EM Future

[Rekt]

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.

Exactly my thought. Ivory tower chumps and/or massive tertiary/quaternary care centers and they're so far removed from reality they have no idea.

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[skougess]

Exactly my thought. Ivory tower chumps and/or massive tertiary/quaternary care centers and they're so far removed from reality they have no idea.

Keep in mind per the Annals of EM jobs report this year, ACEP is actually making a concerted effort to start rural residency programs in a misguided attempt to fix the rural physician shortage (the one that is rapidly fixing itself as we speak.) Its not a bug, it’s a feature.

 

[RoyBasch]

Exactly my thought. Ivory tower chumps and/or massive tertiary/quaternary care centers and they're so far removed from reality they have no idea.

Never attribute to malice which can first be attributed to stupidity and all that huh.

 

[Rekt]

Never attribute to malice which can first be attributed to stupidity and all that huh.

Oh I'm sure CMGs have their hand in the RRC somehow too.

 

[clibby]

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 think we need to increase the minimum procedure requirements and hospital requirements to accredit and re-accredit residencies. 35 ETT, 20 CVLs, 6 pacing, 30% simulated? Not nearly enough. Also, simulating any of your common procedures like ETTs, CVLs, resuscitations, etc. should not be allowed and the peds should not be simulated either. If you can't secure good peds training sites, you shouldn't be a residency. STEMI center should be a requirement.

I also think there should be 10,000 patients per year per resident per class. 75,000 patients per year = no more than 7 residents per year so they can see enough pathology and have access to enough procedures/resuscitations to be not just mediocre, but highly skilled like the specialists we should be. This limitation also needs to include concurrent PA/NP residencies so if you want 4 PAs in a residency along side 10 EM residents per year, you better see 140,000 pts/year. (In no world will those midlevels be as productive and would not be worth it vs more residents). How can you be prepared to see it all when I don't get the chance to see it all in residency. By our 3rd year every resident needs to be seeing >2pts per hour if only to see the diversity of patients, never mind the training on being thorough while also efficient.

Finally, faculty time also needs to be protected and mandated so these CMGs can't just use their current docs as "faculty" and the lecture logs need to be audited during accreditation reviews.

Until we raise the bar to reflect the training we should have, the RRC can't do much.

 

[Mushdoc]

The executive director for the EM review committee (along with Nuc Med and Rads) is an MHA, not a physician. How is that possible?

Review Committee Executive Directors

www.acgme.org

 

[skougess]

So the 2021 EM match concluded today and nearly all 2850 spots were filled (im sure the rest with SOAP). So where are the steady-state 75,000 EM trained physicians supposed to get jobs in 20 years?

 

[Rekt]

So the 2020 EM match concluded today and nearly all 2850 spots were filled (im sure the rest with SOAP). So where are the steady-state 75,000 EM trained physicians supposed to get jobs in 20 years?

2850 spots. Holy ****.

 

[skougess]

2850 spots. Holy ****.

Yep. Right now we have 45,000 practicing EM physicians and there is a job shortage. Maybe reach back out to that $65/hr job.

 

[miacomet]

All these folks matching on Twitter, half at HCA residencies....

 

[VA Hopeful Dr]

The executive director for the EM review committee (along with Nuc Med and Rads) is an MHA, not a physician. How is that possible?

Review Committee Executive Directors

www.acgme.org

Traditionally, the executive director of an organization is the one that keeps things organized. They sometimes (often?) don't really get a vote on decisions.

 

[Apollyon]

Traditionally, the executive director of an organization is the one that keeps things organized. They sometimes (often?) don't really get a vote on decisions.

Yeah, they're like the residency coordinator. Not a doctor.

 

[DeadCactus]

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.

I share your hope. I just find the idea hilarious, that a bunch of people are going to get together and form a large, powerful corporation and somehow the same people eager to throw us under the bus for money are magically not going to climb into power this time around.

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.

Excluding some really competitive markets, I don't see salaries permanently going below <$150/hr. Once we hit that range, residencies will go unmatched and trained emergency physicians will move to other sources of income. Lower salaries reduce the barrier to exit and, at some point, one of the many alternative things we can do for money will be more enticing. Fellowship, corporate work, wound care, aesthetic practice, testosterones clinic, concierge medicine, total career change. All viable options made undesirable by our historic salaries that will suddenly be worth a closer look. Imagine the irony? It's 2030 and the family medicine forum is complaining about all the emergency medicine physicians who think they can just take a few short-courses and open a concierge practice.

 

[nexus73]

I share your hope. I just find the idea hilarious, that a bunch of people are going to get together and form a large, powerful corporation and somehow the same people eager to throw us under the bus for money are magically not going to climb into power this time around.



