EM Future

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Old_Mil said:
I checked the marketplace to see what health insurance would cost to bridge to Medicare.

1,700 a month, 17,000 a year deductible.

For a Blue HMO.

It's pretty easy for the government to hide inflation.
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You get DPC and do what people w/o insurance do. Go to ED for extended care...
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Taurus said:
I’m a member of a 100+ radiology group and we are in the final stages of creating a radiology residency program. I can tell you that it’s not that easy to just create such a program. To get accreditation, you must have enough volume and subspecialty radiologists for residents to rotate through, ie, body, chest, MSK, neuro, mammo, IR, peds, nucs, etc. An HCA hospital with 2-3 radiologists on-site won’t cut it. Even smaller radiology residencies usually have around 20 radiologists in the department. That’s part of the reason why you haven’t seen an explosion of radiology residency spots over the last 10 years.
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But that's most tertiary care community hospitals, many of which don't have residencies. There is room for expansion, certainly.
 
miacomet said:
But that's most tertiary care community hospitals, many of which don't have residencies. There is room for expansion, certainly.
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The key question is whether the RRC will sign off on HCA's money grubbing residency proposals. If they do, it doesn't matter what a radiology residency requires. Or they can get around the requirements by farming out their residents to tertiary care hospitals for rotations they can't do in house. Which is exactly what has happened with emergency medicine residencies.
 
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Exactly.
How many EM residencies use Shock Trauma for their Level I trauma requirement?
 
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Taurus said:
I’m a member of a 100+ radiology group and we are in the final stages of creating a radiology residency program. I can tell you that it’s not that easy to just create such a program. To get accreditation, you must have enough volume and subspecialty radiologists for residents to rotate through, ie, body, chest, MSK, neuro, mammo, IR, peds, nucs, etc. An HCA hospital with 2-3 radiologists on-site won’t cut it. Even smaller radiology residencies usually have around 20 radiologists in the department. That’s part of the reason why you haven’t seen an explosion of radiology residency spots over the last 10 years.
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I hope for your specialty that you are correct but if history/money is an indication of anything, they could open up hundreds of radiology residencies in the next 5 yrs. I mean, who needs a physical hospital? Why can't nighthawk create an adjunct residency attached to a hospital?

Truthfully, radiology is one of the most vulnerable specialties. You guys are dependent on the hospital. You do not own your own patients. Hospital owns the equipment.

I remember when I first did EM, radiologist were a pain in the behind with slow reads. Fast forward with all the metrics, Rads were found to be the rate limiting factor to times, within a year Rads were on time metrics too.

The only docs least vulnerable are the ones that owns their building, their patients, their equipment. Even then, when we get a single payer system, then they will be owned to by the system..
 
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Agreed, except I think single payer is less of a threat than private equity.
Plenty of sub-specialists in the UK make bank with private practices.

But I agree that for any hospital based specialty in the US things are looking bleak for the reasons EmergentMD detailed.
 
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Taurus said:
I’m a member of a 100+ radiology group and we are in the final stages of creating a radiology residency program. I can tell you that it’s not that easy to just create such a program. To get accreditation, you must have enough volume and subspecialty radiologists for residents to rotate through, ie, body, chest, MSK, neuro, mammo, IR, peds, nucs, etc. An HCA hospital with 2-3 radiologists on-site won’t cut it. Even smaller radiology residencies usually have around 20 radiologists in the department. That’s part of the reason why you haven’t seen an explosion of radiology residency spots over the last 10 years.
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What are you doing man? Please Tell me PE isnt coming for the buyout and you made a residency to make it even more attractive.
 
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bravotwozero said:
Then they'll fire you...
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you do just enough to not get fired...and you turn into a passive aggressive slug that isn't exactly causing problems but isn't helping either, and the whole machine slows down. And most everyone will do this because it inherently happens when people don't get compensated what they're worth.
 
