EM Future

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I don't tap them in the ER just for regular arthritic effusions. I only do it if there is concern for acute infection. Getting lidocaine, talking the patient through the procedure, finding the US, cleaning the US, and doing the procedure takes 20-30 minutes of time.

BTW, why is getting lidocaine from the nurses in the ED so tough?? I remember when we used to just have a drawer full of them and would grab what we needed.
 
GeneralVeers said:
I don't tap them in the ER just for regular arthritic effusions. I only do it if there is concern for acute infection. Getting lidocaine, talking the patient through the procedure, finding the US, cleaning the US, and doing the procedure takes 20-30 minutes of time.

BTW, why is getting lidocaine from the nurses in the ED so tough?? I remember when we used to just have a drawer full of them and would grab what we needed.
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I don't do them regularly because then we'd have a line of people using us as a tap-convenience-store.

Overarching point here is: the PMD should tap the knee, not send non-emergent things to the emergency room.
Secondary point: Jenny McJennyson doesn't know dog$hit; because she ordered a x-ray and CBC for an uncomplicated effusion.

Dude; you don't need the ultrasound or lidocaine to do this.
 
RustedFox said:
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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Jenny McJennyson's gonna jenny-mcjennsyson
 
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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Glad to see that there are jobs and not all jobs are in the dearth of civilization. EM is not the way it used to be where we were wined and dined but nice to see your whole residency get jobs that they like in major metro cities.

I stopped working in the pit the past year but I still have many friends working the hospitals. I still get offers to help with coverage and even a full time gig if I ever want it. Just talked to a friend that offered me a full time gig at $350/hr working in some out of place ER in one of the northern states but that is not where I want to be right now.
 
RustedFox said:
I don't do them regularly because then we'd have a line of people using us as a tap-convenience-store.

Overarching point here is: the PMD should tap the knee, not send non-emergent things to the emergency room.
Secondary point: Jenny McJennyson doesn't know dog$hit; because she ordered a x-ray and CBC for an uncomplicated effusion.

Dude; you don't need the ultrasound or lidocaine to do this.
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PMD's doing their part to keep 2500+ annual EM grads employed 🤣
 
VA Hopeful Dr said:
The appointment time wasn't the issue. Its the idea that start to finish tapping a knee takes 60 seconds that I disagree with.
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Explaining the procedure takes :60 seconds.
Paperwork takes :30 seconds.
Sticking a needle in a knee and sucking out fluid takes :60 seconds.

That's 2.5 minutes.
 
RustedFox said:
I don't do them regularly because then we'd have a line of people using us as a tap-convenience-store.

Overarching point here is: the PMD should tap the knee, not send non-emergent things to the emergency room.
Secondary point: Jenny McJennyson doesn't know dog$hit; because she ordered a x-ray and CBC for an uncomplicated effusion.

Dude; you don't need the ultrasound or lidocaine to do this.
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I need ultrasound....my success rate without is near zero.
 
emergentmd said:
Glad to see that there are jobs and not all jobs are in the dearth of civilization. EM is not the way it used to be where we were wined and dined but nice to see your whole residency get jobs that they like in major metro cities.

I stopped working in the pit the past year but I still have many friends working the hospitals. I still get offers to help with coverage and even a full time gig if I ever want it. Just talked to a friend that offered me a full time gig at $350/hr working in some out of place ER in one of the northern states but that is not where I want to be right now.
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Many people have also posted their classmates still have no jobs or just defaulted to fellowship. Ns are Ns on both sides.
 
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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Assuming this program is in Ohio. Are Dayton and Toledo considered major metro areas ?
 
GeneralVeers said:
US is a crutch....
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I don’t think I would even know how to use US to tap a knee. The landmarks are easy to identify and the space is hard to miss.

that said, we all have our weaknesses. I suck at subclavian lines and would be terrified to try an IJ without US guidance. I’m pretty rusty on central lines in general since I’ve spent most of my post residency career at a place with 24 hr intensivist coverage, and they don’t like us putting in lines on any of the patients headed their way, and are cool with peripheral pressors temporarily.
 
RustedFox said:
Explaining the procedure takes :60 seconds.
Paperwork takes :30 seconds.
Sticking a needle in a knee and sucking out fluid takes :60 seconds.

That's 2.5 minutes.
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Are you seriously trying to tell me how I do things and how much long what I do personally takes when I do it?
 
