EM Future

[bravotwozero]

Those are good points. TBH, I don’t have an intimate enough knowledge of other healthcare systems to comment much on this. My question is, is the need for midlevels actually so great in the US?

Need for midlevels, no. Desire for lots of profit by cutting costs, you betcha. That's why we have them.

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[gamerEMdoc]

You are usually an optimist...thoughts now?

I stand by the data that ACEP presented, which is what I've said before. I think the oversupply is a definite concern in the longrun. I think the issues we are seeing with jobs right at the moment are secondary to COVID.

 

[gamerEMdoc]

Hm i was wrong about MS4 EM demand dropping. I was thinking it'd follow the radonc recent decline but looks unlikely.

I need to revisit the posted slides and earlier discussions but how likely is forcing EM programs to take in fewer interns? And thus make EM artificially more competitive and selective to sort out the saturation issues. Closing EM programs looks unlikely

Closing or even stopping new programs from opening is going to be very tricky. Get into trust lawsuits quickly I'd imagine.

 

[gamerEMdoc]

I think there will be many EM spots in the SOAP next year. Do you really think programs will not fill their slots just because an applicant in the SOAP does not have a SLOE?

Don't be so certain. Again, even if 10% of students decide to do something else, it won't make a dent in programs filling their spots. And even if more competitive students decide not to apply, there will be people who otherwise wouldn't have applied who now see that opportunity. I don't think we are anywhere close yet to seeing programs struggling to fill their spots in any kind of meaningful way.

It's going to take several years for peoples career aspirations to change for there to be a dramatic enough shift. I don't think less students applying is going to fix this problem anytime soon.

 

[VA Hopeful Dr]

Those are good points. TBH, I don’t have an intimate enough knowledge of other healthcare systems to comment much on this. My question is, is the need for midlevels actually so great in the US?

So great being a bit vague I can't say, but there is a need.

The anesthesia forum talks about this every so often. There are places that would love to be MD only but can't find enough people to sit in chairs to pull that off.

 

[coachB]

This is exactly what I’m seeing in close friends who are pursuing EM for the match next year. I abandoned EM and anesthesia both as options. The writing is on the wall and I don’t want to be the one taking on that uphill battle.

Remind me again, why the hell do we have midlevels at all when other countries get by just fine without them?

Because ours is just about the only country where making money is the first priority in health care delivery.

 

[xaelia]

So – yes to "rationing care" other countries in an explicit sense, rather than just an "unanticipated consequence" of for-profit medicine. It does not quite extend to telling folks to bugger off when they come to the ED for their jammed ?fractured finger, but manifests more overtly in wait times and a high-bar for specialist/technology referrals for other medical issues (joint replacements, rheumatology/gastroenterology, MRIs, specialty drugs etc.). The idea is still to provide the level of care in the ED you'd hope a family member would receive (because, well, it will probably happen eventually!)

As far as "how do other countries get on without midlevels", and the answer is ... they don't, necessarily? Just because the system isn't for-profit doesn't mean they don't likewise recognise the lack of value-add from a physician seeing each and every patient. We have plenty of APPs with varying level of scope working in "fast track" portions of our ED, as well (not to mention the whole house officer/registrar aspect of much of acute care across Australasia + British models of care, which are clearly less expensive than board-certified folks).

I don't think there's any future in trying to prop up demand for ED physicians – gotta hit it on the supply side through whichever means are legal to reduce the number of annual graduates. Things will have to have already gone to total hell before the EM spots don't fill to capacity through the match.

 

[Birdstrike]

Med students in general
are also naive. I was the same way. Even if someone told me EM was collapsing, I still woulda followed my path. I mean were all unique and special and “ill find a job!” “I wont be that guy” etc etc. Too many med students when I bring up the issues say the same things “ cant see myself doing anything else” “ id do EM for 100/hr” etc etc etc.

EM will still fill for years to come.

I was the same way: Naive, seeking my “passion” and goal to “save lives” and “help people.” I ignored the Paul Revere’s of EM and what I find instead was tiny dash of my idealistic vision of EM melted away into a large, bubbling vat of pungent reality.

 

[RustedFox]

I was the same way: Naive, seeking my “passion” and goal to “save lives” and “help people.” I ignored the Paul Revere’s of EM and what I find instead was tiny dash of my idealistic vision of EM melted away into a large, bubbling vat of pungent reality.

