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Recent thread posts reflect unemployed EM docs, surge in residency programs, rise in corporate medical groups, mid-level encroachment, etc that have real impacts on the specialty. There are various posters talking about the past exodus from EM, current exodus or exploring the options for future exodus.

I couldn't help but think that EM should flip the paradigm, and not be a base specialty but instead revert to a fellowship of 1-3 years duration. Tap into the roots where IM/FM were the original EM. This could even allow a fast track process similar to Psychiatry with Child & Adolescent Psychiatry where the PGY-IV year becomes the first year of fellowship. It could be a fast track option where after 2 year of IM/FM, the ensuing 2 years are EM and folks can become double boarded.

I believe this could be a win for the specialty because it would allow an out, an alternative for docs who are burned out in years to come. The main fall back currently is urgent care. And lesser so a fellowship in Hospice, Aerospace, Toxicology, Pain, etc.

Should EM cling to the current model as a base specialty?
 
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clibby

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The problem is that we have shown you don't need IM or FM training to be a good ED doc and ED training alone isn't enough to to IM or FM. What benefit would there be to a 3 year EM fellowship vs a 3 year EM residency? They already have EM/IM and EM/FM combined residencies and they are 5 years. I guess I'm not sure the problem that is being solved by your proposed change.

If anything, EM is likely to become a bigger feeder into CCM and more desired in the urgent care market. EM docs can also do a 1-2 year fellowship in occupational medicine, critical care, hyperbarics, pain, hospice, and addiction to completely change their practice environment and to an extent sports medicine and informatics too. Most residences will grant 6-12 months credit for completing a different residency. Otherwise a 3 year fellowship sounds like a second residency to me...
 
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sylvanthus

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I get what OP is getting at. The public, the powers-that-be, CMGs, hospitals, patients, all are basically saying EM training is not needed. Our expertise is unnecessary. NPs, PAs with minimal experience is "adequate." So, if this is what is genuinely going on behind the scenes, why have EM as a specialty? Why not do IM, FM, PEDs, etc and get a "certificate" in EM with some additional training? Don't get me wrong, I think EM training is absolutely necessary and should be the standard, but unfortunately the powers-that-be seem to not agree. The decline/death of the specialty is seriously on the horizon if things don't improve.
 
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sylvanthus

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Anyone find it a little F'ed up that ACEP recently celebrated all the "fathers of EM" who were pushing so hard for years to get EM to be a respected and needed training pathway/specialty for practice in the ED, while simultaneously allowing the downfall of the specialty to "midlevels?"

Ugh, depressing.
 
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Tenk

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This is a terrible idea.

We needed less residency programs (yes, past tense) or more emergency departments. Seeing as how hard it is to build a hospital, reducing the number of programs is the move. This will probably happen anyways as more doom and gloom spreads and people don’t want to match EM out of fear. A valid fear, sadly.
 
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This is a terrible idea.

We needed less residency programs (yes, past tense) or more emergency departments. Seeing as how hard it is to build a hospital, reducing the number of programs is the move. This will probably happen anyways as more doom and gloom spreads and people don’t want to match EM out of fear. A valid fear, sadly.

We need to lose at least 200 spots. I'd be absolutely shocked if I even see one place close within ten years.
 
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cyanide12345678

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The problem is that we have shown you don't need IM or FM training to be a good ED doc and ED training alone isn't enough to to IM or FM. What benefit would there be to a 3 year EM fellowship vs a 3 year EM residency? They already have EM/IM and EM/FM combined residencies and they are 5 years. I guess I'm not sure the problem that is being solved by your proposed change.

If anything, EM is likely to become a bigger feeder into CCM and more desired in the urgent care market. EM docs can also do a 1-2 year fellowship in occupational medicine, critical care, hyperbarics, pain, hospice, and addiction to completely change their practice environment and to an extent sports medicine and informatics too. Most residences will grant 6-12 months credit for completing a different residency. Otherwise a 3 year fellowship sounds like a second residency to me...

We can go into occupational medicine and addiction medicine? What's the market for that like? Didn't know we had those outs :p
 

Brigade4Radiant

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Bad idea. You can’t just go back to going into psych when you’ve been in the ED for 20 years.