VA Hopeful Dr said:
Are you seriously trying to tell me how I do things and how much long what I do personally takes when I do it?
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No; but that's about how long it takes me in the ED.
No, I'm not going to count the time for physical exam/documentation/etc - because I'm going to do that for every patient, regardless of what I have to do with them.

I'm not trying to be adversarial, amigo.
 
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.
Click to expand...

That's great to hear. What areas, if you don't mind sharing, generally?
 
bravotwozero said:
Never tap prosthetic knees
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Yeah. The joint's gone. There's no reason to stick a needle in it. What're you gonna suck out of it? Metal?

Post TKR: That's ortho's baby.

Unless of course, they replace the knee and it still hurts. Then ortho sends 'em to me to somehow perform a miracle. But really, you can occasionally get relief on these, by doing a genicular (3) nerve ablation. It doesn't always work, but when it does it's something no one else could do for them.
 
Birdstrike said:
Yeah. The joint's gone. There's no reason to stick a needle in it. What're you gonna suck out of it? Metal?

Post TKR: That's ortho's baby.

Unless of course, they replace the knee and it still hurts. Then ortho sends 'em to me to somehow perform a miracle. But really, you can occasionally get relief on these, by doing a genicular (3) nerve ablation. It doesn't always work, but when it does it's something no one else could do for them.
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well they could have a prosthetic joint infection...
 
bravotwozero said:
well they could have a prosthetic joint infection...
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True. That's still ortho's baby. Call them and let them stick a needle into their titanium. It's not like you've got to worry about "joint destruction" because tapping it was delayed 2 hours. As long as they're not septic, it's ortho's baby to burp. And if septic, treat as such. Your antibiotics won't kill every bacterium in their puss filled knee such that you can't get a culture after the fact. If so, abscesses wouldn't need to be drained.
 
Rekt said:
Many people have also posted their classmates still have no jobs or just defaulted to fellowship. Ns are Ns on both sides.
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True and thus the market lies somewhere in the middle. I agree the market is tightening up and it has been a quick 180 from 3 yrs ago where you could get a job almost anywhere at crazy rates.

If some residencies have placed all of their residents with some weighing multiple offers, then the residents that can't not find a job needs to expand their geography. I am quite confident I could find a decent paying job somewhere in my state next month if I really looked.

If some EM docs are so pessimistic or locked geographically, then its time to reinvent yourself. Every business/field has peeks/valley. There are alot you can do with an EM degree but may take some risks. Get involved in FSERs, UC, Telemed, Med spa, open up a non medical business.

If you are pessimistic today, then sitting around doing EM hospital work will not improve things. Thing likely will be getting worse so unhappy today will be cliff jumping tomorrow. There are so much an EM doc can do.

This will be by far my most successful and gratifying year. I moved out of the Pits 2-3 yrs ago not because I didn't have the same high paying job in one of the most sought after cities that docs would kill to have, I just didn't like the metrics/admin stuff/lost of autonomy.

So I got into FSERs to regain my autonomy and will be opening up UCs which can make a decent amount of $$$ while letting NPs see all the pts. I am also getting deep into real estate and this year will gross as much as the avg EM doc makes in a year with very little work. I am dipping my feet into apartment investing and maybe some commercial in the future.
 
sylvanthus said:
“and will be opening up UCs which can make a decent amount of $$$ while letting NPs see all the pts”


Well guess we may as well all sell out at this point and make some cash before it all implodes
Click to expand...

Selling out? I think you sell out way more signing NP charts throughout your shift than my opening up an UC. We employ and have EM doc owners running the show without any VC involvement seeing patients without any C suite overlords or nurse managers telling me what to do, how far to jump, how quick to click, and fast to dispense narcs for patient satisfaction.

I am quite sure I promote the EM profession way more than you ever can do as a Pit doctor following the overlords orders. We actually create an environment where EM docs dictate policies, hire/fire whoever we want, and actually care for patients without worrying about made up metrics. Nice going to work with everyone including our nurse manager understanding that the EM doc is the boss when he/she is on shift. Something as simple as wanting an upgraded computer with dual monitors takes one quick email to get it done rather than begging the ED nurse manager then told its not in budget.
 
emergentmd said:
Selling out? I think you sell out way more signing NP charts throughout your shift than my opening up an UC. We employ and have EM doc owners running the show without any VC involvement seeing patients without any C suite overlords or nurse managers telling me what to do, how far to jump, how quick to click, and fast to dispense narcs for patient satisfaction.

