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Leonthemedico said:
An NP can't do it. But I get your point. The question is can an experienced ER doctor do it?
In Sweden FM residency is 5 years.
I guess the EM doctors can't harm a patient doing primary care because you know the emergencies.
But not harming the patient is just one part of doing PC.
The other question is can you solve the patient's problem? Can you do it in an efficient way in terms of money and time? Are you fast enough? Can you make a diagnosis using only your clinical gestalt after a short history taking? How comfortable are you with diagnosing chest pain patients without ordering troponin? How comfortable are you not sending that patient to the ER.
People tend to think that primary care is easy. Until they start to do it. Also people thing that PC only sends patients to secondary level but the thruth is different. One doctor refers patients rarely maybe once every three days but you see many patients from many different FM docs.

On the other hand a FM doctor is never scared of midlevels. They can never do our job.
Click to expand...
Midelevels can't do our job either, but that doesn't stop the PE firms from hiring them anyway.
 
Leonthemedico said:
On the other hand a FM doctor is never scared of midlevels. They can never do our job.
Click to expand...
The can't do your job, but have legislated themselves equivalency, granted themselves the same title, shielded themselves from as much liability, and can bill the same. For the near term I think we've been outmaneuvered.

From the employer's perspective they can do your job better (profit = income* - expenses**) and from most patient's perspectives they are the same or better than you. Most patients with DM, obesity, smoking, etc. don't really give a rip about their health (addressing the fundamentals), they just want tests, pills, and reassurance. E.g. sore throat? MD = evaluation, education, and NSAIDS, NP = inhaler, steroids, z-pack, codeine syrup. Who provided "more" health care?... "We chose NPs"!

*greater due to more testing and admissions
**less due to lower labor costs
 
zNoodlez said:
Patients don't know that.
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Exactly. The disconnect in what patients want versus what is actually good care is one of the problems with market forces in EM. Patients don't know what good care actually is, and can actually shop around for worse care. More testing, more ABx and more narcs equals worse outcomes. Unlike a car, or phone where the market can reasonably meet patient expectations and become more efficient.
 
Leonthemedico said:
An NP can't do it. But I get your point. The question is can an experienced ER doctor do it?
In Sweden FM residency is 5 years.
I guess the EM doctors can't harm a patient doing primary care because you know the emergencies.
But not harming the patient is just one part of doing PC.
The other question is can you solve the patient's problem? Can you do it in an efficient way in terms of money and time? Are you fast enough? Can you make a diagnosis using only your clinical gestalt after a short history taking? How comfortable are you with diagnosing chest pain patients without ordering troponin? How comfortable are you not sending that patient to the ER.
People tend to think that primary care is easy. Until they start to do it. Also people thing that PC only sends patients to secondary level but the thruth is different. One doctor refers patients rarely maybe once every three days but you see many patients from many different FM docs.

On the other hand a FM doctor is never scared of midlevels. They can never do our job.
Click to expand...
I'm not advocating specialty jumping without board certification. I'm just telling you I know someone who did it, and by all indications is thriving in his group. It's just an n of 1. I'm not saying it applies across the board, or should be policy. In fact, I don't recommend it.

I personally favor rigorous standards and a high bar to certification. That's why when I was looking for alternatives to the day to day practice of EM, I made sure to get the training (ACGME fellowship) and get ABMS board certification. I did it the hard way. And that's what I think is best. However, I'm just observing that those lines are breaking down more and more, and its not always a one way street. If it's being used to our disadvantage, it makes sense to at least be aware of example where its been used to our advantage.
 
MechEDoc said:
The can't do your job, but have legislated themselves equivalency, granted themselves the same title, shielded themselves from as much liability, and can bill the same. For the near term I think we've been outmaneuvered.

