Academia is now paying a price for its silence

[miacomet]

Just curious, how do other fields prevent new programs from being created out of proportion to their demand? Does Dermatology have such strict program requirements that new programs can't be started in any but the most urban settings? Does any specialty have criteria for opening a new program such that new programs aren't allowed to be opened due to insufficient demand?

They don't in many cases- look at law, pharmacy, NP....

Urology and radiology have strict requirements

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[Rekt]

Just curious, how do other fields prevent new programs from being created out of proportion to their demand? Does Dermatology have such strict program requirements that new programs can't be started in any but the most urban settings? Does any specialty have criteria for opening a new program such that new programs aren't allowed to be opened due to insufficient demand?

The requirements to open an emergency medicine residency are exceptionally pathetic and simple with many work arounds.

There’s programs that are open that barely even see 40k pts a year. There’s even a couple around 35k. Of course volume is only one component but there’s places out there when I interviewed that openly stated they had issues getting procedure numbers and said that simulation makes up for it. And that’s with requirements for procedures being absurdly low. Like 35 intubations in 3 years? Wtf.

I’ve moonlit at places that see 30k a year with just me and an PLP. Couldn’t imagine 5k more a year is acceptable for a residency. There’s no way those places are getting enough sick pts. I’ve said this before and it’s controversial on here but volume is king. With volume everything else comes. Strokes stemi trauma sick dying old people Peds and the subsequent procedures.

Shut down any program that didn’t fill 75%. Any program that didn’t fill 50% is on automatic probation and investigation. Current residents can finish. Increase procedure requirements. Simulations don’t count anymore. Increase faculty requirements. Increase volume requirements to a per resident number. Something like 7.5k per year per resident but a yearly total minimum of some number per year. At least 50k which I think is still too low.

 

[DocEspana]

Also plenty of pas doing IR.

Medicine is in for a major reshuffling. The ONLY positive for docs is the focus on corporate medicine will hopefully push that back to some degree. Similarly, the non compete thing if it passes and I am a skeptic would be huge. Hospitals and corporations are pipe feel like they owned us. They view us as indentured servants. Treat you like crap and if you leave you will be uprooting your family.

I mean... CMS had a recommendation theyve been kicking down the road for years now. Theyre so pissed that we bill *every* PA chart as if a physician saw it that they want to make it so whomever actually documents the most is the one who gets paid the 'rate.' Which could lead to a situation where - for those corporate groups - PAs/NPs dont actually make sense as a force/income multiplier. You would need to have the doctors actually see and actually write a nearly full note on all those people to get the credit - so what did the PA really accomplish? You realistically can't whip doctors into seeing all those patients if they also need to write bigger notes than the PA. you just need to decide if you'll accept PAs literally taking a small amount out of your bottom line with every patient they see, or realize a (productive) doctor brings in more money under that system than a PA would.

I just want CMS to go and pull the trigger on this. Its amazing how much doctors (not just CMGs.... actual, regular, doctors) have fought against this tooth and nail because they like the scrap RVUs they get from cosigning notes that they did no work on rather than a system that is more friendly to doctors and more hostile to midlevels.

 

[Neurogeneral]

Medical University of South Carolina is putting out 10 EM residents a year.

His program is putting out 13 EM residents a year in Columbia.

There is probably another program or two in the state I don't know about.

Does South Caroline really need 23 new EM physicians a year?

I have to ask, did Dr Cook cut the number of residents in his program?

If not, his words are in the end no different than everyone else: "Someone" should do something.

Yup way too many EM programs in Michigan. Pretty much every small community/satellite hospital over there has an EM residency unfortunately.

 

[Apollyon]

But but but what about that retrocecal appendix? Lmao

You laugh, but, it's not a problem - until it is. As I said, the surgeon isn't there for when it's textbook, but, when it isn't. I remember a case from when I was a resident - the pt went right from ED to OR. Among other trauma, poss cervical spinal injury. Pt starts to retch, and, what does CRNA do, by rote? Tried to wrench the head to the side. Fortunately, I was still holding inline stabilization, and the CRNA didn't pith the pt. The surgeon and anesthesiologist, like a flash, were livid.