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emergentmd said:
Truthfully, radiology is one of the most vulnerable specialties. You guys are dependent on the hospital. You do not own your own patients. Hospital owns the equipment.
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Most decent-sized radiology groups have their own imaging centers. My group has 17 of them. The radiology group usually owns the equipment in these imaging centers. We often own the real estate too. Inpatient and ED imaging account for about 50% of our revenues. The other 50% is from outpatient imaging. To get the referrals for the outpatient imaging depends a lot on marketing and developing relationships with the primary care providers and specialists. Some radiology groups have no involvement with hospitals at all. Mammo-only groups are often outpatient only. Our mammo business is a significant part of our revenues for example. So your facts are way off.

We can argue til the cows come home about this and that. I don’t have time for that anymore. Radiology is better positioned than EM for the future. More than 10 years ago, I predicted three areas that I thought were susceptible to midlevel encroachment (go ahead, do a search). Primary care. Anesthesia. EM. Why? Because there is not a large moat separating you from the midlevel. If the midlevel is taking easier cases than you but essentially doing the same function, they will claim or the MBA’s will think that they’re equivalent to the physician. That’s what the CRNA’s and NP’s have done. To be safe from midlevel encroachment, the midlevel cannot be doing anything close to what the physician is doing. That’s why surgery is safe. I’m not worried about midlevels in radiology either. The biggest threat in radiology is corporate radiology and Wall Street.
 
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bravotwozero said:
The key question is whether the RRC will sign off on HCA's money grubbing residency proposals. If they do, it doesn't matter what a radiology residency requires. Or they can get around the requirements by farming out their residents to tertiary care hospitals for rotations they can't do in house. Which is exactly what has happened with emergency medicine residencies.
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I don’t know how hard it is to open a radiology residency compared to other types. I know in our experience it’s a pain in the ass. I guess if HCA is intent in creating an oversupply of any type of physician they can throw money at it and try to make it happen. You can say that about any primary care field or specialty and that no one is safe. FM? Radiology? Orthopedic surgery? Neurosurgery? While our societies cannot stop HCA from doing this, I would hope that they counteract these attempts by raising the accreditation requirements to make it more difficult to do so. I would argue that certain fields are easier logistically and financially to oversupply than others. For example, it’s a lot easier and cheaper for universities to create law and pharmacy schools than medical schools and hence why the market is oversaturated with them. What does it take to create a residency in FM or EM versus radiology or neurosurgery? Could HCA cobble together a radiology residency by stringing together a dozen hospitals in a dozen states? Probably. Does it make sense financially or logistically? Probably not. Would medical students want to attend such a residency? Probably not. You can follow this by monitoring residency expansion. Which field is expanding fastest and what’s driving it? So far, you can see that radiology has not significantly expanded spots over the past 10 years.
 
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Taurus said:
I don’t know how hard it is to open a radiology residency compared to other types. I know in our experience it’s a pain in the ass. I guess if HCA is intent in creating an oversupply of any type of physician they can throw money at it and try to make it happen. You can say that about any primary care field or specialty and that no one is safe. FM? Radiology? Orthopedic surgery? Neurosurgery? While our societies cannot stop HCA from doing this, I would hope that they counteract these attempts by raising the accreditation requirements to make it more difficult to do so. I would argue that certain fields are easier logistically and financially to oversupply than others. For example, it’s a lot easier and cheaper for universities to create law and pharmacy schools than medical schools and hence why the market is oversaturated with them. What does it take to create a residency in FM or EM versus radiology or neurosurgery? Could HCA cobble together a radiology residency by stringing together a dozen hospitals in a dozen states? Probably. Does it make sense financially or logistically? Probably not. Would medical students want to attend such a residency? Probably not. You can follow this by monitoring residency expansion. Which field is expanding fastest and what’s driving it? So far, you can see that radiology has not significantly expanded spots over the past 10 years.
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I hope Rads and other specialties are immune to this. I have my doubts about any of these societies standing up for docs. All HCA and VC needs to do is line their pockets and they will fall in line.

Once VC/PE takes over Rads and they want to increase profit, lowering Doc pay is one of the easiest way. I don't see much of a barrier to creating Rad residencies but I may be wrong.

Good luck but there are more headwinds than just increased residencies to Radiology. Medicare will cut rates, private will fall in line. Single payer will come in some form. Just like any field, we are at the mercy of our insurers.

If there is money to be made, who controls the pocketbooks makes the rules. There are no docs that owns the pocketbooks/pts.
 