From the employer's perspective they can do your job better (profit = income* - expenses**) and from most patient's perspectives they are the same or better than you. Most patients with DM, obesity, smoking, etc. don't really give a rip about their health (addressing the fundamentals), they just want tests, pills, and reassurance. E.g. sore throat? MD = evaluation, education, and NSAIDS, NP = inhaler, steroids, z-pack, codeine syrup. Who provided "more" health care?... "We chose NPs"!

*greater due to more testing and admissions
**less due to lower labor costs
Click to expand...

This. So much this.
Your average or even above-average American Muggle simply will not make any lifestyle change or even entertain the idea that they're responsible for their own health. They just want "tests, pills, and reassurance", and they want it to be easy for them to understand. Forget things like relative risk, odds ratios, efficacy, etc - they can only wrap their heads around "positive" or "negative", and want a pill to fix it instantly.

A muggle friend of mine (and this is one of the better ones out there), was concerned about potential adverse effects of the COVID-19 vaccination. He said to me: "Well, I'm a fast-metabolizer - so if I do get anything, it won't stick around for long."

So many things wrong with that statement; but I knew that I couldn't even begin to dissect the errors he was making because he was incapable of understanding them.

1. You have no indication that you are, in fact, a "fast metabolizer".
2. You don't know what that term means.
3. That concept doesn't apply to vaccination and the immune response.
4. Shut up.

Nope. Can't reach even the better ones. Now deal with 20-30 of those in a 10 hour EM shift and you see how the futility is quickly overwhelming and bewildering.
 
GeneralVeers said:
Exactly. The disconnect in what patients want versus what is actually good care is one of the problems with market forces in EM. Patients don't know what good care actually is, and can actually shop around for worse care. More testing, more ABx and more narcs equals worse outcomes. Unlike a car, or phone where the market can reasonably meet patient expectations and become more efficient.
Click to expand...
Exactly. Bad medicine gets higher PG scores. "Go right ahead. You do you! Eat burgers, drink, smoke. Whatever! We love you just the way you are and don't worry, we have a pill to fix everything."

That guy gets 5 stars every time.
 
Birdstrike said:
I'm not advocating specialty jumping without board certification. I'm just telling you I know someone who did it, and by all indications is thriving in his group. It's just an n of 1. I'm not saying it applies across the board, or should be policy. In fact, I don't recommend it.

I personally favor rigorous standards and a high bar to certification. That's why when I was looking for alternatives to the day to day practice of EM, I made sure to get the training (ACGME fellowship) and get ABMS board certification. I did it the hard way. And that's what I think is best. However, I'm just observing that those lines are breaking down more and more, and its not always a one way street. If it's being used to our disadvantage, it makes sense to at least be aware of example where its been used to our advantage.
Click to expand...
In my opinion EM folks need 2 years of additional training to work like us in the clinic. Maybe 1 year if they are a genius.
One additional year is needed to learn all the additional chronic conditions and another year to gain efficiency to be able to earn money and see more patients in an hour.
 
Leonthemedico said:
An NP can't do it. But I get your point. The question is can an experienced ER doctor do it?
In Sweden FM residency is 5 years.
I guess the EM doctors can't harm a patient doing primary care because you know the emergencies.
But not harming the patient is just one part of doing PC.
The other question is can you solve the patient's problem? Can you do it in an efficient way in terms of money and time? Are you fast enough? Can you make a diagnosis using only your clinical gestalt after a short history taking? How comfortable are you with diagnosing chest pain patients without ordering troponin? How comfortable are you not sending that patient to the ER.
People tend to think that primary care is easy. Until they start to do it. Also people thing that PC only sends patients to secondary level but the thruth is different. One doctor refers patients rarely maybe once every three days but you see many patients from many different FM docs.

On the other hand a FM doctor is never scared of midlevels. They can never do our job.
Click to expand...

Here's the thing. While it's probably not a MI in a patient without a typical history and few risk factors, it can still be something terrible (which I found). I told the staff not to schedule chest pain patients, but they are pressured to keep doing it.
 
d2305 said:
Here's the thing. While it's probably not a MI in a patient without a typical history and few risk factors, it can still be something terrible (which I found). I told the staff not to schedule chest pain patients, but they are pressured to keep doing it.
Click to expand...

