Decline of EM

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RADRULES

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I’m a Rad, but I’m curious what has happened to EM exactly? It was a competitive field to match in the early 2000s when I finished med school. Corporate take over?
 
same as rads a decade ago. job supply decreased. i switched from rads to EM after a year of rads; no regrets.
 
RADRULES said:
Corporate take over?
Click to expand...
Yes. The corporate takeover destroyed it. The cancer started decades ago, and was real bad when I worked my last EM shift 10 years ago. From what I read here on SDN-EM, it’s progressed to stage IV, and very near terminal.
 
RADRULES said:
I’m a Rad, but I’m curious what has happened to EM exactly? It was a competitive field to match in the early 2000s when I finished med school. Corporate take over?
Click to expand...
1: Going from 1600 to 2900 graduating residents in the past five years (Yes, real numbers). Significant majority of the increase is from corporations (HCA, Envision, TeamHealth, etc) starting EM residencies since the requirements to start one are laughably bad.
2: Over-utilization of inferior non-physician providers in place of EM physicians (Also mainly by CMCs)
3: CMCs/hospitals purposefully chronically understaffing EM FTEs.
4: CMCs continuing to take over contracts from hospitals/private groups and fire EM docs
5: Constant increase in Minuteclinics/urgent care lights popping up everywhere (staffed by NPPs).
6: Decreasing ER utilization (US wide ED visits were decreasing even before Covid).
etc


CoffeeGourmand said:
same as rads a decade ago. job supply decreased. i switched from rads to EM after a year of rads; no regrets.
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Oof_Size_Large.jpg

This is much different than what happened to rads.
 
Radiology is still OK due to explosion in volume over the 15 years (lifestyle much worse however) and lack of mid level intrusion. Corps / VC is starting to creep into the field lately however. Rad Onc, however, seems to be struggling these days also.
 
CoffeeGourmand said:
same as rads a decade ago. job supply decreased. i switched from rads to EM after a year of rads; no regrets.
Click to expand...

For context…. This is a guy who did an FM residency.




Anyway, Em has changed a lot even over the past 3-5 years. This is probably very dependent on what part of the country you are in, but at least in my ED, there are essentially zero chief complaints that get managed in outpatient settings.

30% of my patients are in the ED with things that absolutely could have been managed with a phone call to their PCP

30% called their PCP office, and were told by someone to “call 911 and immediately go to an ER” for a complaint that could be managed outpatient

30% need admission, but essentially all we do in the ED is identify the disease and admit

10% are emergencies requiring a board certified ED physician.



The problem is that at least half of the FP offices have NPs managing their phone calls and results/callbacks who say stuff like “OMFG your blood Sugar is 500, Go right to the ED or you will die!”




The answer is not putting FPs in the ED

We need to put competent FPs in FP offices
 
CallMeDoctorLov said:
For context…. This is a guy who did an FM residency.




Anyway, Em has changed a lot even over the past 3-5 years. This is probably very dependent on what part of the country you are in, but at least in my ED, there are essentially zero chief complaints that get managed in outpatient settings.

30% of my patients are in the ED with things that absolutely could have been managed with a phone call to their PCP

30% called their PCP office, and were told by someone to “call 911 and immediately go to an ER” for a complaint that could be managed outpatient

30% need admission, but essentially all we do in the ED is identify the disease and admit

10% are emergencies requiring a board certified ED physician.



The problem is that at least half of the FP offices have NPs managing their phone calls and results/callbacks who say stuff like “OMFG your blood Sugar is 500, Go right to the ED or you will die!”




The answer is not putting FPs in the ED

We need to put competent FPs in FP offices
Click to expand...
No FP office has NPs answering patient questions. At absolute best it's an RN and that's becoming very rare as is. Usually it's an LPN or MA.
 