As I've said since for what seems like time immemorial, we're not there for the 95/100 cases that are innocuous, but the 5/100 that ARE the danger, that are interspersed among the 95, randomly, and look a lot like each other. "The eye does not see what the mind does not know" - if you don't know what Fournier's looks like, you won't know it when you see it. Chronic sinusitis, or nasopharyngeal carcinoma?

 

[EctopicFetus]

I mean... CMS had a recommendation theyve been kicking down the road for years now. Theyre so pissed that we bill *every* PA chart as if a physician saw it that they want to make it so whomever actually documents the most is the one who gets paid the 'rate.' Which could lead to a situation where - for those corporate groups - PAs/NPs dont actually make sense as a force/income multiplier. You would need to have the doctors actually see and actually write a nearly full note on all those people to get the credit - so what did the PA really accomplish? You realistically can't whip doctors into seeing all those patients if they also need to write bigger notes than the PA. you just need to decide if you'll accept PAs literally taking a small amount out of your bottom line with every patient they see, or realize a (productive) doctor brings in more money under that system than a PA would.

I just want CMS to go and pull the trigger on this. Its amazing how much doctors (not just CMGs.... actual, regular, doctors) have fought against this tooth and nail because they like the scrap RVUs they get from cosigning notes that they did no work on rather than a system that is more friendly to doctors and more hostile to midlevels.

Yes. It’s 85% for cms. That’s still stupidly too high. Should be paid at about 1/3 since they will have to pay more for all the stupid tests ordered and unnecessary consults.

 

[EctopicFetus]

Yes but same could be said for em or any other field. I’m just showing how it can and will eventually impact all of us as physicians and unfortunately eventually as patients.

 

[RustedFox]

2 intern years. Consult service with the lowest threshold to be consulted. PTSD from neuroanatomy. I think I read on reddit 500k+ is easy to get now as a new grad. If that’s the standard, it’ll definitely become more competitive. If it’s 300-350k range then you have to weigh vs IM/FM because they can make similar now for one less year of training.

Last TeleStroke Alert I called at work had a PLP on the screen.

 

[BoardingDoc]

Last TeleStroke Alert I called at work had a PLP on the screen.

Our teleneuro service discussed using midlevels for code strokes during recent contract renegotiation. Our leadership relatively reflexively blurted out "why would I want to consult someone who definitionally knows less than me?"

When they asked for clarification, the response was "No thank you. If you connect us to a midlevel during a stroke, we will terminate our contract with you."

 

[GonnaBeADoc2222]

You laugh, but, it's not a problem - until it is. As I said, the surgeon isn't there for when it's textbook, but, when it isn't. I remember a case from when I was a resident - the pt went right from ED to OR. Among other trauma, poss cervical spinal injury. Pt starts to retch, and, what does CRNA do, by rote? Tried to wrench the head to the side. Fortunately, I was still holding inline stabilization, and the CRNA didn't pith the pt. The surgeon and anesthesiologist, like a flash, were livid.

As I've said since for what seems like time immemorial, we're not there for the 95/100 cases that are innocuous, but the 5/100 that ARE the danger, that are interspersed among the 95, randomly, and look a lot like each other. "The eye does not see what the mind does not know" - if you don't know what Fournier's looks like, you won't know it when you see it. Chronic sinusitis, or nasopharyngeal carcinoma?

I wholeheartedly agree.

My point is admin does not care.

 

[collegestud2013]

2 intern years. Consult service with the lowest threshold to be consulted. PTSD from neuroanatomy. I think I read on reddit 500k+ is easy to get now as a new grad. If that’s the standard, it’ll definitely become more competitive. If it’s 300-350k range then you have to weigh vs IM/FM because they can make similar now for one less year of training.

MGMA data from 2022 still has neurology median at $330k, which is on par with FM and IM hospitalist and requires at least 1 year more of training. However 90th percentile goes up to $554k which is probably most from PP partners. I doubt $500k is anywhere near the standard for new grad. To make >$500k as an employed new grad you must be working like crazy and pulling in crazy volumes and RVUs so don’t assume it’s the norm, especially from N=1 on reddit.

