Can you please elaborate on what are the changes that caused EM to go sharply downhill?
Just curious as someone who seriously considered EM, 20 years ago.
A confluence of many factors, but probably the biggest ones are:
*Private equity buying up physician-owned groups.
Predictively results in lower levels of physician coverage, increased midlevel coverage (arguably more dangerous than any other field of medicine), and, of course, pay cuts. PE groups view physicians as nothing more than widget makers and liability sponges… and as that becomes apparent in all facets of your job, you really begin to question why you keep showing up.
*For profit-hospitals and private equity groups creating EM residencies at ERs that shouldn’t have them.
This happens for two reasons, both of which are 100% about money: the short term gain of very cheap labor and then longer term gain of flooding the market to tip the balance of power to the hands of employers…and so lower labor costs in the long-term.
As the ACGME and ABEM don’t have the balls to step in and stop this nonsense, nor do any of the EM societies have either the spine or the resources to do anything…this reckless expansion went unchecked. Compared to when I was applying to residency a little over a decade ago, I think the total number of EM residency spots has literally doubled.
*Incredibly poor/unpredictable ED staffing and ancillary resources. The majority of ERs have never been the "fully staffed" kind of place. 10 years ago ER nurses were raging about having shifts where they'd have somewhat high staffing ratios that were probably not safe (1:4 or 5 semi-sick patients) and then peri-covid it could go to 1:8 or 9 or 10...wildly unsafe. And very few places listened to them...so with covid there was an understandable accelerated exodus of RN and techs from many ERs. This kind of thing destroys your efficiency, drastically increases wait times, delays care, and decimates department morale. I've had shifts where 1/3 of the scheduled nursing staff would "call out" and there'd be no coverage for them. All this severely limits what you can do for patients. Then when you get more "help" it's often brand new nurses (who a decade ago wouldn't have been allowed to start their career by working in any reasonably-high acuity ED). So they understandably make mistakes, especially with critical patients. But when you finally do stabilize a critically ill patient, there's sometimes nowhere to send them anyway. Which brings us to perhaps the most critical problem...
*Increasing amounts of moral injury…no support, no system capacity, increased boarding times, insolent and sometime violent patients, employers leaving you out to dry, idiotic press gainey scores, frivolous lawsuits, oblivious admin, wildly unrealistic patient expectations, wildly unrealistic consultant expectations, preposterous societal expectations that the ER is the place to get everything fixed, etc…all the while trying to do the actual medicine like catch critical diagnosis, treat things promptly, prevent morbidity, occasionally revive the dead, and more regularly keeping the nearly-dead undead while trying to connect them with definitive care.
Saying "moral injury" can sound wishy-washy and abstract, so here's some examples:
Example A: ER doc on shift before me sees a patient with GIB badly needing scope. On-call GI says pt "too sick" to be scoped at our hospital and they recommend transfer to tertiary care center. ER doc calls 7 such places across 3 states (cannot spend any more time on the phone as he's also managing a full department) and nobody has capacity to accept so patient put on waitlists. He then begs our on call GI to at least come see the patient and try. They refuse (against hospital by-laws). I come on to start my shift as patient slowly bleeds out in our ED and and outgoing doc signs patient out to me with the plan = "to die" because no GI doc could/would see the patient. Fortunately family was there for the end. On-call GI doc "investigated" by hospital and no substantive repercussions. One of the most gut-wrenching aspects of cases like this is that you know that if the patient was just driven to one of the bigger hospitals hospital ERs than their GI docs would have then had to see the patient and the scope would've happened. But if you dare told the patient that, it would trigger an EMTALA violation by which the government can fine you 50k, you'd likely be fired and have trouble getting another job, and you'd be easily sued if anything bad happened to the patient on the way there (even though they'll clearly die if they continue to hang out in your ER).
Example B: Busy evening in the ER and EMS brings in a CPR in progress. Younger looking patient, reports of minimal down time, as we're going through typical ED code stuff we start getting brief runs of ROSC before pt codes again in PEA. I notice one leg clearly bigger than the other and take a look at pts heart with bedside sono and see right ventricle is way dilated. So with massive PE possible I look at my little code team and tell them I want to push lytics but it'll commit us to doing CPR for at least 30 minutes or until we get sustained ROSC...basically, it's gonna tire the heck our of staff and kill throughput through the department, but hey this is why we're here. Patient ends up living and transferred to ICU. Next day on shift some C-suite suit comes over to me and asks why a family member of a local politician had such a "long" length of stay in the ED (for their bull**** complaint) when I was working the code and "we just need to do better." Then a few hours later my ED director comes up and tells me how expensive alteplase is and the patient is almost certainly going to be brain damaged from the downtime before CPR etc and it wasn't worth it and tied up other dept resources blah blah blah. Two days later ICU doc tells me patient is extubated and completely neuro intact. ED director still tells me I was "reckless with resources." To brighten my day I go to see the patient now on the floor. Introduce myself and patient says: "Oh you're the one. You should have called my sister before bringing me back, she would have told you I would've been happier to stay dead. I didn't give you permission to do what you did and you really should have called my sister."
Lol yup good times in the ED...
Despite the above, I feel lucky to have done EM. The practicality of the actual swath of medicine it covers cannot be rivaled by any other field. I've had some good saves, plenty of losses, and have better stories than most. I didn't run "from" EM but rather ran "to" Pain when I found out it was an approved path...EM started to most severely spiral out of control a bit after that.
Anyway, that was long-winded but hopefully makes the point-- while the knowledge and skillset of EM is swell, you're quite lucky you picked something else.