Excluding some really competitive markets, I don't see salaries permanently going below <$150/hr. Once we hit that range, residencies will go unmatched and trained emergency physicians will move to other sources of income. Lower salaries reduce the barrier to exit and, at some point, one of the many alternative things we can do for money will be more enticing. Fellowship, corporate work, wound care, aesthetic practice, testosterones clinic, concierge medicine, total career change. All viable options made undesirable by our historic salaries that will suddenly be worth a closer look. Imagine the irony? It's 2030 and the family medicine forum is complaining about all the emergency medicine physicians who think they can just take a few short-courses and open a concierge practice.

and since everyone already thinks they're a psychiatrist, ED docs are already prepared to see psych patients without any extra training

 

[GeneralVeers]

I share your hope. I just find the idea hilarious, that a bunch of people are going to get together and form a large, powerful corporation and somehow the same people eager to throw us under the bus for money are magically not going to climb into power this time around.



Excluding some really competitive markets, I don't see salaries permanently going below <$150/hr. Once we hit that range, residencies will go unmatched and trained emergency physicians will move to other sources of income. Lower salaries reduce the barrier to exit and, at some point, one of the many alternative things we can do for money will be more enticing. Fellowship, corporate work, wound care, aesthetic practice, testosterones clinic, concierge medicine, total career change. All viable options made undesirable by our historic salaries that will suddenly be worth a closer look. Imagine the irony? It's 2030 and the family medicine forum is complaining about all the emergency medicine physicians who think they can just take a few short-courses and open a concierge practice.

I disagree. I think salaries can and will go lower than $150. Plenty of doctors, especially new grads don't know how to start anything else, and when they come out of residency with $3k/month in loans they have to pay, they will need income fast. Also, residencies will always fill even with FMGs. People from poverty-stricken countries will have no problem working for $65-$100/hour in this country.

 

[sylvanthus]

I disagree. I think salaries can and will go lower than $150. Plenty of doctors, especially new grads don't know how to start anything else, and when they come out of residency with $3k/month in loans they have to pay, they will need income fast. Also, residencies will always fill even with FMGs. People from poverty-stricken countries will have no problem working for $65-$100/hour in this country.

Agree with above, no way that EM residency programs will go unfilled, even if EM continues to suck. Foreign med grads will gladly take the spots.

 

[Apollyon]

and since everyone already thinks they're a psychiatrist, ED docs are already prepared to see psych patients without any extra training

??

You need to put some context here, as to from where this comes. The post you quoted didn't mention psych (at least that I saw).

Also, even though only anecdotal, I've never known any EM doc that wanted to see psych patients. Some were good at it, but nobody was seeking out these pts.

 

[blue.jay]

Wre is

So the 2021 EM match concluded today and nearly all 2850 spots were filled (im sure the rest with SOAP). So where are the steady-state 75,000 EM trained physicians supposed to get jobs in 20 years?

Where is this data posted? I don't see anything in NRMP site.

 

[DeadCactus]

New graduates may not immediately go into entrepreneurial fields but many more will start looking at fellowship and many more will work to exit the field much sooner than the 20+ year careers required to saturate the job market even at 3,000 grads/year especially as lower salaries decrease the relevance of mid-level providers.

Pay at <$150/hr is dropping salaries near or below pediatrics, psychiatry, family medicine, and internal medicine except they can generally work regular hours with weekends and holidays off. The competitive IMG applicants will turn to them just as much as US graduates will. Of the 7,000 non-citizen IMGs, how many actually would want to do EM in this context, couldn't match IM/Peds/Psych/FM, and are still going to provide enough benefit to a CMG group to be worth keeping residencies around to train them?

To say salaries will routinely be less than $150/hr is saying a specialty that involves nights, weekends, holidays, abuse, and high medicolegal liability will somehow become a competitor for the single least paid specialty even compared to things like preventative medicine and pediatrics. I find that unlikely.

 

[Restart13]

I think at a minimum you’re going to need a ultimate freeze on new EM residency spots for the time being as well as an across the board reduction of current EM residency spots. Sure, it’ll create chaos for a short while until they...wait for it...increase attending coverage (or fill with app spots 😑).

 

[EctopicFetus]

The field is screwed. There is no doubt. Full melt down may happen in 5 years or 10 or 20. But it used to be slightly hard to find a decent SDG gig, now its nearly impossible and there is a line of people waiting. New grads are happy to be within 90 mins of civilization All while making terrible pay.

As the CMGs whine about OON reimbursement and COVID volumes pay will get cut. Maybe quickly, maybe slowly. Chop chop chop. Schumacher cut pay effectively at 15%. APP forced their docs to work for less while they “lent” APP money to make it thru covid. These experiences are trials for these guys to see what they can get away with.

Scribes - gone, CME gone, pay cut. Moving folks to RVU based pay will help them cut pay more and make their risk lower when more and more care leaves the ED. The future is dim and getting darker.