Most med students will still just look at the average and median pay for a given specialty when looking at financial considerations, and for now it’s still not that high for neurology compared to some others like radiology, anesthesiology, IM sub specialties like cardiology or GI. or surgical subspecialties which report medians of $400-500k, even if they have longer training times.

Also it makes sense that as a mostly a non-procedural specialty, and with many diagnoses still based on doing time consuming historical and thorough neuro exams, it’s hard to generate high RVUs in neurology since it’s probably not realistic to see around 30 patients per day everyday.

 

[thegenius]

Emergency Medicine, in the United States where health care is consumer-driven, urgent-care on demand run by businessmen, is unfixable. Anyone that says they can fix it for you, is lying.

It.

Can't.

Be.

Fixed.

I love ya man but sometimes you are such a downer!

 

[Birdstrike]

I love ya man but sometimes you are such a downer!

I’m sorry

 

[Fox800]

The requirements to open an emergency medicine residency are exceptionally pathetic and simple with many work arounds.

There’s programs that are open that barely even see 40k pts a year. There’s even a couple around 35k. Of course volume is only one component but there’s places out there when I interviewed that openly stated they had issues getting procedure numbers and said that simulation makes up for it. And that’s with requirements for procedures being absurdly low. Like 35 intubations in 3 years? Wtf.

I’ve moonlit at places that see 30k a year with just me and an PLP. Couldn’t imagine 5k more a year is acceptable for a residency. There’s no way those places are getting enough sick pts. I’ve said this before and it’s controversial on here but volume is king. With volume everything else comes. Strokes stemi trauma sick dying old people Peds and the subsequent procedures.

Shut down any program that didn’t fill 75%. Any program that didn’t fill 50% is on automatic probation and investigation. Current residents can finish. Increase procedure requirements. Simulations don’t count anymore. Increase faculty requirements. Increase volume requirements to a per resident number. Something like 7.5k per year per resident but a yearly total minimum of some number per year. At least 50k which I think is still too low.

I trained at a 120,000+ visit/year, big name, P o w e r h o u s e (TM) program and we still had to use SIM to hit some procedure numbers, so yeah your suggestion doesn't fully check out. There are only so many TV pacers you can float when you have cards on call 24/7, etc etc

There is too much money involved in having existing resident spots. These crapola programs will not reduce their class sizes, as long as they have established funding.

 

[Fox800]

Yes. It’s 85% for cms. That’s still stupidly too high. Should be paid at about 1/3 since they will have to pay more for all the stupid tests ordered and unnecessary consults.

NPs can get away with as little of 3% of "training" hours* compared to an attending physician coming out of a 3-year residency program. 85% reimbursement is the biggest fraud and joke in modern medicine. Pay should be proportional. PAs train for two years compared to our seven, so pay them 30%, rounded up a little bit for sucking up time-consuming procedures. NPs should get 5-10% at best.

*May not actually be quality training. May be online training, "shadowing" other unqualified NPs that might have been out of training for 6 months longer than the student, or falsified training hours. Ask your doctor if "fraudulent midlevel training" and "fraudulent billing" are right for you.

 

[FlaminHotER]

Just curious, how do other fields prevent new programs from being created out of proportion to their demand? Does Dermatology have such strict program requirements that new programs can't be started in any but the most urban settings? Does any specialty have criteria for opening a new program such that new programs aren't allowed to be opened due to insufficient demand?

Other answered this well but I will add couple other points.

EM programs can just open up as a stand alone program in random pos EDs and hospital systems without having to be tied to any other residency program.

However other specialities are way stricter to be granted permission to open and have to be tied a sister speciality program.

For example, Anesthesiology has to be tied to a sister general surgery program. Same for ortho.

They can’t just open out of thin air like freakin EM can.

This needs to freakin end. Having EM programs tied a sister general surgery residency program would be a start to end this freakin madness.

 

[Brigade4Radiant]

NPs can get away with as little of 3% of "training" hours* compared to an attending physician coming out of a 3-year residency program. 85% reimbursement is the biggest fraud and joke in modern medicine. Pay should be proportional. PAs train for two years compared to our seven, so pay them 30%, rounded up a little bit for sucking up time-consuming procedures. NPs should get 5-10% at best.