The requirements to be an EM program are too lax. Doing 6 or 7 years of training to be an EM physician sounds awful
 
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bronx43

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Making EM a fellowship of IM would fix the job market REALLY quickly... just saying.
 
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Backpack234

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This is a terrible idea.

We needed less residency programs (yes, past tense) or more emergency departments. Seeing as how hard it is to build a hospital, reducing the number of programs is the move. This will probably happen anyways as more doom and gloom spreads and people don’t want to match EM out of fear. A valid fear, sadly.
It would be nice if some of these poor quality shops closed down. Sadly the opposite is more likely to happen. Heck even near me, one of the “rural” jobs is opening up a new residency program.
 

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EM is still very glamorized for the layperson and I see tons of pre-clinical, MS3s and MS4s who are eager to go into EM.
 
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A challenge of making EM a fellowship of IM or whatever is that, to a decent extent, the mindset and broad lens by which EM docs view patients and problem solve may be lost. That wouldn't be good.

To address the oversupply of EM docs, a good first step is to make it financially unpalatable for the HCAs and CMGs of the world to have residencies. One way to achieve this, while also improving resident education, would be to require a 1:1 core faculty:resident ratio with both clinical work hour caps for core faculty along with mandatory paid teaching/research/admin hours for core faculty. HCA would probably voluntarily end their EM residencies overnight.

To help address EM burnout, I think we need way more combined residencies. Given the meat and potatoes of EM, it seems EM/FM, EM/IM, EM/CC, EM/Psych, EM/Peds, EM/Anesthesia and maybe EM/Neuro all probably make sense. That'd give docs straightforward options if they ended up not wanting to solely work in an ED. It would also improve these docs bargaining power while helping to stabilize supply.
 

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I see where the OP is coming from. Given the realities of the situation, I don't think it's the worst idea ever. It's basically the Peds->PEM route. This field is f'd, I would never recommend anyone go into it.

This is a terrible idea.

We needed less residency programs (yes, past tense) or more emergency departments. Seeing as how hard it is to build a hospital, reducing the number of programs is the move. This will probably happen anyways as more doom and gloom spreads and people don’t want to match EM out of fear. A valid fear, sadly.
I don't see it. We're all very open about it online, but my guess is that people are far less negative in person, and especially at teaching hospitals. Just go on Reddit or Facebook, for every honest poster, there's another person chiming in that they're doing great and USACS is fantastic employer.

Plus, even once decent candidates stop pursuing it, I doubt residencies will go unfilled. They'll just take IMGs and bottom of the barrel grads.
 
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Rekt

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I see where the OP is coming from. Given the realities of the situation, I don't think it's the worst idea ever. It's basically the Peds->PEM route. This field is f'd, I would never recommend anyone go into it.


I don't see it. We're all very open about it online, but my guess is that people are far less negative in person, and especially at teaching hospitals. Just go on Reddit or Facebook, for every honest poster, there's another person chiming in that they're doing great and USACS is fantastic employer.

Plus, even once decent candidates stop pursuing it, I doubt residencies will go unfilled. They'll just take IMGs and bottom of the barrel grads.
Yep. Medical schools are destroying medicine just as fast as fast as EM is destroying itself. Multiple extremely shady schools opening for both MD/DOs. No specialty is even close to how many spots were splooging out, so all these extremely weak applicants will trickle into EM.
 
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RadsWFA1900

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Yep. Medical schools are destroying medicine just as fast as fast as EM is destroying itself. Multiple extremely shady schools opening for both MD/DOs. No specialty is even close to how many spots were splooging out, so all these extremely weak applicants will trickle into EM.

They really are! My state opened 3 in the last 15 years. Oh I’m sure they only take the best.

Where are these idiots gonna go? The health system wants cheap cogs.
 
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clibby

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We can go into occupational medicine and addiction medicine? What's the market for that like? Didn't know we had those outs :p
No idea the day to day as I haven't done it. Occupational medicine primarily deals with workplace health/injuries. Addiction medicine was hot for a bit with all the MAT, but it can be more than that. Both would likely result in an outpatient style practice that is more predictable, but would also likely make less money.
 

