Dammit

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Rekt said:
EM still sucks the least of all the other specialties. You just have to be fine with making a meager salary compared to what it once was along with likely working in a location you don't really enjoy.
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Has the downfall really already happened? I'm still making bookoo bucks but I have been at the same job and locked into my rate.... haha
 
Groove said:
I'd hate to be ortho. Can you imagine being on call and having to argue with all those EM goons about sending home unstable bimal/trimal fxs that I don't want to admit for ORIF because I know they don't have insurance and I'm trusting they won't make it through screening to the clinic because they can't afford the office visit?
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🤣

I know you say it in jest, but I think there is some pretty heavy truth to it
 
ShockIndex said:
Define lifestyle?

If the dollar amount per hour is paramount to what you define as a lifestyle, then community EM is very hard to beat. You had just better make damn sure that you have embraced the customer service driven, protocolized-out-the-ass, cookie cutter models of care delivery that have become so prevalent in EM.

By cookie cutter I’m taking about nursing triage orders, provider in triage, code stroke, code sepsis, and the protocolized way we now wipe our collective asses. For example, my last academic shop had a protocol for suspected kidney stones that mandate a CT for almost every patient to facilitate urologic follow-up. I had gatekeeper PGY2s tell me that I needed to get a BS under 300 and SBP under 170 to admit patients to the floor because...you know - patient safety. 😵

On the other hand, if lifestyle means enjoying taking care of a particular patient population (critically ill, athletes, etc.), you may find a lower per hour dollar amount acceptable. For example, I’ll probably make about $300-400k as an intensivist after fellowship and work more hours than most EM attendings. A friend of mine is the medical director for NASA and a colleague was the medical director for the FBI - they both probably work 50 hrs/week and make far less that $300K. However, none of us will be spending any time answering complaints because we didn’t work-up someone’s chronic abdominal pain or give opiates to back pain. I also no longer have to debate IM PGY2s about admissions or field ridiculous questions on why I didn’t get an ICU consult on patients with hyperglycemia, trace ketones, and a normal pH/bicarbonate. That right there is pure gold when applied across the 20 or so more years I have left ahead of me.
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A lot of these problems exist because we are working in a hospital environment. If you want a good lifestyle, and you don't care too much about the KIND of medicine you practice, and you are smart enough to match into anything, then the way to go is probably doing a brand of medicine that completely takes insurance out of the equation, people pay cash, and you are doing cataracts or plastic surgery all day.

CCM is burdened by hospital politics too. You guys have to (to the same extent ER and Hospitalist do) continue to do sepsis bundles, this and that. And you have to deal with families who refuse to withdraw care, threaten to sue or do a variety of things that will make you practice bad critical care medicine. Like extending the life of old, bedbound people using pressors and putting in PEG tubes in demented people who can't talk.

You can come back and say "well this and that", "I don't have to deal with as many consults", "I have more freedom to deviate from protocols", etc. Well, it's all relative.
 
Renaissance Man said:
How is this? I don't regret medical school, student loans, or choosing EM. I think it is a pretty great job 75% of the time. I never dread going to work and often have a few cases that make me feel very satisfied. The time passes quickly during shifts, I enjoy keeping up with learning about the field, and during my recent job search I had multiple offers to make ~$350K a year (not to mention the benefits and retirement match).

The other 25% of time I remind myself that it is a job and I am just like Joe Insurance Guy in that way.
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Agreed...I try to approach EM like this, the way @GeneralVeers does as well. It's a job. If you did private equity, software engineering, or Hiaku massage, they are all jobs too. A means to an end. With the right approach you can find enjoyment in the job you have.

We see a lot of stupid stuff in the ED, but for example sometimes telling someone who is pregnant with bleeding they are going to be OK is satisfying.
 
