Too many EM residency spots?

Haemr Head said:

As someone who routinely helps people find jobs, this last cycle of recruitment seemed to offer far less choice than in the past. I once thought that there would be a strong demand for EM specialists into the foreseeable future, one that would exceed anything that our residencies could produce, even with the 3-4% growth in positions that we've seen over the past 20 years. The growing trend of many graduates to take part time positions, the growth of EM volume and acuity, and hospitals and EM groups prioritizing residency training for new hires, are all stolid reasons to assume great job security. However, I am concerned that we are beginning to feel the pressure created by the adoption of PAs into EM practice. For example, in one of our local hospitals, over 2/3rds of the EM patients are seen only by a PA. The groups that use them are very happy with the care delivered by the PA model which also offers substantial time/income benefits.

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What is the name of that hospital? What is their acuity mix? I've never worked at, or heard of a shop that had a >1:1 mix of midlevels to EPs. Is it a PA residency program, and has PAs being taught by an EP acting almost exclusively as a supervisor? Otherwise, I'm really tempted to call shenanigans.

Good jobs in EM are going to be difficult to find in certain markets (everyone wants to live on the West Coast, Colorado, or NYC). I live in a city that has >600k people, and ~4 residency trained EPs. As the field expands, marginal physicians are going to have more difficulty finding and maintaining high paying jobs in places that are "desirable". I'm actually ok with this.

If this does happen, wouldn't it be somewhat offset by the increase in patients due to healthcare reform? (Which I guess that in itself has yet to be seen, so it may not even turn out that way.)

All the same, from the perspective of a student there seems to be VERY few specialties (mainly surgical) that are insulated from the increase of NP's/PA's. So, given that it's likely to happen, what do people think the answer and/or outcome will be? What about the rapid increase in med school enrollment? If physician's jobs are already decreasing then what is going to happen when the increased wave of med students hits the market along with an increase in midlevels? Unless this is just the outcome of people in power caring only about money and not about the profession/students, it doesn't make a lot of sense.

Haemr Head said:

...However, I am concerned that we are beginning to feel the pressure created by the adoption of PAs into EM practice. For example, in one of our local hospitals, over 2/3rds of the EM patients are seen only by a PA. The groups that use them are very happy with the care delivered by the PA model which also offers substantial time/income benefits...

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Interesting post. To some extent, isn't this utilization of PAs what we want? Using the PAs to siphon off the lower acuity and pseudo primary care cares, freeing up the EPs to see the truly sick?

Haemr Head said:

Access to EM residency spots is certainly easier than in years past. Certainly a good thing if you want to train in the specialty but not so good if you want to be sure to land a great job with high income afterwards...

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Path is going through this crisis right now. They changed their residency structure (5 yrs -> 4 yrs) increasing the number of graduates produced/year, as well as increasing their total number of spots. The result was that nearly all residents must go on to do 1-3 fellowships before they can land a job, if they can land a job.

TeamZissou said:

If this does happen, wouldn't it be somewhat offset by the increase in patients due to healthcare reform? (Which I guess that in itself has yet to be seen, so it may not even turn out that way.)

All the same, from the perspective of a student there seems to be VERY few specialties (mainly surgical) that are insulated from the increase of NP's/PA's. So, given that it's likely to happen, what do people think the answer and/or outcome will be? What about the rapid increase in med school enrollment? If physician's jobs are already decreasing then what is going to happen when the increased wave of med students hits the market along with an increase in midlevels? Unless this is just the outcome of people in power caring only about money and not about the profession/students, it doesn't make a lot of sense.

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Healthcare reform in MA increased ED visits some 11%. We should see a similar increase across the US as the components of the recent healthcare reforms are enacted.

The surgical fields are not insulated from PAs and NPs - they are used widely in PP. Often patients will only see their surgeon's PA/NP post-op. In the OR, PAs are frequently part of the surgical team.

The increase in med student enrollment, while true, will not affect students and residencies like you think. Because there has not been an attendant increase in US residency positions, the increase in students will simply push out the IMG/FMG residency applicants. It will also make all residencies more competitive for US students, as the top 10% of a given class will be a larger absolute number. Yes, some stellar FMGs will be chosen over a poor US students (and rightly so), but this case will be the minority. The general trend will be to make US residencies for US med students, and the overall number of residents trained per year hasn't changed.

One of the smaller ED's I moonlight at is staffed ONLY by PA's. No physicians present. It's good, and terrifying sometimes too. But the model works there because the volume is so low. It's critical access hospital though, so they can't just close the doors.

Here's a GREAT paper about EM, physicians, PA's, NP's, and workforce data....