*May not actually be quality training. May be online training, "shadowing" other unqualified NPs that might have been out of training for 6 months longer than the student, or falsified training hours. Ask your doctor if "fraudulent midlevel training" and "fraudulent billing" are right for you.

This why do residency and bother with the match when it only accounts for 15% more? soon they will advocate for 85% pay in the coming years

 

[EctopicFetus]

This why do residency and bother with the match when it only accounts for 15% more? soon they will advocate for 85% pay in the coming years

Already happening including in state legislatures.

 

[BoardingDoc]

I trained at a 120,000+ visit/year, big name, P o w e r h o u s e (TM) program and we still had to use SIM to hit some procedure numbers, so yeah your suggestion doesn't fully check out. There are only so many TV pacers you can float when you have cards on call 24/7, etc etc

I would agree that sim is likely necessary for some things like crics or a pericardiocentesis but I honestly don't think sim should be allowed for anything else.

This is the official required list:
Adult Medical Resuscitation 45
Adult Trauma Resuscitation 35
Cardiac Pacing 6
Central Venous Access 20
Chest Tubes 10
Cricothyrotomy 3
Dislocation Reduction 10
ED Bedside Ultrasound 150
Intubations 35
Lumbar Puncture 15
Pediatric Medical Resuscitation 15
Pediatric Trauma Resuscitation 10
Pericardiocentesis 3
Procedural Sedation 15
Vaginal Delivery 10

Cardiac pacing isn't required to be transvenous, and as for the rest of them, if your program can't produce those numbers over 3 years, you shouldn't have a residency program at all. I went to a program with much lower volume than you and I stopped tracking my procedures by mid 2nd year as I was already well over the requirement.

 

[WilcoWorld]

I would agree that sim is likely necessary for some things like crics or a pericardiocentesis but I honestly don't think sim should be allowed for anything else.

This is the official required list:
Adult Medical Resuscitation 45
Adult Trauma Resuscitation 35
Cardiac Pacing 6
Central Venous Access 20
Chest Tubes 10
Cricothyrotomy 3
Dislocation Reduction 10
ED Bedside Ultrasound 150
Intubations 35
Lumbar Puncture 15
Pediatric Medical Resuscitation 15
Pediatric Trauma Resuscitation 10
Pericardiocentesis 3
Procedural Sedation 15
Vaginal Delivery 10

Cardiac pacing isn't required to be transvenous, and as for the rest of them, if your program can't produce those numbers over 3 years, you shouldn't have a residency program at all. I went to a program with much lower volume than you and I stopped tracking my procedures by mid 2nd year as I was already well over the requirement.

Gosh, looking at those numbers makes many seem like a really low bar to clear. 35 traumas? 20 central lines? 10 reductions?!?

 

[Brigade4Radiant]

Already happening including in state legislatures.

I’m curious to see what the result will be. If it pushes through a lot of people will not go to med school anymore.

 

[Arcan57]

I would agree that sim is likely necessary for some things like crics or a pericardiocentesis but I honestly don't think sim should be allowed for anything else.

This is the official required list:
Adult Medical Resuscitation 45
Adult Trauma Resuscitation 35
Cardiac Pacing 6
Central Venous Access 20
Chest Tubes 10
Cricothyrotomy 3
Dislocation Reduction 10
ED Bedside Ultrasound 150
Intubations 35
Lumbar Puncture 15
Pediatric Medical Resuscitation 15
Pediatric Trauma Resuscitation 10
Pericardiocentesis 3
Procedural Sedation 15
Vaginal Delivery 10

Cardiac pacing isn't required to be transvenous, and as for the rest of them, if your program can't produce those numbers over 3 years, you shouldn't have a residency program at all. I went to a program with much lower volume than you and I stopped tracking my procedures by mid 2nd year as I was already well over the requirement.