We should probably rename Emergency Medicine. Most of what is seen in the ED any more isn’t an emergency. Also, from a societal demand standpoint, people want the ability to have their acute medical condition evaluated more quickly. Often primary care doesn’t meet that need as they don’t have the resources or immediate availability of an ED. Sadly with the corporate takeover of medicine where health care is a business it is time for a rebranding. We should probably rename ourselves as Acute Medical Specialists and the specialty should be renamed Acute Care Medicine. It’s not as sexy sounding without Emergency in the name, but then again neither is practicing the specialty doing low risk chest pain ruleouts, evaluating vague abdominal pain in the middle aged, xraying/splinting sprains that clearly aren’t fractures for customer satisfaction or fear of liability, and taking care of the bajillionth meth head in the middle of the night. The ED isn’t really the premier heart or stroke center for the hospital, but convenience care for those that don’t want to wait for outpatient workups and a money pot for administrators.
 
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Rekt said:
1: Going from 1600 to 2900 graduating residents in the past five years (Yes, real numbers). Significant majority of the increase is from corporations (HCA, Envision, TeamHealth, etc) starting EM residencies since the requirements to start one are laughably bad.
2: Over-utilization of inferior non-physician providers in place of EM physicians (Also mainly by CMCs)
3: CMCs/hospitals purposefully chronically understaffing EM FTEs.
4: CMCs continuing to take over contracts from hospitals/private groups and fire EM docs
5: Constant increase in Minuteclinics/urgent care lights popping up everywhere (staffed by NPPs).
6: Decreasing ER utilization (US wide ED visits were decreasing even before Covid).
etc



Oof_Size_Large.jpg

This is much different than what happened to rads.
Click to expand...

In the last five years, the field of EM has added more residency positions than the total amount of position available in radiology.
 
CallMeDoctorLov said:
For context…. This is a guy who did an FM residency.




Anyway, Em has changed a lot even over the past 3-5 years. This is probably very dependent on what part of the country you are in, but at least in my ED, there are essentially zero chief complaints that get managed in outpatient settings.

30% of my patients are in the ED with things that absolutely could have been managed with a phone call to their PCP

30% called their PCP office, and were told by someone to “call 911 and immediately go to an ER” for a complaint that could be managed outpatient

30% need admission, but essentially all we do in the ED is identify the disease and admit

10% are emergencies requiring a board certified ED physician.



The problem is that at least half of the FP offices have NPs managing their phone calls and results/callbacks who say stuff like “OMFG your blood Sugar is 500, Go right to the ED or you will die!”




The answer is not putting FPs in the ED

We need to put competent FPs in FP offices
Click to expand...

Anyone in EM knows this.

But diverting traffic from the ED is the twisting the dagger that's already impaled us. Anyone in EM has to have the mindset of thank you for the business and this stimulating consult. Half the time you can therapeutically talk to the patient and discharge them without doing anything or a therapeutic blood draw or a healing radiograph. Put on the show.
 
We seriously should not be focusing on diverting traffic from the ED in these times. We should be encouraging tons of volume. What do I care why a patient presents? I am paid for my time and I have to be there regardless. We should be offering other services to make us more competitive. We did BAM infusions during the height of COVID which was a great low resource way to increase our value to the health system. We should expand to botox/fillers in the ED. Cash only. Why not?
 
Mount Asclepius said:
We should probably rename Emergency Medicine.
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The name "Emergency Medicine" is a euphemism in the true sense of the word. It retains the title only because it would be too embarrassing to call EM what it actually is. EM should be renamed what it is, which is:

"Profit-Centered Health Care On Demand"
 
Birdstrike said:
The name "Emergency Medicine" is a euphemism in the true sense of the word. It retains the title only because it would be too embarrassing to call EM what it actually is. EM should be renamed what it is, which is:

"Profit-Centered Health Care On Demand"
Click to expand...
What was that stupid EMRAP term?

"Availabilitist"
 
Mount Asclepius said:
We should probably rename Emergency Medicine. Most of what is seen in the ED any more isn’t an emergency. Also, from a societal demand standpoint, people want the ability to have their acute medical condition evaluated more quickly. Often primary care doesn’t meet that need as they don’t have the resources or immediate availability of an ED. Sadly with the cooperate takeover of medicine where health care is a business it is time for a rebranding. We should probably rename ourselves as Acute Medical Specialists and the specialty should be renamed Acute Care Medicine.
Click to expand...

I'm going to take an unpopular stance on this board (and in the world of EM):

I think we need to embrace this new identity of "Acute Care Medicine" (and not exclusively emergency medicine).