I am quite sure I promote the EM profession way more than you ever can do as a Pit doctor following the overlords orders. We actually create an environment where EM docs dictate policies, hire/fire whoever we want, and actually care for patients without worrying about made up metrics. Nice going to work with everyone including our nurse manager understanding that the EM doc is the boss when he/she is on shift. Something as simple as wanting an upgraded computer with dual monitors takes one quick email to get it done rather than begging the ED nurse manager then told its not in budget.
Click to expand...


I don't blame you in the least, but I still consider this, in the grand scheme of things, to be selling out. Repeat this type of thing across a variety of settings, inpatient, ED, outpatient, etc and it exacerbates the midlevel enroachment problem. You do you though man, just don't pretend you are taking the high road.
 
sylvanthus said:
I don't blame you in the least, but I still consider this, in the grand scheme of things, to be selling out. Repeat this type of thing across a variety of settings, inpatient, ED, outpatient, etc and it exacerbates the midlevel enroachment problem. You do you though man, just don't pretend you are taking the high road.
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This is really short sighted and would essentially make 95% of the docs sell outs. 99% of the docs who are hospital employed have APCs working for them in some capacity. 90% of Private practices I know have APCs working for them in some capacities.

Does that make them all sell outs? We all have to have jobs and even if you owned your own group you still have to be competitive. Hiring APCs are essential for survival which is the economic reality. Either you sit on your high horse/refuse APCs and go out of business or you hire APCs to be competitive.

Imagine if two private Cardiology groups with 4 doc each across the street from each other with the same volume/revenue. Each doc takes home $1M/yr. Both groups volume explodes and volume has 4x. Insurance reimbursement plummets and revenue only goes up by 50%.

Group A, high horse group, hires all MDs now has 16 MDs with $6M in profits. Now each doc takes home $375K. Docs start to all quite and go work for the local hospital making 500K/yr with much less business hassle. Group goes bankrupt and closes down.

Group B, economically savvy, figure out that most of the work/overnight call can be handled by APCs. They hire 12 APCs and costs them 1.5M in salary. These 4 docs now share 4.5M in profits. Each now take home $1.1M.

Do you want to be the high horse group now working for a new master or the economically savvy group still calling the shots?

I would say the economically savvy group is doing more for their specialty by allowing a future outlet to hire cardiologist b/c they are economically sound. The other group just died on their high horse.

I would never pretend that I am any more moral than anyone else. Economics drives business which drives what you are able to do. I would love to turn back the clock 20 yrs when I started where we owned our private group making 400K/yr with almost complete autonomy. This is just not the reality so either you do what is best for you/your specialty or reality gets showed down your throat.
 
emergentmd said:
This is really short sighted and would essentially make 95% of the docs sell outs. 99% of the docs who are hospital employed have APCs working for them in some capacity. 90% of Private practices I know have APCs working for them in some capacities.

Does that make them all sell outs? We all have to have jobs and even if you owned your own group you still have to be competitive. Hiring APCs are essential for survival which is the economic reality. Either you sit on your high horse/refuse APCs and go out of business or you hire APCs to be competitive.

Imagine if two private Cardiology groups with 4 doc each across the street from each other with the same volume/revenue. Each doc takes home $1M/yr. Both groups volume explodes and volume has 4x. Insurance reimbursement plummets and revenue only goes up by 50%.

Group A, high horse group, hires all MDs now has 16 MDs with $6M in profits. Now each doc takes home $375K. Docs start to all quite and go work for the local hospital making 500K/yr with much less business hassle. Group goes bankrupt and closes down.

Group B, economically savvy, figure out that most of the work/overnight call can be handled by APCs. They hire 12 APCs and costs them 1.5M in salary. These 4 docs now share 4.5M in profits. Each now take home $1.1M.

Do you want to be the high horse group now working for a new master or the economically savvy group still calling the shots?

I would say the economically savvy group is doing more for their specialty by allowing a future outlet to hire cardiologist b/c they are economically sound. The other group just died on their high horse.

I would never pretend that I am any more moral than anyone else. Economics drives business which drives what you are able to do. I would love to turn back the clock 20 yrs when I started where we owned our private group making 400K/yr with almost complete autonomy. This is just not the reality so either you do what is best for you/your specialty or reality gets showed down your throat.
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It is good for the group to hire midlevels but bad for the profession.