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Listen2Savage said:
i think i would be happy in either field

just makes me sick reading all this cmg takover doom and gloom on here when surgery is going the opposite direction with free standing surgical centers.
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I mean I'm sure it's just a matter of time before large private equity funded groups buy out all the surgical centers and just start employing surgeons. You'll get to work at 5a, operate until 2p, then see clinic patients until 7p, and spend your evenings co-signing APP notes on patients you didn't see 5 days a week, then spend occasional nights and weekends taking call. The days of physicians as small business owners are finished, for better or worse, except for some very unique situations (cosmetic medicine, concierge medicine). I think if you just accept the fact you'll be an employee, and just go into whatever field of medicine you feel like you hate the least (for whatever reason, hours, patient population, subject matter, etc) you'll be the happiest. All jobs suck, at least we make >200K though.
 
thegenius said:
CCM is burdened by hospital politics too. You guys have to (to the same extent ER and Hospitalist do) continue to do sepsis bundles, this and that. And you have to deal with families who refuse to withdraw care, threaten to sue or do a variety of things that will make you practice bad critical care medicine. Like extending the life of old, bedbound people using pressors and putting in PEG tubes in demented people who can't talk.

You can come back and say "well this and that", "I don't have to deal with as many consults", "I have more freedom to deviate from protocols", etc. Well, it's all relative.
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Not at all relative. I have a much greater say over what comes through my front door and how it leaves through the back end than when I was an ED attending. Not. Even. Close.

My choice is definitely not for everyone, but it’s a way out for those who still enjoy medicine but are tired of being told to be all thing to everyone and then being criticized if the experience was less than 5 out of 5 stars.
 
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SamtheWise said:
I mean I'm sure it's just a matter of time before large private equity funded groups buy out all the surgical centers and just start employing surgeons. You'll get to work at 5a, operate until 2p, then see clinic patients until 7p, and spend your evenings co-signing APP notes on patients you didn't see 5 days a week, then spend occasional nights and weekends taking call. The days of physicians as small business owners are finished, for better or worse, except for some very unique situations (cosmetic medicine, concierge medicine). I think if you just accept the fact you'll be an employee, and just go into whatever field of medicine you feel like you hate the least (for whatever reason, hours, patient population, subject matter, etc) you'll be the happiest. All jobs suck, at least we make >200K though.
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Yea I’m on a GI rotation right now. Apparently the hot-button issue in GI these days is private equity firms and physician staffing companies gobbling up GI practices like hot cakes.

The fellows were all complaining about how they have to look farther and farther outside the city to find a good job, because all the practices in town have been conglomerated into some GI version of a CMG (GICare or something). This company forces them to supervise 2 mid levels and caps their clinic visit length, or else some administrator comes knocking on the door.

It sounded strikingly familiar.
 
The Knife & Gun Club said:
Yea I’m on a GI rotation right now. Apparently the hot-button issue in GI these days is private equity firms and physician staffing companies gobbling up GI practices like hot cakes.

The fellows were all complaining about how they have to look farther and farther outside the city to find a good job, because all the practices in town have been conglomerated into some GI version of a CMG (GICare or something). This company forces them to supervise 2 mid levels and caps their clinic visit length, or else some administrator comes knocking on the door.

It sounded strikingly familiar.
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The group I'm with now is a physician owned multi-specialty group with 40+ providers. We're big enough to have security but still small enough to have control over 95% of things that matter to us, like our schedules, the type and quantity of patients we see and how we practice. Not too long ago, two nearby hospital systems came buy and offered to buy us out. We all want to remain independent as we're all seasoned enough to know how likely they are to offer you a good looking deal then turn around and screw you as soon as they can. We told them, "No thanks, not accepting offers," and didn't even give them a chance to try to seduce us with poisonous offers and promises.
 
Birdstrike said:
The group I'm with now is a physician owned multi-specialty group with 40+ providers. We're big enough to have security but still small enough to have control over 95% of things that matter to us, like our schedules, the type and quantity of patients we see and how we practice. Not too long ago, two nearby hospital systems came buy and offered to buy us out. We all want to remain independent as we're all seasoned enough to know how likely they are to offer you a good looking deal then turn around and screw you as soon as they can. We told them, "No thanks, not accepting offers," and didn't even give them a chance to try to seduce us with poisonous offers and promises.
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That's good but what about 5 years from now?
 
