Splenda88

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We created that mess by thumping our chest and saying "I am the best." Medicine keep asking for more and more from us while other healthcare fields are asking for less and less.

I can not get over that thread where someone who completed 2-year of TY and was not able to get a categorical/advanced position was asking how can move forward and do primary care and the whole army of chest thumping docs were telling this individual: 'try to get into an FM program or just move on with your life if you can't because you will provide substandard care to your patients.' Do physicians take themselves seriously like that? Maybe it's hard for me to understand that mindset since I am a non traditional doc.
 
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Brigade4Radiant

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We created that mess by thumping our chest and saying "I am the best." Medicine keep asking for more and more from us while other healthcare fields are asking for less and less.

I can not get over that thread where someone who completed 2-year of TY and was not able to get a categorical/advanced position was asking how can move forward and do primary care and the whole army of chest thumping docs were telling this individual: 'try to get into an FM program or just move one with your life if you can't because you will provide substandard care to your patients.' Do physicians take themselves seriously like that? Maybe it's hard for me to understand that mindset since I am a non traditional doc.

Yeah can you post a link? SDN is kinda ridiculous. NP's practice primary care all the time but a MD with a two year transitional spot. However if we don't then midlevels will have even more ammo.
 
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Splenda88

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Yeah can you post a link? SDN is kinda ridiculous. NP's practice primary care all the time but a MD with a two year transitional spot. However if we don't then midlevels will have even more ammo.
 

thegenius

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This is called going from depressed to living life again. amazing how marriage can suck the souls out of some people.

See this transformation all the time.

Just imagine all the time and money spent keeping her alive before she drank herself to death, all the trips to the doctor, the ER, hospitalizations, bleeding problems, confusion, etc. (Or maybe none of that ever happened.)
 

thegenius

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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.

Makes sense to me
 

thegenius

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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.

It's funny how people want to leave medicine due to midlevel encroachment, and then they want to start a UC and hire midlevels.

(I'm not critiquing you...I just think it's humorous in a sadistic way)
 
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bronx43

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It's funny how people want to leave medicine due to midlevel encroachment, and then they want to start a UC and hire midlevels.

(I'm not critiquing you...I just think it's humorous in a sadistic way)
That’s because people aren’t mad that midlevels are taking over. They’re just mad that they aren’t the ones who are benefitting from said takeover.
 
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emergentmd

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It's funny how people want to leave medicine due to midlevel encroachment, and then they want to start a UC and hire midlevels.

(I'm not critiquing you...I just think it's humorous in a sadistic way)
Well, at the end of the day this is all a business. Maybe generations ago, medicine was more pure and docs/hospitals opened up to care for people but would be skeptical.

Medicine is like a business just like anything else. Docs are never taught to look at medicine like a business and only see it when forced upon them. If you are not owning something, you are no better than a nurse to the owners. I rather open up something and make the best decisions possible for patient care given the economic restrictions. I would love to staff the UC with FM/ER docs and not worry about clinical care but its unrealistic/economically not viable.
 
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bronx43

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Interesting how entirely wrong white coat investor was.
Honestly, anyone who isn't completely bearish on the entire medical profession is and will be entirely wrong.
 
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blue.jay

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This guy seemed to be a little ahead of the curve...

Lord Humongous..shorted EM residency back in 2015.. Michael Burry of GME predicting job market collapse.

Very Funny how some ppl said they don't see any reason why ED visits can go down because americans love that convenience.
Bam! COVID happened with surge in tele-health people realized they didn't always have to go to the ED plus the rise of midlevels.
 
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sloh

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Interesting how entirely wrong white coat investor was.

All it took was ~5 years for the chickens to come home to roost. No specialty is safe. Get that fu money quick if you can. No compunction.

Absolutely no compunction.


“Mathews said the commission was "cognizant of the fact that clinicians, like the rest of us, do experience year-over-year inflation in the cost of living, which does involve the cost of running a practice.” —CMS also doesn’t care about us.
 
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Splenda88

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Anyone here working for BJC healthcare.

How is it like working for them?
 

bronx43

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All it took was ~5 years for the chickens to come home to roost. No specialty is safe. Get that fu money quick if you can. No compunction.

Absolutely no compunction.


“Mathews said the commission was "cognizant of the fact that clinicians, like the rest of us, do experience year-over-year inflation in the cost of living, which does involve the cost of running a practice.” —CMS also doesn’t care about us.
This is the most likely outcome. Inflation ramps up significantly over next few years/decade, while physicians see significant decrease in real income. And this isn't even factoring in the fact that increasing labor/input costs will lead to hospital administrators (who will keep their own incomes at inflation-adjusted levels) further putting downward pressure on physician compensation.

Already in bigger cities (and diffusing into smaller/mid-size cities), younger physicians are finding it difficult to purchase homes. Just wait until price of everyday goods and services skyrocket...
 
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BoardingDoc

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Lord Humongous..shorted EM residency back in 2015.. Michael Burry of GME predicting job market collapse.

