CC is the next EM

[inthezone2]

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I'm pretty sure most people are aware now that EM is undergoing substantial issues w/ it's job market 2/2 to multiple factors including midlevels, residency proliferation, COVID, etc. I am here to put forward the prediction that critical care is next within 10 years.

I want to be wrong, because my SO is gun-ho about CC and I have been trying to convince her to pursue something else. I want her to pursue her passion, but at the same time I don't want her to get burned. Is there anything I'm missing?

 

[jdh71]

Seems like there are still plenty of ICUs out there without even a single critical care doc. APP are extenders not replaces in the ICU. It’s still cheaper to employ than contract with “CMGs” for the most part. Private practice contracts where the locals pulm guy was making high six figures by keeping the hospital over the barrel probably is dead. I have big doubts anyone is going to starve.

 

[chessknt]

Have you ever done ICU work? This is not the field midlevels are going to be taking over, there is too much complexity and nuance and way too much potential for things to go wrong. EM has a large amount of worried well that midlevels handle (eg urgent care level)--they arent responding to level 1 traumas or blue extremis status 1 patients. ICU almost never has low level crap in it. Hell with COVID the population has selected for even sicker people as the floors have become more comfortable managing respiratory failure.

 

[DrMetal]

I'm pretty sure most people are aware now that EM is undergoing substantial issues w/ it's job market 2/2 to multiple factors including midlevels, residency proliferation, COVID, etc. I am here to put forward the prediction that critical care is next within 10 years.

Here is why:
1) Extensive midlevel involvement
2) Questionable fellowship proliferation. Pulm-crit has undergone 29% increase in spots over the past 5 years per NRMP. Anecdotally, 2 yr CC fellowships have proliferated as well. Can anyone point out a source for the number of 2 yr CC spots?
3) Significant CMG involvement, like Envision. They will push for more APP involvement and open up more CC training spots.
4) HRSA already predicted saturation by 2025.
5) Bonus: A new wave of EM people will crowd into critical care fellowships depressing the market in 5-10 years.

I want to be wrong, because my SO is gun-ho about CC and I have been trying to convince her to pursue something else. I want her to pursue her passion, but at the same time I don't want her to get burned. Is there anything I'm missing?

Yep. You're not wrong, you're spot on. Neuro-CC, Nephro-CC, ID-CC, what next? Psych-CC??? (why not, you can OD pretty hard and some psychotropics).

I was always of the opinion that CC should only be done by those trained in hospital medicine and surgery (ie Internists and General Surgeons: because they know the hospital the best, and they know how to take care of sick patients for lengthy stays and complex issues) .....but clearly the rest of the world disagrees with me. We've opened up CC to everyone but the janitor, and they all love to bill for 'critical care time'.

Have you ever done ICU work? This is not the field midlevels are going to be taking over, there is too much complexity and nuance

Uh yes, and there's mid-levels all over the place, especially doing procedures (and to be honest, they're quite good at it). I don't know that they're 'taking over' the field, but they're definitely encroaching.

 

[chessknt]

Uh yes, and there's mid-levels all over the place, especially doing procedures (and to be honest, they're quite good at it). I don't know that they're 'taking over' the field, but they're definitely encroaching.

We are all shaded by our experiences I suppose. I havent seen many midlevels in the hospital-based setting in the majority of places in the midwest where I have worked. In academia I see midlevels in the specialty ICUs (Neuro, CT, trauma) but I feel they offer consistency over rapidly rotating trainees and have worked there for 5-10+ years. I have seen almost no midlevels in general ICUs in the community and those that do are rounding on vented patients awaiting dispo or post-op CT patients/post-TPA/DKA patients that are not actual ICU patients. I dont think they have much interest in taking over a crashing COVID sepsis or 40 year old NICM who might need to go on ECMO or an undifferentiated medical disaster who has been languishing on the floor for a week.

Definitely not 'all over the place' in my 6+ hospital 3 state experience.

 

[CCM-MD]

Right now things in CCM are pretty freaking great. The money is great and mid levels are not currently a big issue. My personal experience as an intensivist that has worked in various hospitals and locations is similar to chessknt.

The future is uncertain. I believe we are headed in the same direction as EM. I believe midlevels, hospital administrators and staffing companies are going to lead to major problems.