Me three.

 

[Rekt]

Med students in general
are also naive. I was the same way. Even if someone told me EM was collapsing, I still woulda followed my path. I mean were all unique and special and “ill find a job!” “I wont be that guy” etc etc. Too many med students when I bring up the issues say the same things “ cant see myself doing anything else” “ id do EM for 100/hr” etc etc etc.

EM will still fill for years to come.

I was the same way: Naive, seeking my “passion” and goal to “save lives” and “help people.” I ignored the Paul Revere’s of EM and what I find instead was tiny dash of my idealistic vision of EM melted away into a large, bubbling vat of pungent reality.

Me three.

I think you probably don't give yourself enough credit. This is a very unique situation. In the past it was doom and gloom from maybe some occasional residents, some random attendings you chat with, some more things voiced on SDN.

This is legit hard data from the leading organization of the specialty stating there's a severe oversupply issue. If I saw this from ACEP in my 4th year of med school, there is 100% chance I would have switched and I was 100% dead on EM like many of us (prior scribe for years, only liked EM, etc).

My hope is medical students take this data extremely seriously for their own sake as the solutions from acep are beyond laughable.

 

[kuzy]

I think you probably don't give yourself enough credit. This is a very unique situation. In the past it was doom and gloom from maybe some occasional residents, some random attendings you chat with, some more things voiced on SDN.

This is legit hard data from the leading organization of the specialty stating there's a severe oversupply issue. If I saw this from ACEP in my 4th year of med school, there is 100% chance I would have switched and I was 100% dead on EM like many of us (prior scribe for years, only liked EM, etc).

My hope is medical students take this data extremely seriously for their own sake as the solutions from acep are beyond laughable.

They won't. N=1 here as an M2 (who was also dead set on EM at the start), but in the lab the other day I was telling my friends about everything and how none of us should apply to EM, when one of them legit said "I don't care EM is all I can see myself doing, and honestly if people back out that's just one less applicant to compete with" She also spoke with the PD of our school's EM residency about it when he was teaching us and he blamed the job market on COVID, which is just willful ignorance at this point.

 

[blue.jay]

Other countries: ration care, don't go to the doctor with every jammed finger and sore throat that they woke up with literally that day, don't have our malpractice environment/EMTALA/satisfaction scores so doctors there can say "there's nothing wrong with you, go home".

I'm sure there's more but those are the big ones.

In many countries around the world, Registrars/Medical officers who staff ER/casualty are non-residency trained medical school mbbs grads. They triage pts as medical vs surgical for admission and do basic urgent care stuff much like PA/NP. US is the only country to have a robust EM training and own board certification/speciality but seems like US healthcare system is drifting to third world country style by having these NP/PA click on bunch of order sets, scan whatever part of the body the patient complains, give a dose of vanc/zosyn for anyone with any infection and admit generously thereby minimizing the value of residency training. The true value of the training dealing with very sick patients, STEMI, cardiac arrest doesn‘t happen too regularly to justify staffing ED with fully MDs and that’s how the midlevel encroachment started.

 

[miacomet]

In many countries around the world, Registrars/Medical officers who staff ER/casualty are non-residency trained medical school mbbs grads. They triage pts as medical vs surgical for admission and do basic urgent care stuff much like PA/NP. US is the only country to have a robust EM training and own board certification/speciality but seems like US healthcare system is drifting to third world country style by having these NP/PA click on bunch of order sets, scan whatever part of the body the patient complains, give a dose of vanc/zosyn for anyone with any infection and admit generously thereby minimizing the value of residency training. The true value of the training dealing with very sick patients, STEMI, cardiac arrest doesn‘t happen too regularly to justify staffing ED with fully MDs and that’s how the midlevel encroachment started.

Canada, NZ, and Aus, too, UK to some degree

 

[alpinism]

I've been staying we need to raise the residency standards for years and hopefully this will lead to some positive change.

That being said you'd be surprised how many well known established programs couldn't even meet the most basic requirements.

Let's take the 10,000 patients a year per resident in each class at the primary teaching hospital suggestion:

Probably 50% of all the current programs would have to cut spots or close their programs.

Here's a perfect example:

Maryland's residency matches 15 residents per year at their program.