 

[wamcp]

2850 spots. Holy ****.

looks like there were 1556 spots in 2010 match. Nearly doubled in 10 years and still increasing, huh?

 

[Arcan57]

I think we need to increase the minimum procedure requirements and hospital requirements to accredit and re-accredit residencies. 35 ETT, 20 CVLs, 6 pacing, 30% simulated? Not nearly enough. Also, simulating any of your common procedures like ETTs, CVLs, resuscitations, etc. should not be allowed and the peds should not be simulated either. If you can't secure good peds training sites, you shouldn't be a residency. STEMI center should be a requirement.

My gut feeling is that we're going to be less and less defined by our procedural skills as time goes on. While personally lucrative in an RVU system, the time/$$$ ratio to the people that actually profit off of us heavily disincentivizes procedures. They need us evaluating and dispo'ing patients as fast as we can. As a result, nobody on the hospital side is spending time teaching nurses and techs exactly what equipment we need for what procedure. Anything that's not a crash airway is going to be 20-30 minutes of searching for rarely used equipment, waiting for a nurse to pull meds out of the PIXIS, or waiting for an RT to finish beaming down to the ED. And the indication for procedures keeps narrowing. Over half my tubes in residency were for hypertensive flash pulmonary edema or for behavioral control in polytrauma patients. Since BiPap and high dose nitro gtts, it's been years since I've had to tube a CHF exacerbation. 4mg/kg IM ketamine means I'm not tubing people just to get their head spun. Pacing? Many places have a cath lab I can activate faster while doing transcutaneous than it will take just to find the generator and the introducer kit to float a transvenous. LP? Neg CT within 6 hours of onset of headache has nerfed the CT then LP paradigm and if you're worried about meningitis start the vanc and rocephin and have IR do it in the am. Central lines? IO or U/S PIV until you can get the PICC team to place one during business hours.

In terms of peds being simmed, are you talking including simulated encounters to make up for not seeing kids or are you talking simming pediatric procedures? If it's the first, that's unacceptable. If it's the 2nd, even PEM fellows at huge institutions like Cincy Childrens don't get enough procedures to become competent during their training.

 

[trackrunner321]

What happens when the POWERHOUSE Programs can no longer find jobs for their residents? Could that cause the pendulum to shift slightly?

 

[sylvanthus]

Noooppppee, noone cares.

 

[Birdstrike]

What happens when the POWERHOUSE Programs can no longer find jobs for their residents? Could that cause the pendulum to shift slightly?

My guess is that after struggling to find MD coverage for EDs for 30 years, begging docs to cover shifts higher rates, the hospitals want a turn with doctors begging them to be able to cover shifts, for lower rates.

They're businessmen. They want cheap labor, like any other businessmen. Have you ever known a businessman to lament having too many potential employees wanting to work for less money?


A) Shortage of expensive labor, versus

B) Oversupply of cheap labor.


The businessmen will choose B, everytime.

And who's going to tell them otherwise?

The corporate CMG crew?

Aren't they businessmen, too?

 

[miacomet]

I just asked my friends at academic centers about job prospects for their residents.

They said any job issues were "timing" with Covid, no concern whatsoever with oversupply, and they were oh-so-sure that the market would rebound post-Covid, said they were pretty sure everyone was employed, and that well, some folks were doing fellowships.

Uh-huh

 

[bravotwozero]

R.I.P. EM
1976-2021

 

[Birdstrike]

I just asked my friends at academic centers about job prospects for their residents.

They said any job issues were "timing" with Covid, no concern whatsoever with oversupply, and they were oh-so-sure that the market would rebound post-Covid, said they were pretty sure everyone was employed, and that well, some folks were doing fellowships.

Uh-huh

Are volumes still down due to COVID? It seems most states are pretty much past any lockdowns, viral numbers are going down, the elderly (who were most prone to avoid EDs during covid) are getting vaccinated and ED volumes should be coming back?

Are they not back to, or at least close to, pre-COVID numbers?

 

[bravotwozero]

Where I am, most of that volume has come right back. Especially in December, I was working shifts in freestanding Eds, and thoroughly ended up getting my butt handed to me.

At our FSEDs, our contract says we get RVUs on top of base pay if patient volume for the month is 28 patients per day or in excess. This doesn't usually happen most months, but for december it certainly did. Keep in mind these are single coverage with no midlevels or scribes.

 

[oldtown]

Are volumes still down due to COVID? It seems most states are pretty much past any lockdowns, viral numbers are going down, the elderly (who were most prone to avoid EDs during covid) are getting vaccinated and ED volumes should be coming back?

Are they not back to, or at least close to, pre-COVID numbers?