I wouldn't be suprised if the training landscape is very different now then when you graduated (my impression is you've been out a while). I went to a PH(TM) residency in the mid 00s and hit my numbers easy. Looking back, some to most of those procedures wouldn't have been done today. The use of PPV for flash pulmonary edema, US to identify PTX, , faster CT scanners so far fewer pts need sedating/intubating to get them done, neg head CT within 6 hrs r/o SAH, US guided PIV meaning CVCs aren't being placed simply due to lack of IV access, etc. mean that a lot fewer chances to learn.

 

[BoardingDoc]

I wouldn't be suprised if the training landscape is very different now then when you graduated (my impression is you've been out a while). I went to a PH(TM) residency in the mid 00s and hit my numbers easy. Looking back, some to most of those procedures wouldn't have been done today. The use of PPV for flash pulmonary edema, US to identify PTX, , faster CT scanners so far fewer pts need sedating/intubating to get them done, neg head CT within 6 hrs r/o SAH, etc. mean that a lot fewer chances to learn.

I've been out ~6 yrs. I would agree that LP for SAH rule out has largely disappeared but that was already pretty much gone by the time I was a resident (unless I had a much older and less up to date attending). BiPAP staved off a lot of intubations for sure, but I still easily did 50+ as a resident.

The acceptance of peripheral pressors has largely changed my practice as an attending in that I now do maybe 2-5 CVLs / year instead of the 20+ as a resident, though from what I gather the ICU is still placing them upstairs and the tertiary care ERs I transfer to will still place them in the ED, so it doesn't seem like that has changed either.

Maybe we place fewer chest tubes now? I certainly don't do them often, but I work in the community so I really don't know.

All of that said, I'm now several years removed from academics so I could certainly be wrong about things having changed, but I'd be surprised to learn that it's gone from "trivially easy to do" to challenging in 6 yrs.

 

[Brigade4Radiant]

Chest tubes are just using the small chest tube kit. inflate the lung and let the trauma team but in the large chest tube. Central lines are mostly infection risks and there is no need if you can get peripheral access.

LPs for SAH even if its out of the window CTA if you need to now if an aneurysm is bleeding then admit and have IR do a lumbar puncture. With needing to see code strokes, MI's and so on there has to be a good reason for me to do a procedure

 

[Rekt]

Chest tubes are just using the small chest tube kit. inflate the lung and let the trauma team but in the large chest tube. Central lines are mostly infection risks and there is no need if you can get peripheral access.

LPs for SAH even if its out of the window CTA if you need to now if an aneurysm is bleeding then admit and have IR do a lumbar puncture. With needing to see code strokes, MI's and so on there has to be a good reason for me to do a procedure

Yikes

 

[Siggy]

The acceptance of peripheral pressors has largely changed my practice as an attending in that I now do maybe 2-5 CVLs / year instead of the 20+ as a resident, though from what I gather the ICU is still placing them upstairs and the tertiary care ERs I transfer to will still place them in the ED, so it doesn't seem like that has changed either.

From the upstairs perspective, if it’s a small dose that will likely come off soon, then I’ve started feeling more comfortable with longer durations. It feels a little wrong now to place a line because the patient is still on 0.05 mcg/kg/hr of levo. I’ve had a few patients on that amount for a few days peripherally.

Higher doses, multiple pressors, a feeling like the patient is going to get worse first, or poor location (forearms, hands, or excess tissue) would more likely push me towards a central line.

There’s a company that makes an iv patency monitor that works similar to a pulse ox (light based probe looking for changes in tissue reflection) that I’m trying to get my hospital to do a demo run for. Technically speaking these lines are supposed to be checked every hour, but that’s unlikely to occur.

 

[miacomet]

I've been out ~6 yrs. I would agree that LP for SAH rule out has largely disappeared but that was already pretty much gone by the time I was a resident (unless I had a much older and less up to date attending). BiPAP staved off a lot of intubations for sure, but I still easily did 50+ as a resident.

The acceptance of peripheral pressors has largely changed my practice as an attending in that I now do maybe 2-5 CVLs / year instead of the 20+ as a resident, though from what I gather the ICU is still placing them upstairs and the tertiary care ERs I transfer to will still place them in the ED, so it doesn't seem like that has changed either.