Pressured by whom?

This illustrates another critical shortcoming of our healthcare system: "nobody listens to the physician".
 
Backpack234 said:
I wonder how this is gonna go.....

www.acep.org

I Need a Job! Getting Hired in a Pandemic, presented by ACEP Young Physicians Section and Online Education Committee

Join a panel of leaders from the Young Physician Section to explore challenges and opportunities for finding a job or switching directions with the world turned upside down. This webcast will review the current EM job market, discuss unique challenges to securing EM employment in 2021, and...
www.acep.org www.acep.org
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Free for ACEP members.
Hey, ACEP... If you did your job, you wouldn't be needing to have this event.
 
sloh said:
Lol this guy...

Click to expand...

It takes a stunning lack of empathy to gaslight people about employment opportunities by suggesting that they should simply move to potsdam, ny. Also, these people don't realize that many of these listings are out-dated 'ghost listings', or just left up for CMGs to collect CV's and emails. (I know because I contacted many of the ones he cited)

It's the EM version of 'Learn to Code'.
 
Backpack234 said:
I wonder how this is gonna go.....

www.acep.org

I Need a Job! Getting Hired in a Pandemic, presented by ACEP Young Physicians Section and Online Education Committee

Join a panel of leaders from the Young Physician Section to explore challenges and opportunities for finding a job or switching directions with the world turned upside down. This webcast will review the current EM job market, discuss unique challenges to securing EM employment in 2021, and...
www.acep.org www.acep.org
Click to expand...

Spoiler alert; it was shockingly out of touch with reality and really offered no help beyond what people already know. Although you could see some deep worry on a couple of their faces, but they couldn't bring themselves to say anything.
 
I feel for the new grads, they have the shortest end of the stick right now. If you're in the situation, your best bet is to try and stay on as faculty at the program you trained at, though I realize not everyone can do that.
 
Rekt said:
Spoiler alert; it was shockingly out of touch with reality and really offered no help beyond what people already know. Although you could see some deep worry on a couple of their faces, but they couldn't bring themselves to say anything.
Click to expand...

Clicking on the link now brings up a "we're sorry; we can't find that link" page.
 
bravotwozero said:
I feel for the new grads, they have the shortest end of the stick right now. If you're in the situation, your best bet is to try and stay on as faculty at the program you trained at, though I realize not everyone can do that.
Click to expand...

Agreed.

Next best option for new grads, if they're OK to live anywhere, is to seek out a hospital-employed, federal, or Kaiser gig. They tend to offer the best combination of job security/stability, working conditions+liability coverage, and not perpetually getting the short end of the scheduling stick. While the $ ceiling is not as high as SDGs the floor is generally higher than CMGs. But that's assuming you can find one of these and really able to move anywhere.

It's so painful to see the new grads dealing with this. At the same time, it's almost worse hearing some of the tails from my buddies I used to work at a place bought out by a CMG...these highly experienced, excellent docs remain severely underemployed. They're only being scheduled for 60% of their regular hours despite volumes bouncing back to 90% pre-covid volumes...oh, but the CMG is hiring midlevels. These docs live in fear they can be canned at a moment's notice so are afraid to voice concerns about pt safety of makes waves. Their shifts sound miserable but their family/kids are entrenched in the area so tough to move...and what ED would they be able to move to right now anyway?
 
Rekt said:
Spoiler alert; it was shockingly out of touch with reality and really offered no help beyond what people already know. Although you could see some deep worry on a couple of their faces, but they couldn't bring themselves to say anything.
Click to expand...
ACEP needs to hear from all of you guys. They need to be losing sleep just as much as you all are over the issue.

They posted a link to this on their twitter page here


It should be blown up with negative comments.
 