Holy crap
The Knife & Gun Club said:
Yea I’m on a GI rotation right now. Apparently the hot-button issue in GI these days is private equity firms and physician staffing companies gobbling up GI practices like hot cakes.

The fellows were all complaining about how they have to look farther and farther outside the city to find a good job, because all the practices in town have been conglomerated into some GI version of a CMG (GICare or something). This company forces them to supervise 2 mid levels and caps their clinic visit length, or else some administrator comes knocking on the door.

It sounded strikingly familiar.
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Sent from my Pixel 3 using SDN mobile
 
Brigade4Radiant said:
That's good but what about 5 years from now?
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Are you asking if I'd consider "selling out" to a hospital 5 years from now? If so, the answer is, "No, I wouldn't." I have shares in my group that the group has to buy back from me when I leave. It does nothing for me to have a hospital buy my portion of the company from me, instead of my group. There's no incentive for me to sell out to a hospital when I'm just going to sell my portion of the company back to the company anyways and I doubt any hospital would offer some amount significantly over the valuation of our stock value.
 
Birdstrike said:
The group I'm with now is a physician owned multi-specialty group with 40+ providers. We're big enough to have security but still small enough to have control over 95% of things that matter to us, like our schedules, the type and quantity of patients we see and how we practice. Not too long ago, two nearby hospital systems came buy and offered to buy us out. We all want to remain independent as we're all seasoned enough to know how likely they are to offer you a good looking deal then turn around and screw you as soon as they can. We told them, "No thanks, not accepting offers," and didn't even give them a chance to try to seduce us with poisonous offers and promises.
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Is your group able to perform its procedures outside of the hospital? Also, is your group participating in any value-based reimbursement models?
 
ShockIndex said:
Is your group able to perform its procedures outside of the hospital? Also, is your group participating in any value-based reimbursement models?
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Depending on the specialty we’re able to perform some, but not all procedures outside the hospital. All of my procedures are done in my office, none in a hospital. Our CCM docs on the other hand do their ICU procedures in hospital and sleep stuff outside. Our Cards do all in hospital, but we’re soon setting up to do much outside (echo, stress, etc). Rheum infusions are done office based.

As far as value based payment models, we did agree to be part of a nearby hospital systems’ data set, so we can potentially get value based payment increases from Medicare. We did get a 1% increase last year (1% bonus in all Medicare payments) for being above average in “metrics.” Lol. We tend to score above average for the groups included so we probably could get same or better payments without them.

Being part of the network requires in no way being owned by them, become owned by them or even any of of being on staff at their hospitals. They have zero input into our operations. We can opt out with no penalty at any time. It’s a very loose, optional association that ends when it stops being mutually beneficial.
 
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ShockIndex said:
Is your group able to perform its procedures outside of the hospital? Also, is your group participating in any value-based reimbursement models?
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I’m curious as to why you asked these questions. These seem to be the two furthest things on the minds of people here on this forum. Good questions, though.
 
Birdstrike said:
I’m curious as to why you asked these questions. These seem to be the two furthest things on the minds of people here on this forum. Good questions, though.
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I’m very interested in learning how other specialities are adapting to the changing landscape. For example, I suspect that some specialities that require hospital facilities for procedures (ortho, vascular surgery, etc.) are under different pressures to embrace health system ownership, value-based reimbursement, etc. compared to multi-speciality groups that can vary their output between in-patient and out-patient environments. It sounds like your group is able to effectively respond to its environment in an adaptive and physician-friendly manner. That should interest all of us.

I also like hearing as many perspectives as possible on how to adapt and thrive. I take what guys like you post, internalize it, and see if it might shed some light on what the future might hold for my circumstances.

Sure, much of my time on SDN is making jokes at the BS we contend with - that is the noise. However, there are some interesting perspectives to be considered which is the real signal of a forum like this.
 