Because the bottom line is, if only 10% of cases are truly emergent (probably a decent estimate) and we truly kept the other 90% of patients out of the ER, then 90% of us wouldn't have jobs.

The reality is there aren't enough true emergencies to go around to keep us all employed doing exclusively that.

I think the pandemic and the huge drop in volumes was a big wake up call that on some level we NEED these wimpy chief complaints more than they need us (febrile toddlers, ankle sprains, low risk chest pain). I missed those RVUs last year, I don't know about you guys.

Maybe I'm a little jaded now, but if I can get just as much pay seeing a no-risk anxious college student with low risk chest pain, I'm not sure that's worse than seeing a 75 year old chest pain who has an aortic dissection that may die, stroke-out, or go into renal failure despite perfect care.

I think if you only enjoy taking care of critically ill patients, you may be better served by a specialty such as pulmonary/critical care, cardiothoracic surgery, transplant surgery, etc. There are going to be many fewer patients on your census in those specialties that don't have critical and life threatening pathology.

I think EM has for the last 20 years or so had a bit of a weird false advertising towards med students. The EMERGENCY part is heavily emphasized, and the rest is not. I remember rotating as a student a decade ago and spending almost my entire rotation in the trauma/resus bay of a level 1 center. My residents and attendings did not have me "see" the ankle sprains and URIs, but I'm sure there were tons of them getting seen elsewhere in the ER away from the curious eyes of the students.

I think on some level if you want to enjoy EM long term, you have to embrace these acute care but non-emergent cases. Believe-it-or-not I actually enjoy reassuring low risk chest pain patients they are not having an MI, I find some satisfaction in turning around mild-to-moderate asthma exacerbations, I enjoy reducing shoulders. None of these patients are going to die without my care though. All of them possibly could have gotten care somewhere else.

When I work with students now, I try to emphasize the bipolar nature of the specialty, yes you have to be a good resuscitationist, and that is an important part of the field. But you also have to be able to switch gears and be good at the low-acuity (statistically more numerous) patients, and find enjoyment in those cases as well.
 
The name "Emergency Medicine" itself, is a powerful and purposeful recruiting lie.
 
4 years into attendinghood, I am learning to embrace and enjoy some of these lower acuity situations. I very much like reassuring a low-risk chest pain like you said - however, with one important caveat - the patient needs to be normal/grateful for me to enjoy the interaction. If they are seeking/malingering/threatening/cluster B, just chalk another one up on the ol' burnout ticker.

The lie of EM is defff sold hardcore to medical students. In hindsight, I would have done PCCM or interventional cards if I wanted actual consistent acuity. In my current job with no overnights and staffing up the wazoo, the lifestyle is actually great, however I'm waiting for the bottom to drop out...
 
GonnaBeADoc2222 said:
4 years into attendinghood, I am learning to embrace and enjoy some of these lower acuity situations. I very much like reassuring a low-risk chest pain like you said - however, with one important caveat - the patient needs to be normal/grateful for me to enjoy the interaction. If they are seeking/malingering/threatening/cluster B, just chalk another one up on the ol' burnout ticker.

The lie of EM is defff sold hardcore to medical students. In hindsight, I would have done PCCM or interventional cards if I wanted actual consistent acuity. In my current job with no overnights and staffing up the wazoo, the lifestyle is actually great, however I'm waiting for the bottom to drop out...
Click to expand...

Meh critical care is no better. Higher acuity, sure, but we get bored pretty fast with the 90 y/o full codes that come in septic or post MI/cpr; etc. Not fixing anything, just delaying the inevitable a few days or weeks isnt exactly exciting and rewarding.

My original plan was to do both EM and CCM, but with the complete lack of ED jobs im getting pretty damn bored with the unfixable gomers.
 
sylvanthus said:
Meh critical care is no better. Higher acuity, sure, but we get bored pretty fast with the 90 y/o full codes that come in septic or post MI/cpr; etc. Not fixing anything, just delaying the inevitable a few days or weeks isnt exactly exciting and rewarding.

My original plan was to do both EM and CCM, but with the complete lack of ED jobs im getting pretty damn bored with the unfixable gomers.
Click to expand...
Here’s an idea whose time has come: open up a freestanding ICU!!!
 
