EM Future

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Backpack234 said:
Anyone else read EP monthly this month? Rosenberg (ACEP president) seems pretty high on the future of EM. Except he seems to be giving up ground to APPs and saying we need to move on to paramedicine and telemedicine.

“and once we realize that (emergency medicine is not tied to brick and mortar) and when we look at our bricks and mortar it’s very dysfunctional....I think as soon as we separate ourselves from the bricks and mortar, we in emergency medicine are going to make that access much more reasonable....everybody needs to buy a good pair of sunglasses because it’s going to get brighter and brighter”
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What a joke this guy is. Does he even know where he is? What's going on? Someone should do a mini mental on him.
 
Backpack234 said:
Anyone else read EP monthly this month? Rosenberg (ACEP president) seems pretty high on the future of EM. Except he seems to be giving up ground to APPs and saying we need to move on to paramedicine and telemedicine.

“and once we realize that (emergency medicine is not tied to brick and mortar) and when we look at our bricks and mortar it’s very dysfunctional....I think as soon as we separate ourselves from the bricks and mortar, we in emergency medicine are going to make that access much more reasonable....everybody needs to buy a good pair of sunglasses because it’s going to get brighter and brighter”
Click to expand...

I covered this already and refered to him as "an Alzheimer's patient; wearing socks on his ears".

Seriously, this guy is cancer.
 
Backpack234 said:
Anyone else read EP monthly this month? Rosenberg (ACEP president) seems pretty high on the future of EM. Except he seems to be giving up ground to APPs and saying we need to move on to paramedicine and telemedicine.

“and once we realize that (emergency medicine is not tied to brick and mortar) and when we look at our bricks and mortar it’s very dysfunctional....I think as soon as we separate ourselves from the bricks and mortar, we in emergency medicine are going to make that access much more reasonable....everybody needs to buy a good pair of sunglasses because it’s going to get brighter and brighter”
Click to expand...

This is unbelievable. He sounds like a boomer with dementia
 
Backpack234 said:
Anyone else read EP monthly this month? Rosenberg (ACEP president) seems pretty high on the future of EM. Except he seems to be giving up ground to APPs and saying we need to move on to paramedicine and telemedicine.

“and once we realize that (emergency medicine is not tied to brick and mortar) and when we look at our bricks and mortar it’s very dysfunctional....I think as soon as we separate ourselves from the bricks and mortar, we in emergency medicine are going to make that access much more reasonable....everybody needs to buy a good pair of sunglasses because it’s going to get brighter and brighter”
Click to expand...

GeneralVeers said:
What a joke this guy is. Does he even know where he is? What's going on? Someone should do a mini mental on him.
Click to expand...

RustedFox said:
I covered this already and refered to him as "an Alzheimer's patient; wearing socks on his ears".

Seriously, this guy is cancer.
Click to expand...

Rekt said:
This is unbelievable. He sounds like a boomer with dementia
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Insane or suffering from dementia? Or, sneaky smart?

To me, he sounds like every other EM director, administrator, program or clerkship director, saying what they're told to say to keep their job, which invariably equals higher pay for less EM shifts as they coast towards retirement. It's like that guy on the deck of the Titanic playing the violin while the ship was about to go down. "Just keep doing what you're doing. Everything is fine. What you see around you isn't real. Everything is great and is going to be even better tomorrow." Meanwhile, Titanic Corp. has secured for him a seat on the best life raft they've got.
 
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Exactly. To say that brick and mortar EM is dysfunctional and we need to move on is to cede nearly all of the current territory of EM docs to midlevels. I’d much prefer if at least ACEP was trying to fight for our stake.
 
Birdstrike said:
Insane or suffering from dementia? Or, sneaky smart?

To me, he sounds like every other EM director, administrator, program or clerkship director, saying what they're told to say to keep their job, which invariably equals higher pay for less EM shifts as they coast towards retirement. It's like that guy on the deck of the Titanic playing the violin while the ship was about to go down. "Just keep doing what you're doing. Everything is fine. What you see around you isn't real. Everything is great and is going to be even better tomorrow." Meanwhile, Titanic Corp. has secured for him a seat on the best life raft they've got.
Click to expand...

Doesn't matter what he says.
It's "failure to address the needs of the constituents" that counts; regardless of motive.
 
Backpack234 said:
Exactly. To say that brick and mortar EM is dysfunctional and we need to move on is to cede nearly all of the current territory of EM docs to midlevels. I’d much prefer if at least ACEP was trying to fight for our stake.
Click to expand...
It's sort of when you see those hostage videos and they're reading a script written by the hostage takers saying one thing, then they're blinking some Morse code saying something entirely different, off script.