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namethatsmell said:
At the same time, it's almost worse hearing some of the tails from my buddies I used to work at a place bought out by a CMG...these highly experienced, excellent docs remain severely underemployed. They're only being scheduled for 60% of their regular hours despite volumes bouncing back to 90% pre-covid volumes...oh, but the CMG is hiring midlevels. These docs live in fear they can be canned at a moment's notice so are afraid to voice concerns about pt safety of makes waves. Their shifts sound miserable but their family/kids are entrenched in the area so tough to move...and what ED would they be able to move to right now anyway?
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It used to be I wasn't worried about getting fired as I could move to the two other jobs in my state or just fly out and do locums to pay the bills. Now there's nowhere to go. At this point if I got fired, it would be the end of my career. There is little point uprooting for a crappy job, in a 3rd tier city with no job security and low pay.
 
Rekt said:
Spoiler alert; it was shockingly out of touch with reality and really offered no help beyond what people already know. Although you could see some deep worry on a couple of their faces, but they couldn't bring themselves to say anything.
Click to expand...

It's kind of like the recent EMRAP podcast on the topic of whether EM is dying or not. They spend the entire time talking about the death being related to disillusionment and despondency surrounding accepting the reality that we deal with 90% non critical illness and then giving a pep talk about feeling proud that we are so "adaptable" and able to rise to the occasion and provide care under any circumstance...with gusto. Absolutely nothing about the REAL current crisis. Nothing about lack of jobs and over supply of residency programs. It's a perfect example of these academic guys being completely out of touch. Afterwards, I kept going "WTF? THIS is what you guys think is threatening our specialty?"
 
We had a really strong scribe a few years back who I follow on instagram and he recently posted match day with a big sign saying that he matched into EM somewhere. Smiling face, ecstatic happiness, celebratory... I never thought I would feel this way but I found myself feeling so incredibly sorry for him to be coming into the specialty at this time and wish he would have reached out to me during his 3rd or 4th year so I could re-direct him away from EM. I couldn't help but think about what a difficult road he has ahead.
 
bravotwozero said:
ACEP needs to hear from all of you guys. They need to be losing sleep just as much as you all are over the issue.

They posted a link to this on their twitter page here


It should be blown up with negative comments.
Click to expand...


Good thing we have the EM Careers website from ACEP. We can freely find all the new program director positions opening in up for these new upcoming programs!
 
Groove said:
It's kind of like the recent EMRAP podcast on the topic of whether EM is dying or not. They spend the entire time talking about the death being related to disillusionment and despondency surrounding accepting the reality that we deal with 90% non critical illness and then giving a pep talk about feeling proud that we are so "adaptable" and able to rise to the occasion and provide care under any circumstance...with gusto. Absolutely nothing about the REAL current crisis. Nothing about lack of jobs and over supply of residency programs. It's a perfect example of these academic guys being completely out of touch. Afterwards, I kept going "WTF? THIS is what you guys think is threatening our specialty?"
Click to expand...
Is it that they're out of touch, and unaware of the real problems? Or are they afraid of the social response and being accused of being "too negative," "downers" or "burned out"?

My guess is, it's the latter. The reason I say that is, anytime I've told what I thought were undeniable truths about EM over the years, many of which I got pushback on but now I'm seeing more agreement on, I faced the same intense backlash. It's strong enough if you're (semi) anonymous online. I can only imagine it's an order of magnitude worse if you're a high profile, public person in EM, especially when you've built a career on being "Rah! Rah! Pro-EM!"

It's a lot safer and socially acceptable in EM, to be in denial of EMs problems. It's much riskier socially, to be a truth teller.
 
bravotwozero said:
I feel for the new grads, they have the shortest end of the stick right now. If you're in the situation, your best bet is to try and stay on as faculty at the program you trained at, though I realize not everyone can do that.
Click to expand...