Board certified in EM use to mean badass. These guys/gals trained at Level 1/2 trauma centers. Saw everything. Recruiters paid premium to have you staff their ERs. I had great boards and grades and I only got a handful of interviews. Matched at a well respected program at a county hospital out in west coast. Graduated during the "golden age" of EM. I had my pick of the litter. Paid off my debt in 1yr. Then the bottom fell out. What happened? CMGs, human greed from sellouts, overuse of midlevels.

Will I do EM again? Yes, if I still want to practice medicine. The real question is : Is medicine still a good deal? CMGs have completely penetrated EM successfully. What's to stop them from other specialties? Derm is also getting hit too from PE but they are safe now due to their scarcity and they have more control of their midlevels. Until we enforce the laws on the books that bans corporate practice of medicine, I think it's only a matter of time before most of medicine is controlled from a boardroom.
 
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Kryptocoin said:
Derm is also getting hit too from PE but they are safe now due to their scarcity and they have more control of their midlevels. Until we enforce the laws on the books that bans corporate practice of medicine, I think it's only a matter of time before most of medicine is controlled from a boardroom.
Click to expand...

Dermatology is screwed, their clock is already starting to tick. PE has noted they are overfed for under-provision on their service line. They see this as a ripe opportunity for the picking. The older derms will be happy to sell out the younger generation in exchange for slightly earlier retirements and sell off their practices (which will never be wrestled back from PE-backed entities).

More derm residencies are coming on line, corporate entities, PE, and contract management groups are starting to infiltrate. Too much of what they do can easily be done by mid levels with high supervision ratios.

My bet is in 10 years dermatology will have pay equal if not lower than primary care and almost no independent practice.

The only escape hatches for them will be derm-path and Moh's surgery, which are already very competitive among dermatology residents.
 
In the not so distant future, there will be basically be corporate vs. non-corporate fields and the non-corporate fields will be the very competitive ones. Some fields are simply low-hanging fruit to be corporatized, and I include my own field Rads in this list. There are fields, however, that I think are resistant to Corps or where Corps will have a difficult time. Most of those fields are where the doctor has skills which are needed and difficult to replace - in other words fields where the physicians have significant leverage.
 
RoyBasch said:
Dermatology is screwed, their clock is already starting to tick. PE has noted they are overfed for under-provision on their service line. They see this as a ripe opportunity for the picking. The older derms will be happy to sell out the younger generation in exchange for slightly earlier retirements and sell off their practices (which will never be wrestled back from PE-backed entities).

More derm residencies are coming on line, corporate entities, PE, and contract management groups are starting to infiltrate. Too much of what they do can easily be done by mid levels with high supervision ratios.

My bet is in 10 years dermatology will have pay equal if not lower than primary care and almost no independent practice.

The only escape hatches for them will be derm-path and Moh's surgery, which are already very competitive among dermatology residents.
Click to expand...

I'm curious where derm is going to be in the next 10 yrs. PE has already zeroed in on them. The saving grace is limited residencies and little transference from other specialties. FM and IM docs can work in the ER and call themselves "ER physician" but they can't open a skin clinic and call themselves "dermatologist" or "skin doctor", even if they could I don't think malpractice insurers will cover them.

How easy is it to open a derm program? Are they going to water it down like EM program now with HCAs?
 
What are these new program PDs telling their incoming interns? Ignore the ACEP report? All is well? "Follow your passion"?

Any new PD wanna chime? It's an anonymous forum. Don't be shy.
 
Kryptocoin said:
What are these new program PDs telling their incoming interns? Ignore the ACEP report? All is well? "Follow your passion"?

Any new PD wanna chime? It's an anonymous forum. Don't be shy.
Click to expand...
They’re doing what every EM program director has always done: Say all those things while quietly plotting how to get their EM shifts as close to zero per month as possible, however, wherever, anyway they can.

Why do you think they signed up to be PD to begin with?

(Spoiler: Less shifts)
 
Kryptocoin said:
What are these new program PDs telling their incoming interns? Ignore the ACEP report? All is well? "Follow your passion"?

Any new PD wanna chime? It's an anonymous forum. Don't be shy.
Click to expand...