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Taurus said:
I don’t know how hard it is to open a radiology residency compared to other types. I know in our experience it’s a pain in the ass. I guess if HCA is intent in creating an oversupply of any type of physician they can throw money at it and try to make it happen. You can say that about any primary care field or specialty and that no one is safe. FM? Radiology? Orthopedic surgery? Neurosurgery? While our societies cannot stop HCA from doing this, I would hope that they counteract these attempts by raising the accreditation requirements to make it more difficult to do so. I would argue that certain fields are easier logistically and financially to oversupply than others. For example, it’s a lot easier and cheaper for universities to create law and pharmacy schools than medical schools and hence why the market is oversaturated with them. What does it take to create a residency in FM or EM versus radiology or neurosurgery? Could HCA cobble together a radiology residency by stringing together a dozen hospitals in a dozen states? Probably. Does it make sense financially or logistically? Probably not. Would medical students want to attend such a residency? Probably not. You can follow this by monitoring residency expansion. Which field is expanding fastest and what’s driving it? So far, you can see that radiology has not significantly expanded spots over the past 10 years.
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I agree that it's far more difficult to open a rad or any type of surgical specialty as opposed to IM/FM/EM. However, if they (HCA) do, they find plenty of warm bodies (AMG/IMG/FMG) to fill up these spots.
 
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We really need to get PE out of medicine. The conflict of interest is just unbelievable. They are the ones pushing for more non-physician care. In addition, other doctors throwing each other, or in this case an entire specialty, under the bus:

One surgeon at the hospital told Medscape he has no problem with the CRNA model. "It's a misconception that physicians are required to administer anesthesia," Adam Dachman, MD, told Medscape.

www.beckershospitalreview.com

Wisconsin hospital replaces anesthesiologists with CRNAs

Watertown (Wis. ) Regional Medical Center has replaced its anesthesiologists with certified registered nurse anesthetists, and some physicians aren't happy about the change, according to Medscape Medical News.
www.beckershospitalreview.com www.beckershospitalreview.com
 
Taurus said:
Most decent-sized radiology groups have their own imaging centers. My group has 17 of them. The radiology group usually owns the equipment in these imaging centers. We often own the real estate too. Inpatient and ED imaging account for about 50% of our revenues. The other 50% is from outpatient imaging. To get the referrals for the outpatient imaging depends a lot on marketing and developing relationships with the primary care providers and specialists. Some radiology groups have no involvement with hospitals at all. Mammo-only groups are often outpatient only. Our mammo business is a significant part of our revenues for example. So your facts are way off.

We can argue til the cows come home about this and that. I don’t have time for that anymore. Radiology is better positioned than EM for the future. More than 10 years ago, I predicted three areas that I thought were susceptible to midlevel encroachment (go ahead, do a search). Primary care. Anesthesia. EM. Why? Because there is not a large moat separating you from the midlevel. If the midlevel is taking easier cases than you but essentially doing the same function, they will claim or the MBA’s will think that they’re equivalent to the physician. That’s what the CRNA’s and NP’s have done. To be safe from midlevel encroachment, the midlevel cannot be doing anything close to what the physician is doing. That’s why surgery is safe. I’m not worried about midlevels in radiology either. The biggest threat in radiology is corporate radiology and Wall Street.
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What’s to keep PE from muscling into a lucrative market like yours, replacing physicians with physician extenders for the “easy” reads and then gradually increasing their scope of practice? They could also use physician extenders for easy IR procedures (thoracentesis, paracentesis, etc.)? They could then split professional fees with the hospital to subsidize the hospitalists and consolidate the imaging to in house to grab higher facility fees? Low volume hours could use corporate teleradiology services and do away with local docs…
 
Once hospitals realize that CRNAs can do a decent job at 90% of the standard cases, they will start to go from 4:1 to 10:1 model. Anesthesiologist will complain but there will be a line of them wanting to be the 10:1 doc. Where else are they going to go? What else are they going to do?

Atleast for EM, we are able to work in UC, open UCs, FSERs, open a private practice, Wound care, rehab, telemed, etc. Hell, we could open a med spa.

What are anesthesiologist going to do? Their skills are pigeon holed and have no real options.