Data is always good...

http://www.luxxium.org/wp_luxxium/wp-content/uploads/2008/03/2008_interprofessional.pdf

Being an intern I'm not intimately familiar with what was available this year. However, all of my program's graduating seniors seem happy with where they've landed jobs and some are going to very competitive job markets.

physasst said:

One of the smaller ED's I moonlight at is staffed ONLY by PA's. No physicians present. It's good, and terrifying sometimes too. But the model works there because the volume is so low.

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I'm all for PA's working in the ED, but this seems dangerous to me. Not sure why you think this is good. It doesn't matter how low the volume is if there's one patient that you have not been trained to handle.

old_boy said:

I'm all for PA's working in the ED, but this seems dangerous to me. Not sure why you think this is good. It doesn't matter how low the volume is if there's one patient that you have not been trained to handle.

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What makes you think we can't stabilize someone? I was a corpsman in the Navy, and with far less training than as a PA I was chiefly responsible with stabilizing and treating military personnel in the field.

I'm not dismissing your concern, I understand it, but I also would argue that there is no evidence that a well trained, and experienced PA (BTW, they won't hire anyone with less than 5 years experience) cannot initially evaluate, stabilize and initiate treatment on ANY patient. If they're sick they don't stay at the small hospital, irregardless of provider. They get stabilized and transferred.

Would you rather have an experienced EM PA who knows his way around a trauma, and or managing a code, or an FP physician who probably hasn't intubated someone in 15 or so years? Most of the ED attendings I work with at my main gig, have stated that they would MUCH rather have an experienced EM PA.

I've heard this "an EXPERIENCED PA....beats a... whatever" argument more than a few times.

Everyone needs to remember this: experience is not a function of degree. Experience is experience. You can re-write the above sentence to read "an EXPERIENCED EM physician", and the statement holds true. You're always going to want an experienced individual making the calls over an inexperienced individual.

The dove-tail argument here is that being an MD and completing an EM residency gives you more experience by definition as a sheer function of hours spent in training. Period.

My two-cents is as follows: Is there a lot of completely irrelevant nonsense taught in medical school? You bet. Nobody cares about things like JAK-STAT pathways and naming the cofactors in the oxidative phosphorylation. Can medical school be streamlined to create better physicians in less time? Sure; I'm doing my 'academic project' on how a lot of med-school material is just useless and shouldn't be taught. However, I've also taught a number of PA-school lectures, and there's no comparison. MDs know more because they learn more material; MDs have a broader and deeper understanding of pathophysiology. Period. Graduate an MD and a PA at the same time; and you're going to have two individuals with an equal number of years of experience as they both go on. One is always going to know more.

RustedFox said:

I've heard this "an EXPERIENCED PA....beats a... whatever" argument more than a few times.

Everyone needs to remember this: experience is not a function of degree. Experience is experience. You can re-write the above sentence to read "an EXPERIENCED EM physician", and the statement holds true. You're always going to want an experienced individual making the calls over an inexperienced individual.

The dove-tail argument here is that being an MD and completing an EM residency gives you more experience by definition as a sheer function of hours spent in training. Period.

My two-cents is as follows: Is there a lot of completely irrelevant nonsense taught in medical school? You bet. Nobody cares about things like JAK-STAT pathways and naming the cofactors in the oxidative phosphorylation. Can medical school be streamlined to create better physicians in less time? Sure; I'm doing my 'academic project' on how a lot of med-school material is just useless and shouldn't be taught. However, I've also taught a number of PA-school lectures, and there's no comparison. MDs know more because they learn more material; MDs have a broader and deeper understanding of pathophysiology. Period. Graduate an MD and a PA at the same time; and you're going to have two individuals with an equal number of years of experience as they both go on. One is always going to know more.

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I never claimed that an experienced EM PA was equivalent to an experienced EM MD. I was merely stating that if there is a choice between an EM PA who has worked in EM for years, and managed difficult airways, started central lines, done US, etc.etc.etc.etc., would you rather have an FP doc who hasn't done any of that, or the PA?

See my article above about EM physician supply, demand, and projections. I would also posit that their projections are likely inaccurate in lieu of the recent legislation, and the subsequent (probable) increase in demand.

physasst said:

I never claimed that an experienced EM PA was equivalent to an experienced EM MD. I was merely stating that if there is a choice between an EM PA who has worked in EM for years, and managed difficult airways, started central lines, done US, etc.etc.etc.etc., would you rather have an FP doc who hasn't done any of that, or the PA?

See my article above about EM physician supply, demand, and projections. I would also posit that their projections are likely inaccurate in lieu of the recent legislation, and the subsequent (probable) increase in demand.

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I would posit that the over-aggressive expansion of para-medical specialty will more than offset any perceived increase in job opportunities for established ER docs.

Mid-levels were created to help fill the gap in PRIMARY CARE not muscle into the realm of the specialists and, by extension, limit job opportunity and income for real doctors.

