EM Future

[GeneralVeers]

I just heard about a recent Envision presentation.

Essentially they stated in the presentation that they are starting these new residencies with guarantees to all the newly graduated residents of jobs in the local area where they train at "market rate". Ladies and gentleman, that means $150-$170/hour. In two years when the first of these residents in my area graduates, they will displace 8 practicing ED physicians who are currently making much more than that. 8 more the next year. 8 more the year after that (assuming no residency expansion). In 5-6 years they can have most, or all of the existing workforce replaced with new grads making half of what the old-timers were making before.

This will happen nationwide.

It's over.

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[Rekt]

This place is a trip sometimes. "The only thing that stops a bad guy with a corporation is a good guy with a corporation!"

An SDG isn't a corporation.

You lose.

 

[GeneralVeers]

An SDG isn't a corporation.

You lose.

Also they often aren't good guys.

 

[turkeyjerky]

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.

Definitely possible. Although I think midlevels will be replaced first, as there'll be a need for a doc to sign off on the AI recs due to liability concerns. I think there'll be a decade or so where the work just sucks before we're completely out of a job and dependent on UBI.

 

[turkeyjerky]

I just heard about a recent Envision presentation.

Essentially they stated in the presentation that they are starting these new residencies with guarantees to all the newly graduated residents of jobs in the local area where they train at "market rate". Ladies and gentleman, that means $150-$170/hour. In two years when the first of these residents in my area graduates, they will displace 8 practicing ED physicians who are currently making much more than that. 8 more the next year. 8 more the year after that (assuming no residency expansion). In 5-6 years they can have most, or all of the existing workforce replaced with new grads making half of what the old-timers were making before.

This will happen nationwide.

It's over.

Makes sense. Win-win for them, and how else are they going to fill. Everyone working for a CMG is absolutely eff'd.

 

[GeneralVeers]

Makes sense. Win-win for them, and how else are they going to fill. Everyone working for a CMG is absolutely eff'd.

Which is probably 90% of the jobs at this point.

 

[MechEDoc]

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

I will not be surprised to see a contraction in residencies. Medical students are smart and intuitively avoid poorly compensated specialties. CMGs and crappy hospitals (HCA and their ilk) have no qualms opening residencies and I doubt they'll have any hesitation to close a program when it suites their interests.

 

[RustedFox]

I will not be surprised to see a contraction in residencies. Medical students are smart and intuitively avoid poorly compensated specialties. CMGs and crappy hospitals (HCA and their ilk) have no qualms opening residencies and I doubt they'll have any hesitation to close a program when it suites their interests.

The real question is : the RRC has some splaining to do.

Asking the important questions here.

 

[namethatsmell]

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...

If Amazon is reading this, please consider the following marketing slogan-- "Alexa Health: brain of a doctor, heart of an NP."

The schadenfreude of watching the AANP try to push back against this would be spectacular.

 

[Arcan57]

Also they often aren't good guys.

This. The correctness of this statement can't be overstated. With very few exceptions, the CMGs we know and love today are composed of dozens of SDGs that had a couple of docs doing admin that worked really hard to build and maintain multi-group practices, and just completely cashed out when they were ready to retire. It's kinda tough to criticize them. They worked their behinds off to get where they ended up. At the same time, just like so much of society, the idea of creating something whose value benefits future generations was just lost on them. **Rant warning** Society stops advancing and improving when people stop trying to make things better for the future. It's not everyone, but damn does it feel like the boomers saw a land of plenty and decided that the best way to use that plenty was to go about dismantling it for personal profit. ***end rant***

 

[Rekt]

This. The correctness of this statement can't be overstated. With very few exceptions, the CMGs we know and love today are composed of dozens of SDGs that had a couple of docs doing admin that worked really hard to build and maintain multi-group practices, and just completely cashed out when they were ready to retire. It's kinda tough to criticize them. They worked their behinds off to get where they ended up. At the same time, just like so much of society, the idea of creating something whose value benefits future generations was just lost on them. **Rant warning** Society stops advancing and improving when people stop trying to make things better for the future. It's not everyone, but damn does it feel like the boomers saw a land of plenty and decided that the best way to use that plenty was to go about dismantling it for personal profit. ***end rant***

SDGs can be bad but the majority are not. They were faced with well we can buy you out or just take over the contract. Pretty simple vote there. That was back in the day. Now they just take it over. It's not like SDGs are just handing it over. Like Sure!

You'll know very quickly if you're in a predatory SDG. Most are not.

 

[DeadCactus]

An SDG isn't a corporation.

You lose.

"Like minded burnt out EM docs, create the same corporation in every state."

That doesn't sound like a small democratic group.

 

[alpinism]

I just heard about a recent Envision presentation.