If you think EM is screwed, watch what will happen to Anesthesiology. You think opening an EM residency is easy, it will be just as easy to open an anesthesiology residency paying the residents 60K vs 200K for a CRNA.
 
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emergentmd said:
Once hospitals realize that CRNAs can do a decent job at 90% of the standard cases, they will start to go from 4:1 to 10:1 model. Anesthesiologist will complain but there will be a line of them wanting to be the 10:1 doc. Where else are they going to go? What else are they going to do?

Atleast for EM, we are able to work in UC, open UCs, FSERs, open a private practice, Wound care, rehab, telemed, etc. Hell, we could open a med spa.

What are anesthesiologist going to do? Their skills are pigeon holed and have no real options.

If you think EM is screwed, watch what will happen to Anesthesiology. You think opening an EM residency is easy, it will be just as easy to open an anesthesiology residency paying the residents 60K vs 200K for a CRNA.
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You think an EP is somehow more qualified to open a med spa or do rehab than an anesthesiologist? For these options that don't require board certification I don't think there is much difference. In fact, anesthesiologists could probably claim a greater procedural skill set.
 
coachB said:
You think an EP is somehow more qualified to open a med spa or do rehab than an anesthesiologist? For these options that don't require board certification I don't think there is much difference. In fact, anesthesiologists could probably claim a greater procedural skill set.
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Med spas can be opened by anyone with a license, take a 6 wk course, and hire a bunch of NPs. My point being anesthesiologist have limited options.

I would go into EM vs anesthesiology if I had to pick between the two for future outlook. They both are beholden to CMGS but atleast an EM doc can work outside the hospital much easier than anesth.
 
Haven't went to anesthesia's forum but they have the same issues/complaints. More CRNAs, CMGs, insurance payments, HCA residencies, etc. Now they have a hospital that is replacing all docs with CRNAs. This will start to be a trend when the CEOs are making their bonuses and looking to make more $$$

Here is a quote from an anesthesiologist, "It’s so hard for me to reconcile the competitiveness of anesthesia in the match with the reality of the job market (flat/declining salaries, more opt out states, proliferation of AMCs, CRNA mills flooding the market with “cheap providers,” etc). My income has dropped each of the 7 years I’ve been in practice.

Absolutely bizarre."

I have a good anesthesiologist friend and I would say my lifestyle is 10x better than his when I was working the Pits 3-5 yrs ago.
 
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MechEDoc said:
What’s to keep PE from muscling into a lucrative market like yours, replacing physicians with physician extenders for the “easy” reads and then gradually increasing their scope of practice? They could also use physician extenders for easy IR procedures (thoracentesis, paracentesis, etc.)? They could then split professional fees with the hospital to subsidize the hospitalists and consolidate the imaging to in house to grab higher facility fees? Low volume hours could use corporate teleradiology services and do away with local docs…
Click to expand...
I’ve discussed this in some prior posts about why. Radiology doesn’t use midlevels like they do in primary care, anesthesia, or ED. We don’t have midlevels who preread for us and then we blindly sign off on their reports without reviewing the images too. If you do, it’s fraudulent and you will go to prison like this fellow. How often do you blindly sign off on the midlevel’s patients without seeing them yourself in EM? It’s sounds like it’s not uncommon practice in EM.


It’s much faster for me to read a plain film, CT, MRI, etc myself than to have a midlevel preread it and then I review the whole study again with them. That’s what residency training involves and you can’t be productive if you do that. For example, I can view a simple chest X-ray and send off the final report within 5 seconds. How is a midlevel going to help me in that case? They don’t. Midlevels are occasionally used to do simple procedures like thoras, paras , LP’s, PICC, etc but they are not doing the complex procedures like embolization or TIPS. For most paras and thoras, it takes me 10 minutes from saying hello to leaving the room. I’m happy to have a midlevel or resident do it for me. Majority of the profits in radiology is in reading the imaging studies and not doing procedures. In some groups, IR is considered a drag because they don’t produce as much daily RVU’s as the radiologist reading the stack of CT and MRI studies. Anyways, my point is that midlevel encroachment is not a concern in radiology.
 
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Taurus said:
Radiology doesn’t use midlevels like they do in primary care, anesthesia, or ED.
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Radiology doesn't use midlevels yet.
 