I know of at least two ER docs who WANTED to go to a rural area recently (their hometown) and they were turned down by the hospital because the hospital was very happy, thank you very much, that they were now 100% PA staffed in the ED at a significant cost savings. I guess that's more important than safety of patients.

physasst said:

What makes you think we can't stabilize someone? I was a corpsman in the Navy, and with far less training than as a PA I was chiefly responsible with stabilizing and treating military personnel in the field.

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You know, it's not about "stabilizing" someone. It is, after all, almost algorithmic. The hard part is recognizing the occult case - the person who is about to decline that you need to intervene on now. Or the person that is likely to deteriorate during transfer.

This is what I find is the biggest deficit in mid-levels - many of them are adequate for the obvious patient who needs treatment or intervention, but the mid-levels consistently fail to anticipate deterioration or consider wide differentials. They have trouble separating the truly remarkable and meaningful lab results from the routine normal values. Prioritization is often poor.

90% of the time? The mid-level does exactly what needs to be done. But 10% of the time, it's a miss on the subtleties, and this is why it's dangerous to cut corners at hospital admin levels.

The worst part is? The "10%" that is mis- or under-managed by the mid-level is never elucidated to have been as such by the treating mid-level. The "unknown" unknowns. The worst kind.

And don't sell me the happy bull s h it about PAs only replacing FPs in rural centers because it ain't true. Even in academic centers PAs and NPs are TAKING JOBS (to say nothing of CRNAs).

I, personally, oppose now all mid level involvement in my work environment, and have terminated training slots for mid levels.

If ACEP didn't have their damn head buried in the sand looking for their backbone, they would have stood up to this a long time ago, but like all things in medicine, ACEP is toothless.

bulgethetwine said:

I guess that's more important than safety of patients.

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you of course have proof of this correct? You have studies showing a higher rate of adverse outcomes in ED's staffed with PA's? You have evidence of an increased rate of malpractice among PA's staffing rural ED's, right? Surely the AMA has reams of data showing that PA practice is unsafe, correct? You have evidence of these things right?

Fact is none of that exists. So your argument is a non sequiter......got it.

RustedFox said:

...My two-cents is as follows: Is there a lot of completely irrelevant nonsense taught in medical school? You bet. Nobody cares about things like JAK-STAT pathways and naming the cofactors in the oxidative phosphorylation. Can medical school be streamlined to create better physicians in less time? Sure; I'm doing my 'academic project' on how a lot of med-school material is just useless and shouldn't be taught...

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I disagree with the bolded section. I rediscovered the utility of knowing those cofactors in a project I'm working on as a marker of disease. A couple of fellows in my program tested drugs that take advantage of JAK-STAT pathways in SCC. We should not downplay the general preparation and wide information base the MD provides, just because every doc doesn't use 100% of it. You will not know when one of those random facts becomes relevant.

physasst said:

you of course have proof of this correct? You have studies showing a higher rate of adverse outcomes in ED's staffed with PA's? You have evidence of an increased rate of malpractice among PA's staffing rural ED's, right? Surely the AMA has reams of data showing that PA practice is unsafe, correct? You have evidence of these things right?

Fact is none of that exists. So your argument is a non sequiter......got it.

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Give me a break, you twit.

I can't provide proof to you that 12 year old drivers don't cause more car accidents, either.

Some things are self-evident. If you can't see that, I would say that is more proof positive that you have no business playing doctor.

FWIW, the reason why the study you want won't ever be done is because it's already been proven that ERs staffed by EM-boarded docs have less malpractice (and better speeds, reimbursement, etc.) than those staffed with non-EM boarded docs.

So I'm pretty sure that EM-boarded docs would kick the hE11 out of your nurse-staffed ED.

Why don't you quit trying to play doctor, quit diminishing board certification status (to say nothing of diminishing the value of residency training) and either re-join the RN workforce or just suck it up and go to medical school?

bulgethetwine said:

Give me a break, you twit.

I can't provide proof to you that 12 year old drivers don't cause more car accidents, either.

Some things are self-evident. If you can't see that, I would say that is more proof positive that you have no business playing doctor.

FWIW, the reason why the study you want won't ever be done is because it's already been proven that ERs staffed by EM-boarded docs have less malpractice (and better speeds, reimbursement, etc.) than those staffed with non-EM boarded docs.

So I'm pretty sure that EM-boarded docs would kick the hE11 out of your nurse-staffed ED.

Why don't you quit trying to play doctor, quit diminishing board certification status (to say nothing of diminishing the value of residency training) and either re-join the RN workforce or just suck it up and go to medical school?

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Oh, and here I thought we'd be lifelong friends...

Psst. PA's aren't nurses. Never have been one. Where did I diminish board certification status or residency training? I'm not an EM physician, and have never claimed to be....I would only ask that you quit diminishing the status of professionals trained to function in a team providing medical care.