Unless I get fired (always possible these days) or they cut our pay (we got a raise in January, although we lost our match last year) I'm in a fairly protected position, so even though I saw this coming it's still a shock that there are literally unemployed EM docs.

This is not Covid. The market was flooded. And it will not improve.

Is it that easy to get a job at one's residency? At mine it was hard.

The best advice anyone ever gave me was to be an owner, not an employee. While this came too late professionally and I ended up in EM, I've taken it to heart in owning everything else- stocks, real estate, bonds, and building up a nest egg. I see no other way in the current economic system than building generational wealth or getting an overpaid union job (say, nursing in NoCal for 200k a year, fire, police).

These kids coming out with 300k in loans and doing a surgical prelim are screwed in ways I had not even considered. In education as in everything, caveat emptor.
 
Birdstrike said:
Is it that they're out of touch, and unaware of the real problems? Or are they afraid of the social response and being accused of being "too negative," "downers" or "burned out"?

My guess is, it's the latter. The reason I say that is, anytime I've told what I thought were undeniable truths about EM over the years, many of which I got pushback on but now I'm seeing more agreement on, I faced the same intense backlash. It's strong enough if you're (semi) anonymous online. I can only imagine it's an order of magnitude worse if you're a high profile, public person in EM, especially when you've built a career on being "Rah! Rah! Pro-EM!"

It's a lot safer and socially acceptable in EM, to be in denial of EMs problems. It's much riskier socially, to be a truth teller.
Click to expand...

I think it's deeper than that. They make their money by training residents. There is too much ego and money it for them to not just say, but believe, anything else. Where will they be if the Ponzi scheme stops?
 
miacomet said:
I think it's deeper than that. They make their money by training residents. There is too much ego and money it for them to not just say, but believe, anything else. Where will they be if the Ponzi scheme stops?
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Where would they be if the 'Ponzi scheme' stopped? You know exactly where they'd be. They'd be the last place they want to be, which is back working full time in the ED!
 
Birdstrike said:
Where would they be if the 'Ponzi scheme' stopped? You know exactly where they'd be. They'd be the last place they want to be, which is back working full time in the ED!
Click to expand...

Except there are no jobs.
So it would be worse than that!
 
Groove said:
It's kind of like the recent EMRAP podcast on the topic of whether EM is dying or not. They spend the entire time talking about the death being related to disillusionment and despondency surrounding accepting the reality that we deal with 90% non critical illness and then giving a pep talk about feeling proud that we are so "adaptable" and able to rise to the occasion and provide care under any circumstance...with gusto. Absolutely nothing about the REAL current crisis. Nothing about lack of jobs and over supply of residency programs. It's a perfect example of these academic guys being completely out of touch. Afterwards, I kept going "WTF? THIS is what you guys think is threatening our specialty?"
Click to expand...
My thoughts exactly when I listened to that. I was actually embarrassed for them...
 
Arcan57 said:
Of course TX rates weren’t because of ACEP. But the ceiling on EM salaries is set by what can be charged in our name, so preventing across the board cuts (like banning balance billing without a fair and equitable requirement on payors) would nerf both CMG and SDG pay.

Incidentally, a lot of the pay in TX also had to do with the fact that private and Medicaid both paid high rates. Usually they’re inversely correlated, so that made TX a gold mine augmented by explosive (10-15% year over year) growth in ED visits for years in places like Houston which meant that everybody had to distribute that largess to the docs in order to keep their contracts staffed. And then all those positive forces on wages either started stalling out or where actively reversed starting in 2018ish and accelerating in 2020.
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You leave out the real gold. Subsidies. I know a CMG leader he told me they were getting a $15M subsidy to staff a slew of hospitals. Another CMG tried to undercut them to grow and they had to cut their subsidy to $5M.

Now that $10M didnt flow into the hands of the EM docs. The ceiling is really still set by supply and demand. The long term issue is noctors and non EM docs would work for trash rates cutting the demand while increasing the supply of people who work in the ED.
 