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They really are! My state opened 3 in the last 15 years. Oh I’m sure they only take the best.

Where are these idiots gonna go? The health system wants cheap cogs.
MD/DO numbers should sky rocket. We need to ramp up production. This is a good thing. But we need to take steps to further this positive production:
1) end step/level 3 requirements to obtain a medical license in states.
2) grant full unrestricted independent licensure for MD/DO graduates simply at medical school graduation and levels/steps 1 thru 2.
3) Support the old school GP model the preceeded the rise of FM. A fresh grad MD/DO is far superior to an ARNP or PA-C. We flood the market with MD/DO grads that take over all these midlevel positions. We can get back to focusing the specialty societies on appropriate production numbers for specialists. The competition for specialities will drastically rise when there are far more aplicants then positions - but knowing there is a fall back safety net to still practice medicine in some capacity with a base MD/DO will make this more palatable. Some people may actually choose it, because they can hop around like the PA's do. Some folks might want to be the MD/DO grad who does urgent care for a few years, then becomes the NSx rounding assistant, then few years later a Psych CL team member, etc.

In summary, I support the massive influx and increase of MD/DO numbers with those changes. Who do you think is better able to understand their role in the system and when to seek out specialty expertise? An ARNP, a PA, or "GP" type MD/DO? I'd pick the MD/DO "GP' every time.
 
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MD/DO numbers should sky rocket. We need to ramp up production. This is a good thing. But we need to take steps to further this positive production:
1) end step/level 3 requirements to obtain a medical license in states.
2) grant full unrestricted independent licensure for MD/DO graduates simply at medical school graduation and levels/steps 1 thru 2.
3) Support the old school GP model the preceeded the rise of FM. A fresh grad MD/DO is far superior to an ARNP or PA-C. We flood the market with MD/DO grads that take over all these midlevel positions. We can get back to focusing the specialty societies on appropriate production numbers for specialists. The competition for specialities will drastically rise when there are far more aplicants then positions - but knowing there is a fall back safety net to still practice medicine in some capacity with a base MD/DO will make this more palatable. Some people may actually choose it, because they can hop around like the PA's do. Some folks might want to be the MD/DO grad who does urgent care for a few years, then becomes the NSx rounding assistant, then few years later a Psych CL team member, etc.

In summary, I support the massive influx and increase of MD/DO numbers with those changes. Who do you think is better able to understand their role in the system and when to seek out specialty expertise? An ARNP, a PA, or "GP" type MD/DO? I'd pick the MD/DO "GP' every time.
Not sure if the current medical climate of spend, spend, spend, test, test, test will continue into the future. Less money going around means less expensive health care providers.
 

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I think Canada had the right idea, at least to my understanding of their model. Make EM a 5 year training program aimed at producing tertiary care level specialists and staff non-tertiary ED's with FM providers with EM training. The challenge we face is that we built the specialty to be a 3 year community specialty staffing every ED in the country. The problem is that the people who go into the specialty don't want to staff every ED in the country. People generally go into EM to practice the kind of EM you get at a small percentage of hospitals and then need increasingly unsustainable pay to attract them to the "every ED". So now the market gets flooded because you have to collapse the desirable markets to push emergency physicians into the "every EDs" at a sustainable prices. I suspect we'll eventually end up with desirable locations requiring fellowship training to be competitive; essentially the market forcing the Canadian model (with the added downside of not having a strong barrier between the two job markets to allow for a higher salary for people doing extra training).
 
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GeneralVeers

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I think Canada had the right idea, at least to my understanding of their model. Make EM a 5 year training program aimed at producing tertiary care level specialists and staff non-tertiary ED's with FM providers with EM training. The challenge we face is that we built the specialty to be a 3 year community specialty staffing every ED in the country. The problem is that the people who go into the specialty don't want to staff every ED in the country. People generally go into EM to practice the kind of EM you get at a small percentage of hospitals and then need increasingly unsustainable pay to attract them to the "every ED". So now the market gets flooded because you have to collapse the desirable markets to push emergency physicians into the "every EDs" at a sustainable prices. I suspect we'll eventually end up with desirable locations requiring fellowship training to be competitive; essentially the market forcing the Canadian model (with the added downside of not having a strong barrier between the two job markets to allow for a higher salary for people doing extra training).

