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Inspired by personal growth thread and a conversation last night with doc who posed an interesting question "Given today's [practice environment], do you think anyone is going to be able to do 20-30 years of this job?"
My thought was there are going to be people that stick it out that long but it will be rare. But it also got me thinking of what the job was when I came out vs. what the job is currently. And man, things were different back then. In no particular order:
1) Pay: whelp... adjusted for inflation I was making $468k as an IC my first year out working 14 10s/month. I'm making about 25% less now but as an employee working 15-16 9s currently.
2) Pathology: really tough to compare due to different practice environments. Prior to moving to VA, trend seemed to be increases in the extremes- more non-sick can't get into office visits and more "most of my organs don't work" patients with fewer one off (healthy patients with appy/chole/etc) diseases. Very low risk of getting a severe infection from a patient. Post-exposure HIV prophylaxis was a thing, TB was rare in my practice environment, and even though my first winter was H1N1's inaugural visit I don't remember any HCW getting severely ill. Since then we've dealt with COVID/monkeypox/Ebola although only COVID seems to have made a significant change in routine PPE use.
3)Nursing: night and day. NPs were a thing but online NP schools weren't. CRNAs weren't nearly as prevalent either. My large hospital (600+ beds) had 3 non-clinical admin spots for EM nurses (director, manager, education/quality). Bedside nursing was a mostly a terminal position and the majority of the nurses in the ED had 7-8 years of time in the ED and a decade+ of bedside nursing experience. The efficacy of the worst nurse I worked with starting out is roughly on par with what I expect from the average nurse today.
4)Diagnostics: pretty similar. Back in the day we scanned everything and we still do. Could get MRIs for emergent conditions, still can. Roughly similar environments in terms of POC tests. Didn't have quick turn around multi bug respiratory and GI panels but also rarely needed them. Spent a lot of time worrying about CVP and ScVO2...
5)Location of care: Sea change from 2008. I'm not sure I ever set foot in the waiting room during my first year on the job. Director was still fighting to have every patient undressed and in a gown when they were roomed. Occassionally would move a stable admitted patient temporarily to a hallway spot in the ED if we had a code and all of our beds were full. Physician in triage wouldn't start for another 3 years and when it did it was 6 triage rooms with 3 RNs, 2 techs, an MD, a MLP, and 2 experienced scribes.
Now- physician in triage usually just means a doc or MLP, we usually don't have staff to run the tests ordered at triage, and the pace of check-ins during the majority of the day means there's no time for a physical exam thorough enough to significantly change initial management. A growing percentage of "vertical 3s" never see the main ED (probably a net good) and a growing percentage of ESI 2s get admitted from the waiting room without ever receiving treatment except maybe O2 (a definite regression).
6) Charting- paper T's with a scribe. Had to write holding orders for all admissions. Would still take that trade every day of the week. Orders were still written and entered by a unit clerk.
7) Expected pace- working for a Team site, group was pegged to roughly 1.7 pph. Complete butt whuppings where the world was crashing down around you would edge towards 3 pph. Docs that fell under 1.2 pph got talked to but nobody was let go for being "slow". My last year with Team expectation was 2.2 pph, last year with APP our group average was 2.3 solo and mid 3s with MLP. A bad Monday would be 4-4.5 pph solo with a similar acuity as first job.
8) Other docs-definitely trending for the better. I was one of only 2 EM trained docs 6 months into my first job, now even at the VA the majority are EM trained. The head-shaking "How the F did they miss that" cases are much less common. It's been years since I've been in a shouting match with an admitting doc or consultant and almost a decade since being told I'm just a glorified triage nurse. Most consultants seem to have a working understanding of EMTALA.
My thought was there are going to be people that stick it out that long but it will be rare. But it also got me thinking of what the job was when I came out vs. what the job is currently. And man, things were different back then. In no particular order:
1) Pay: whelp... adjusted for inflation I was making $468k as an IC my first year out working 14 10s/month. I'm making about 25% less now but as an employee working 15-16 9s currently.
2) Pathology: really tough to compare due to different practice environments. Prior to moving to VA, trend seemed to be increases in the extremes- more non-sick can't get into office visits and more "most of my organs don't work" patients with fewer one off (healthy patients with appy/chole/etc) diseases. Very low risk of getting a severe infection from a patient. Post-exposure HIV prophylaxis was a thing, TB was rare in my practice environment, and even though my first winter was H1N1's inaugural visit I don't remember any HCW getting severely ill. Since then we've dealt with COVID/monkeypox/Ebola although only COVID seems to have made a significant change in routine PPE use.
3)Nursing: night and day. NPs were a thing but online NP schools weren't. CRNAs weren't nearly as prevalent either. My large hospital (600+ beds) had 3 non-clinical admin spots for EM nurses (director, manager, education/quality). Bedside nursing was a mostly a terminal position and the majority of the nurses in the ED had 7-8 years of time in the ED and a decade+ of bedside nursing experience. The efficacy of the worst nurse I worked with starting out is roughly on par with what I expect from the average nurse today.
4)Diagnostics: pretty similar. Back in the day we scanned everything and we still do. Could get MRIs for emergent conditions, still can. Roughly similar environments in terms of POC tests. Didn't have quick turn around multi bug respiratory and GI panels but also rarely needed them. Spent a lot of time worrying about CVP and ScVO2...
5)Location of care: Sea change from 2008. I'm not sure I ever set foot in the waiting room during my first year on the job. Director was still fighting to have every patient undressed and in a gown when they were roomed. Occassionally would move a stable admitted patient temporarily to a hallway spot in the ED if we had a code and all of our beds were full. Physician in triage wouldn't start for another 3 years and when it did it was 6 triage rooms with 3 RNs, 2 techs, an MD, a MLP, and 2 experienced scribes.
Now- physician in triage usually just means a doc or MLP, we usually don't have staff to run the tests ordered at triage, and the pace of check-ins during the majority of the day means there's no time for a physical exam thorough enough to significantly change initial management. A growing percentage of "vertical 3s" never see the main ED (probably a net good) and a growing percentage of ESI 2s get admitted from the waiting room without ever receiving treatment except maybe O2 (a definite regression).
6) Charting- paper T's with a scribe. Had to write holding orders for all admissions. Would still take that trade every day of the week. Orders were still written and entered by a unit clerk.
7) Expected pace- working for a Team site, group was pegged to roughly 1.7 pph. Complete butt whuppings where the world was crashing down around you would edge towards 3 pph. Docs that fell under 1.2 pph got talked to but nobody was let go for being "slow". My last year with Team expectation was 2.2 pph, last year with APP our group average was 2.3 solo and mid 3s with MLP. A bad Monday would be 4-4.5 pph solo with a similar acuity as first job.
8) Other docs-definitely trending for the better. I was one of only 2 EM trained docs 6 months into my first job, now even at the VA the majority are EM trained. The head-shaking "How the F did they miss that" cases are much less common. It's been years since I've been in a shouting match with an admitting doc or consultant and almost a decade since being told I'm just a glorified triage nurse. Most consultants seem to have a working understanding of EMTALA.