I work in a tertiary care facility (Level 1 trauma center) too. I would agree that staffing EVERY ED with board certified EM physicians would be ideal...but guess what. We couldn't do that even if we wanted to. So quit playing the martyr.

PA's can provide most of the services of a physician, but that doesn't mean they are physicians.....

physasst said:

PA's can provide most of the services of a physician, but that doesn't mean they are physicians.....

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Apparently that hasn't stopped you all from pushing to be more and more like physicians though.

Independent practice?
Ability to write prescriptions?
Taking jobs from *real* doctors?

Yes to all. So pardon me if I will do everything to negate the role of the mid-level outside of primary care.

Now if you will excuse me, I have to go steal the car keys back from my 12 year old.

bulgethetwine said:

Apparently that hasn't stopped you all from pushing to be more and more like physicians though.

Independent practice?
Ability to write prescriptions?
Taking jobs from *real* doctors?

Yes to all. So pardon me if I will do everything to negate the role of the mid-level outside of primary care.

Now if you will excuse me, I have to go steal the car keys back from my 12 year old.

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WHOA...independent practice????? There is not a PA in this country, or a state where PA's can practice independently. We can practice autonomously, but that is not the same. Your lack of education about us is showing. NP's have independent practice in 12 states (maybe 13 soon..) but PA's do not. We are dependent providers. This is only one of several differences between PA's and NP's.

Even at the ED in question, we have FP "backup", variable of course. Last time I had to intubate a patient, I called the FP backup to let him know (as per protocol), and the response was..."You're not expecting me to do it, are you?"

As for the rest......seriously??? taking the jobs of "real" doctors? You do know that we are facing a 159,000 physician shortage by 2025, right? (per the AAMC) and that this not just in primary care...What praytell is your solution?

(again, read the article I cited and linked to above)

RxnMan said:

I disagree with the bolded section. I rediscovered the utility of knowing those cofactors in a project I'm working on as a marker of disease. A couple of fellows in my program tested drugs that take advantage of JAK-STAT pathways in SCC. We should not downplay the general preparation and wide information base the MD provides, just because every doc doesn't use 100% of it. You will not know when one of those random facts becomes relevant.

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I welcome your criticism, as its good for my project.

Counterargument: While your projects are important (and sound very cool) you're doing academic research; not clinical medicine. Until it becomes clinically applicable medicine; it could be left out of medical school and save we clinicians a lot of suffering and time. The vast majority of MDs out there never do what you're doing, and as a result don't care and don't need to care. I propose keeping "medical school" for clinicians, and streamlining the process to get more docs out there, faster, with better clinical acumen. That's what the nation needs right now.

Your research sounds cool; but its PhD work; not MD work. If we cut out the PhD work; you can spend more time learning clinical medicine and coming out of school more competent. If the knowledge is very specialty-specific (say, the SCC that you mention); then it can and should be learned in that specific residency/fellowship. Your average say, Anesthesiologist is never going to use that data; so why torture him/her by making him learn it?

This all stemmed from the following phenomenon, which I know wasn't unique to me. During my intern year, I found myself able to recite all sorts of USELESS knowledge about PKB and signaling pathways; and was mystified by the 'routine' things that went into clinical decision-making. All the nurses knew that you had to double-cover for Pseudomonas, but why didn't I? I spent a large portion of medical school forcefeeding myself clinically useless junk. Bogus. I felt like I was robbed of time. Make me a better clinician; I thought that's what you learned in medical school.

More comments/criticism welcome.

RustedFox said:

This all stemmed from the following phenomenon, which I know wasn't unique to me. During my intern year, I found myself able to recite all sorts of USELESS knowledge about PKB and signaling pathways; and was mystified by the 'routine' things that went into clinical decision-making. All the nurses knew that you had to double-cover for Pseudomonas, but why didn't I? I spent a large portion of medical school forcefeeding myself clinically useless junk. Bogus. I felt like I was robbed of time. Make me a better clinician; I thought that's what you learned in medical school.

More comments/criticism welcome.

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Heh, how else would we know who deserves to be the neuro surgeons? From my perspective it seems those in power will never get rid of a way to stratify individuals, unless you provide an alternative.

physasst said:

You do know that we are facing a 159,000 physician shortage by 2025, right? (per the AAMC) and that this not just in primary care...What praytell is your solution?

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Um.... how about you train more DOCTORS and stop cutting corners by replacing them with cheaper (and less skilled) mid-level providers?

Put the mid-levels in primary care and stop bemoaning that docs don't go into primary care.

I wouldn't go into primary care, either, what with nurses (CRNAs, whatever) making more than primary care doctors.

emedpa said:

no pa in the country has "independent practice" and no one is asking for this.
pa's have been writing rxs for decades. that isn't a new development.
pa's are only taking jobs docs don't want in places they wouldn't work for money they wouldn't work for. you want to work full time rural em for 90k/yr or primary care for 70k/yr as a doc? be my guest.
everything pa's have was granted to us by physicians. we are licensed and practice under boards of medicine. no pa has ever worked anywhere doing anything without md approval.