Which results in substandard care for patients who don't live near a tertiary care center. But substandard care is the norm for treatment of many conditions in Canada, so add emergency care to the list.
 
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JacobMcCandles

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I suspect we'll eventually end up with desirable locations requiring fellowship training to be competitive; essentially the market forcing the Canadian model (with the added downside of not having a strong barrier between the two job markets to allow for a higher salary for people doing extra training).
Are these fellowships that haven't been created yet? EM is different than most other specialties because doing a fellowship doesn't make you more valuable/desirable in the community. Academics? Sure. Community? Waste of time.
 

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Which results in substandard care for patients who don't live near a tertiary care center. But substandard care is the norm for treatment of many conditions in Canada, so add emergency care to the list.
So the healthcare system bankrupting patients while they get more and more of their care from advanced practice providers is claiming superior care because they have 3 year residency graduates at all levels while Canada has 3 year graduates at the local level and 5 year graduates at the tertiary level?

Are these fellowships that haven't been created yet? EM is different than most other specialties because doing a fellowship doesn't make you more valuable/desirable in the community. Academics? Sure. Community? Waste of time.
Sure, EM is different from every single other job in existence. We absolutely won't end up with people pursuing additional training and certification to stand-out in an increasingly competitive job market. Every other specialty in medicine is progressively emphasizing more and more subspecialization but EM won't.
 

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I think Canada had the right idea, at least to my understanding of their model. Make EM a 5 year training program aimed at producing tertiary care level specialists and staff non-tertiary ED's with FM providers with EM training. The challenge we face is that we built the specialty to be a 3 year community specialty staffing every ED in the country. The problem is that the people who go into the specialty don't want to staff every ED in the country. People generally go into EM to practice the kind of EM you get at a small percentage of hospitals and then need increasingly unsustainable pay to attract them to the "every ED". So now the market gets flooded because you have to collapse the desirable markets to push emergency physicians into the "every EDs" at a sustainable prices. I suspect we'll eventually end up with desirable locations requiring fellowship training to be competitive; essentially the market forcing the Canadian model (with the added downside of not having a strong barrier between the two job markets to allow for a higher salary for people doing extra training).

Ahh yes. Canada with the great system that leaves 20%, yes twenty percent of their physicians unemployed. Good thing the US exists to suck up all their unemployed grads.

 
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DeadCactus

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Ahh yes. Canada with the great system that leaves 20%, yes twenty percent of their physicians unemployed. Good thing the US exists to suck up all their unemployed grads.

Specialists, not physicians as a whole and 20% is in certain specialties not overall. That they have their own flaws in their healthcare system and training pathway doesn’t negate their approach to emergency medicine.

Just take the Canada sentence out of my
first post since some of you seem so triggered by the country.
 

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Sure, EM is different from every single other job in existence. We absolutely won't end up with people pursuing additional training and certification to stand-out in an increasingly competitive job market. Every other specialty in medicine is progressively emphasizing more and more subspecialization but EM won't.
EM is different than other specialties, it's why it's its own specialty. Do you really think that pointless fellowships that bring little to the table in the community are going to be what distinguishes candidates?
 
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DeadCactus

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EM is different than other specialties, it's why it's its own specialty. Do you really think that pointless fellowships that bring little to the table in the community are going to be what distinguishes candidates?
Every specialty is unique, that’s why they are all specialties. No specialty has needed fellowships until the job market got tight. Where you trained for residency never mattered until the job market gets tight. But sure, EM will run contrary to literally every other career field in existence.
 

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Every specialty is unique, that’s why they are all specialties. No specialty has needed fellowships until the job market got tight. Where you trained for residency never mattered until the job market gets tight. But sure, EM will run contrary to literally every other career field in existence.

Fellowships are meant to instill a very specific skillset and value. Most fellowships for most specialties do this. EM fellowships are more about personal interests than bringing a skillset or value to a community hospital. I'll be the first to admit when I'm wrong when our group hires somebody over another strictly because they have a Global EM fellowship under their belt. Actually, their Global EM fellowship will end up not getting them hired because they'll probably want extended time off to travel for Global EM stuff.
 