EctopicFetus said:
You leave out the real gold. Subsidies. I know a CMG leader he told me they were getting a $15M subsidy to staff a slew of hospitals. Another CMG tried to undercut them to grow and they had to cut their subsidy to $5M.

Now that $10M didnt flow into the hands of the EM docs. The ceiling is really still set by supply and demand. The long term issue is noctors and non EM docs would work for trash rates cutting the demand while increasing the supply of people who work in the ED.
Click to expand...
The biggest issue in Houston (that required those $$$ subsidies) is that the FSED market sucked a ton of docs out of hospital based EDs starting in 2011-2014. If you worked in a hospital ED then and were more than 8 yrs out of residency, you were likely an FMD or AFMD. Docs would be making $350/hr and jump ship to someplace desperate enough to pay $400/hr.
 
Arcan57 said:
The biggest issue in Houston (that required those $$$ subsidies) is that the FSED market sucked a ton of docs out of hospital based EDs starting in 2011-2014. If you worked in a hospital ED then and were more than 8 yrs out of residency, you were likely an FMD or AFMD. Docs would be making $350/hr and jump ship to someplace desperate enough to pay $400/hr.
Click to expand...
That's exactly what happened. You could almost name your own price to work last minute shifts in smaller cities in TX back then. Around 2017 the bottom fell out of the FED market as many companies went bankrupt, and the hospitals got wise and opened their own FEDs. By 2018 the market was dying and salaries were collapsing. I quit locums altogether in November of 2018 as it was no longer worth the stress of travel.
 
miacomet said:
I think it's deeper than that. They make their money by training residents. There is too much ego and money it for them to not just say, but believe, anything else. Where will they be if the Ponzi scheme stops?
Click to expand...
Come to think of it....this is very similar to a Ponzi scheme. Gaslight away.
 
sloh said:
Come to think of it....this is very similar to a Ponzi scheme. Gaslight away.
Click to expand...

Yep.
There is not a need for at least 30% of the EM docs we are training.
These people have jobs and careers based on training EM docs.
Without a constant supply of clueless med students, the docs wouldn't have jobs.
So they need a constant infusion of residents and GME dollars to keep the scheme going.
How is that not a Ponzi scheme?
 
Groove said:
We had a really strong scribe a few years back who I follow on instagram and he recently posted match day with a big sign saying that he matched into EM somewhere. Smiling face, ecstatic happiness, celebratory... I never thought I would feel this way but I found myself feeling so incredibly sorry for him to be coming into the specialty at this time and wish he would have reached out to me during his 3rd or 4th year so I could re-direct him away from EM. I couldn't help but think about what a difficult road he has ahead.
Click to expand...

If it makes you feel better, he probably wouldnt have listened anyhow. If tried steering people away, but im sure they are internally rolling their eyes at me.
 
RustedFox said:
For the past 5 or so years, I stood with my mouth open because the FM crowd wouldn't do the simplest of things and sent these cases immediately over to me in the ER. Simple things. Tap a knee, suture a lac, apply a CDM rule for head injury, talk someone with asymptomatic HTN off the ledge, or what have you.
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I don't want to derail the thread too much, but I've never heard of a PCP tapping a joint.

In all fairness, if I've decided a joint needs to be tapped, I'm not sure I'd be comfortable with the slow turnaround time that would come with an outpatient lab.
 
Franzd'Epinay said:
I don't want to derail the thread too much, but I've never heard of a PCP tapping a joint.

In all fairness, if I've decided a joint needs to be tapped, I'm not sure I'd be comfortable with the slow turnaround time that would come with an outpatient lab.
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Outpatient setting:

-If I don't suspect infection (chronic, no fever, redness, warmth, etc) but there's an effusion, I tap the joint and the fluid is clear, yellow (almost always non-infectious chronic-osteoarthritis, gout or pseudo-gout). Inject with steroids. Send to outpatient lab. Couldn't care less about turnaround time, but they'll call me if the gram stain shows something crazy. I've never had one of these come back septic, because clinically they're chronic. These patients almost always feel better after drainage and steroids.

