourly.

 

[deleted6669]

for the amount of work, including procedures done, being knowledgable in pretty much every field, and dealing with a large volume of patients--the going hourly rate of attending EM docs seems woefully low when compared to radiologists, anesthesiologists, etc.

what's the deal?

i'm not greedy, just curious.

the em docs I work with make 145-180/hr and work 3 10 hr shifts/week. that aint too shabby....that's $259,200/yr for essentially part time work.....

 

[NinerNiner999]

Wait a minute...I have to bill patients? Thought we were all hourly.

Somebody has to bill the patients (usually your group or employer) and what they collect from everyone in your group is your group's revenue. That is where your hourly pay comes from...

 

[mfleur]

Somebody has to bill the patients (usually your group or employer) and what they collect from everyone in your group is your group's revenue. That is where your hourly pay comes from...

But does my hourly pay depend on how much they bill? I understand if I am partner in one of these groups but....

 

[deleted87716]

Hell, yes...you're underpaid. I wouldn't do your job for a million bucks a year!

Just kidding...for a mil, I'd probably do it. But no less.

 

[NinerNiner999]

But does my hourly pay depend on how much they bill? I understand if I am partner in one of these groups but....

Your hourly pay is completely dependent on the group's COLLECTIONS. You can bill 20million dollars a year, but if you only collect $100,000 of that, guess what - that is the group revenue to cover expenses and, yes, your salary. Therein lies the problem - we bill every patient we treat, but the homeless, uninsured, and those who simply refuse to pay, period, eat away at our collections...

 

[DropkickMurphy]

Hell, yes...you're underpaid. I wouldn't do your job for a million bucks a year!

Just kidding...for a mil, I'd probably do it. But no less.

Should I loan you my Rottweiler?

 

[docB]

Are EPs underpaid? Good question. The answer depends on a lot of factors. We have ralatively short residencies, we have schedule flexibility and decent time off, we have a great deal of portability and job options. On the other hand we work in high stresss, chaotic and often even dangerous situations with high liability. We are required to perform medically and procedurally at a very high level at a moment's notice in an often total vacuum of information. Those are the discussion points, no answer, just discussion.

I can tell you why rads, surg, gas, derm, optho, ENT and others make more than us. They all get to choose their patients. If you don't have insurance or case good luck seeing an ENT. These specialists take call and get stuck seeing some uninsured pts but that's just a few times a month. For EPs every single shift is worked seeing whatever payor mix your population provides. The vast majority of EPs don't have any choice in their payor mix.

 

[EctopicFetus]

I have a question to some of the more senior people
on here. EMTALA which dictates that we see the non-payors doesnt state we have to solve the problem just that we have to medically stabilize them. From a purely financial point of view why do we go as far treating these people as we do?

 

[iatrosB]

Should I loan you my Rottweiler?

 

[Apollyon]

I have a question to some of the more senior people
on here. EMTALA which dictates that we see the non-payors doesnt state we have to solve the problem just that we have to medically stabilize them. From a purely financial point of view why do we go as far treating these people as we do?

Because "stabilizing" treatment and "definitive" treatment very frequently are the same thing. And, as of yet, no self-insured crusader has sacked up enough to challenge it or see where the line is between the one and the other.

 

[EctopicFetus]

Because "stabilizing" treatment and "definitive" treatment very frequently are the same thing. And, as of yet, no self-insured crusader has sacked up enough to challenge it or see where the line is between the one and the other.

Thanks for the reply.. for example (and i know this is relatively cheap) but why should I sew some dudes lac? if he isnt bleeding isnt he stable and wouldnt it be better if i just gave him some keflex and sent him on his way?

No infection then he is ok.. he might be disfigured and not pretty but if he retains function what they hey. If he wants to look pretty come with the cash.. like the plastic surgeon!

 

[NinerNiner999]

All treatment and even "screening exams" must meet the accepted standard of care, which means those lacs need to be sewn, that tender abdomen will need labs, the "I don't know what else was in my joint" will need observation, etc... Of course, the simplest solution is the screening exam, honest counseling of risks and wait time, and the more often than not AMA form with instructions to return with worsening symptoms. Of course once the exam in done, the triage forms and physician record are completed, and the paperwork is complete, you're still looking towards at least a 20 minute visit for maybe $30...