Very Funny how some ppl said they don't see any reason why ED visits can go down because americans love that convenience.
Bam! COVID happened with surge in tele-health people realized they didn't always have to go to the ED plus the rise of midlevels.
Rise of midlevels and churning out a bunch more docs than needed yes. That said, our ED volume is basically back to pre-covid numbers and rising again. Not sure about others.
 
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maxxor

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Already in bigger cities (and diffusing into smaller/mid-size cities), younger physicians are finding it difficult to purchase homes. Just wait until price of everyday goods and services skyrocket...
True for me. Impossible to find anything in my area with a reasonable commute that isn’t absurdly expensive.
 
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wamcp

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Interesting how entirely wrong white coat investor was.
Crazy that was like 5 years ago. Must suck for any MS3 and MS4 at the time who saw the thread, and felt reassured, and then went into EM...
 
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bravotwozero

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Rise of midlevels and churning out a bunch more docs than needed yes. That said, our ED volume is basically back to pre-covid numbers and rising again. Not sure about others.
Yeah volume wise we're back to normal. APP even went back to their pre-covid staffing hours/ratios at all of our sites.
 
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bravotwozero

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That’s good to hear. Are you guys single coverage with midlevels or did they bring back all the doc hours too?
One of our shops is. Midlevel and doc hours have mostly been brought back, except weekends where we have historically lower volumes.
 

qwerty89

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Unclear if this is an EM program or not but its a perfect example of the quality of HCA residencies

 

miacomet

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No. They are recommending...opening more slots in rural areas, telehealth, correctional medicine, proceduralist. They are not in contact with reality. And they say they can't cut slots due to anti-trust regulations.
We are completely screwed, and I am angry at myself for not having picked a real field. I always thought EM was full of shysters, and now I've been shystered.
 
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sum dude

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No. They are recommending...opening more slots in rural areas, telehealth, correctional medicine, proceduralist. They are not in contact with reality. And they say they can't cut slots due to anti-trust regulations.
We are completely screwed, and I am angry at myself for not having picked a real field. I always thought EM was full of shysters, and now I've been shyste
B/C THEY CANT CUT SLOTS...that's true. For as much as people want to bash ACEP, they do know what they are talking about in this--it is absolutely anti-trust. The market flooded b/c HCA and other medical centers planned this. Your academic centers want this--increase supply lowers their physician costs. APP oversupply gives them a new revenue stream and even cheaper labor. Did ACEP enable some of this w/ CMG's..absolutely...CMG's were their top Funders. ACEP has to pay the bills too. Can AAEM fix this? LOL, no--they don't have a quarter of the influence in Washington that DC has. It's naive to think ACEP can fix this...in truth today's EM doctors under 40 were hosed by previous docs (both CMG and SDG's that sold out), hospitals, businesses, academic centers, etc.

Face it everyone here...MEDICINE IS A BUSINESS. Everyone for themselves. Go watch Wall Street or read a business book--no one gives a rip about top quality, they just want affordable and moldable employees so that they can institute algorithm led care for least amount of costs. The only shot you have is to fight business mentality w/ new a better business mentality. The sooner EM physicians realize they have to divorce themselves from hospital-contracts, the better they'll be. Start a DPC w/ other doctor fields, better tele-medicine model, or hell fight Stark and open a physician led hospital. But don't go crying to ACEP, who don't have the power or ability to fight the 1000lb Insurer and Hospital gorillas who now call the shots in Washington.
 
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Spikebd

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No. They are recommending...opening more slots in rural areas, telehealth, correctional medicine, proceduralist. They are not in contact with reality. And they say they can't cut slots due to anti-trust regulations.
We are completely screwed, and I am angry at myself for not having picked a real field. I always thought EM was full of shysters, and now I've been shystered.
Why couldn’t an EM doc just start working at a primary care clinic? It seems normal to me for EM to slide over there if midlevels and execs push docs out.
sports med?
Urgent care?

I do think it’s a little ironic that guys like Panda Bear MD used to post a lot about how a lot of Emergency patients don’t actually need emergency care. “Be careful what you wish for...”
 
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VA Hopeful Dr

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Why couldn’t an EM doc just start working at a primary care clinic? It seems normal to me for EM to slide over there if midlevels and execs push docs out.
sports med?
Urgent care?

I do think it’s a little ironic that guys like Panda Bear MD used to post a lot about how a lot of Emergency patients don’t actually need emergency care. “Be careful what you wish for...”
With a bit of studying, you probably could.

Finding someone to hire you would be tricky but not impossible.
 
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thegenius

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Why couldn’t an EM doc just start working at a primary care clinic? It seems normal to me for EM to slide over there if midlevels and execs push docs out.
sports med?
Urgent care?

I do think it’s a little ironic that guys like Panda Bear MD used to post a lot about how a lot of Emergency patients don’t actually need emergency care. “Be careful what you wish for...”

ER does aren't trained to do primary care. This is nonsense.
 
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Rekt

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And you can bet they made the numbers look as good as possible. Am I done being "the" doomer yet
 
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clibby

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Reading between the lines, I heard that we can't cut slots for workforce issues due to anti-trust regulations; which is entirely valid. However, if we raise the bar for what the minimum requirements are to be an emergency medicine trained physician and therefore the minimum requirements for a residency training program, than many programs will not be able to meet those standards.