 

[DrMetal]

We are all shaded by our experiences I suppose. I havent seen many midlevels in the hospital-based setting in the majority of places in the midwest where I have worked. In academia I see midlevels in the specialty ICUs (Neuro, CT, trauma) but I feel they offer consistency over rapidly rotating trainees and have worked there for 5-10+ years. I have seen almost no midlevels in general ICUs in the community and those that do are rounding on vented patients awaiting dispo or post-op CT patients/post-TPA/DKA patients that are not actual ICU patients. I dont think they have much interest in taking over a crashing COVID sepsis or 40 year old NICM who might need to go on ECMO or an undifferentiated medical disaster who has been languishing on the floor for a week.

Definitely not 'all over the place' in my 6+ hospital 3 state experience.

A typical scenario I've seen is where the NPs are used for mundane stuff (procedures, the 'light' ICU volume), so the intensivist can spend more time conducting family meetings (goals of care, palliative discussions, etc etc) and/or teaching residents. It actually works well, can't blame 'em.

 

[Katheudontas parateroumen]

This thread is the thing I fear. Although I think it's less likely given ICU team are commonly primary to their patients. And EM had it going in for them given all the triaging of simple things that do not happen in the ICU. Floor patients ran by APPs are needing higher level of care from... other APPs? Haha.

 

[chessknt]

This thread is the thing I fear. Although I think it's less likely given ICU team are commonly primary to their patients. And EM had it going in for them given all the triaging of simple things that do not happen in the ICU. Floor patients ran by APPs are needing higher level of care from... other APPs? Haha.

Go look at the anesthesia forum. They have been bemoaning the end of their field because of CRNAs for 20+ years and their job prospects are excellent currently. Nobody knows nuthin

 

[DrMetal]

Go look at the anesthesia forum. They have been bemoaning the end of their field because of CRNAs for 20+ years and their job prospects are excellent currently. Nobody knows nuthin

Excellent? Come to San Diego and try to find a job as an Anes making $400k/year. Not likely. Nor is it likely in any other huge metro city. With the advent of CRNAs, a good portion of their market is saturated.

No one's starving, but it's far from 'excellent'.

Those in CC are rightfully concerned. Hopefully they can do something now to avoid the same fate.

 

[ACSurgeon]

We are all shaded by our experiences I suppose. I havent seen many midlevels in the hospital-based setting in the majority of places in the midwest where I have worked. In academia I see midlevels in the specialty ICUs (Neuro, CT, trauma) but I feel they offer consistency over rapidly rotating trainees and have worked there for 5-10+ years. I have seen almost no midlevels in general ICUs in the community and those that do are rounding on vented patients awaiting dispo or post-op CT patients/post-TPA/DKA patients that are not actual ICU patients. I dont think they have much interest in taking over a crashing COVID sepsis or 40 year old NICM who might need to go on ECMO or an undifferentiated medical disaster who has been languishing on the floor for a week.

Definitely not 'all over the place' in my 6+ hospital 3 state experience.

I’ll offer a different experience. Our tertiary care community hospital (busy cardiac and transplant hospital) has over a handful of cc NPs that have been doing this for a while and have become fairly good at bedside procedures, US, resuscitation. Now, this group has been around for over 10 years and worked really hard for many years and got good training. The next generation of NPs is trained by the first generation of NPs, so we’ll see how they turn out.

overall I agree that most midlevels aren’t competent or motivated enough to do high level critical care but some are.

 

[CCM-MD]

I’ll offer a different experience. Our tertiary care community hospital (busy cardiac and transplant hospital) has over a handful of cc NPs that have been doing this for a while and have become fairly good at bedside procedures, US, resuscitation. Now, this group has been around for over 10 years and worked really hard for many years and got good training. The next generation of NPs is trained by the first generation of NPs, so we’ll see how they turn out.

overall I agree that most midlevels aren’t competent or motivated enough to do high level critical care but some are.

Do these NPs work primarily on the surgical units? I feel like there is a much larger mid level presence on the surgical critical care side, even in academia.

 

[nycitygas]

Excellent? Come to San Diego and try to find a job as an Anes making $400k/year. Not likely. Nor is it likely in any other huge metro city. With the advent of CRNAs, a good portion of their market is saturated.

No one's starving, but it's far from 'excellent'.