Essentially they stated in the presentation that they are starting these new residencies with guarantees to all the newly graduated residents of jobs in the local area where they train at "market rate". Ladies and gentleman, that means $150-$170/hour. In two years when the first of these residents in my area graduates, they will displace 8 practicing ED physicians who are currently making much more than that. 8 more the next year. 8 more the year after that (assuming no residency expansion). In 5-6 years they can have most, or all of the existing workforce replaced with new grads making half of what the old-timers were making before.

This will happen nationwide.

It's over.

TeamHealth has been saying the exact same thing when recruiting for their new residencies.

 

[alpinism]

The other problem that hasn't been discussed yet is what happens to non CMG residencies that can't guarantee jobs.

When the job market does truly become saturated most non CMG residencies won't be able to offer jobs to even a quarter of their graduates leading to a situation where CMG residences become the only viable option for securing a job upon graduation. If this does ever occur it would
make it extremely difficult for many non CMG residencies to recruit students and eliminate a large number of established residency programs.
The end result is becoming a medical specialty with CMG residencies that function to produce metrics focused community physicians combined
with non CMG residencies that function to produce research focused academic physicians.

 

[bravotwozero]

Thread title is pretty much an oxymoron.

 

[GeneralVeers]

What are the CMGs supposed to do once the hospitals are saturated with new grads. How do they continue to make room for the incoming classes? Do ED physicians get fired after 3 years of employment to make way for the next crop? I think we very easily would see a scenario at that point where US grads shy away from EM.

 

[Rekt]

What are the CMGs supposed to do once the hospitals are saturated with new grads. How do they continue to make room for the incoming classes? Do ED physicians get fired after 3 years of employment to make way for the next crop? I think we very easily would see a scenario at that point where US grads shy away from EM.

Yeah exactly. Pumping 10-15 idiot grads into a city a year? I mean everything is already full, but let's say they actually follow up..then they pump 1-2 cycles and it will for sure be full. Doesn't even make sense.

 

[MechEDoc]

Yeah exactly. Pumping 10-15 idiot grads into a city a year? I mean everything is already full, but let's say they actually follow up..then they pump 1-2 cycles and it will for sure be full. Doesn't even make sense.

Easy, change class size or end the program. What do they care?

 

[sylvanthus]

Doesnt matter to them, the programs will continue to fill regardless. Record number of EM applicants at my med school this year, poor bastards.

But, if not american grads, foreign grads would gladly take the EM spots.

 

[bronx43]

Easy, change class size or end the program. What do they care?

Why would they end the program when they could NOT end the program and continue to use cheap labor?

They would simply stop promising jobs at the end, and still fill their rosters.

 

[MechEDoc]

Why would they end the program when they could NOT end the program and continue to use cheap labor?

They would simply stop promising jobs at the end, and still fill their rosters.

I think they would only downsize or end if they couldn't reliably fill their rosters. Perhaps MAGA 2.0 will reduce FMG slots?

 

[turkeyjerky]

The more you think about it, the most logical possibilities are really horrifying. Absent mass exodus or governmental regulation banning PE, I really don't see how things could change for the better.

 

[maxxor]

The more you think about it, the most logical possibilities are really horrifying. Absent mass exodus or governmental regulation banning PE, I really don't see how things could change for the better.

It’s really amazing that lawyers have ethical standards with teeth that prevent ownership of law firms by non-lawyers. Perhaps we need states boards to bar PE employment of physicians. Aren’t these corporate practice of medicine laws already in force?

 

[Sushirolls]

Well, once there are piles of unemployed EM docs and the income level drops to that of midlevels, and the ED becomes 100% staffed by EM as a result of the oversupply then change will start to happen.

Change will come in the form of EM docs entering politics at state and national level. Hopefully they are all of one political wing so as to not further grid lock at those political battle fields.

 

[RustedFox]

Speaking of... match week is next week. Where did all the matchitis threads go to?

 

[Rekt]

Speaking of... match week is next week. Where did all the matchitis threads go to?

No one's proud to match EM anymore.

 

[RustedFox]

No one's proud to match EM anymore.

That notwithstanding, I'd still follow it for a few reasons.

 

[oldtown]

Speaking of... match week is next week. Where did all the matchitis threads go to?

I suspect that the PollyAnna MS4’s don’t hear what they want to hear on this forum of grizzled attendings, and their cognitive dissonance has led them elsewhere.

 

[GeneralVeers]

Easy, change class size or end the program. What do they care?

I had hope during the peak of COVID that Envision or Teamhealth would go bankrupt. They were on the brink. Unfortunately that didn't happen and it's now just spurred them to make cuts and return profits to the VC overlords.

 

[wamcp]

Well, once there are piles of unemployed EM docs and the income level drops to that of midlevels, and the ED becomes 100% staffed by EM as a result of the oversupply then change will start to happen.