Rekt said:
EM still sucks the least of all the other specialties. You just have to be fine with making a meager salary compared to what it once was along with likely working in a location you don't really enjoy.
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I'm still hearing of 500k salaries 40/hr weeks. Nothing meager about that. In my state averages are usually 400-650/year. Are you considering that meager or is it much lower in your area?
On another note, I do have an MBA and do want to have administrative side gigs. Is it more just being at the right hospital at the right time? Do most hospital boards prefer to have MD/DO administrators vs. just suit types? Hoping to clear it all up in residency but that is the reason I chose to go with the dual degree to begin with.
 
Birdstrike said:
Lifestyle: Definitely Pain. By a mile, at least for me.

Pay?

I'm not sure. I make more than I did in EM, but I've been out 9 years now and these things change year to year. The last time I looked at an MGMA survey, Pain averaged more than EM and it has every time I've looked since I left to do my fellowship. But again, you have to look at the most recent data.
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What are different private clinic opportunities in EM? You did pain, and I've also seen some EM docs switch to wound care as a side gig, but what are some other options? Would it be reasonable to open a procedures clinic?
 
PathoTurnUp1865 said:
What are different private clinic opportunities in EM? You did pain, and I've also seen some EM docs switch to wound care as a side gig, but what are some other options? Would it be reasonable to open a procedures clinic?
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I've seen a couple people do mens clinics

anyone know how hard is it to get that going?
 
Listen2Savage said:
lol TRT/hormone therapy is unethical now?
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In a vacuum, no of course not. But I've yet to see one of these places that wasn't shady.

After all, Primary care, endocrine, and urology all deal with this stuff. If you're opening a clinic that does nothing but TRT/hormone therapy, what makes you different from all of them?
 
Yeah it seems like you just complain of fatigue and get some T even with normal labs around here.

VA Hopeful Dr said:
In a vacuum, no of course not. But I've yet to see one of these places that wasn't shady.

After all, Primary care, endocrine, and urology all deal with this stuff. If you're opening a clinic that does nothing but TRT/hormone therapy, what makes you different from all of them?
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VA Hopeful Dr said:
Well you first have to divest yourself of your soul and any ethical bones in your body.

Once that's done, its quite easy.
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and yes i could do this if the bottom truly does drop out and im stuck holding d1ck/400k in loans
 
PathoTurnUp1865 said:
What are different private clinic opportunities in EM? You did pain, and I've also seen some EM docs switch to wound care as a side gig, but what are some other options? Would it be reasonable to open a procedures clinic?
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I did a one year, accredited Pain fellowship (along side Anesthesia, PMR and neuro) and became board certified, which opens up all the same options available to Pain fellowship trained Anesthesiologists, Physiatrists and others. It was a 180 degree career change as opposed to a "side gig."
 
PathoTurnUp1865 said:
I'm still hearing of 500k salaries 40/hr weeks. Nothing meager about that. In my state averages are usually 400-650/year. Are you considering that meager or is it much lower in your area?
On another note, I do have an MBA and do want to have administrative side gigs. Is it more just being at the right hospital at the right time? Do most hospital boards prefer to have MD/DO administrators vs. just suit types? Hoping to clear it all up in residency but that is the reason I chose to go with the dual degree to begin with.
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This is absolutely not the norm what-so-ever. There's a few SDGs across the country (that get hundreds of applications) where you can land this kind of pay, but to state this is typical is absurd.
 
Rekt said:
This is absolutely not the norm what-so-ever. There's a few SDGs across the country (that get hundreds of applications) where you can land this kind of pay, but to state this is typical is absurd.
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They stated 500k for 40hrs/wk. If they want to work 40hrs/wk in em, be my guest.

The 650k number does not exist outside of unicorn jobs or working an unhealthy number of hours, so they're either exaggerating, misinformed, or only speaking to aforementioned unicorns.
 
Rekt said:
This is absolutely not the norm what-so-ever. There's a few SDGs across the country (that get hundreds of applications) where you can land this kind of pay, but to state this is typical is absurd.
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I did not say it was the norm for the country, but where I'm from it is. We have not seen one ounce of doom and gloom. Which has made me very confused about reading ish on here. However, I have heard it from people in the more blue states.
I don't care what happens as long as I make >300k and am able to fund my business ventures. All the doom and gloom on here hopefully makes it a less desirable specialty and drives up demand. All of these things come in cycles, because people follow the money.
 