Maybe we place fewer chest tubes now? I certainly don't do them often, but I work in the community so I really don't know.

All of that said, I'm now several years removed from academics so I could certainly be wrong about things having changed, but I'd be surprised to learn that it's gone from "trivially easy to do" to challenging in 6 yrs.

Also community, suburban/ruburban, not too hard to xfer at my last shop. Plenty of chest tubes because we saw a ton of trauma, although surgery is happy to help. Somewhat fewer tubes, although plenty. Some docs did a ton of central lines, I feel more comfy with peripheral and fast xfer, but some docs just liked them. I worry we are moving too far away from LPs in general (if not for SAH).

Yes, I would say high-risk procedures are fewer and far between, but stuff like reductions are more and more the responsibility of the ED.

 

[Brigade4Radiant]

Yikes

Wow what a strong rebuttal

 

[dozitgetchahi]

I mean... CMS had a recommendation theyve been kicking down the road for years now. Theyre so pissed that we bill *every* PA chart as if a physician saw it that they want to make it so whomever actually documents the most is the one who gets paid the 'rate.' Which could lead to a situation where - for those corporate groups - PAs/NPs dont actually make sense as a force/income multiplier. You would need to have the doctors actually see and actually write a nearly full note on all those people to get the credit - so what did the PA really accomplish? You realistically can't whip doctors into seeing all those patients if they also need to write bigger notes than the PA. you just need to decide if you'll accept PAs literally taking a small amount out of your bottom line with every patient they see, or realize a (productive) doctor brings in more money under that system than a PA would.

I just want CMS to go and pull the trigger on this. Its amazing how much doctors (not just CMGs.... actual, regular, doctors) have fought against this tooth and nail because they like the scrap RVUs they get from cosigning notes that they did no work on rather than a system that is more friendly to doctors and more hostile to midlevels.

The only problem I could see with this is that it could be a next step towards trying to make midlevels practice fully independently.

 

[DocEspana]

The only problem I could see with this is that it could be a next step towards trying to make midlevels practice fully independently.

Cool. Let them do it. And also let them carry their own malpractice. You'll see how quickly that whole system collapses when they are liable like us but paid like they are (and no one is going to pay the same price WILLINGLY for noctor care)

 

[dozitgetchahi]

Cool. Let them do it. And also let them carry their own malpractice. You'll see how quickly that whole system collapses when they are liable like us but paid like they are (and no one is going to pay the same price WILLINGLY for noctor care)

Oh I agree. I hope that’s the way it plays out.

 

[emergentmd]

There are only a few academic programs that care and it doesn't matter when CMGs/HCAs open residencies. They can complain as much as they want, then do what? Drop spots, lose money to see more CMG programs opening up. Academia in medicine has and always been ivory tower meetings with little teeth.

If you can't beat them, join them right?

Our FSER just was approved for 10 spots starting this year. Combined we see about 75K volume and during covid close to 200K. So you can finish the 3 years knowing that you will be adept in pt sat scores, metrics, running a business, and most importantly knowing you graduated from a 100K PH Program.

 

[doctalaughs]

I predict Medicine has to eventually respond the way law has— unlimited number of graduates but create a tiered system. Good training leads to joining a group with better reputation multiples of pay and better care (faster access, longer appointments, better doctors, no midlevels etc). Bad training gets you low pay, 10x fewer opportunities, systems that cater to low-reimbursing clients etc.

Sucks for patients who will have to deal with this tiered system but it’s already started by corporate-takeover of medicine and flooding the market with midlevels and poorly trained doctors. Specialization of “firms” catering to different levels of wealth is just the next logical step.

 

[AlmostAnMD]

Cool. Let them do it. And also let them carry their own malpractice. You'll see how quickly that whole system collapses when they are liable like us but paid like they are (and no one is going to pay the same price WILLINGLY for noctor care)

I used to think this was true but I don't think so anymore.

It's logical. Indeed patients will prefer to see a doctor.

But the powers that be that write the checks are ultimately, I think, okay with a few lawsuits here and there, provided costs ultimately go down, which with entirely midlevel staffed facilities is more realistic than you think. Sure they order more tests, sure they kill a few more, but it's going to be more generally accepted than a lot of people are willing to admit

 

[DocEspana]

I used to think this was true but I don't think so anymore.