Their primary teaching hospital currently only sees 40,000 patients.

Based on the numbers they would be required to close their program.

 

[miacomet]

Residency standards for EM are a mess, I agree.

I'm curious as to what how academic EM docs are advising students, and if their programs have plans for the inevitably unemployed docs they will graduate. Any thoughts or insight @gamerEMdoc?

 

[Taurus]

Do these not qualify?

Graduate Medical Education Programs at HCA Healthcare

HCA offers innovative, high-quality graduate medical education programs.

hcahealthcare.com

Looks like the smallest program (Trinity) has 10 radiology faculty. I'm not sure when they opened, but it looks like they have 4 residents, so it must have been within the last 2 years.

Edit:
Additionally, if you include "Diagnostic Radiology" with "Radiology" it includes MountainView Hospital in Nevada. It looks like both Trinity and MountainView both have opened in the last 2 years.

That's interesting info. The question I have is, are these radiology residencies spots funded traditionally by Medicare or is HCA funding them wholly? Is the HCA hospital just an affiliate/partner institution that outside residents rotate through? For example, they list Tulane Medical Center in New Orleans. I'm guessing that Tulane Medical Center and its radiology residency are probably owned by Tulane University School of Medicine and not by HCA? The other listed programs are tiny, based in small community hospitals, and probably not very good. Many of them are probably DO-based programs. My group is highly unlikely to hire any graduates from such programs.

Take a closer look at the booklet that lists all of the HCA residencies and fellowships (starting at page 14). It not only includes radiology and EM but other desirable specialities like derm, ENT, orthopedic surgery, neurosurgery, vascular surgery, plastic surgery, cardiology, and GI.

Trinity Radiology

This interactive flipbook is created with FlippingBook, a service for streaming PDFs online. No download, no waiting. Open and start reading right away!

online.flippingbook.com

Combined, all HCA hospitals have the financial resources, infrastructure, network, and volume to create whatever residencies and fellowships they want. Our respective medical societies need to make sure that the accreditation requirements are high enough to deter for-profit entities like HCA from easily creating residencies and fellowships at each tiny community hospital it owns. Make it so financially and logistically painful for HCA to open one so that they have to really want it based on real need instead of financial/market control reasons. This is how you prevent HCA from flooding and controlling the market.

 

[namethatsmell]

Combined, all HCA hospitals have the financial resources, infrastructure, network, and volume to create whatever residencies and fellowships they want. Our respective medical societies need to make sure that the accreditation requirements are high enough to deter for-profit entities like HCA from easily creating residencies and fellowships at each tiny community hospital it owns. Make it so financially and logistically painful for HCA to open one so that they have to really want it based on real need instead of financial/market control reasons. This is how you prevent HCA from flooding and controlling the market.

Quoting for interwebs posterity another spot-on way to combat the corporate destruction of medicine.

The two best ways to stop the likes of HCA in their tracks are 1) take away their profit/put them in the red >>>>> 2) create laws to contain them.

 

[miacomet]

My guess is that nothing can or will stop HCA. I mean, capitalism is religion here; why shouldn't a for-profit be able to open residencies, flood the market, and lower salaries?

 

[namethatsmell]

My guess is that nothing can or will stop HCA. I mean, capitalism is religion here; why shouldn't a for-profit be able to open residencies, flood the market, and lower salaries?

While they certainly seem like the unstoppable 800lb gorilla in the room, so too did Standard Oil, Enron, Lehman Brothers/Bear Stearns...until they weren't.

 

[GeneralVeers]

While they certainly seem like the unstoppable 800lb gorilla in the room, so too did Standard Oil, Enron, Lehman Brothers/Bear Stearns...until they weren't.

Don't forget Enron. Thr comparison with Envision is apt.

 

[Tipsy McStagger]

Don't forget Enron. Thr comparison with Envision is apt.

Couldn't help myself...

 

[GeneralVeers]

Couldn't help myself...

View attachment 334764

Hah hah love your name BTW. It's from a Simpsons drunk driver's ed video if I remember correctly.

 

[Tipsy McStagger]

Hah hah love your name BTW. It's from a Simpsons drunk driver's ed video if I remember correctly.

haha thanks. Yep it's from the flaming moe's episode. The company that is going to pay for the flaming homer until Homer gives it away for free as a result of his psychosis.