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From 2021 on, any choice of a medical field where your lifestyle is worse than a bank teller, is a devastatingly bad mistake.

You’ve been warned.

It’s just not worth it anymore.
 
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emergentmd said:
Once hospitals realize that CRNAs can do a decent job at 90% of the standard cases, they will start to go from 4:1 to 10:1 model. Anesthesiologist will complain but there will be a line of them wanting to be the 10:1 doc. Where else are they going to go? What else are they going to do?

Atleast for EM, we are able to work in UC, open UCs, FSERs, open a private practice, Wound care, rehab, telemed, etc. Hell, we could open a med spa.

What are anesthesiologist going to do? Their skills are pigeon holed and have no real options.

If you think EM is screwed, watch what will happen to Anesthesiology. You think opening an EM residency is easy, it will be just as easy to open an anesthesiology residency paying the residents 60K vs 200K for a CRNA.
Click to expand...

emergentmd said:
Haven't went to anesthesia's forum but they have the same issues/complaints. More CRNAs, CMGs, insurance payments, HCA residencies, etc. Now they have a hospital that is replacing all docs with CRNAs. This will start to be a trend when the CEOs are making their bonuses and looking to make more $$$

Here is a quote from an anesthesiologist, "It’s so hard for me to reconcile the competitiveness of anesthesia in the match with the reality of the job market (flat/declining salaries, more opt out states, proliferation of AMCs, CRNA mills flooding the market with “cheap providers,” etc). My income has dropped each of the 7 years I’ve been in practice.

Absolutely bizarre."

I have a good anesthesiologist friend and I would say my lifestyle is 10x better than his when I was working the Pits 3-5 yrs ago.
Click to expand...

None of those are realistic outs for EM and you already know that.

We also have twice as many spots as anesthesia and they have many more outs than us. Even today idiot boomer docs were congratulating themselves on ACGME approving another EM residency in Georgia. We're significantly worse off and it's not even close.

giphy.gif
 
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Birdstrike said:
From 2021 on, any choice of a medical field where your lifestyle is worse than a bank teller, is a devastatingly bad mistake.

You’ve been warned.

It’s just not worth it anymore.
Click to expand...
It's really not worth it. I am 100% exiting from this EM/clinical medicine mess. I just haven't decided when to pull the trigger. I have three entrepreneurial things I will be starting (all different from each other, only one of them is heathcare-ish), but will take some time to get going. I guess I am worried I will feel unproductive if I quit before my other stuff really gets going. I have the savings to peace out of medicine forever, though. Waiting to be pushed past some unknown threshold, I suppose. We'll see what it is.
 
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Cinclus said:
It's really not worth it. I am 100% exiting from this EM/clinical medicine mess. I just haven't decided when to pull the trigger. I have three entrepreneurial things I will be starting (all different from each other, only one of them is heathcare-ish), but will take some time to get going. I guess I am worried I will feel unproductive if I quit before my other stuff really gets going. I have the savings to peace out of medicine forever, though. Waiting to be pushed past some unknown threshold, I suppose. We'll see what it is.
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What's your number? I relatively new this game, young family soon, and already wondering where my lifeboat is...
 
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Rekt said:
None of those are realistic outs for EM and you already know that.

We also have twice as many spots as anesthesia and they have many more outs than us. Even today idiot boomer docs were congratulating themselves on ACGME approving another EM residency in Georgia. We're significantly worse off and it's not even close.

giphy.gif
Click to expand...
 
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Cinclus said:
It's really not worth it. I am 100% exiting from this EM/clinical medicine mess. I just haven't decided when to pull the trigger. I have three entrepreneurial things I will be starting (all different from each other, only one of them is heathcare-ish), but will take some time to get going. I guess I am worried I will feel unproductive if I quit before my other stuff really gets going. I have the savings to peace out of medicine forever, though. Waiting to be pushed past some unknown threshold, I suppose. We'll see what it is.
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I agree on all docs working to have an out. I have been working on this for the past 3 years. I just figured out I could be out tomorrow and not work another day keeping the same life style but my current work is more fun than work; actually working right now.
 
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Rekt said:
None of those are realistic outs for EM and you already know that.