Change will come in the form of EM docs entering politics at state and national level. Hopefully they are all of one political wing so as to not further grid lock at those political battle fields.

How likely is change though. Was there really any change in other job market wrecked fields like pathology or radonc?

 

[RoyBasch]

I think the feedback loop onto medical student choosing a specialty is a very long one, maybe 10ish years. People have to pick EM, finish EM residency, be dissatisfied with career options and salaries for a period of years and realize there simply aren't any good jobs at all out there. That then has to become widespread enough that all the attendings starts to report back to medical students that this isn't the best option for people who want to optimize their income/lifestyle.

Will people still choose the specialty because they are genuinely interested in it? Sure. But it's not a coincidence that the most competitive specialties with the most applicants have the highest compensation and most ideal schedules(derm, ortho, plastics, etc. y'all know the usual suspects here). I think once it becomes clear that EM in terms of compensation and schedulability is more in line with with FM, pediatrics, etc. There will be a fairly precipitous drop in applicants.

Choosing a specialty has a lot of factors obviously, but compensation, flexibility, and job options weigh heavily (understandably so) on the minds of medical students. The "bill of goods" I was sold as a med student apply to EM was "only 3 years of residency and then 400k salary, with flexible hours, 14 days off a month, anywhere in the country you want to be." I mean that's a pretty enticing pitch even if you find the work itself is appalling. By the time I graduated residency several years ago the bill of goods was still mostly true with the exception that certain markets were very tight (large coastal cities, mountains, etc.) and usually involved concessions in salary and schedule.

It's pretty clear that now and probably in the foreseeable future the "bill of goods" will not be true at all. I think eventually this will negatively feedback on the students and applications will drop, but as stated above, this will be a period of years (10+).

Unfortunately this negative feedback loop will not result in a market correction as FMGs/IMGs will simply swell into the places given up by USMGs very much like FM, peds, psych, etc.

 

[Rekt]

How likely is change though. Was there really any change in other job market wrecked fields like pathology or radonc?

Rad/onc SOAPd my year. So eventually med students will figure it out, obviously too late by then. Recent rad/onc post from a felllow talked about how destroyed the market is and that even still ivory tower academic rad/onc physicians are completely clueless. Everyone does a fellowship and you're lucky to get a job at all and if you land anything, it's rural.

 

[EctopicFetus]

This place is a trip sometimes. "The only thing that stops a bad guy with a corporation is a good guy with a corporation!"

I hope AAEM and other groups are successful in starting new practices. The CMGs are going to get hurt when it comes to the OON legistlation. How badly? No one knows. They can cut doc pay and increase proportion of MLPs they use. Hospitals will hopefully care about the turnover and trash care.

ACEP wants to save the CMGs and hasn’t had the balls to stand up for the insane growth in residencies.

 

[skougess]

Medical students have already started catching on. This year continued the trend because apps were being finalized by the time word got out how screwed everyone was. They are talking about it on the med student boards though.

The “bill of goods” theory is a good one. When I was an intern I told med students this was the best specialty by a lot. Now when they ask me, I tell them to look elsewhere. And I still like the job, but that means nothing if you can’t get one in the first place.

 

[Rekt]

Medical students have already started catching on. This year continued the trend because apps were being finalized by the time word got out how screwed everyone was. They are talking about it on the med student boards though.

The “bill of goods” theory is a good one. When I was an intern I told med students this was the best specialty by a lot. Now when they ask me, I tell them to look elsewhere. And I still like the job, but that means nothing if you can’t get one in the first place.

I've told several and most can't grasp it as a reality. I've had a few say it's just COVID. Then I go into CMGs and residency expansion, etc. They're completely clueless on how staffing and employment work in EM. It's actually impressive how many 4th years trying to match EM don't have the slightest idea what a CMG/PE is.

 

[southerndoc]

It all boils to supply and demand. Demand > supply = high cost to CMG, supply > demand = low cost to CMG (low pay to doc).

There are too many residents graduating and too many PA/NP's taking doc jobs that pay is being driven down. 10 years from now pay will be <$100/hr. It's already <$150/hr in some states. Not even worth the liability risk. I can make that doing other things that have much less risk.

 

[alpinism]

Someone just posted an emergency medicine job for 65/hr in SoCal on the EMDOCS forum.

Now to be fair its with Kindred Healthcare but shows how far salaries will fall in the future.

 

[RadsRocks!]

Medical students have already started catching on. This year continued the trend because apps were being finalized by the time word got out how screwed everyone was. They are talking about it on the med student boards though.

The “bill of goods” theory is a good one. When I was an intern I told med students this was the best specialty by a lot. Now when they ask me, I tell them to look elsewhere. And I still like the job, but that means nothing if you can’t get one in the first place.