In fairness, here in the Midwest (IL/IN) all 6 sites At which I’m on staff are still at about 75% of pre Covid volume, and have been since volumes rebounded last fall from down 50% post covid. This spans a range of suburban sites in Chicago Metro and 30-40k volume sites in more rural parts of IL & IN

 

[HemorrhagicShock]

Here in the PNW numbers are still down by 25%. A majority of the "missing" patients are the ESI 4-5s too, which is hurting the pocketbook.

I just asked my friends at academic centers about job prospects for their residents.

They said any job issues were "timing" with Covid, no concern whatsoever with oversupply, and they were oh-so-sure that the market would rebound post-Covid, said they were pretty sure everyone was employed, and that well, some folks were doing fellowships.

Uh-huh

I have a feeling that most academicians actually know what's going on across the profession. They're not dumb, and while yes they're isolated in the ivory tower, I do think a lot of their opinion is swayed by having to tow the party line. Their very position depends on them taking that stance, whether they believe it or not.

 

[bravotwozero]

On a more cynical bent, if we're all going to go down we should take all the a-hole administrators with us. How? by setting up a website where you can anonymously name and shame these people. @Hamhock was on to something. Put up their corporate email and contact info, and let them feel some heat. It will also have the added benefit of informing EPs looking to be hired at a certain place, of who to watch out for.

 

[Arcan57]

Here in the PNW numbers are still down by 25%. A majority of the "missing" patients are the ESI 4-5s too, which is hurting the pocketbook.





I have a feeling that most academicians actually know what's going on across the profession. They're not dumb, and while yes they're isolated in the ivory tower, I do think a lot of their opinion is swayed by having to tow the party line. Their very position depends on them taking that stance, whether they believe it or not.

The challenge of changing the mind of someone who’s livelihood depends on not believing what you’re saying.

 

[miacomet]

Here in the PNW numbers are still down by 25%. A majority of the "missing" patients are the ESI 4-5s too, which is hurting the pocketbook.





I have a feeling that most academicians actually know what's going on across the profession. They're not dumb, and while yes they're isolated in the ivory tower, I do think a lot of their opinion is swayed by having to tow the party line. Their very position depends on them taking that stance, whether they believe it or not.

Oh, I agree 100%. And more than their jobs, their egos depend on this.

 

[alpinism]

The problem with people in academics is that a large portion are completely out of touch with the job market.

Most senior faculty haven't applied for jobs in twenty years and have no clue what's happening to our specialty.

 

[deleted6669]

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.

That can't be for an EM Physician. That is starting wage for an EM PA/NP.

 

[GassYous]

That can't be for an EM Physician. That is starting wage for an EM PA/NP.

Maybe it's for a globaldoc

 

[deleted6669]

Maybe it's for a globaldoc

No, they make more than that. That is what a globaldoc made 10 years ago.

 

[GeneralVeers]

We should take bets on how low the job market will get in 5 years. Under $100/hr is certainly a possibility in CA.

 

[Fox800]

We should take bets on how low the job market will get in 5 years. Under $100/hr is certainly a possibility in CA.

USUCKS was already paying EM docs $120/hr in Denver pre-COVID (this was October 2018).

 

[Rekt]

USUCKS was already paying EM docs $120/hr in Denver pre-COVID (this was October 2018).

The great equalizer will be whatever PLPs make for the specific market. That's eventually what our salary will be.

That's how we "win" the fight. They'll hire a doc instead if it's the same price

 

[Fox800]

The great equalizer will be whatever PLPs make for the specific market. That's eventually what our salary will be.

That's how we "win" the fight. They'll hire a doc instead if it's the same price

Are you referring to LLPs (low level providers?) Noctors with <3% of the clinical hours of a physician aren't "mid-level" in any way. Closer to the floor (nursing) than the ceiling (physician).

 

[Arcan57]

Maybe it's for a globaldoc

Kindred is a chain of rehab hospitals.

 

[Franzd'Epinay]

Maybe it's for a globaldoc

No, they make more than that. That is what a globaldoc made 10 years ago.

What's a globaldoc? A google search just has results about some sort of language interpreter line.

 

[Fox800]

What's a globaldoc? A google search just has results about some sort of language interpreter line.

A physician assistant that really, really wants folks to think they’re a physician. They have a doctorate in global health or something.

 

[GeneralVeers]

A PA that really, really wants folks to think they’re a physician. They have a doctorate in global health or something.

The GLOBAL = MORE QUALIFIED

 

[turkeyjerky]

A physician assistant that really, really wants folks to think they’re a physician. They have a doctorate in global health or something.

Heart of a doctor, mind of a nurse! But globally!

 

[Old_Mil]

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

A good start would be having a specialty college that wasn't led around by the nose by CMGs...and perhaps had a residency trained guy at the top.

 

[EctopicFetus]

A physician assistant that really, really wants folks to think they’re a physician. They have a doctorate in global health or something.

PAs are much better clinicians than NPs in my 15 years or so of experience.