BoardingDoc said:
They stated 500k for 40hrs/wk. If they want to work 40hrs/wk in em, be my guest.

The 650k number does not exist outside of unicorn jobs or working an unhealthy number of hours, so they're either exaggerating, misinformed, or only speaking to aforementioned unicorns.
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GeneralVeers said:
Right now $300 is about the most you can expect. At 1400 hours/year that's $420K.
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I mean... where are y'all pooling your numbers from? I talk to residents and physicians in my area who throw these numbers around weekly. Maybe some do work more hours, but I literally just talked to a third year who got a job offer of 500k for 45 hr/wk. I'm not just pulling these numbers out my ***.
 
PathoTurnUp1865 said:
I mean... where are y'all pooling your numbers from? I talk to residents and physicians in my area who throw these numbers around weekly. Maybe some do work more hours, but I literally just talked to a third year who got a job offer of 500k for 45 hr/wk. I'm not just pulling these numbers out my ***.
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you're an attending, resident or student ?
 
PathoTurnUp1865 said:
I mean... where are y'all pooling your numbers from? I talk to residents and physicians in my area who throw these numbers around weekly. Maybe some do work more hours, but I literally just talked to a third year who got a job offer of 500k for 45 hr/wk. I'm not just pulling these numbers out my ***.
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45 hr/week is a fast track to burn out in EM unless you’re seeing 1 pph. Plus if that number does not include vacation, it’s 2340 hours for the year (45 x 52) and just under $214/hour.

This is not a good counter example to the doom and gloom on here, but rather a testament to it.
 
180 hrs / month lmao
GatorCHOMPions said:
45 hr/week is a fast track to burn out in EM unless you’re seeing 1 pph. Plus if that number does not include vacation, it’s 2340 hours for the year (45 x 52) and just under $214/hour.

This is not a good counter example to the doom and gloom on here, but rather a testament to it.
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Sent from my Pixel 3 using SDN mobile
 
On a slightly positive note counter to do the doom and gloom, one of my friends working for a major CMG got a pay raise recently (not TH, although wouldn't that be funny). Now instead of far-below market rate money he is now getting almost-market rate money. I think his shop is really short staffed as of late and they are afraid he will be next to jump ship, though.
 
GatorCHOMPions said:
On a slightly positive note counter to do the doom and gloom, one of my friends working for a major CMG got a pay raise recently (not TH, although wouldn't that be funny). Now instead of far-below market rate money he is now getting almost-market rate money. I think his shop is really short staffed as of late and they are afraid he will be next to jump ship, though.
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How is this a positive note. Lmao
 
Rekt said:
He's a medical student. Clearly more knowledgeable on the subject of attending pay than attendings and residents.
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1581738287921.png


this is why im not concerned about matching
 
PathoTurnUp1865 said:
I mean... where are y'all pooling your numbers from? I talk to residents and physicians in my area who throw these numbers around weekly. Maybe some do work more hours, but I literally just talked to a third year who got a job offer of 500k for 45 hr/wk. I'm not just pulling these numbers out my ***.
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When you understand why the bolded part makes no sense, come back and talk. I would make well over 500k if I worked those hours. Only extreme outliers work those hours in EM. It is not sustainable.
 
PathoTurnUp1865 said:
I mean... where are y'all pooling your numbers from? I talk to residents and physicians in my area who throw these numbers around weekly. Maybe some do work more hours, but I literally just talked to a third year who got a job offer of 500k for 45 hr/wk. I'm not just pulling these numbers out my ***.
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45 hours a week is a lot of emergency medicine man, that's more than some residents work. That's 5-6 shifts a week (if doing 8s), which means that either your only day off or one of your two days off will be you flipping from nights to days. Trust me, those are not days off, waking up at 1pm with a headache and forcing yourself to get out of bed then spending the rest of the day nauseous and tired. You are not going to be able to productively pursue outside business ventures, hobbies, or really anything.