 

[EctopicFetus]

Curious we have to provide so much free care.. little is expected of other fields.

 

[EctopicFetus]

I know it is part of the deal and im not whining im more just curious.

 

[Roadie9]

There was an interesting article in New York Times. They talked about how some hospitals would start providing free primary care for some patients - simply because it was cheaper for the hospitals in the long run. This may be in smaller cities with just one hospital, though.

The same arguments can be made for ED care. Working up a 55 year old guy for chest pain (even though he is stable enough to go home) is a lot cheaper than days of post-CABG ICU care 2 years later because he was lost to follow-up.

 

[Jeff698]

The same arguments can be made for ED care. Working up a 55 year old guy for chest pain (even though he is stable enough to go home) is a lot cheaper than days of post-CABG ICU care 2 years later because he was lost to follow-up.

Ah, but that's not why we work him up. We work him up (and, frequently admit him) even when we suspect he is stable for out patient follow up because we can't prove nothing bad will happen in the next 30-ish days.

Across the country, EPs have a missed MI rate of around 1-2%. While that's better than any other country and, in all likelihood, impossible to improve much on, it is still unacceptable in this country.

Our legal system has forced the standard of care for the ED workup of chest pain (or chest pain equivalent...basically anything walking through the door) to not only detect acute MIs when they're occuring but pick up almost any degree of coronary artery disease.

While a PCP can get away with not going to downtown MI-ville on a 45 year old woman with 'weakness', an emergency physician in the same group practice can't. The standard is just different. Reasonable? Maybe not, but different still.

That's why we work up these patients. And, in most cases, it isn't even close to cheaper. The vast majority of patients admitted for ACS are discharged from the hospital with a non-ACS diagnosis. Often after nuclear stress testing and cath. The last time I looked, the 'true positive' rate for ACS patients admitted from the ED is about 15%. It is incredibly expensive to admit that other 85%. But, since missed MI cases account for the largest malpractice payouts in emergency medicine, there aren't many of us willing to go out on a diagnostic limb.

Unfortunately, we don't have a tool that will allow us to reliably distinguish between the 15% that have the disease and the 85% that don't.


Take care,
Jeff

 

[deleted87716]

While a PCP can get away with not going to downtown MI-ville on a 45 year old woman with 'weakness', an emergency physician in the same group practice can't. The standard is just different. Reasonable? Maybe not, but different still.

I'm not sure where you're getting that idea. A missed MI is a missed MI, whether you're in a primary care office or the ED.

If I see someone in the outpatient setting and suspect ACS, I'm under the same obligation that you are to deliver appropriate care...which in this case may be emergent transport to the nearest ED after appropriate stabilizing treatment.

Different setting, same standard of care.

 

[Roadie9]

That's why we work up these patients. And, in most cases, it isn't even close to cheaper. The vast majority of patients admitted for ACS are discharged from the hospital with a non-ACS diagnosis. Often after nuclear stress testing and cath. The last time I looked, the 'true positive' rate for ACS patients admitted from the ED is about 15%. It is incredibly expensive to admit that other 85%. But, since missed MI cases account for the largest malpractice payouts in emergency medicine, there aren't many of us willing to go out on a diagnostic limb.

Unfortunately, we don't have a tool that will allow us to reliably distinguish between the 15% that have the disease and the 85% that don't.


Take care,
Jeff

Jeff, good thoughts. I respectfulyl disagree with a few things, though.

If you've got lots of patients being discharged with a non-ACS diagnosis after a cath, you've got a trigger-happy cardiology department. I would say of the people we send to cath, maybe 1 in 10 comes back clean. Sure, some are less than 70% stenosed and don't get intervention but their chest pain is quite likely cardiac anyway. If a good clinician risk-stratifies a patients and gives him a good work-up, the negative cath is pretty rare.

And I don't think that the admit-to-rule-out-and-do-a-cardiolyte-in-the-morning is a bad thing. Sure, it's 2000 bucks out the window right now but then you've got your claws in a guy you can talk to about statins and merformin and seeing a dietician. You tell someone about these things when they have their butt hanging out from a patient gown, you've got a captive audience. That's where you might save some money in the long run. And, trust me, I have bitched and moaned about CP admits, but don't forget they come in because they have been told by us that "any pain can be a sign of a heart attack, especially if you are a woman".