 

[miacomet]

There goes radiology:

American College of Radiology backs bipartisan push to address ‘alarming’ resident physician shortages

Lawmakers recently introduced the Resident Physician Shortage Act of 2021 to address doc shortfalls by bolstering the number of Medicare-supported residency positions.

www.radiologybusiness.com

 

[sylvanthus]

Dont worry midlevels would be happy to fill that gap in radiology.

 

[bravotwozero]

There goes radiology:

American College of Radiology backs bipartisan push to address ‘alarming’ resident physician shortages

Lawmakers recently introduced the Resident Physician Shortage Act of 2021 to address doc shortfalls by bolstering the number of Medicare-supported residency positions.

www.radiologybusiness.com

Is every professional organization of every specialty in this country run by a bunch of complete tools?

 

[Kuratz]

Is every professional organization of every specialty in this country run by a bunch of complete tools?

*Sell-outs.
They don’t care about the profession if it means making a quick buck.

I try to be as active as possible in this kind of stuff and have spoke with ACR leaders on this topic specifically so it’s very disappointing when they throw the profession under the rug. We absolutely need to get the ACGME to not allow for-profit hospitals to sponsor residency programs. It’s a huge conflict of interest. Their foremost responsibility is to shareholders first, which is at odds with not only physicians but patients too, but I digress. This is the only way I can see helping a lot of fields with one broad stroke.

 

[ace_inhibitor111]

There goes radiology:

American College of Radiology backs bipartisan push to address ‘alarming’ resident physician shortages

Lawmakers recently introduced the Resident Physician Shortage Act of 2021 to address doc shortfalls by bolstering the number of Medicare-supported residency positions.

www.radiologybusiness.com

Every news source cites the AAMC’s bull**** data report ”shortage of up to 121,000.” Not only is it based on the same non-peer-reviewed bad data, they always cite the highest possible shortage even though the mean scenario according to the report is 20-40,000 (less than 5% of the total physician population). Meanwhile, independent sources such as the BLS and HRSA all estimate a surplus of doctors in the next 5-10 years.

 

[Apollyon]

Good sign: "Will Work For Food".

Bad sign: "Need Help. God Bless."

 

[clibby]

The problem is that we do need more primary care docs. Getting in can take months in some areas. However, we don't need more EM, RadOnc, or CT surgery docs. It's a distribution problem more than a total numbers problem.

 

[miacomet]

An Open Letter to the Specialty of Emergency Medicine | AAEM Resident and Student Association

The American Academy of Emergency Medicine Resident and Student Association (AAEM/RSA) is a non-profit professional association for emergency medicine residents and medical students.

www.aaemrsa.org

The person who wrote this has no clue about the law.

 

[vm26]

*Sell-outs.
They don’t care about the profession if it means making a quick buck.

I try to be as active as possible in this kind of stuff and have spoke with ACR leaders on this topic specifically so it’s very disappointing when they throw the profession under the rug. We absolutely need to get the ACGME to not allow for-profit hospitals to sponsor residency programs. It’s a huge conflict of interest. Their foremost responsibility is to shareholders first, which is at odds with not only physicians but patients too, but I digress. This is the only way I can see helping a lot of fields with one broad stroke.

Funny there is a new post on the ACRs internal forum "Engage" with a link leading to an open letter from AAEM/RSA which raises several issues including ED saturation with predicts surplus of ED physicians of about 10K by 2030. I was not aware of the ACR's agenda. I always struggle with renewing my ACR membership. Their agenda is completely out of touch for the average rad, however there are no other options for advocacy (my understanding is that RADPAC is essentially ACR). Totally deflating. Between CMS cuts and this nonsense, theres' no doubt in my mind that this is part of a bigger picture to completely strip physicians of any power. Really time to unionize (as that letter suggests).

https://www.aaemrsa.org/UserFiles/file/FINAL_Official_AnOpenLettertotheSpecialtyofEmergencyMedicine.pdf

 

[Birdstrike]

Funny there is a new post on the ACRs internal forum "Engage" with a link leading to an open letter from AAEM/RSA which raises several issues including ED saturation with predicts surplus of ED physicians of about 10K by 2030. I was not aware of the ACR's agenda. I always struggle with renewing my ACR membership. Their agenda is completely out of touch for the average rad, however there are no other options for advocacy (my understanding is that RADPAC is essentially ACR). Totally deflating. Between CMS cuts and this nonsense, theres' no doubt in my mind that this is part of a bigger picture to completely strip physicians of any power. Really time to unionize (as that letter suggests).

https://www.aaemrsa.org/UserFiles/file/FINAL_Official_AnOpenLettertotheSpecialtyofEmergencyMedicine.pdf

Absolutely. I've been saying this for years and the typical response I get from physicians is, "But it's illegal." And they haven't spent 30 seconds to even start researching it.