-If I suspect septic arthritis is likely: Send to ER to be tapped there and have the joint washed out + IV abx if positive.

(Derail complete)
 
Birdstrike said:
Outpatient setting:

-If I don't suspect infection (chronic, no fever, redness, warmth, etc) but there's an effusion, I tap the joint and the fluid is clear, yellow (almost always non-infectious chronic-osteoarthritis, gout or pseudo-gout). Inject with steroids. Send to outpatient lab. Couldn't care less about turnaround time, but they'll call me if the gram stain shows something crazy. I've never had one of these come back septic, because clinically they're chronic. These patients almost always feel better after drainage and steroids.

-If I suspect septic arthritis is likely: Send to ER to be tapped there and have the joint washed out + IV abx if positive.

(Derail complete)
Click to expand...
That's my approach as well
 
RustedFox said:
For the past 5 or so years, I stood with my mouth open because the FM crowd wouldn't do the simplest of things and sent these cases immediately over to me in the ER. Simple things. Tap a knee, suture a lac, apply a CDM rule for head injury, talk someone with asymptomatic HTN off the ledge, or what have you.
Click to expand...
Volume Is King

I don't practice FM but I practice side by side with PCPs in my group. None of them want to do any procedures at all, even quick ones that pay. That includes a PA and MD who both used to work in the ED are aren't remotely afraid of procedures. The reason is, they're under as much pressure to move the meat, as you are in the ED. Primary Care, like EM, is a volume business. They book their schedules solid and crank through them barely with time to come up for air. I've tried to encourage them to pop steroids in a shoulder or knee, here or there, explaining how quick and easy it would be, but they don't want to, for fear of getting derailed and too far behind. I get it now, seeing their schedules and volume. I'm happy to schedule these people and line up a bunch of easy injections to do for them, so it works out pretty good.
 
Wanted to give an update on job market for my smaller community Midwest graduating residency class. All of us have secured jobs in places we wanted to go. Most of us are going to major metros that have other residency programs. It may have taken longer than past years but most of us had multiple interviews.
 
Birdstrike said:
Volume Is King

I don't practice FM but I practice side by side with PCPs in my group. None of them want to do any procedures at all, even quick ones that pay. That includes a PA and MD who both used to work in the ED are aren't remotely afraid of procedures. The reason is, they're under as much pressure to move the meat, as you are in the ED. Primary Care, like EM, is a volume business. They book their schedules solid and crank through them barely with time to come up for air. I've tried to encourage them to pop steroids in a shoulder or knee, here or there, explaining how quick and easy it would be, but they don't want to, for fear of getting derailed and too far behind. I get it now, seeing their schedules and volume. I'm happy to schedule these people and line up a bunch of easy injections to do for them, so it works out pretty good.
Click to expand...

Volume.

A lot of physicians don’t appreciate this until they get out in the real world and practice. For PM&R, one of the most lucrative gigs is 1099 SAR (rounding at SNF’s); it’s at least 350k for like 20-24 hrs work/week. The reason is volume. You can round on a lot of SNF patients very quickly, much faster than an outpatient practice where you have to schedule patients into time slots and deal with logistical issues. Every time I need to perform an injection, it actually slows me down considerably.

You see this commonly in derm and optho as well. Clinics are high volume (even accounting for the procedures).
 
Buckeye1992 said:
Wanted to give an update on job market for my smaller community Midwest graduating residency class. All of us have secured jobs in places we wanted to go. Most of us are going to major metros that have other residency programs. It may have taken longer than past years but most of us had multiple interviews.
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That's awesome, and congrats.




That said, Ohio state still sucks.