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DeadCactus

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While many fellowships in other specialties result in a career metamorphosis (i.e. IM -> Cards), many just carve an area of expertise in that specialty (Cards -> Heart Failure) that allows hospitals to set up new service lines, programs, or QI projects to improve patietn

Additionally, I think the idea of hiring cogs to fill a spot and move meat is a dieing paradigm in the era where NP/PA cogs are so much cheaper. The pressure will be on to bring more to the group, the hospital, and the system than a warm body.

Certain specialties like global health will certainly be more of an academic niche. Other’s like ultrasound, EMS, addiction medicine, QI, administration, have applications in community settings even beyond the simple “these candidates both look good but this one has more training”.

To reiterate, I don’t think this will apply to people looking at all EM jobs but those looking for jobs at major hospitals in large, desirable cities.

Ultimately, we’re both just making educated guesses so we’ll just have to see.
 
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It makes sense to have 1 US guy for a group staffing a few ERs to do QI for billing purposes. It makes sense to have an admin guy for medical director or for COO of a smaller group. Having an EMS guy might help if the ER you staff has a hospital based EMS system. Otherwise not much help
 
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I really don't think it's time for us to proverbially flee to the fellowship hills.. I think we're starting to see the death of multi specialist ED physicians. I'm seeing it happen in front of my eyes in my own city. IM and FM guys are being pushed out of the EDs and replaced with BCEM docs. Many of them fresh out of residency. I think this pattern will go on until all the IM/FM guys slowly get pushed out or into more rural locations. When that has been completed, which will likely take years, then we can panic. Although the salaries will likely drop during this process due to market forces of supply/demand, it's honestly probably not a bad thing insofar as long term health and viability of our specialty. It's really hard to command respect when so many other docs with various backgrounds can ALL do your job.
 

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I appreciate the thought but I feel like you will have longer training/opportunity cost and they'll still hire the PA/NP over you or not pay you extra/etc. They don't care about your training/skills, just want a warm body to move patients and bring on revenue.
 
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sylvanthus

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I know we all think we have this buffer of pushing out the non EM board guys to make room for us, but I just don't see it. Hospital admin clearly doesnt care about training or experience, its whatever is cheapest. If that means hiring a bunch of midlevels and 1 doc, than so be it, If they can pay the FM, or IM guy less and not hire an EM boarded doc, they are going to do it. I think were being a tad naive by assuming that our skills are valued, needed, or respected.
 
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bravotwozero

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I know we all think we have this buffer of pushing out the non EM board guys to make room for us, but I just don't see it. Hospital admin clearly doesnt care about training or experience, its whatever is cheapest. If that means hiring a bunch of midlevels and 1 doc, than so be it, If they can pay the FM, or IM guy less and not hire an EM boarded doc, they are going to do it. I think were being a tad naive by assuming that our skills are valued, needed, or respected.

That's definitely the case in the sticks, but the opposite has been true and trending for quite some time in the urban/suburban areas, where non EM docs have been consistently pushed out. I'm sure that's not due to a lack of wanting from hospital admin, but more and more hospitals in said areas are stipulating in their hospital bylaws the requirement for ABEM boarded docs to staff their EDs.
 
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sylvanthus

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If that's true, I think it will change. These big city academic centers are also creating PA/NP residencies in emergency medicine. When they flood the market more, theyre not just going to go to rural areas.

 

sylvanthus

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Maybe some EM guys will be lucky and be the ones "supervising" several midlevels in big cities instead of FM/IM guys doing it?
 

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That's definitely the case in the sticks, but the opposite has been true and trending for quite some time in the urban/suburban areas, where non EM docs have been consistently pushed out. I'm sure that's not due to a lack of wanting from hospital admin, but more and more hospitals in said areas are stipulating in their hospital bylaws the requirement for ABEM boarded docs to staff their EDs.