They have jobs so they don’t care unlike other specialties ED is limited to the ER
 
Derm is now dime a dozen. In my neck of the woods, you can easily get same week appointments. The last couple of patients I referred, they got next day appointments.
In my old practice location, you can basically see a derm practice every few blocks just driving down the street.
 
bronx43 said:
Derm is now dime a dozen. In my neck of the woods, you can easily get same week appointments. The last couple of patients I referred, they got next day appointments.
In my old practice location, you can basically see a derm practice every few blocks just driving down the street.
Click to expand...
Must be nice. 2-3 months to see derm, 3-4 weeks for their PAs here.
 
VA Hopeful Dr said:
Must be nice. 2-3 months to see derm, 3-4 weeks for their PAs here.
Click to expand...
Everything is saturated here except some of the surgical specialties. We are scheduling out 2-3 weeks for rheum, but derm really has oversaturated themselves big time…
 
Isn’t this really just the basic supply and demand principle of economics? If you can’t get in to see a specialist outpatient within a few weeks, then there isn’t enough supply. The arrogance of medicine is that we’ve controlled the supply to the detriment of patient access and over utilization of emergency services. I say this sadly knowing full well that as the supply of specialists goes up and patient access improves, that ED demand then goes down along with our compensation. However, as our specialties feel the squeeze, it will allow improved access that will hopefully allow for self selection of appropriate ED visits that are closer to emergent level care. The pendulum in our specialty has already surprisingly crossed an over supply of EPs (forget the 10 year projection, as we are already there), and I have hope that it will swing back within the next decade. We weren’t the first domino to fall with a tight job market that was excellerated by COVID-19, but we won’t be the last to fall. Luckily, I think we will rebound in volume a little here the rest of this year. In the long run though there will possibly be a contraction in ED care as society and business realize the cost, and outpatient specialty care becomes more available yet controlled unfortunately by private equity.
 
Mount Asclepius said:
Isn’t this really just the basic supply and demand principle of economics? If you can’t get in to see a specialist outpatient within a few weeks, then there isn’t enough supply. The arrogance of medicine is that we’ve controlled the supply to the detriment of patient access and over utilization of emergency services. I say this sadly knowing full well that as the supply of specialists goes up and patient access improves, that ED demand then goes down along with our compensation. However, as our specialties feel the squeeze, it will allow improved access that will hopefully allow for self selection of appropriate ED visits that are closer to emergent level care. The pendulum in our specialty has already surprisingly crossed an over supply of EPs (forget the 10 year projection, as we are already there), and I have hope that it will swing back within the next decade. We weren’t the first domino to fall with a tight job market that was excellerated by COVID-19, but we won’t be the last to fall. Luckily, I think we will rebound in volume a little here the rest of this year. In the long run though there will possibly be a contraction in ED care as society and business realize the cost, and outpatient specialty care becomes more available yet controlled unfortunately by private equity.
Click to expand...

If we only saw real emergencies EM jobs would be immediately cut by 75%. People going into EM need to realize a majority of your job is being a fecal filter for the hospital and a punching bag for consultants. In return for that abuse, we were compensated appropriately with appropriate time off. Now with the EM market in the gutter and only getting worse with compensation to follow shortly, is it worth it?

Everything you mentioned only hurts EM docs further. Should we go into EM with. 200-400k debt and make 140/hr? You can't infantize medicine to simply supply and demand. Is my debt going to contract too as supply increases? There's a significant time opportunity cost to becoming a physician, do I get that back? Control of supply is completely appropriate.
 
Rekt said:
If we only saw real emergencies EM jobs would be immediately cut by 75%. People going into EM need to realize a majority of your job is being a fecal filter for the hospital and a punching bag for consultants. In return for that abuse, we were compensated appropriately with appropriate time off. Now with the EM market in the gutter and only getting worse with compensation to follow shortly, is it worth it?

Everything you mentioned only hurts EM docs further. Should we go into EM with. 200-400k debt and make 140/hr? You can't infantize medicine to simply supply and demand. Is my debt going to contract too as supply increases? There's a significant time opportunity cost to becoming a physician, do I get that back? Control of supply is completely appropriate.
Click to expand...