It's logical. Indeed patients will prefer to see a doctor.

But the powers that be that write the checks are ultimately, I think, okay with a few lawsuits here and there, provided costs ultimately go down, which with entirely midlevel staffed facilities is more realistic than you think. Sure they order more tests, sure they kill a few more, but it's going to be more generally accepted than a lot of people are willing to admit

Doubt it will be accepted by the noctors. They enjoy skirting legal responsibility.

 

[AlmostAnMD]

Doubt it will be accepted by the noctors. They enjoy skirting legal responsibility.

They'll continue to skirt. They lobby better. There will be one doc on the hook for a hospital full of midlevels. Think about it. Why would the ceo care? Why would the noctors care? If doc complains replace him with one that doesn't.

To be clear, I'm 100% on your side. But I'm just slowly seeing most people and organizations....just aren't. Financial and corporate institutions will exploit the weakest link and physicians as a group are just awful at organization and protecting themselves. Easier to sell out like the people before me.

 

[VA Hopeful Dr]

They'll continue to skirt. They lobby better. There will be one doc on the hook for a hospital full of midlevels. Think about it. Why would the ceo care? Why would the noctors care? If doc complains replace him with one that doesn't.

To be clear, I'm 100% on your side. But I'm just slowly seeing most people and organizations....just aren't. Financial and corporate institutions will exploit the weakest link and physicians as a group are just awful at organization and protecting themselves. Easier to sell out like the people before me.

Keep in mind that inpatient billing is different from ED billing. Doing too many tests will cost the hospital money on admitted patients as will an increasing length of stay, the first of which has been proven to be a problem with mid levels and I'd be shocked if the second isn't a problem as well.

 

[Trousseau]

I predict Medicine has to eventually respond the way law has— unlimited number of graduates but create a tiered system. Good training leads to joining a group with better reputation multiples of pay and better care (faster access, longer appointments, better doctors, no midlevels etc). Bad training gets you low pay, 10x fewer opportunities, systems that cater to low-reimbursing clients etc.

Sucks for patients who will have to deal with this tiered system but it’s already started by corporate-takeover of medicine and flooding the market with midlevels and poorly trained doctors. Specialization of “firms” catering to different levels of wealth is just the next logical step.

We sort of already have this. It’s just that top grads do ENT and get paid multiples of what FM gets.

 

[DeadCactus]

I predict Medicine has to eventually respond the way law has— unlimited number of graduates but create a tiered system. Good training leads to joining a group with better reputation multiples of pay and better care (faster access, longer appointments, better doctors, no midlevels etc). Bad training gets you low pay, 10x fewer opportunities, systems that cater to low-reimbursing clients etc.

Sucks for patients who will have to deal with this tiered system but it’s already started by corporate-takeover of medicine and flooding the market with midlevels and poorly trained doctors. Specialization of “firms” catering to different levels of wealth is just the next logical step.

I don't see that happening. Top law students go to top law firms to help top clients with major cases. The top tier of the legal system gets paid orders of magnitude more their work because major clients trust them with million and billion dollar deals. In medicine, it generally doesn't matter if you graduated from the Ivy League or the Caribbean - you're still seeing Medicare patients or seeing wealthy patients as an academic center employee. Entrepreneurship, shilling, and unethical or illegal practices are generally the only path to wealth in the medicine and generally have little to do with talent or pedigree. A negligible amount of people may be able to carve out a business as an elite service for the wealthy but even then the majority of the wealth generated will just go to a founder/owner. At the end of the day, the majority of medical care is paid for by government and insurance payors and none of them care about the quality of provider or care enough to pay a premium.

 

[Brigade4Radiant]

Medici one even with its pains is still better than a lot of jobs go to community college the. A state school do MD or DO if you match family medicine you can work anywhere and if you work like a resident for three years after graduating or do army you get healthcare and loans paid off

I’m Dentistry you pretty much have to join to get your loans paid off

 

[Trousseau]

Keep in mind that inpatient billing is different from ED billing. Doing too many tests will cost the hospital money on admitted patients as will an increasing length of stay, the first of which has been proven to be a problem with mid levels and I'd be shocked if the second isn't a problem as well.