We also have twice as many spots as anesthesia and they have many more outs than us. Even today idiot boomer docs were congratulating themselves on ACGME approving another EM residency in Georgia. We're significantly worse off and it's not even close.
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We just have to disagree. Hospital work has become increasingly more difficult and I likely would open up an UC and have APCs working them. Opening an UC is not that difficult and there are many untapped areas. You will not get rich but I know many friends who have making 30-100K/mo and just managing these places.
 
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Birdstrike said:
I know a guy who had an alcoholic wife he he talked about divorcing. But he never did. His reasoning was, “It would cost me too much.” She eventually drank herself to death, which is what he apparently had banked on. At the funeral he looked all cross-fitted up and had gone from round to super buff at 60. He took his new biceps and pecs, promptly quit EM, and I haven’t heard from him since.
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Um, this was me. Well, except the crossfitty part. And I did divorce him.


Finished paying my 4 years of alimony (which included 3 years of COBRA - I'm not heartless) and he drank himself into his early grave that next year.
The divorce was worth every penny. He was only 36 and I wasn't going to gamble away another decade or four of my own life. I mean, we see the elderly alcoholics who just won't die all the time.
There is a time to cut and run. (And same goes for EM, for that matter. Sometimes the costs are worth it for the mental health.)
 
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dchristismi said:
Um, this was me. Well, except the crossfitty part. And I did divorce him.


Finished paying my 4 years of alimony (which included 3 years of COBRA - I'm not heartless) and he drank himself into his early grave that next year.
The divorce was worth every penny. He was only 36 and I wasn't going to gamble away another decade or four of my own life. I mean, we see the elderly alcoholics who just won't die all the time.
There is a time to cut and run. (And same goes for EM, for that matter. Sometimes the costs are worth it for the mental health.)
Click to expand...

There definitely is a point where you have to pull the scab off and get out of a bad relationship. Time is the most valuable thing in your life, and time spent miserable is wasted.

I have found that alcoholism seems to infer some protective benefits. It gives you +2 elemental resistance, and +4 armor versus blunt trauma.
 
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GeneralVeers said:
There definitely is a point where you have to pull the scab off and get out of a bad relationship. Time is the most valuable thing in your life, and time spent miserable is wasted.

I have found that alcoholism seems to infer some protective benefits. It gives you +2 elemental resistance, and +4 armor versus blunt trauma.
Click to expand...

Yessss.
D&D stats.

You're my favorite variety of nerd.
 
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GeneralVeers said:
Yes, but I rarely used him. My lineup was Fighter/Thief/White Mage/Black Mage

Best part was mid-game when you get "upgraded" and the Thief becomes a Ninja and starts doing major damage.
Also the airship.
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You may not know this: but the programming for the Thief was buggy, resulting in him having none of his reported advantages like luck, initiative, run ability, etc. He truly was useless until after class change.
 
doctalaughs said:
FF1 red mage - see there’s nerds in all specialties.

Man, that was a good game.
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You're either derm or psych if I remember correctly.

"There's nerds in all specialties" honestly made me laugh out loud when I read it. Thanks.
 
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EMhawkeye said:
Why god? Why?
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That's actually going to turn out to be a good program. They see >100k/year. They are about to go for Level I trauma center designation (already have a surgery residency). They've been trying to get approved for a few years now. It's a non-profit health system.
 
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southerndoc said:
That's actually going to turn out to be a good program. They see >100k/year. They are about to go for Level I trauma center designation (already have a surgery residency). They've been trying to get approved for a few years now. It's a non-profit health system.
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True, and they actually meet qualifications to have a residency. The problem is that there simply isn't a need for one new program anywhere in the country. For every proper residency that wants to open, let's close down two garbage HCA/Envision ones.
 
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southerndoc said:
That's actually going to turn out to be a good program. They see >100k/year. They are about to go for Level I trauma center designation (already have a surgery residency). They've been trying to get approved for a few years now. It's a non-profit health system.
Click to expand...

Just because a hospital could be a good training program does not mean it should be. I also think a high volume L2 is much better than L1 since EM runs the show completely instead, but in the end it doesn't matter. They'll have decently trained grads unemployed.
 
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