Yes however I know hospitals such as HCA who replace all the docs with ABEM to start a residency
 

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I get what OP is getting at. The public, the powers-that-be, CMGs, hospitals, patients, all are basically saying EM training is not needed. Our expertise is unnecessary. NPs, PAs with minimal experience is "adequate." So, if this is what is genuinely going on behind the scenes, why have EM as a specialty? Why not do IM, FM, PEDs, etc and get a "certificate" in EM with some additional training? Don't get me wrong, I think EM training is absolutely necessary and should be the standard, but unfortunately the powers-that-be seem to not agree. The decline/death of the specialty is seriously on the horizon if things don't improve.
As an EM outsider, I've been chin stroking more about the impending death of EM. This isn't meant to be a hostile poke at y'all since EM peeps get fiesty at times, but merely an exercise of possible solutions. This is important to EM outsiders because what happens in one medical specialty is very capable of spreading to others.

Assertion: EM is on the trajectory of being a dying specialty.
Solution: Like minded burnt out EM docs, create the same corporation in every state. It serves a dual purpose to be a PAC lobbying body to replace the failings of the existing ones, and serves to be an EM doc friendly medical group. In essence, create a more doc based equitable medical group with goals to service all EDs. This is a massive, monumental movement that will need all docs voluntarily on board with leaving their current jobs to signup and attach themselves to this corporate group. In summary it would basically be a union - without being a union. Aggressively each doc who signs up needs to do their part to recruit colleagues. Each new doc in this would encourage dropping memberships in the failed medical societies. Have an open equitable as possible contract structure for all 50+ state/territories corporations that is the exact same. As more people sign on and members/employees etc increase, they take over more contracts for the hospitals.

Summary: Y'all need to rise together, or y'all fall together.
 
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bronx43

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As an EM outsider, I've been chin stroking more about the impending death of EM. This isn't meant to be a hostile poke at y'all since EM peeps get fiesty at times, but merely an exercise of possible solutions. This is important to EM outsiders because what happens in one medical specialty is very capable of spreading to others.

Assertion: EM is on the trajectory of being a dying specialty.
Solution: Like minded burnt out EM docs, create the same corporation in every state. It serves a dual purpose to be a PAC lobbying body to replace the failings of the existing ones, and serves to be an EM doc friendly medical group. In essence, create a more doc based equitable medical group with goals to service all EDs. This is a massive, monumental movement that will need all docs voluntarily on board with leaving their current jobs to signup and attach themselves to this corporate group. In summary it would basically be a union - without being a union. Aggressively each doc who signs up needs to do their part to recruit colleagues. Each new doc in this would encourage dropping memberships in the failed medical societies. Have an open equitable as possible contract structure for all 50+ state/territories corporations that is the exact same. As more people sign on and members/employees etc increase, they take over more contracts for the hospitals.

Summary: Y'all need to rise together, or y'all fall together.
Golden handcuffs. What you’re proposing is relatively risky for the employed doc making $275k who just has to put their head down, tip toe around everyone, clock in and clock out.

When someone has a big mortgage, two car payments, a couple kids in private school, it takes a lot for them to risk it for the unknown.
 
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Sushirolls

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Golden handcuffs. What you’re proposing is relatively risky for the employed doc making $275k who just has to put their head down, tip toe around everyone, clock in and clock out.

When someone has a big mortgage, two car payments, a couple kids in private school, it takes a lot for them to risk it for the unknown.
Absolutely, but those golden handcuffs are going to turn into silver, then bronze, and eventually basic pine handcuffs with each passing year. One way or another those handcuffs are coming off based on current trajectory. From the sounds of it, there are some who don't even have handcuffs.
 
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EctopicFetus

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Absolutely, but those golden handcuffs are going to turn into silver, then bronze, and eventually basic pine handcuffs with each passing year. One way or another those handcuffs are coming off based on current trajectory. From the sounds of it, there are some who don't even have handcuffs.
The issue is for young docs they need a job and few have the knowledge or the balls to do something. The mid career docs need “another few good years” to be set. The older / end of career docs are set and screwed everyone else so why bother switching back / little to gain.

This may be controversial but it’s the truth.
 