Didn’t this year have a record number of EM applicants? I figured before the season that it would drop a lot but people seemed to flock to EM...

 

[skougess]

Someone just posted an emergency medicine job for 65/hr in SoCal on the EMDOCS forum.

Now to be fair its with Kindred Healthcare but shows how far salaries will fall in the future.

I can see the posts now on the premed board about how great an honor it would be to work for $65/hr.

The obligatory “my parents never made more than $15/hr so $65/hr sounds great” (leaving out they were boomers with a high school education and still managed to buy a 4 bedroom house in a decent part of town)

And of course the “$65/hr seems great to me. Especially for only having to work 14 shifts a month!” (Says the guy who’s parents are paying his way through med school and has never worked a job or paid bills in his life so has zero concept of money. Oh and the inheritance should tie up any loose ends.)

 

[GeneralVeers]

I can see the posts now on the premed board about how great an honor it would be to work for $65/hr.

Better yet, pay THEM to work! That way you are giving back to the community and helping out the less fortunate. According to pre-med theory no one should take a salary to practice medicine.

 

[RustedFox]

I can see the posts now on the premed board about how great an honor it would be to work for $65/hr.

The obligatory “my parents never made more than $15/hr so $65/hr sounds great” (leaving out they were boomers with a high school education and still managed to buy a 4 bedroom house in a decent part of town)

And of course the “$65/hr seems great to me. Especially for only having to work 14 shifts a month!” (Says the guy who’s parents are paying his way through med school and has never worked a job or paid bills in his life so has zero concept of money. Oh and the inheritance should tie up any loose ends.)

I live near a small city where there's a DO school.
The students there drive luxury cars that I can't afford because mommy/daddy bought it for them as a present for getting into med school.
I wish this were a tall tale.

 

[miacomet]

If I could do it again, I'd seriously consider the trades.

 

[southerndoc]

Someone just posted an emergency medicine job for 65/hr in SoCal on the EMDOCS forum.

Now to be fair its with Kindred Healthcare but shows how far salaries will fall in the future.

Wow. Nurses make more than that.

 

[miacomet]

Can we retrain as nurses?

 

[miacomet]

I can be Miacomet MD RN BSN EMT MPH their Royal Highness

 

[RustedFox]

For all our talk, there's one thing that remains unclear.

Who are the rats on the RRC that are continuing to give the a-okay to these new residencies?

 

[bravotwozero]

Yup, time to name and shame

 

[MechEDoc]

If I could do it again, I'd seriously consider the trades.

For sure. Finding a skilled tradesperson with a brain and work ethic is super rare. I think if I had devoted my efforts to being a general contractor I would be killing it.

 

[RoyBasch]

For all our talk, there's one thing that remains unclear.

Who are the rats on the RRC that are continuing to give the a-okay to these new residencies?

I get that this whole deal is kind of a political microcosm, where a powerful moneyed group (The CMGs, PE, etc.) have basically obtained a regulatory capture of the governing body (ACEP, RRC, etc.) and is influencing them in their favor.

But this seems like one of the easiest most immediate things we can do to try to slow down the downfall of the specialty.

Get the RRC to STOP rubber stamping accreditation of these **** HCA residencies.

Can we turn off this bullsh*t spigot?

I don't know very much about EM/academics on an administrative level, but maybe some of the people on this forum who are more savvy can weigh in. Why is the RRC granting accreditation to these programs? Can we make them stop? What is the actual leverage the power players have over them? Is it possible are they really such benighted fools that they think the country and the specialty NEEDS more graduates?

 

[GatorCHOMPions]

I get that this whole deal is kind of a political microcosm, where a powerful moneyed group (The CMGs, PE, etc.) have basically obtained a regulatory capture of the governing body (ACEP, RRC, etc.) and is influencing them in their favor.

But this seems like one of the easiest most immediate things we can do to try to slow down the downfall of the specialty.

Get the RRC to STOP rubber stamping accreditation of these **** HCA residencies.

Can we turn off this bullsh*t spigot?

I don't know very much about EM/academics on an administrative level, but maybe some of the people on this forum who are more savvy can weigh in. Why is the RRC granting accreditation to these programs? Can we make them stop? What is the actual leverage the power players have over them? Is it possible are they really such benighted fools that they think the country and the specialty NEEDS more graduates?

I worked with someone who was part of the RRC board and asked them these questions. According to them, the RRC’s function isn’t to police how a program gets approved. There are set criteria and if they are met the program gets approval. I then asked who sets the criteria and forget the exact answer, but it wasn’t directly the RRC board.

This was all about 6 months ago. I mentioned the concern about the oversupply and this person seemed pretty clueless, thinking we were not close to saturation. Keep in most of the RRC people are in academia with titles like PD, Vice Chair, Chair, etc. so they are somewhat biased and/or clueless about the average doc.