Lots of people would say its even higher at 90% if we're only talking about true life or death emergencies.

If that happened most community ERs would see their volumes drop to only 2-3 patients per day and would have to immediately close their doors because they would lose millions in profits. The only thing left would be major university ERs and even after taking all the other hospitals patients
combined they would still only see 20-30 patients per day which could easily be staffed by a single attending and a couple residents on shifts.
 
Rekt said:
Anyone in EM knows this.

But diverting traffic from the ED is the twisting the dagger that's already impaled us. Anyone in EM has to have the mindset of thank you for the business and this stimulating consult. Half the time you can therapeutically talk to the patient and discharge them without doing anything or a therapeutic blood draw or a healing radiograph. Put on the show.
Click to expand...

I know what you are getting at but I disagree, all the nonsense distracts us from actually rendering good emergency care for patients who really need it.

Listen man...I know that all these idiotic referrals by medical assistants, nurses, and phone staff indicating "MD REF" is what butters our bread. But we are not really helping the masses by running useless tests and therapeutic xrays just to tell them that "they don't have an emergency and they need to go see their PCP."

They tried to see their PCP. They couldn't get in. And now we tell them to go right back there. It's so sad and such a waste of money and time.
 
thegenius said:
I know what you are getting at but I disagree, all the nonsense distracts us from actually rendering good emergency care for patients who really need it.

Listen man...I know that all these idiotic referrals by medical assistants, nurses, and phone staff indicating "MD REF" is what butters our bread. But we are not really helping the masses by running useless tests and therapeutic xrays just to tell them that "they don't have an emergency and they need to go see their PCP."

They tried to see their PCP. They couldn't get in. And now we tell them to go right back there. It's so sad and such a waste of money and time.
Click to expand...
I wish it was that simple.

Every doctor in my office (9 of us) has large numbers of same day and work in appointment spots. I haven't completely filled my schedule more than once per week ever. So it's a combination of other factors: patients thinking something is more serious than it is, not wanting to wait until the availability appointment, not happy after they did see me about a problem, not wanting to pay a co pay. You get the idea.
 
VA Hopeful Dr said:
I wish it was that simple.

Every doctor in my office (9 of us) has large numbers of same day and work in appointment spots. I haven't completely filled my schedule more than once per week ever. So it's a combination of other factors: patients thinking something is more serious than it is, not wanting to wait until the availability appointment, not happy after they did see me about a problem, not wanting to pay a co pay. You get the idea.
Click to expand...
On phone with scheduler: "I can't come early because I don't wake up until 11. And since I don't drive, my neighbor can only take me on Wednesdays between the hours of 1:30 and 2:00. But only on even days, odd days don't work. And next week I'm having lunch with Melba who only eats meat plus carbs, so...."

In room with me: "YOU'RE IMPOSSIBLE TO GET IN TO SEE, DOC!"
 
thegenius said:
I know what you are getting at but I disagree, all the nonsense distracts us from actually rendering good emergency care for patients who really need it.

Listen man...I know that all these idiotic referrals by medical assistants, nurses, and phone staff indicating "MD REF" is what butters our bread. But we are not really helping the masses by running useless tests and therapeutic xrays just to tell them that "they don't have an emergency and they need to go see their PCP."

They tried to see their PCP. They couldn't get in. And now we tell them to go right back there. It's so sad and such a waste of money and time.
Click to expand...

Fairytale land right here. PCPs either have built in EM or posthospital follow up or they can slot them in fairly quickly. I used to call all the time for patients to get follow up and never had issues getting fast appointments before the little life force I had left was sapped from my body. Yeah it's definitely a huge waste but also the reason you get to go on several vacations a year and/or your kids go to the best school.

As Rustedfox says, patients are the worst part of medicine.
 
EM isn't dying. People overreacting. There's like 3x as many FM residencies than EM right now, they're not suffering for any jobs.
 
scoopdaboop said:
EM isn't dying. People overreacting. There's like 3x as many FM residencies than EM right now, they're not suffering for any jobs.
Click to expand...

It's hard to believe someone in medicine could be dumb enough to write this statement. We have more residencies than radonc has positions. They're totally fine right?

It's quite literally, actually shockingly dumb
 
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