It is 100% legal for physician employees, if employed by a private, state or country employer, to unionize. Yet, the typical response you'll get from docs is, "Wait. Wut?"

I need hear a lot more, "Fight the power!" than "Uh...wut?" coming from docs, before I'll expect meaningful change to happen in my work-lifetime.

 

[RustedFox]

Absolutely. I've been saying this for years and the typical response I get from physicians is, "But it's illegal." And they haven't spent 30 seconds to even start researching it.

It is 100% legal for physician employees, if employed by a private, state or country employer, to unionize. Yet, the typical response you'll get from docs is, "Wait. Wut?"

I need hear a lot more, "Fight the power!" than "Uh...wut?" coming from docs, before I'll expect meaningful change to happen in my work-lifetime.

So how do we stop them from classifying us as 1099/ICs? Because to be an employee, we need to be designated as such.

Not being argumentative. Seriously asking.

 

[Birdstrike]

So how do we stop them from classifying us as 1099/ICs? Because to be an employee, we need to be designated as such.

Not being argumentative. Seriously asking.

I think you just realized how cunningly smart the people running CMGs are.

 

[miacomet]

So how do we stop them from classifying us as 1099/ICs? Because to be an employee, we need to be designated as such.

Not being argumentative. Seriously asking.

My guess is a lot of this characterization is mostly illegal. Do you have to show up at a certain time? Work a certain amount? These all point to being employed, not a contractor. But physicians never fight it.

 

[Birdstrike]

They can either:

1) Hire you as an employee and you can fight back together, collectively bargaining with Marvel-hero power, tens of thousands strong, or

2) Get you to agree to work as a "self" employed doc, an anemic collective of one, with no recourse but to quit.

Which choice did the business people make?

Show this post to most docs and they'll look at you with a blank stare.

We, as physicians, are no match for these people in our current state.

cc: @RustedFox

 

[miacomet]

Physicians lack critical thinking skills in many ways....

 

[GeneralVeers]

We are W2 with the big CMG but it's something of a unicorn contract for them. Most are 1099 with no benefits. Even still, there is no due process despite being "employed". It's a simple 90 day out with no cause. If they want you gone badly enough, they can manufacture cause and get you off shifts immediately.

 

[bravotwozero]

We are W2 with the big CMG but it's something of a unicorn contract for them. Most are 1099 with no benefits. Even still, there is no due process despite being "employed". It's a simple 90 day out with no cause. If they want you gone badly enough, they can manufacture cause and get you off shifts immediately.

Yeah, I'm not sure how well unionizing works in a 'right to work' state where you can always find a non union scab to work in a pinch..

 

[miacomet]

Boom.

Physician Collects $26 Million After Litigation Over Inadequate E.R. Staffing Finally Ends

The original $29 million award was one of the biggest jury awards in Missouri in 2018.

www.kcur.org

 

[bravotwozero]

I actually posted that article in a thread back in 2018, didn't garner as much attention. But yeah, occasionally the little guy wins. In another related story, a group of Cardiologists also just won $10 million in a wrongful termination suit against Tenet health, who owns and runs Detroit Receiving Hospital.

 

[turkeyjerky]

So how do we stop them from classifying us as 1099/ICs? Because to be an employee, we need to be designated as such.

Not being argumentative. Seriously asking.

I think there was actually a case in Texas regarding this and I think the docs were successful in obtaining standing as employees with the right to unionize. McNamara posted on facebook about it a while back. The 1099 vs W2 thing is really more of a tax issue than a true designation regarding the right to unionize, which would be determined by the labor review board.

 

[oldtown]

Boom.