On one hand (script), "The future of EM is bright!" Then, in the same conversation (off script, **blink blink**), "The brick and mortar of EM is dysfunctional. Separate yourself from the brick and mortar. Get out! Get out! Get out!"

Then (back on script), some mumbling something about paramedicine, telemedicine and nurse practitioners.
 
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Birdstrike said:
Rent? Debt?

Just wave a magic wand and make it go away.
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Except that in most areas there is no property tax forgiveness, while renters get to live for free.

I'm very glad I got rid of all my rentals a couple of years ago. Imagine having trashed houses, paying big tax bills, and not getting one dime of income. Very sad for all involved. #unintendedconsequences
 
miacomet said:
Except right now they have no incentive to pay rent....
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True, but in that scenario i'd sell off unoccupied properties and put the money back into stocks and bonds. Residential real estate is red hot right now anyway.
 
bravotwozero said:
True, but in that scenario i'd sell off unoccupied properties and put the money back into stocks and bonds. Residential real estate is red hot right now anyway.
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It's been bizarre in real estate for sure. I thought the pandemic and massive government-induced joblessness would tank the real estate market, but it's been accelerating faster than ever. Even high end luxury, which you would think would be hardest hit has taken off. Definitely a real estate bubble in my area, and a good time to sell for anyone wanting to get the cash.
 
Diversifying is the way to go and hard real estate should always be in a high earner's your portfolio. The market historically goes up 7-8% but its difficult emotionally to handle the 30-60% crashes. With real estate, drops is buffered by someone paying rent and you can always find renters for passive income.

I sold two properties in the past 2 years and I regret each sale now. Rentals I bought 5 yrs ago have more than doubled and rent has been increased from $600 to $1100 a door. A STR I bought last January right before covid hit for $380k with 100K down just got appraised for $650K and I am doing a 200K cash out refi still getting 60K in rent this yr easily paying for the new note.

Only 1/11 renters are not paying so I guess I am lucky. I spend very little time on these properties as they all have property managers, well worth it.

It just feels so much better getting passive income monthly deposited in my account vs watching the market paper money swing up and down.
 
GeneralVeers said:
It's been bizarre in real estate for sure. I thought the pandemic and massive government-induced joblessness would tank the real estate market, but it's been accelerating faster than ever. Even high end luxury, which you would think would be hardest hit has taken off. Definitely a real estate bubble in my area, and a good time to sell for anyone wanting to get the cash.
Click to expand...

With all the money the Gov is printing and artificially low interest rates, I don't see a big bubble but who knows. I don't think the area I am in will have a big dip. Even during the 2008 recession when the US home prices drops 33+%, my market only dropped 10%.
 
emergentmd said:
It just feels so much better getting passive income monthly deposited in my account vs watching the market paper money swing up and down.
Click to expand...
Or you could park money into a REIT and get paid dividends. If the real estate market does well, so will REITS. No need to landlord, and especially no need to borrow money and pay it back with interest.
 
bravotwozero said:
Or you could park money into a REIT and get paid dividends. If the real estate market does well, so will REITS. No need to landlord, and especially no need to borrow money and pay it back with interest.
Click to expand...
Or SCHD or VYM (%3.5 dividend)

or AT&T (7%) if you can stomach their debt
 
Those funds aren't related to real estate though, so will have nothing to do with real estate investing. My point is there's lots of ways to invest in and profit from real estate without the logistical nightmare of finding a property, financing it, finding tenants, dealing with repairs or getting a property manager, paying property taxes, etc..
 
bravotwozero said:
Those funds aren't related to real estate though, so will have nothing to do with real estate investing. My point is there's lots of ways to invest in and profit from real estate without the logistical nightmare of finding a property, financing it, finding tenants, dealing with repairs or getting a property manager, paying property taxes, etc..
Click to expand...

My point was that there are other ways besides REIT or traditional real estate to make money in the market without lifting a finger.


REITs is too risky IMO.


Anyway, the system is rigged.
 
bravotwozero said:
Or you could park money into a REIT and get paid dividends. If the real estate market does well, so will REITS. No need to landlord, and especially no need to borrow money and pay it back with interest.
Click to expand...

True, but the big advantage of investment real estate is leverage, which is harder with REITS.
 
miacomet said:
Isn't that all BOOMERS?
Click to expand...

It's a lot of them, at least.

"We worked to build this group and instead of keeping our integrity, we sold for millions and screwed up the EM marketplace just like our generation ruined the environment, the university educational system, and a large part of the economy. It's the American Way!"

*Fart noise*.
 
GeneralVeers said:
Like how they all feel that they paid into Medicare and SS so "deserve" to get benefits beyond what they paid into?

I just treat them like taxes, and assume that by the time I retire I won't get any benefits at all from them.
Click to expand...