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1) PAs, NPs, same difference. Still mid-levels taking doctor jobs when they're not working in primary care.

2) Independent practice. More autonomy. Potayto, potato.

3) No, I want physicians to have the opportunity to work in a full time rural position and not be low-balled by 90K/yr offers due to the downward pressure of salaries thanks to you lot, a group of para-medical providers that might command only 90K, but then again, you get what you pay for.

4) That all your powers were granted by physicians is not lost on me. The same weak physicians who have a notoriously poor public lobby. Or unscrupulous ones who supplement their own income by this means.

Just because it is, doesn't mean it should be.

bulgethetwine said:

Um.... how about you train more DOCTORS and stop cutting corners by replacing them with cheaper (and less skilled) mid-level providers?

Put the mid-levels in primary care and stop bemoaning that docs don't go into primary care.

I wouldn't go into primary care, either, what with nurses (CRNAs, whatever) making more than primary care doctors.

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We are training more physicians, 30% increase by 2018, but that won't even fix the problem cause ACGME isn't increasing residency slots. All it will do is force IMG's out of american residencies. In order to increase ACGME slots, the government needs a lot more money....SO, again, how do you address the shortages? There is simply not enough money to staff every position with a physician and control costs. Or would you like to continue to see your premiums rise by 10.2% annually (average of the last ten years)

Disclaimer- My other role, outside of being an EM PA is that of a physician/medical workforce/policy researcher/analyst, and I am currently completing my doctoral in health policy.

I'm just curious as to why you think it's only taking a job if they work outside the field of PC. Docs can fill those jobs too. Only thinking of it as an intrusion when it happens to be your field smacks of the attitude that opened this whole can of worms.

FWIW, I see PAs as much less of a threat than NPs. PAs still require a physician to actually do their jobs, whereas our nursing counterparts are pushing hard to break away from that, all the while practicing under BONs and not BOMs.

Then again, I'm very much aware of how little I know about this whole mess, so I could be completely wrong and I'm open to being pointed in the right direction.

physasst said:

We are training more physicians, 30% increase by 2018, but that won't even fix the problem cause ACGME isn't increasing residency slots.

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On this we agree wholeheartedly.

Ok, ok, time to stop blustering.

My BIG ISSUE is that I think the government is trying to fix the underlying problem with a band-aid, trying to cut corners when it comes to costs by expanding (conveniently) the scope of the mid-level. The push by the NPs (admittedly, more aggressive than the PAs) to have more autonomy (READ: Independent practice) is just opportunistic in my opinion.

If we had true supply and demand, compensation for primary care providers would increase and those who chase the paycheck would go into primary care preferentially. But this can't happen because the country is broke, and the priorities are all screwed up in that the imbalance between procedure compensation (think neurosurgery or cardiac cath jockeys) and those who provide preventative and "surveillance" medicine is unduly wide.

So, instead of admitting the system is flawed and blowing it up (which would require a complete re-think of how insurance companies work, how reimbursement gets paid -- i.e. no longer such an imbalance between rewarding procedures over preventative medicine) the government wants to replace a skilled workforce with a less-skilled (and cheaper) one.

The unintended consequence is that those skilled physicians now face diminishing options for practice in terms of location and downward pressure on salary that is not related to supply and demand... all the while, some percentage of patients are not getting the skilled healthcare that they should in a Western nation.

So the government's ineptitude and the narcissistic push by the NPs makes people like me get pissed such that even a rational person plays Devil's advocate (shrug).


Cool that you're doing health policy. That's important work, and we need smart people like you working on these problems going forward.

Physio Doc 2 Be said:

I'm just curious as to why you think it's only taking a job if they work outside the field of PC. Docs can fill those jobs too. Only thinking of it as an intrusion when it happens to be your field smacks of the attitude that opened this whole can of worms.

FWIW, I see PAs as much less of a threat than NPs. PAs still require a physician to actually do their jobs, whereas our nursing counterparts are pushing hard to break away from that, all the while practicing under BONs and not BOMs.

Then again, I'm very much aware of how little I know about this whole mess, so I could be completely wrong and I'm open to being pointed in the right direction.

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Well, it's not just my field, it's basically any specialist field. I think I would tolerate it more for primary care because their is such a shortage and that was the original thrust of the whole mid-level movement.

But I think it's even WORSE in emergency medicine because we deal with undifferentiated complaints. Even in some specialty services, I can see how a mid-level can be useful and safe for patients (for instance, those on CT surgery teams who basically collect data and report back to the docs for management changes).