It's really hard to come up with a solid number for EM pay because it varies so much based on the market, the year and who you ask, every resident plays up their job offer to make it sound better and every attending in academia inflates private pay from their end stage grass-is-greener complex. I'm not trying to perpetuate doom and gloom, but I suspect EM physicians will continue to take pay cuts as legislation against balance billing is passed and new residencies pump out grads that CMGs use to saturate even once non-competitive markets and drive down pay. But unfortunately that's the reality of every medical specialty, not just EM. Anesthesia, hospitalists and family medicine docs have it way worse than us in terms of job degradation. Maybe sub-specialty surgeons will still have high pay and more autonomy, but at the cost of working 60+ hours a week for an entire career after a decade of residency and fellowship.
 
BoardingDoc said:
When you understand why the bolded part makes no sense, come back and talk. I would make well over 500k if I worked those hours. Only extreme outliers work those hours in EM. It is not sustainable.
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Unless you’re single and have no friends family Or SO and use work as a mechanism to cope with depression I’d say nobody pulls that in for long.
 
SamtheWise said:
It's really hard to come up with a solid number for EM pay because it varies so much based on the market, the year and who you ask, every resident plays up their job offer to make it sound better and every attending in academia inflates private pay from their end stage grass-is-greener complex. I'm not trying to perpetuate doom and gloom, but I suspect EM physicians will continue to take pay cuts as legislation against balance billing is passed and new residencies pump out grads that CMGs use to saturate even once non-competitive markets and drive down pay. But unfortunately that's the reality of every medical specialty, not just EM. Anesthesia, hospitalists and family medicine docs have it way worse than us in terms of job degradation. Maybe sub-specialty surgeons will still have high pay and more autonomy, but at the cost of working 60+ hours a week for an entire career after a decade of residency and fellowship.
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The bolded is the part that continues to not make much sense to me of all the doom and gloom talk on this forum. I first started lurking around this forum as a premed around 2012. I remember the debate as far as EM salary was concerned at that time to be "will I make over 200k or not." Now, 8 years later as I near my own match day, salaries of less than 300k are viewed as below market rate and the average seems to be around 350k if not higher. That is a very substantial increase during a time of very little economic inflation. Available ACEP salary surveys seem to support this trend, and from what I've heard about whats in the MGMA reports, they support this as well.

Certainly balance billing legislation has the potential to eat into salary if insurer-backed proposals win and market saturation is an important concern, but what is the source of the pay cuts that are "continuing" to happen. They data would support that at the present moment, EM docs are doing better than ever.
 
Torsion said:
The bolded is the part that continues to not make much sense to me of all the doom and gloom talk on this forum. I first started lurking around this forum as a premed around 2012. I remember the debate as far as EM salary was concerned at that time to be "will I make over 200k or not." Now, 8 years later as I near my own match day, salaries of less than 300k are viewed as below market rate and the average seems to be around 350k if not higher. That is a very substantial increase during a time of very little economic inflation. Available ACEP salary surveys seem to support this trend, and from what I've heard about whats in the MGMA reports, they support this as well.

Certainly balance billing legislation has the potential to eat into salary if insurer-backed proposals win and market saturation is an important concern, but what is the source of the pay cuts that are "continuing" to happen. They data would support that at the present moment, EM docs are doing better than ever.
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The wave already crested man.
 
RadsWFA1900 said:
The wave already crested man.
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Possibly, but it wouldn't be a realistic expectation for earnings growth in any field to significantly outpace inflation in perpetuity. If salary growth levels out that doesn't concern me. What would be concerning is if there is a sharp decrease in real or inflation-adjusted annual earnings.
 
Torsion said:
Possibly, but it wouldn't be a realistic expectation for earnings growth in any field to significantly outpace inflation in perpetuity. If salary growth levels out that doesn't concern me. What would be concerning is if there is a sharp decrease in real or inflation-adjusted annual earnings.
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Nothing goes on forever but you can bet your behind inflation can and is eroding salary and it happens all the time and it’s happening now. By the time you start to notice it it’s too late. A few years of not meeting inflation your easily making 10-20% less for the same work.
 
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