Those in CC are rightfully concerned. Hopefully they can do something now to avoid the same fate.

Actually I have a several friends in SD making >500 in anesthesia. Starting salaries in most big cities are around 400k.

 

[DrMetal]

Actually I have a several friends in SD making >500 in anesthesia. Starting salaries in most big cities are around 400k.

Coming outta residency, or have been in practice there for 2 decades? I have friends commuting to Riverside (~100 miles away) for work.

I'm sorry, but you guys set the mold for mid-level encroachment, and now every other specialty is following suit.

 

[spacegun]

Coming outta residency, or have been in practice there for 2 decades? I have friends commuting to Riverside (~100 miles away) for work.

I'm sorry, but you guys set the mold for mid-level encroachment, and now every other specialty is following suit.

He mentioned $400K is starting salary in most big cities. So I assume $500k+ is mid-career.

It's true about anesthesia and mid-levels (CRNAs), but at least as far as I know that's not this generation of anesthesiologists, but a previous generation or generations. So I wouldn't blame this generation, generally speaking. This generation of anesthesiologists isn't exactly happy with mid-level encroachment either, at least from what I can see. Just my impression but I could be wrong. I'd be glad to be corrected if so.

 

[DrMetal]

He mentioned $400K is starting salary in most big cities. So I assume $500k+ is mid-career.

It's true about anesthesia and mid-levels (CRNAs), but at least as far as I know that's not this generation of anesthesiologists, but a previous generation or generations. So I wouldn't blame this generation, generally speaking. This generation of anesthesiologists isn't exactly happy with mid-level encroachment either, at least from what I can see. Just my impression but I could be wrong. I'd be glad to be corrected if so.

Fair point. And quite frankly it doesn't matter which generation is to blame, it's the fact that it happened at all. And quite honestly, no one really is to blame. The medical industry is succumbing to economic pressures, to circumvent it's most expensive asset (the physician). This happens in almost every industry. Legal tries to circumvent high-priced lawyers, the tech sector tries to undercut PhD scientists (etc etc).

What's foolish about us (physicians) in medicine, is that we thought we were somehow immune to said economic pressure/trends. Indeed, we are not. The 21st Century is demonstrating that!

 

[emergentmd]

There are about a zillion online NP schools and a large amount of new nurses are doing online NP degrees while easily working full time.

10 yrs ago, NPs/PAs were sought after and difficult to find. Now NPs/PAs are oversupplied and have difficulty time finding jobs. This will depress their salary and make it that much more appetizing to hire them to do everything Docs do not want to do. They may not be able to do everything a doc does, but instead of hiring a doc due to increased volume, they will just hire an NP to do the basic stuff and make more $$$$.

So they may not take your job but they will decrease the need for almost all fields.

Anyone thinking they are protected is just kidding themselves. Even the most protected field will be drastically affected by an eventual single payer system. Anyone graduating today will unlikely have a 30 year career making 500K+ with a prolonged doctor shortage.

There may not be a current rush to open a bunch of medical schools but there is a push to open many new residencies which will be filled by hungry Caribbean graduates.

 

[ACSurgeon]

Do these NPs work primarily on the surgical units? I feel like there is a much larger mid level presence on the surgical critical care side, even in academia.

I work with them in surgical where they are very good. They also cover medical cardiac and neuro icu’s and seem to be just as good but I’m not in those units.

a lot of what we do can be taught to a hard working learner with some book knowledge. An ICU nurse with 5-10 years experience who becomes a CC NP in the same ICU and 5-10 years after that they can become quiet good with a big chunk of the what we do. The problem is when you have PAs or fast tracked NPs showing up with no ICU experience wanting to be treated like a doc.

 

[chessknt]

I work with them in surgical where they are very good. They also cover medical cardiac and neuro icu’s and seem to be just as good but I’m not in those units.

a lot of what we do can be taught to a hard working learner with some book knowledge. An ICU nurse with 5-10 years experience who becomes a CC NP in the same ICU and 5-10 years after that they can become quiet good with a big chunk of the what we do. The problem is when you have PAs or fast tracked NPs showing up with no ICU experience wanting to be treated like a doc.

That argument could be applied to anybody. We could take high school students and stick them on rounds every day, skip medical school and residency and boom they'll be good to go after 5 years. Respiratory therapists and social workers too. Until of course something comes up they haven't seen and been told what to do (hopefully by someone who was actually doing it right).