But in EM, I think it's risky as hell because the real danger for ER doctors is missing occult presentations, and even with extensive experience at the physician level, it is tricky.

bulgethetwine said:

So, instead of admitting the system is flawed and blowing it up (which would require a complete re-think of how insurance companies work, how reimbursement gets paid -- i.e. no longer such an imbalance between rewarding procedures over preventative medicine) the government wants to replace a skilled workforce with a less-skilled (and cheaper) one.



Cool that you're doing health policy. That's important work, and we need smart people like you working on these problems going forward.

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This is what I think as well, I think that the current system needs to be completely dismantled. I support bundled payment systems such as prometheus, and have even written about addressing the primary care pay disparity gap.....Admittedly not popular. I would only add that PA's are not a replacement of physicians, we are an augmentation....not that same thing...

Just from a MS-IV's viewpoint, it may also be the EM has become INTENSELY popular over the past few years, looking at the scoring trends it has gone from a residency that was relatively easily to get to a competitive residency. And it's very young as far as specialties go, this may merely be a version of the eternal metaphor between a population and a food source (where there is plenty of food initially but now the population is getting to the point where it's reaching a balance?)

But i know it's not saturated, i my last rotation in nyc had head hunters calling ER docs all the time, perhaps it's just getting to a point where supply and demand doesn't so severely favor er doctors?

physasst said:

.....

As for the rest......seriously??? taking the jobs of "real" doctors? You do know that we are facing a 159,000 physician shortage by 2025, right? (per the AAMC) and that this not just in primary care...What praytell is your solution?

(again, read the article I cited and linked to above)

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OK, here's what I don't get -- why do you place such faith in these predictions? Surely you know the history of predictions on physician workforce needs... and its piss poor track record. Don't feel bad, though, for these failures are in no way unique to the realm of physician need forecasting; in fact, central economic planning has failed rather remarkably time and again across both time, economic, and governance systems. Hell, it has even managed to take down a world superpower -- and is readying a run at another.

MOHS_01 said:

OK, here's what I don't get -- why do you place such faith in these predictions? Surely you know the history of predictions on physician workforce needs... and its piss poor track record. Don't feel bad, though, for these failures are in no way unique to the realm of physician need forecasting; in fact, central economic planning has failed rather remarkably time and again across both time, economic, and governance systems. Hell, it has even managed to take down a world superpower -- and is readying a run at another.

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They aren't predictions, they are at best projections, and yes, they are far from perfect, but in the absence of other data, it's what we have. Hehe, central economic planning is not the root of all evil. (The old economist in me would love to have that debate, but perhaps in another thread...as a new keynesian at least)

physasst said:

They aren't predictions, they are at best projections, and yes, they are far from perfect, but in the absence of other data, it's what we have. Hehe, central economic planning is not the root of all evil. (The old economist in me would love to have that debate, but perhaps in another thread...as a new keynesian at least)

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Why is it not surprising to hear that you are a Keynesian.... that's the problem with intellectuals -- they overestimate their own capacity and fail miserably when they venture beyond their limited scope......... perhaps in some free time you can pick up a little book called Intellectuals and Society.

...and you are correct -- central economic planning is a symptom, not the disease; the disease is pride and the lust for power over ones fellow man. **** "projections" are still ****.

Excellent thread. I rarely post any longer as I have a busy schedule and don't often find a thread that interests me. But those who remember me will recall that I was a PA before I went to medical school. That gives me the unique perspective of being somewhat unbiased and able to objectively discuss this issue. As much as I would like to discuss it in detail, my opinion on this matter has recently changed.

I don't think midlevels should ever be on the main side of the ED, and preferably not in the ED at all, unless they are completely supervised. And when midlevels are completely supervised in the ED, any gain in revenue slowly gets eaten away by the time taken to supervise. Now don't get me wrong, it is an ideal environment if it is done correctly, but the vast majority of groups using midlevels don't care about patient care, and have no guilt in throwing their group docs into a pseudo supervision role (sign this chart at the end of the shift please!) in order to make a buck.

I work at several different ED's as an emergency physician. One is a place where I can safely say that midlevels are valuable and completely supervised, at least when I am attending. We run a program where we have 2-3 PA's all day except for 6 uncovered hours from 3AM to 9AM. The physician coverage is 12 hours on, single coverage, no overlap. As the attending we pick up all new patient charts and go in and do a quick cursory H&P (like 1 minute max!), and then we institute our plan. The PA's pick up the charts after the plan has been started and then they go and do a more detailed exam, and document the whole encounter. we just document our shoprt first initial encounter. About 95% of the time our initial impression is correct. The PA's have some of their autonomy gone in this system, but they safely see more patients and provide a valuable service, and they make a cash cow! All the PA's in this system make well over 100k, some upwards of 140k.