All this will change, of course, in 5 years. Our institution just bought a 128-slice CT scanner for cardiac angiography. Oh, yeah . This will essentially mean the end of low-risk CP admits.

At some point, the resolution will be so good that people will get screened and receive a cardiac risk staging (30% narrowing can be stable as hell or just about to pop; something we can't tell from a cath today). This will give EPs a helping hand in telling who can go home and who stays.

Wow, talk about going off on a tangent. I just happen to like this topic.

Oh yeah, I agree with KentW. An internist or FP should do the same tests and admit by the same standards as an EP. In my experience, internists get very easily freaked out by ongoing chest pain and very often admit patients.

 

[southerndoc]

I'm not sure where you're getting that idea. A missed MI is a missed MI, whether you're in a primary care office or the ED.

If I see someone in the outpatient setting and suspect ACS, I'm under the same obligation that you are to deliver appropriate care...which in this case may be emergent transport to the nearest ED after appropriate stabilizing treatment.

Different setting, same standard of care.

I think I see where Jeff is trying to go with this. Basically patients that present to the ED are held to a higher standard because all available resources are usually at the hospital, plus it can be argued that the patient felt it was serious enough and just by presenting to the ED they are more likely to have worse pathology and outcomes.

At least I think that's where he's headed with this.

Kent is right though. A missed MI is a missed MI in terms of patient care and outcome, but in terms of legal defense, a missed MI in the ED is a little different than a missed MI in an outpatient setting.

 

[kungfufishing]

second the self selected higher risk population point

 

[deleted87716]

Kent is right though. A missed MI is a missed MI in terms of patient care and outcome, but in terms of legal defense, a missed MI in the ED is a little different than a missed MI in an outpatient setting.

The expectation as to what we're supposed to do with a patient when we suspect ACS is different by virtue of our practice settings. However, we're still under the same obligation to make the diagnosis or refer the patient to somebody else who can make the diagnosis in a timely fashion, and to manage the case appropriately while it's still in our hands. For example, we're responsible for rendering appropriate prehospital care, e.g., EKG, O2, ASA, NTG, CPR and early defibrillation (ideally) in the event of arrest, etc. and arranging transport via EMS. Simply telling a chest pain patient, "It could be your heart...drive yourself to the hospital immediately" is wrong as wrong can be. Sure, we may have made the diagnosis, but there's plenty of room to screw up after that.

 

[Seaglass]

The expectation as to what we're supposed to do with a patient when we suspect ACS is different by virtue of our practice settings. However, we're still under the same obligation to make the diagnosis or refer the patient to somebody else who can make the diagnosis in a timely fashion, and to manage the case appropriately while it's still in our hands. For example, we're responsible for rendering appropriate prehospital care, e.g., EKG, O2, ASA, NTG, CPR and early defibrillation (ideally) in the event of arrest, etc. and arranging transport via EMS. Simply telling a chest pain patient, "It could be your heart...drive yourself to the hospital immediately" is wrong as wrong can be. Sure, we may have made the diagnosis, but there's plenty of room to screw up after that.

I don't think that we are saying that PCPs neglect CP, I think that we are saying that if Patient X comes to your office with low risk CP you are OK with doing nothing. If they come to us we have to rule them out. If that patient leaves your office or our ED and has an MI your colleagues would say that you did the right thing, the cardiologists would say we are negligent.

 

[Roadie9]

I don't think that we are saying that PCPs neglect CP, I think that we are saying that if Patient X comes to your office with low risk CP you are OK with doing nothing. If they come to us we have to rule them out. If that patient leaves your office or our ED and has an MI your colleagues would say that you did the right thing, the cardiologists would say we are negligent.

Seaglass, I see your point but a PCP already knows the patient and can probably tell if the CP is real before he enters the exam room. Plus a PCP can tell a patient to call him back later that day or tomorrow and tell him how he's doing. As such, what seems like doing nothing to you is, in fact, active follow-up.

The relationship between a PCP and a patient is vastly different from the busy ER environment.