Sorry, just needed to get that out of my system.
(go wolverines)
 
Birdstrike said:
Volume Is King

I don't practice FM but I practice side by side with PCPs in my group. None of them want to do any procedures at all, even quick ones that pay. That includes a PA and MD who both used to work in the ED are aren't remotely afraid of procedures. The reason is, they're under as much pressure to move the meat, as you are in the ED. Primary Care, like EM, is a volume business. They book their schedules solid and crank through them barely with time to come up for air. I've tried to encourage them to pop steroids in a shoulder or knee, here or there, explaining how quick and easy it would be, but they don't want to, for fear of getting derailed and too far behind. I get it now, seeing their schedules and volume. I'm happy to schedule these people and line up a bunch of easy injections to do for them, so it works out pretty good.
Click to expand...

See; I hear you on this, amigo: but let me point this out.

The patient is then the one who suffers. Had a buddy call me last week, wife had a patellar effusion.

She went to her PMD, who sent her to the ER (?)
ER says "not an emergency, go back to your PMD."
PMD says: "lets send you to ortho in 6 weeks or so"

Just freaking tap the knee, people. Takes :60 seconds.


Sidebar: Patient was seen by a NP in the ED, who did an x-ray and sent labs, said "everything is normal" and sent her home.
As it was explained to me, the x-ray/labs were "to see if it's infected".
Patient was told by PLP that "its dirty here in the ER; so we won't tap it here" (What, send it to the OR?!)
Buddy sent me a picture. Uncomplicated, simple effusion.
You have to have a very smooth brain to wonder whether or not its "infected, lolz - bettr send labz. Look! I'm healthcaring".
 
Last edited:
RustedFox said:
See; I hear you on this, amigo: but let me point this out.

The patient is then the one who suffers. Had a buddy call me last week, wife had a patellar effusion.

She went to her PMD, who sent her to the ER (?)
ER says "not am emergency, go back to your PMD."
PMD says: "lets send you to ortho in 6 weeks or so"

Just freaking tap the knee, people. Takes :60 seconds.


Sidebar: Patient was seen by a NP in the ED, who did an x-ray and sent labs, said "everything is normal" and sent her home.
As it was explained to me, the x-ray/labs were "to see if it's infected".
Patient was told by PLP that "its dirty here in the ER; so we won't tap it here" (What, send it to the OR?!)
Buddy sent me a picture. Uncomplicated, simple effusion.
You have to have a very smooth brain to wonder whether or not its "infected, lolz - bettr send labz. Look! I'm healthcaring".
Click to expand...
If it makes you feel any better, I would’ve tapped it. I like sticking needles in stuff.
 
RustedFox said:
See; I hear you on this, amigo: but let me point this out.

The patient is then the one who suffers. Had a buddy call me last week, wife had a patellar effusion.

She went to her PMD, who sent her to the ER (?)
ER says "not am emergency, go back to your PMD."
PMD says: "lets send you to ortho in 6 weeks or so"

Just freaking tap the knee, people. Takes :60 seconds.


Sidebar: Patient was seen by a NP in the ED, who did an x-ray and sent labs, said "everything is normal" and sent her home.
As it was explained to me, the x-ray/labs were "to see if it's infected".
Patient was told by PLP that "its dirty here in the ER; so we won't tap it here" (What, send it to the OR?!)
Buddy sent me a picture. Uncomplicated, simple effusion.
You have to have a very smooth brain to wonder whether or not its "infected, lolz - bettr send labz. Look! I'm healthcaring".
Click to expand...
Ha, that's funny. Takes way longer than that in a non-ortho outpatient practice.
 
Birdstrike said:
If it makes you feel any better, I would’ve tapped it. I like sticking needles in stuff.
Click to expand...

What's upsetting is that a country PMD wouldn't do it and sent it to the ER.

What's more upsetting is that Jenny McJennyson, PLP-123 demonstrated that she failed at physical exam skills, diagnostic knowledge, and didn't ask for the guidance of a physician.
 
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