Another place I work has a midlevel in fast track, a midlevel on the main side, and a single coverage doc. These midlevels see lots of patients and there is not enough time to supervise them completely. Some of the midlevels are really, really awesome, but some are not. The problem is that these midlevels are admitting and discharging people that you never know existed until the board of medicine calls you 6 months later about a complaint over something the PA did. Then you get slapped with a failure to adequately supervise warning. This group could easily afford and should move to a system with more overlapping physician shifts instead of midlevels, but the group director rarely works and actually owns the contract. Of course he would prefer to have midlevels because it's cheaper for him, and easier to pass the liability on to the docs. This system is not acceptable to me and I am in the process of ceasing to work there.

My last and most recent job does not use midlevels at all. Instead we have overlapping physician shifts that allow us to not get killed, but work at a reasonable pace and make slightly less money than when you work with a PA elsewhere. But in the end I feel best about job number 1 where I have complete say over the midlevels, and job 3 where we have none. To me there is no middle ground.

I realize there are the rare PA's like EMED and a few others that are probably as competent as an average EP. But this is the exception and not the rule. One of my absolute best friends on earth is an EM PA who was once my mentor when I was a PA, and I still think he is way smarter than myself. In the rarer instance where I could teach and nurture a PA like him and have only THAT PA work shifts with me, I might let them operate more like an unsupervised colleague and just take my lumps if something bad happens.

Midlevels were designed to be supervised, and this supervision cannot be sold up river to save a few bucks.

Numbers game:

Massachusetts experienced an 11% jump in visits after enacting it's insurance reform.
This resulted from a drop of % uninsured of 10.3% in 2004-2005 to 7.9% 2007-2008.

(Source: 2008 US Census Bureau)


Basically, an 11% jump in demand from a TINY 2.4% increase in insured patients.

What do you think is going to happen when states like Texas, Florida, and California, all with uninsured rates hovering around 20% enact reform?

The fallout jump in # of visits is going to be MASSIVE compared to what Massachusetts saw.

Bottom line: I think you guys are safe

RustedFox said:

I welcome your criticism, as its good for my project.

Counterargument: While your projects are important (and sound very cool) you're doing academic research; not clinical medicine. Until it becomes clinically applicable medicine; it could be left out of medical school and save we clinicians a lot of suffering and time. The vast majority of MDs out there never do what you're doing, and as a result don't care and don't need to care. I propose keeping "medical school" for clinicians, and streamlining the process to get more docs out there, faster, with better clinical acumen. That's what the nation needs right now.

Your research sounds cool; but its PhD work; not MD work. If we cut out the PhD work; you can spend more time learning clinical medicine and coming out of school more competent. If the knowledge is very specialty-specific (say, the SCC that you mention); then it can and should be learned in that specific residency/fellowship. Your average say, Anesthesiologist is never going to use that data; so why torture him/her by making him learn it?

This all stemmed from the following phenomenon, which I know wasn't unique to me. During my intern year, I found myself able to recite all sorts of USELESS knowledge about PKB and signaling pathways; and was mystified by the 'routine' things that went into clinical decision-making. All the nurses knew that you had to double-cover for Pseudomonas, but why didn't I? I spent a large portion of medical school forcefeeding myself clinically useless junk. Bogus. I felt like I was robbed of time. Make me a better clinician; I thought that's what you learned in medical school.

More comments/criticism welcome.

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What about the physician scientist? Would you characterize your position as: "If you want to be a physician scientist, then do an MD/PhD?"

Also, if you go back to some of the PA vs Physician argument where we find the differences in that 10%, is that 10% not part of the extra things we learn? And then where do you start to draw a line, and where does the slippery slope stop? Techinically, one could teach a kid straight out of high school to do surgery with all of the post op care that entails, but would this make him a "physician"?

I mean we do get a doctorate degree. I don't think it's always consciously evident, but I think there is some utility to the foundation.

Jarabacoa said:

1. Why are you such a hate-monger of new kineysians? I had never heard of the term until you got after physassist. I looked it up on wikipedia, but I don't quite get it honestly.

2. What do you think of John Stossel's take in the following link? Do you disagree with him and why?

http://video.google.com/videoplay?docid=5741854395922611620#

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Hatemonger -- perhaps, as that is a judgment call and matter of opinion.... and a goodly portion of any detected vitriol stems from previous conversations between physasst and I on these topics. Let me be quick to say that I believe physasst to be a good guy with good intentions, just wrong and misguided on this topic... and you know what they say paves the road to hell...

I'll have to listen to Stossel tomorrow, possibly on the drive home -- but I will likely agree with most of what he says based upon my previous knowledge of Stossel's views and opinions.