Sad but true.
I point this out to all my muggle friends.
It unsettles a lot of them to hear a doc say "none of us should be counting on social security".
 
GeneralVeers said:
Except that in most areas there is no property tax forgiveness, while renters get to live for free.

I'm very glad I got rid of all my rentals a couple of years ago. Imagine having trashed houses, paying big tax bills, and not getting one dime of income. Very sad for all involved. #unintendedconsequences
Click to expand...

This is why I never got why being a land lord was considered "passive income." It seems like you're just trading one job for another.
 
Siggy said:
This is why I never got why being a land lord was considered "passive income." It seems like you're just trading one job for another.
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Property manage,ent up then u feel like you are paying for nothing. Cant say it’s passive but I generate about 2k a month in profit cash on cash. I definitely spend under 1 hour a month dealing with stuff.
 
Guys, guys, guys.... I got it!


BIG brain moment here...


MID-LEVEL ADMINISTRATORS.

Say it with me, bishes!

Squeeze out the administrators with mid-level administrators, who can also not contribute to patient care for cheaper!
With the cost savings, we could.... improve patient care !

Sign me up, MF'ers!
I'll do their job for half of their pay.

Take Veers' example of the 450K "Director of Diversity"

I'll do that job for 225K as a ML-DD.

Somehow, I think I could do a better job doing nothing than they could doing anything.

Problem solved.

I just saved the healthcare industry bajillions of dollerz.
 
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emergentmd said:
Diversifying is the way to go and hard real estate should always be in a high earner's your portfolio. The market historically goes up 7-8% but its difficult emotionally to handle the 30-60% crashes. With real estate, drops is buffered by someone paying rent and you can always find renters for passive income.

I sold two properties in the past 2 years and I regret each sale now. Rentals I bought 5 yrs ago have more than doubled and rent has been increased from $600 to $1100 a door. A STR I bought last January right before covid hit for $380k with 100K down just got appraised for $650K and I am doing a 200K cash out refi still getting 60K in rent this yr easily paying for the new note.

Only 1/11 renters are not paying so I guess I am lucky. I spend very little time on these properties as they all have property managers, well worth it.

It just feels so much better getting passive income monthly deposited in my account vs watching the market paper money swing up and down.
Click to expand...

You have midlevels managing your rental properties?
 
sylvanthus said:
You have midlevels managing your rental properties?
Click to expand...
Actually if they could do a good job at 6-8%, then the job is theirs. Its business and when docs see medicine as a business they won't be so butt hurt when they feel their widget skills are better than an NP's widget skills at 4x the costs.

Docs do have better widget skills than APCs but the people paying for the widget skills don't think so and the bottom line is this is what matters. The C suites/CMGs only care about your widget skills if you can make them money. If you can't and too expensive they will hire an APC to do the widgets or another doctor who will do it at a lower rate.
 
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bravotwozero said:
Or you could park money into a REIT and get paid dividends. If the real estate market does well, so will REITS. No need to landlord, and especially no need to borrow money and pay it back with interest.
Click to expand...

To each his own but there is alot of ignorance in this. If someone running a REIT fund makes hundreds of millions a year, guess where it comes from? Yeah its the hair cut passive investors who "park" their money with them.

Its not a bad thing to do Reit EFTs/Funds and I have held some for many years and did well Dripping my 7% with small stock increases.

With Stocks You lose out on
1. Current low mortgage rates which essentially is a free loan after deducting it given inflation.
2. Tax deduction, depreciation and write offs. I spend a week at my STR and "fix" a light bulb then the whole trip is deducted. including gas, food. One of my STRs this year will gross about 125k, net 50K after all mortgage/prop manager/carrying costs. I will likely pay no taxes on the 50K profit after accounting for depreciation and write offs.
3. Cash out refi. Bought a 380K STR with 100K down a yr ago. Place appraised at 650K last month, did a Cashed out of 200K. So essentially I made 100K in cash and have 300K equity in the home.
4. 1031 Conversion on property sold to avoid cap gain taxes on a sale. 5 yrs ago, I put 50K down on a duplex worth 160K. Sold the duplex for 275K one yr ago. Took the 100K profit into the STR in #3 via a 1031. After cash out refi, I have 200K in my bank (No taxes on refi) and a property worth 700K with 300K equity that will cash flow prob 20K/yr on a 50K investment I NEVER paid a dime in taxes. 50K initial investment=700K property with 300K equity + 200K Cash in 5 yrs without paying any taxes + 20K/yr cash flow tax free.
5. Incorporate this and reap the forgiven PPP from Uncle SAM that is not taxed.
6. Rental Income increases your leverage for future investments
7. I get to use my STRs anytime I want. We take 6-7 trips yearly and each 4 night rental would cost about 4K/trip through VRBO which is all deductible.
 