For example:
1. Raise the minimum procedure numbers with no simulation. i.e. 50-75 intubations IN THE ED, 50+ CVL, 20+ chest tubes, no simulated pediatrics, 20+ dislocation reductions, etc.
2. Tie the number of spots per year to the volume at the home institution. Only include secondary institutions with a waiver that requires a good academic justification.
3. Require that the home institution be a STEMI/Stroke/Trauma center
4. No concurrent midlevel training program in the same department as a residency

Many programs will have to close, including some established programs, and others will have to cut resident spots per year, but the quality will go up, patients will get better doctors who may be able to be trained in doing more (dialysis lines, nerve blocks, ECMO, etc.) and the market will be stabilized.
 
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miacomet

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Agreed. Is there the willpower to do this? So many are literally invested in opening residencies.

I really like your thoughts, and honestly EM residencies vary hugely in quality, not just HCA. How many programs can really be served by Shock Trauma and other Level I trauma centers that are just flooded?
Agreed procedures at many places are all sim now, and that grads are not as practiced as they should be.

I agree with your suggestions, and also would suggest extending training to five years, like Canada.
 

maxxor

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Reading between the lines, I heard that we can't cut slots for workforce issues due to anti-trust regulations; which is entirely valid. However, if we raise the bar for what the minimum requirements are to be an emergency medicine trained physician and therefore the minimum requirements for a residency training program, than many programs will not be able to meet those standards.

For example:
1. Raise the minimum procedure numbers with no simulation. i.e. 50-75 intubations IN THE ED, 50+ CVL, 20+ chest tubes, no simulated pediatrics, 20+ dislocation reductions, etc.
2. Tie the number of spots per year to the volume at the home institution. Only include secondary institutions with a waiver that requires a good academic justification.
3. Require that the home institution be a STEMI/Stroke/Trauma center
4. No concurrent midlevel training program in the same department as a residency

Many programs will have to close, including some established programs, and others will have to cut resident spots per year, but the quality will go up, patients will get better doctors who may be able to be trained in doing more (dialysis lines, nerve blocks, ECMO, etc.) and the market will be stabilized.
Who exactly is on the RRCs for the various specialities and how does one get on them?

I’ve thought for a long time that the radiology requirements are *too* low. Perhaps I should start agitating to have those raised.
 

sum dude

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ER does aren't trained to do primary care. This is nonsense.
What do you think a lesser trained APP does? EM this year, ortho next, maybe derm next year. The only good? thing that will come out of this is that outpatient clinic boards won't matter much in 10 years or so. Not great for quality, but probably good for some others pocket books.
 
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I imagine the oversupply issue will also face at least anesthesia, IM, general surgery, and psychiatry soon. HCA has tons of spots in these residencies and plans on continuously opening more...
 
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miacomet

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Not sure about gen surg, but it's possible.
I would add FP, rads, maybe peds, rad onc, ob-gyn....
 

Alvarez13

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Backpack234

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If increases the standards for residency programs is anticompetitive, isn't it anticompetitive to have standards at all? What's stopping Backpacks Hospital Shack that sees 10 patients per year from opening its own ER residency program? If they refuse to allow it, that's anticompetitive!
 
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Rekt

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If increases the standards for residency programs is anticompetitive, isn't it anticompetitive to have standards at all? What's stopping Backpacks Hospital Shack that sees 10 patients per year from opening its own ER residency program? If they refuse to allow it, that's anticompetitive!
I feel like everyone just echos "anti-trust!!!!!!!" without any actual knowledge. Can anyone smarter than my small pea brain comment on what this means truly and why we cannot just say to stop opening, etc
 

emergentmd

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There is almost nothing docs in any field can do to stop the inevitable takeover of medicine by corporate and eventual single payer system.

Lobbyist are what makes laws and unless you have tens of millions to line the pockets like these Billion Dollar companies, there is no way docs can have any power short of striking and I doubt anyone will risk their 300K jobs.

EVERY field is vulnerable and the ones who think they are not vulnerable just do not know it yet.

Unless you are a cash pay field outside of the insurance web, you ARE vulnerable.

Imagine you are a dermatologist who spent 5 yrs building up their practice and able to sit back collecting $$$ while hiring 5 more dermatologist. What will happen if BCBS who is 75% of your patients suddenly gives the dermatologist this ultimatum. Take a 50% cut in reimbursement or be out of network.

This has happened to some practices I know of and there is NOTHING the docs can do.

There are no wiser words to make your money, be your own boss. I tell all docs to spend their money and create a business outside of medicine. You have the $$$$, you are smart, just take some risks.
 
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cyanide12345678

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Crazy that was like 5 years ago. Must suck for any MS3 and MS4 at the time who saw the thread, and felt reassured, and then went into EM...

Yeah i think i remember that thread. I was a 3rd year in early 2015 so had just started to finalize that decision. The idea of a shortage was novel at the time. Every ER doctor you talked to bragged about how they got 50+ emails for jobs and they could get a job posting 300/hr tomorrow if they wanted. EM has been good to me so far. How the tide has changed in just 5-6 years.
 
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