Keynes is the jackass who advocated and popularized the notion that the State and central banks can get us out of economic calamities via deficit spending in response to economic contractions, paying no particular heed to what caused the contraction to start with. While it is a bit too much to get into in this format, the summary opinion is that he was full of **** and this grand experiment will once again prove the neoclassical and Austrian schools right -- much to our general detriment. They believe that state spending can replace private spending in times of a downturn... but never ask "where does the state get its money to begin with?" Is this money somehow miraculous manna from Heaven? I think not -- and it is often money that must be borrowed and paid back at interest.... or printed and paid back via inflation, either way, not a particularly great choice of outcomes for the citizen.

Keynes believed in an economic policy that is -- and has been -- a wet dream for those bent on statism. He had this flawed and twisted philosophy on the "problem" with capitalism is that it has inherent to it a time preferential toward a future return that can take precedent over present consumption... this is to say that the capitalist system encourages folks to forgo present consumption and save for future consumption (or investment), and, when taken in aggregate (his whole system was aggregate based), can lead to irrational contractions to the entire economy's detriment. This led to a thought process of engaging in perpetual pro-inflationary policy, thereby forcing "rational economic agents" into present consumption in preference of future consumption due to the diminished purchasing power of savings that results from such policy. The "new Keynesians" seek to explain the macro-BS of Keynes through a more concrete and directly observable microeconomic manner, and they do have some validity insofar as their recognition of wage and price "stickiness" -- but they apparently fail to recognize the reasons for this stickiness is largely state regulation, legislation, and agents of collusion induced (think unions and their heavy handed contracts, minimum wage laws, etc). They conveniently ignore the a priori nature of economics as it pertains to human action... and choose to use statistics for support rather than illumination...

MOHS_01 said:

Hatemonger -- perhaps, as that is a judgment call and matter of opinion.... and a goodly portion of any detected vitriol stems from previous conversations between physasst and I on these topics. Let me be quick to say that I believe physasst to be a good guy with good intentions, just wrong and misguided on this topic... and you know what they say paves the road to hell...

I'll have to listen to Stossel tomorrow, possibly on the drive home -- but I will likely agree with most of what he says based upon my previous knowledge of Stossel's views and opinions.

Keynes is the jackass who advocated and popularized the notion that the State and central banks can get us out of economic calamities via deficit spending in response to economic contractions, paying no particular heed to what caused the contraction to start with. While it is a bit too much to get into in this format, the summary opinion is that he was full of **** and this grand experiment will once again prove the neoclassical and Austrian schools right -- much to our general detriment. They believe that state spending can replace private spending in times of a downturn... but never ask "where does the state get its money to begin with?" Is this money somehow miraculous manna from Heaven? I think not -- and it is often money that must be borrowed and paid back at interest.... or printed and paid back via inflation, either way, not a particularly great choice of outcomes for the citizen.

Keynes believed in an economic policy that is -- and has been -- a wet dream for those bent on statism. He had this flawed and twisted philosophy on the "problem" with capitalism is that it has inherent to it a time preferential toward a future return that can take precedent over present consumption... this is to say that the capitalist system encourages folks to forgo present consumption and save for future consumption (or investment), and, when taken in aggregate (his whole system was aggregate based), can lead to irrational contractions to the entire economy's detriment. This led to a thought process of engaging in perpetual pro-inflationary policy, thereby forcing "rational economic agents" into present consumption in preference of future consumption due to the diminished purchasing power of savings that results from such policy. The "new Keynesians" seek to explain the macro-BS of Keynes through a more concrete and directly observable microeconomic manner, and they do have some validity insofar as their recognition of wage and price "stickiness" -- but they apparently fail to recognize the reasons for this stickiness is largely state regulation, legislation, and agents of collusion induced (think unions and their heavy handed contracts, minimum wage laws, etc). They conveniently ignore the a priori nature of economics as it pertains to human action... and choose to use statistics for support rather than illumination...

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so very proud

bulgethetwine said:

I would posit that the over-aggressive expansion of para-medical specialty will more than offset any perceived increase in job opportunities for established ER docs.

Mid-levels were created to help fill the gap in PRIMARY CARE not muscle into the realm of the specialists and, by extension, limit job opportunity and income for real doctors.

I know of at least two ER docs who WANTED to go to a rural area recently (their hometown) and they were turned down by the hospital because the hospital was very happy, thank you very much, that they were now 100% PA staffed in the ED at a significant cost savings. I guess that's more important than safety of patients.

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Originally Posted by physasst
I never claimed that an experienced EM PA was equivalent to an experienced EM MD. I was merely stating that if there is a choice between an EM PA who has worked in EM for years, and managed difficult airways, started central lines, done US, etc.etc.etc.etc., would you rather have an FP doc who hasn't done any of that, or the PA?


I realize this is an older thread, but this kind of chaps my rear. Are you trying to say that FP trained docs are not *real* doctors? By the way, the last time I put in a subclavian was yesterday and the last patient I intubated (three days ago) was 5'2" and weighed 350 pounds.