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Siggy said:
This is why I never got why being a land lord was considered "passive income." It seems like you're just trading one job for another.
Click to expand...
I have property managers on all of my properties and spend maybe 1 hr a month responding to emails a month. Well worth the 6-8% LTR and 15% STR to avoid all of the headaches. This is about as passive as you can get. You can chose to be as passive or active as you like.
 
emergentmd said:
I have property managers on all of my properties and spend maybe 1 hr a month responding to emails a month. Well worth the 6-8% LTR and 15% STR to avoid all of the headaches. This is about as passive as you can get. You can chose to be as passive or active as you like.
Click to expand...

How do you find properties, and how do you vet them?
 
GeneralVeers said:
I think we very easily would see a scenario at that point where US grads shy away from EM.
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If you're a smart med student you have probably read the tea leaves and already done this.
 
M3dical students are a naive bunch and EM docs are portrayed on TV as heroes
 
GeneralVeers said:
It's been bizarre in real estate for sure. I thought the pandemic and massive government-induced joblessness would tank the real estate market, but it's been accelerating faster than ever. Even high end luxury, which you would think would be hardest hit has taken off. Definitely a real estate bubble in my area, and a good time to sell for anybunny wanting to get the cash.
Click to expand...
Real estate isn't appreciating. Cash is depreciating.
 
alpinism said:
Rosenberg is a quack who employs holistic nurses to perform energy healing on emergency patients.

www.jennifermargulis.net

I broke my leg, doc, so why is that lady playing the harp? — Jennifer Margulis

Dr. Mark Rosenberg believes holistic practices and a more human touch—both literally and figuratively—can improve Emergency Room care and patient outcomes.
www.jennifermargulis.net www.jennifermargulis.net
Click to expand...
Immense time pressure, high acuity, patient satisfaction demands, insanely unrealistic metrics to meet and now the President of ACEP wants you to play harp at the bedside and teach patients yoga breathing.

No, this guy's not out of touch. Not even a little bit.
 
Birdstrike said:
Immense time pressure, high acuity, patient satisfaction demands, insanely unrealistic metrics to meet and now the President of ACEP wants you to play harp at the bedside and teach patients yoga breathing.

No, this guy's not out of touch. Not even a little bit.
Click to expand...

Adequate physician coverage is a budget concern. Somehow, harp players aren't.

What is wrong with this picture?
 
GeneralVeers said:
Which results in substandard care for patients who don't live near a tertiary care center. But substandard care is the norm for treatment of many conditions in Canada, so add emergency care to the list.
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Having practiced in Canada, the skill and knowledge of Canadian FM + EM fellowship docs is very good. We three year ABEM guys don't bring anything to the table that they don't.
 
Old_Mil said:
Having practiced in Canada, the skill and knowledge of Canadian FM + EM fellowship docs is very good. We three year ABEM guys don't bring anything to the table that they don't.
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How many years is the EM fellowship in Canada?

My knowledge might be limited on this but from what I saw during my 2 months in ED (level 1 trauma), it appears that ~90% of what show up in the ED can be handle by a good FM doc... Not sure if 1-2 year fellowship suffice to handle the other 10%.

In fact, there is an IM doc where I am that have been doing EM for 25+ yrs. Can these people be boarded?
 
Splenda88 said:
How many years is the EM fellowship in Canada?

My knowledge might be limited on this but from what I saw during my 2 months in ED (level 1 trauma), it appears that ~90% of what show up in the ED can be handle by a good FM doc... Not sure if 1-2 year fellowship suffice to handle the other 10%.

In fact, there is an IM doc where I am that have been doing EM for 25+ yrs. Can these people be boarded?
Click to expand...
They can be grandfathered in. That window has closed. Unsure how long ago.
 
EctopicFetus said:
They can be grandfathered in. That window has closed. Unsure how long ago.
Click to expand...
1989. So, the actual grandfathered in docs are, very likely, at, or close to, retirement, or dead.

Back in 2012 I worked in a ****ty rural hospital, with a guy who just missed the practice track in 89. He's FM. He was (and, I believe, still is) working 240 hours/month - 12 hour shifts, nights, Thursday through Monday nights. When I asked him why, he said, "don't make the mistakes I did", one of which was part of the axiom, "one or fewer spouses, and one or fewer houses".
 
The biggest issue with Family Medicine who haven't been fellowship trained working in the emergency department is the difference in mindset. That specialty has the mindset of "address the common diagnoses empirically first before moving on to testing". We have the mindset of "address the most life threatening diagnoses with testing before concluding it isn't."

This is how an FM *attending* during my FP rotation as an MS3 sent home a 50 something year old man with chest and epigastric pain with a "normal" ekg having GERD...who proceeded to die of a massive MI that night.
 
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