If it were ONLY overnight work sure... but the reality is that it's never just the overnight work. Most midlevels I've seen work better hours than docs.
 
Clean7795 said:
It is good for the group to hire midlevels but bad for the profession.

If it were ONLY overnight work sure... but the reality is that it's never just the overnight work. Most midlevels I've seen work better hours than docs.
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I am not disagreeing that APCs are bad for medicine in general. I wish they never existed but that is not economic reality. On one hand we complain how expensive medicine is and on the other hand we just want MDs that are paid 4x more than an APC.

Reality is APCs are here to stay. If MD groups refuse to hire any APCs, then they will become extinct.
 
emergentmd said:
I am not disagreeing that APCs are bad for medicine in general. I wish they never existed but that is not economic reality. On one hand we complain how expensive medicine is and on the other hand we just want MDs that are paid 4x more than an APC.

Reality is APCs are here to stay. If MD groups refuse to hire any APCs, then they will become extinct.
Click to expand...

I'll take this opportunity to point out that medicine is so expensive because of corporate bloat, cronyism, and needless administration that does nothing to contribute to patient care.

Calling Veers: how much was that "director of D-I-V-E-R-S-I-T-Y" paid?

Having PLPs do things half-assed at half price isn't the answer.
 
RustedFox said:
I'll take this opportunity to point out that medicine is so expensive because of corporate bloat, cronyism, and needless administration that does nothing to contribute to patient care.

Calling Veers: how much was that "director of D-I-V-E-R-S-I-T-Y" paid?

Having PLPs do things half-assed at half price isn't the answer.
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I’ve never heard of patients getting reduced bills when they see a mid level.
 
skougess said:
I’ve never heard of patients getting reduced bills when they see a mid level.
Click to expand...

Correct.

The US keeps paying more and more and more, but physician salaries keep shrinking.

All that money goes to admin nonsense.

Now, admins are at the point where they need to feed their greed, so they're hiring cheaper "providers", passing the savings in labor to themselves.

Meanwhile PLPs screw things up so much, that resource utilization goes up.

Win-win for admin.

Veers has the actual story; he worked for a CMG that paid a "director of D-I-V-E-R-S-I-T-Y" 400k and benefits to... promote diversity.

The parasites that are admins are what is causing this waste.
 
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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.
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Thats precisely my point. Unless you are a partner in a group your pay is solely dictated by supply and demand. No matter what legislative stuff or RUC stuff ACEP does it literally doesnt matter.
 
Until doctors all walk off and stop working, the system will not change. Its great to talk about not having APCs, not teaching them, not hiring them but that is not the reality. Docs need a job and a paycheck. So when is the next walkout going to happen?

I recommend doing something to benefit from the system rather than beating your head against the system that will not change.
 
emergentmd said:
I am not disagreeing that APCs are bad for medicine in general. I wish they never existed but that is not economic reality. On one hand we complain how expensive medicine is and on the other hand we just want MDs that are paid 4x more than an APC.

Reality is APCs are here to stay. If MD groups refuse to hire any APCs, then they will become extinct.
Click to expand...
Not sure this is at all true. There is tremendous value in ownership. There are plenty of docs who dont have MLPs who do quite well. The issue as you alluded to is if you dont do this it is a loss for you.

The easiest example is Derm. The doc can only do so much so they hire some hottie Jenny Mcjennyson to do botox and whatever other BS people pay tons of cash for. The DERM MD can keep doing MD stuff and Jenny can do whatever nonsense cash folks will pay for. MD profits, Jenny makes more than most of her essential oil touting fellow grads.

other option for DERM MD is make less and see fewer patients and DERM MD 2 does this to her and her patients decide to go across town cause everything is done in 1 location.

There is a corollary to this in the medical world. Personally I think MLPs have a role but it is in seeing the level 4/5 nonsense that somehow still filters to the ED. They have NO role IMO in seeing undifferentiated patients. the 4s and 5s have left the ED setting due to cost and abundance of UCs. Im ok with it. All we still have are those silly complaints in the uninsured or medicaid types.

For example, MLP appropriate
1) Ankle sprain
2) Abscess - simple
3) I cut my finger with a knife and need stitches

NOT MLP appropriate
1) Chest pain
2) Belly pain
3) any pregnancy related complaint
4) really problems like SOB, CVA symptoms, psych etc.
 