FWIW our hospital some years back (before I joined) had a harebrained plan to have masses of NPs as hospitalists and force a smaller number of doctors to see 25 pts a day for liability reasons.

It didn’t work and people (Doctor and NP/PA) quit en masse.

 

[HemorrhagicShock]

There are only a few academic programs that care and it doesn't matter when CMGs/HCAs open residencies. They can complain as much as they want, then do what? Drop spots, lose money to see more CMG programs opening up. Academia in medicine has and always been ivory tower meetings with little teeth.

If you can't beat them, join them right?

Our FSER just was approved for 10 spots starting this year. Combined we see about 75K volume and during covid close to 200K. So you can finish the 3 years knowing that you will be adept in pt sat scores, metrics, running a business, and most importantly knowing you graduated from a 100K PH Program.

Am I reading this correctly? Are you starting an EM residency program within your FSED enterprise?

 

[Rekt]

There are only a few academic programs that care and it doesn't matter when CMGs/HCAs open residencies. They can complain as much as they want, then do what? Drop spots, lose money to see more CMG programs opening up. Academia in medicine has and always been ivory tower meetings with little teeth.

If you can't beat them, join them right?

Our FSER just was approved for 10 spots starting this year. Combined we see about 75K volume and during covid close to 200K. So you can finish the 3 years knowing that you will be adept in pt sat scores, metrics, running a business, and most importantly knowing you graduated from a 100K PH Program.

I’m sorry but this is absurd. Also combining volume means nothing and does not count. You will be putting out urgent care residents.

 

[emergentmd]

I’m sorry but this is absurd. Also combining volume means nothing and does not count. You will be putting out urgent care residents.

Wait, you guys can't be that gullible to not see the sarcasm in my post. I mean, if some community hospital can open at will, then I am sure FSERs are around the corner if the money is right.

 

[RustedFox]

I don't think any of you fuggers know how to recognize... Wait... He beat me to it by seconds.

 

[Rekt]

Wait, you guys can't be that gullible to not see the sarcasm in my post. I mean, if some community hospital can open at will, then I am sure FSERs are around the corner if the money is right.

Actually more of a reflection of my confidence in the RRC, ACGME, and ACEP, that I could see them being fine with it. You got me.

 

[emergentmd]

Actually more of a reflection of my confidence in the RRC, ACGME, and ACEP, that I could see them being fine with it. You got me.

I guess you missed the subtle "most importantly knowing you graduated from a 100K PH Program."

 

[HemorrhagicShock]

Wait, you guys can't be that gullible to not see the sarcasm in my post. I mean, if some community hospital can open at will, then I am sure FSERs are around the corner if the money is right.

It's easy to see how anybody who has followed your story and posts over the years could believe you are jumping in on the EM residency grift. It's a money maker for sure, and you're good at making money and creating projects that provide you with steady streams of income.

In fact, I would be surprised if you DIDN'T get into this game if it was open to you given how much money CMS pays per resident spot.

 

[DoctwoB]

They don't in many cases- look at law, pharmacy, NP....

Urology and radiology have strict requirements

Urologist here. It is easier in surgical programs to have numbers that are a high bar for community settings to reach.

Some things are easy to get to, like stone and TUR cases. But others are not. Most community urologists don’t do cystectomies for example. We need 10 to graduate. Ditto for complete peds cases of which we need at least 15. At least 40 renal surgeries. While with a big enough private group you could cobble something together that meets the numbers, we also limit the number of sites you can visit, so they can’t be sending you all over to meet said numbers.

So what you need is not just higher numbers of common things like central lines or intubations, but numbers of things that occur at centralized locations/major centers. Chest tubes? ECMO canullations? Peds trauma? You would know better then I.

 

[Splenda88]

We sort of already have this. It’s just that top grads do ENT and get paid multiples of what FM gets.

500k (ENT) vs. 300k (FM)... not a great disparity IMO.