Physician Collects $26 Million After Litigation Over Inadequate E.R. Staffing Finally Ends

The original $29 million award was one of the biggest jury awards in Missouri in 2018.

www.kcur.org

Now THAT’s an exit strategy.

 

[Brigade4Radiant]

The vast majority of CMG contracts are independent contractors in fact this EMGs have an actually lobby certain states like Tennessee where it’s against the law to classify us asemployees so they can staff the emergency department.

 

[maxxor]

That's interesting info. The question I have is, are these radiology residencies spots funded traditionally by Medicare or is HCA funding them wholly? Is the HCA hospital just an affiliate/partner institution that outside residents rotate through? For example, they list Tulane Medical Center in New Orleans. I'm guessing that Tulane Medical Center and its radiology residency are probably owned by Tulane University School of Medicine and not by HCA? The other listed programs are tiny, based in small community hospitals, and probably not very good. Many of them are probably DO-based programs. My group is highly unlikely to hire any graduates from such programs.

Take a closer look at the booklet that lists all of the HCA residencies and fellowships (starting at page 14). It not only includes radiology and EM but other desirable specialities like derm, ENT, orthopedic surgery, neurosurgery, vascular surgery, plastic surgery, cardiology, and GI.

Trinity Radiology

This interactive flipbook is created with FlippingBook, a service for streaming PDFs online. No download, no waiting. Open and start reading right away!

online.flippingbook.com

Combined, all HCA hospitals have the financial resources, infrastructure, network, and volume to create whatever residencies and fellowships they want. Our respective medical societies need to make sure that the accreditation requirements are high enough to deter for-profit entities like HCA from easily creating residencies and fellowships at each tiny community hospital it owns. Make it so financially and logistically painful for HCA to open one so that they have to really want it based on real need instead of financial/market control reasons. This is how you prevent HCA from flooding and controlling the market.

HCA has bought some academic hospitals (Tulane and I think 1 in Georgia) so the medical school becomes a joint venture between the academic instruction and HCA. It’s sort of like the quasi relationship when a medical school has multiple hospitals (Harvard most notably is like this).

For those hospitals, HCA can claim they provide those residencies, because they do.

After having read through their GME website, I think the residencies at real places were the residencies in existence when a formerly academic hospital was taken over and are probably Medicare funded. However, I do think they have learned from the academic places how to grease the ACGME wheels to open new residencies in abysmal locations which are entirely HCA funded.

that Las Vegas residency is staffed by a Private Equity practice and it’s across 3 medium sized hospitals.

It’s not encouraging to be honest that they are pursuing this in Radiology, even in the early stages. I encourage you to look up the RRC case minimums for us. It’s a joke. I almost had them all by end of R1.

 

[RustedFox]

The vast majority of CMG contracts are independent contractors in fact this EMGs have an actually lobby certain states like Tennessee where it’s against the law to classify us asemployees so they can staff the emergency department.

Its against the law in TN to classify us as W2 employees?

 

[MedLife20]

MS1 here. Well damn. Guess I will scratch EM off my list. Maybe anesthesiology too. How disappointing. At least I got some years to see how things will shake out. Do you think there is any hope for EM or is this specialty screwed?

 

[Monster-Mormon]

MS1 here. Well damn. Guess I will scratch EM off my list. Maybe anesthesiology too. How disappointing. At least I got some years to see how things will shake out. Do you think there is any hope for EM or is this specialty screwed?

For real, I'm a MS1 as well and EM is basically what I have envisioned myself doing my whole life. Going through forums it's tough to see a field where they aren't pessimistic about their future. Rads, Anesthesia, Nephrology, EM, Rad Onc, etc. Like Derm or bust I guess.

 

[bravotwozero]

MS1 here. Well damn. Guess I will scratch EM off my list. Maybe anesthesiology too. How disappointing. At least I got some years to see how things will shake out. Do you think there is any hope for EM or is this specialty screwed?

In the near future it certainly looks like we're toast. But like @emergentmd stated, none of us have a crystal ball to look for unforeseen events. Five years ago, this was unthinkable. Maybe other events can happen and alter the course of our profession in a more positive direction. You just don't know. Regardless, your concerns are well founded, and I think you'd do well to heed the oft given advice here to go into a specialty where you get to own your job, and remain outside the clutches of the hospital system, assuming you like that specialty and are able to enter it of course.