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bronx43

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Absolutely, but those golden handcuffs are going to turn into silver, then bronze, and eventually basic pine handcuffs with each passing year. One way or another those handcuffs are coming off based on current trajectory. From the sounds of it, there are some who don't even have handcuffs.
By then it’s too late... the market will be too far gone. The only way there’s even a chance for success is for everyone to buy in now, but they won’t. The individual will place self above the collective.
 
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bronx43

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The issue is for young docs they need a job and few have the knowledge or the balls to do something. The mid career docs need “another few good years” to be set. The older / end of career docs are set and screwed everyone else so why bother switching back / little to gain.

This may be controversial but it’s the truth.
Exactly. This is happening in every specialty and every industry. The old have it all while the young pick at scraps.
 
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EctopicFetus

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Exactly. This is happening in every specialty and every industry. The old have it all while the young pick at scraps.
When groups sold the old fat slow jaw slacked idiot of a partner who was gonna retire shortly got paid based on the income the new grad was going to generate in his stead. He got the windfall the young guy got the shaft.
 
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sylvanthus

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As an EM outsider, I've been chin stroking more about the impending death of EM. This isn't meant to be a hostile poke at y'all since EM peeps get fiesty at times, but merely an exercise of possible solutions. This is important to EM outsiders because what happens in one medical specialty is very capable of spreading to others.

Assertion: EM is on the trajectory of being a dying specialty.
Solution: Like minded burnt out EM docs, create the same corporation in every state. It serves a dual purpose to be a PAC lobbying body to replace the failings of the existing ones, and serves to be an EM doc friendly medical group. In essence, create a more doc based equitable medical group with goals to service all EDs. This is a massive, monumental movement that will need all docs voluntarily on board with leaving their current jobs to signup and attach themselves to this corporate group. In summary it would basically be a union - without being a union. Aggressively each doc who signs up needs to do their part to recruit colleagues. Each new doc in this would encourage dropping memberships in the failed medical societies. Have an open equitable as possible contract structure for all 50+ state/territories corporations that is the exact same. As more people sign on and members/employees etc increase, they take over more contracts for the hospitals.

Summary: Y'all need to rise together, or y'all fall together.
Youre right, this would be a potential solution. Problem is itll never happen. Like others have said, the older docs are just trying to make it a couple more years and get out. They are absolutely not gonna rock the boat. The midcareer have a mortgage, kids, student loans, too much to risk on bailing out and joining an unknown. New grads can barely find a job, even if they band together and form a collective, who cares? EDs dont need them anyhow! Just hire a few more midlevels.

I honestly cant see a solution. Only thing I see is eventually, decades from now perhaps, the general public will get sick of seeing undertrained people and demand doctor, then we will have negotiating power.

Theres zero chance our national organizations or hospital admin or state governments or anyone coming to the rescur. The pendulum is too heavy, has too much momentum to stop. The next generation of docs just has to hope its swinging back when they graduate.
 
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heyjack70

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With the increasing supply of EM docs, at least now you could try and get cavalier refusing to supervise midlevels. I mean it's not like there aren't EM docs who will take the job.
 
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turkeyjerky

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Yeah, I really don't see stuff getting any better. Think of covid as an inflection point akin to the black death (not with regard to mortality, but it's economic impact upon our field). Much has been made about how it led to greatly better conditions for peasants in Western Europe. However, our situation is more akin to Eastern Europe--where landlords were just a little bit better organized and the plague was just a little bit less severe. These small differences allowed the lords to crack down even harder and led to even worse conditions and 5 more centuries of serfdom.

Also, let's be honest--in the best view of things we probably only have about 20-30 years before AI comes for us and we're made economically useless like the rest of the plebs. You thought working for Envision was bad? Wait until you're executing orders for Alexa as a contractor for Amazon Physician Services...
 
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bronx43

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Also, let's be honest--in the best view of things we probably only have about 20-30 years before AI comes for us and we're made economically useless like the rest of the plebs. You thought working for Envision was bad? Wait until you're executing orders for Alexa as a contractor for Amazon Physician Services...
20-30 years? I think less than that. Way less.

I suspect there will be punctuated equilibrium, whereby the incentives of employers and payers will align and there will be rapid shift towards healthcare AI. Clinicians will be reduced to specialized data entry, and orders will be carried out by nursing staff and techs.
 
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