And when we talk about PCPs, everyone is not created equal. A good internist, who works out- and inpatient should be able to eyeball most CP patients and send them in the right direction. They should be expected to follow the same standard of care as EPs. But don't forget that some women see OB/GYNs for their primary care and some FPs do OB, kids, gyne AND IM. Some PCPs are GPs (ie. just an intern year). Such providers should probably send a CP patient to the ER, actually.

 

[deleted87716]

The relationship between a PCP and a patient is vastly different from the busy ER environment.

True enough. However, "doing nothing" is not an option for me any more than it is for you. Even if I feel that a patient's chest pain is non-cardiac, I'm still obligated to make and treat an alternative diagnosis and/or objectively rule out underlying cardiac pathology if necessary (e.g., with an outpatient EKG, CXR, labs, stress test, etc.) The differential diagnosis of chest pain is as broad for me as it is for you, and I'm still obligated to work it up, even if it ends up being a diagnosis of exclusion. Depending on the patient's presentation and/or risk factors, an outpatient evaluation may or may not be appropriate...that's also something I have to determine.

This is bread-and-butter primary care, by the way...it's a rare day that I don't see a patient who complains of some sort of chest pain. I suspect I'm not alone.

Edit: The discussion really seems to be about defensive medicine, e.g., suggesting that any chest pain in the ED gets the full-court press ACS workup. In reality, that probably happens in the ED more than it does in my office (due to the aforementioned risk level of the average patient), but most of us know where to draw the line. However, we're all going to err on the side of caution in iffy cases...which is why I've occasionally ordered outpatient cardiac evaluations on relatively young patients presenting with what appeared to be straightforward reflux or musculoskeletal chest pain. Every once in a while, weird pathology turns up, and I don't want to be the one who misses it.

 

[edinOH]

Seaglass, I see your point but a PCP already knows the patient and can probably tell if the CP is real before he enters the exam room.

A good internist, who works out- and inpatient should be able to eyeball most CP patients and send them in the right direction.

If it were only that simple...

 

[jmart]

I wouldn't say we are underpaid, I think "underreimbursed" is a more appropriate word. If we actually collected 1/2 of what we billed, we would top some of the "highest paid" specialties. If our collection rates were close to say, the average surgeon who treats patients with private insurance (or even basic insurance for that matter), we would be on top. But, if ifs and buts were candy and nuts, oh what a Christmas it would be...

I'd have to agree. I actually work in the billing department for an ED. NOt only do people not have the money to pay but lack of documentation is also a problem. Sometimes doctors forget to hit submit after documentating or they lose the dictation number. Without the proper documentation/dictation, certain procedures can not be billed.

 

[deleted87716]

I'd have to agree. I actually work in the billing department for an ED. NOt only do people not have the money to pay but lack of documentation is also a problem. Sometimes doctors forget to hit submit after documentating or they lose the dictation number. Without the proper documentation/dictation, certain procedures can not be billed.

What's the average collection percentage for EM, anyway? Just curious. NinerNiner999 mentioned general surgeons...if a surgeon takes ER call (practically all of them do) or - even worse - trauma call, they're taking care of the same uninsured/deadbeat patients as the ER. Most general surgeons are lucky to collect 50% of their charges.

 

[Apollyon]

What's the average collection percentage for EM, anyway? Just curious. NinerNiner999 mentioned general surgeons...if a surgeon takes ER call (practically all of them do) or - even worse - trauma call, they're taking care of the same uninsured/deadbeat patients as the ER. Most general surgeons are lucky to collect 50% of their charges.

I thought it was somewhere between 25 and 30%, across general surgeons, ENT's, and orthopods (I saw it somewhere on SDN). 50% would be glorious.

 

[EctopicFetus]

What's the average collection percentage for EM, anyway? Just curious. NinerNiner999 mentioned general surgeons...if a surgeon takes ER call (practically all of them do) or - even worse - trauma call, they're taking care of the same uninsured/deadbeat patients as the ER. Most general surgeons are lucky to collect 50% of their charges.

I think this depends on state. In chicago the trauma service was one of the biggest money makers. Illinois has some law that basically says any trauma caused by an assualt covers their healthcare costs if they are uninsured.