Would you want to fly on a plane by someone who fast-tracked through a year of flight school and has never flown independently before only as a copilot?

 

[chocomorsel]

Excellent? Come to San Diego and try to find a job as an Anes making $400k/year. Not likely. Nor is it likely in any other huge metro city. With the advent of CRNAs, a good portion of their market is saturated.

No one's starving, but it's far from 'excellent'.

Those in CC are rightfully concerned. Hopefully they can do something now to avoid the same fate.

Well stop crawling all over in these “desirable” cities like crabs in a bucket and yeah, job options are excellent. You can still find a job in a “desirable” market, it just won’t pay that much, or you may have to work extra hard, or you may have to kiss a few surgeon assess but you won’t be broke. Plenty of need for anesthesiologists.

 

[SurfingDoctor]

That argument could be applied to anybody. We could take high school students and stick them on rounds every day, skip medical school and residency and boom they'll be good to go after 5 years. Respiratory therapists and social workers too. Until of course something comes up they haven't seen and been told what to do (hopefully by someone who was actually doing it right).

Would you want to fly on a plane by someone who fast-tracked through a year of flight school and has never flown independently before only as a copilot?

How cheap of a flight to Hawai’i we talking?

 

[chessknt]

How cheap of a flight to Hawai’i we talking?

Its actually the same price as one being flown by a seasoned fully trained pilot but the CEO gets more money and the semi-competent pilot gets paid less

 

[SurfingDoctor]

Its actually the same price as one being flown by a seasoned fully trained pilot but the CEO gets more money and the semi-competent pilot gets paid less

So... I need to become a CEO, hire the worst pilots I can find and reap the reward. Perfect.

 

[Katheudontas parateroumen]

So I will be graduating CCM fellowship in 2022 entering into the market of CCM and/or Anesthesia which both seem to be next in the chopping block. Trends in large corporation take over, mid levels abound, a possible oversupply of CCM doctors from multiple specialties. Is this an inevitable trajectory? What can I do to protect myself but also the future of the specialty? Personally, I do not go out of my way to teach mid level students. I try to never let a mid level do what i do. I am hoping as an attending that I’ll do every procedure possible but I’m sure that’s not feasible with all the work we have to do. I’m really open to teaching residents and letting them get their hands on procedures. I hope to get into hospital leadership if given opportunity. But I understand at this point I don’t know what it’s like to be an attending yet. What else can be done?

 

[chessknt]

So I will be graduating CCM fellowship in 2022 entering into the market of CCM and/or Anesthesia which both seem to be next in the chopping block. Trends in large corporation take over, mid levels abound, a possible oversupply of CCM doctors from multiple specialties. Is this an inevitable trajectory? What can I do to protect myself but also the future of the specialty? Personally, I do not go out of my way to teach mid level students. I try to never let a mid level do what i do. I am hoping as an attending that I’ll do every procedure possible but I’m sure that’s not feasible with all the work we have to do. I’m really open to teaching residents and letting them get their hands on procedures. I hope to get into hospital leadership if given opportunity. But I understand at this point I don’t know what it’s like to be an attending yet. What else can be done?

Marry rich and go live in a private island.

 

[DrMetal]

Actually I have a several friends in SD making >500 in anesthesia. Starting salaries in most big cities are around 400k.

It doesn't seem that I anesthesia colleagues are doing too well:

Wisconsin Hospital Replaces All Anesthesiologists With CRNAs

The long-running battle over nurse anesthetists continues, with one hospital's action causing a flare-up on social media.

www.medscape.com

 

[CCM-MD]

It doesn't seem that I anesthesia colleagues are doing too well:

Wisconsin Hospital Replaces All Anesthesiologists With CRNAs

The long-running battle over nurse anesthetists continues, with one hospital's action causing a flare-up on social media.

www.medscape.com

The CRNA issues are real but MGMA median of 460k says they are still doing pretty damn good right now. Better than general surgeons and most internists/non-procedural IM sub specialists.

 

[Señor S]

COVID may turn out to be the watershed moment here. APP lobbies have used it to ram through many "temporary" FPA measures which they are now pushing to make permanent. And of course we are now hearing about several specialties where jobs have suddenly become scarce. Only time will tell.