RustedFox said:
Veers has the actual story; he worked for a CMG that paid a "director of D-I-V-E-R-S-I-T-Y" 400k and benefits to... promote diversity.

The parasites that are admins are what is causing this waste.
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That was just one example of the nonsense. I have a friend in Boston who's an MBA. He started at the bottom of the admin ladder at an academic hospital. He was told to go back and get a nursing degree as it would help his career. So now he's MBA, RN. He just got a big promotion and is making 7 figures, while the ED docs at his hospital barely crack 300K. He just turned 30. We are all in the wrong field.
 
Any EM docs in their 40s that did a fellowship? I've found myself entertaining the idea of a fellowship with increasing frequency in the event that things get too horrible but the thought of doing one in my mid forties makes my joints and back ache. Ugh...I hate the thought of going back to formal academic training at this stage. I get nauseated thinking about it. Surely we wouldn't implode over the next...15 years? Or is that wishful thinking?
 
Groove said:
Any EM docs in their 40s that did a fellowship? I've found myself entertaining the idea of a fellowship with increasing frequency in the event that things get too horrible but the thought of doing one in my mid forties makes my joints and back ache. Ugh...I hate the thought of going back to formal academic training at this stage. I get nauseated thinking about it. Surely we wouldn't implode over the next...15 years? Or is that wishful thinking?
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I don't think I can stomach another round of training. I was an engineer, then changed to emergency medicine, finishing my residency at the end of my thirties. Can't imagine more training. Things are gloom and doom now, but I can't imagine it will go on this way forever.
 
The Vast majority of docs will continue to see the pressures of downward reimbursement and eventually we will have some form of single payer system. Everyone will make less, work harder for less, and have more bosses.

All docs make good $$$ so we need to take that $$$ and pivot. Take some risks and be your own boss. Until you are your own boss and have passive income, you will never be truly independent.

Do something that makes passive income and let the system make money for you with much work. That is how the rich becomes rich. They don't do it with just collecting a paycheck.

Even if medicine completely implodes tomorrow, I will be financially fine with just my investment properties alone. I will gross over 300K, net 150K this yr. Won't pay all of my expenses but hopefully in the next 2-3 yrs, I will drive those numbers to 500K/400K.
 
RustedFox said:
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.
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Test'N'Pills! I started this clinic a few years ago. You wanna franchise in FL?
 
thegenius said:
Test'N'Pills! I started this clinic a few years ago. You wanna franchise in FL?
Click to expand...

It was YOU that said it originally!

I thought to myself when I was typing that post: "Someone else made this joke already, but I can't remember who it is."

I want to get the hell out of Florida. There are two seasons here: "Jungle" and "Snowbird".

You don't want to go outside during either of them.
 
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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Tap it and send them home. these are not emergencies unless the patient is septic. Ortho sends the analysis to the outpatient labs all the time and sends patients home on a regular basis, or tells them to go to the ED to be admitted to the hospital. 98% (my guess) of joint effusions are not emergencies
 
thegenius said:
Tap it and send them home. these are not emergencies unless the patient is septic. Ortho sends the analysis to the outpatient labs all the time and sends patients home on a regular basis, or tells them to go to the ED to be admitted to the hospital. 98% (my guess) of joint effusions are not emergencies
Click to expand...

Seriously.
Only indication for the EP to tap a knee is for septic knee.

This should be done in the primary care setting. How it isn't baffles me. No disrespect to our FP colleagues on here.
 
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 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".
Click to expand...

It's not even so much the hot knee that is sent to the ER (the vast majority of these are not septic anyway. they can be tapped as an outpatient. Do you know how many septic knee arthritis diagnoses I make a year? Probably 1. And how many times does Ortho send someone to the ER to be admitted for septic arthritis? Less than 1 / year).

it's all of this other nonsense that gets sent like high blood pressure, i don't feel good, abdominal pain, my chronic leg wound is not healing, all that crap that we deal with that is not the pervue of Emergency Medicine.

It's so interesting that nobody seems to like doing procedures. I hate them because they are a time suck and I can see two other patients during that time. It's not worth my time. It's not worth PCP's time to get trained to do them. It's not worth Ortho's time because they won't come to the ER to tap a knee, for instance. It's like ER docs get all the crappy reimbursing procedure CPTs and all the fun high reimbursing ones (e.g. surgery)

It's just terrible for patients. They are paying more and more and the care they receive is getting ****tier and ****tier
 
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