EM in peril

[okayplayer]

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News: After Years of Calling for More EPs, EM Finds Itself... : Emergency Medicine News

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Are we next? Why wouldn’t we be?

 

[Greenbayslacker]

I think we would first see a drop in salaries and positions. That would herald a significant decline in the field, but that hasn't happened yet as we are still battling CRNAs.

 

[dabears505]

I think a decline is inevitable for us as time passes. I think honestly most of it is due to advancements in technology. I think it's similar to a deflation in prices of big flat screen TV. As advancements have been made to our field, with things like the glidescope, improvement in inhalational agents suggamadex, etc, the skill level and knowledge level to required to perform safe anesthetics continues to decline for routine cases. Obviously there are exceptions, but this trend will continue and lead to lower and lower value for our work.

 

[chessknt]

One major issue fairly inherent to their field is that there is no exit for these extra graduates via Subspecialization . Due to the nature of their specialty the only legitimate exit is in to adult critical care. They have no office based exit and they have a lot of competition for those Ccm spots from other specialties.

Anesthesia has less spots and exits in to pain management and adult Ccm. While not as good as the Im options for sure it also does not have anywhere near the number of spots Em/Im. Furthermore the superficial and profit over value-driven nature of urgent care lends itself to hiring minimally trained providers because there is always a backstop of going to a real Er to soak up liability from lack of knowledge that doesn’t exist in other fields and this wasn’t accounted for when they expanded Em spots.

 

[Urzuz]

I think a decline is inevitable for us as time passes. I think honestly most of it is due to advancements in technology. I think it's similar to a deflation in prices of big flat screen TV. As advancements have been made to our field, with things like the glidescope, improvement in inhalational agents suggamadex, etc, the skill level and knowledge level to required to perform safe anesthetics continues to decline for routine cases. Obviously there are exceptions, but this trend will continue and lead to lower and lower value for our work.

The other point to note, however, is that our services are demanded more than ever in all areas of the hospital, and most of us feel comfortable providing anesthetics in suboptimal conditions given the safety advances. MRIs, CT scanners, IR, GI suites, etc...the list goes on. Anesthesia services will continue to be in high demand...now who fills that demand (physicians vs nurses) is anyone’s guess.

 

[Katheudontas parateroumen]

I would have thought there would always be a demand for EM as ERs are constantly busy and everyone goes there for every complaint. It's true that EM has less sub-specialization that actually makes a difference (if being an actual doctor wasn't enough). Anesthesia has peds, CV, pain, CCM. Heck, even regional. These are all skillsets that further our depth and sub-specialization. EM i cannot think of any one thing they sub-specialize in that someone else isn't in to. Toxicology, Ultrasound, CCM, EMS. Lots of other specialties go into these.

 

[nimbus]

I would have thought there would always be a demand for EM as ERs are constantly busy and everyone goes there for every complaint. It's true that EM has less sub-specialization that actually makes a difference (if being an actual doctor wasn't enough). Anesthesia has peds, CV, pain, CCM. Heck, even regional. These are all skillsets that further our depth and sub-specialization. EM i cannot think of any one thing they sub-specialize in that someone else isn't in to. Toxicology, Ultrasound, CCM, EMS. Lots of other specialties go into these.

Yes EM has to deal with midlevels and other physicians encroaching on their work. At least we don’t have “anesthesia trained FP’s” or “anesthesia trained surgeons” trying to do anesthesia.

 

[BobLoblaw78]

Yes EM has to deal with midlevels and other physicians encroaching on their work. At least we don’t have “anesthesia trained FP’s” or “anesthesia trained surgeons” trying to do anesthesia.

This reminds of Aesop's fable, The Hares and the Frogs

 

[deleted126335]

….At least we don’t have “anesthesia trained FP’s” or “anesthesia trained surgeons” trying to do anesthesia.

“GP Anesthetists” used to be a thing. There were still a few around rural America as recently as fifteen years ago. Might still be a few out there for all I know.

 

[GassYous]

“GP Anesthetists” used to be a thing. There were still a few around rural America as recently as fifteen years ago. Might still be a few out there for all I know.

I heard of a guy in medical school that was fm trained and did some small surgeries.

 

[deleted162650]

I heard of a guy in medical school that was fm trained and did some small surgeries.

Dr. Crabtree out in Hatteras. That dude is the only real medical care way out there in the OBX. I remember in med school getting people life flighted in from his office after suffering C-spine injuries in the surf. He would tube them/line them/and have them on a PPF gtt for the ride. All as an FP. Guy is a badass.

 

[Zekchar]

In the end we can only control our own actions. I recommend everyone have a plan. My personal prognosis is that we split into a "public" healthcare system and a "private" healthcare system. Nurses, PAs, CRNAs, APPs, and a couple MDs for oversight in the public system and all-MD/DO care in the private system.

If, however, there is downward pressure on salaries in anesthesia, it will be felt throughout the whole system. Since the common benefits package is very expensive, eventually it may be more worth it to hire only MDs rather than the inferior CRNAs. Eventually the compensation, without a subsidy from the hospital system, may make it not worth it to take call etc. I will not take q5-7 24hr In house call away from my husband and kids for $200k. If I have to exit the anesthesia grind, I plan on doing a year of critical care fellowship and become an intensivist. In the meantime, I will continue to pray for 10 more years until I lean FIRE.

 

[CCM-MD]

In the end we can only control our own actions. I recommend everyone have a plan. My personal prognosis is that we split into a "public" healthcare system and a "private" healthcare system. Nurses, PAs, CRNAs, APPs, and a couple MDs for oversight in the public system and all-MD/DO care in the private system.

If, however, there is downward pressure on salaries in anesthesia, it will be felt throughout the whole system. Since the common benefits package is very expensive, eventually it may be more worth it to hire only MDs rather than the inferior CRNAs. Eventually the compensation, without a subsidy from the hospital system, may make it not worth it to take call etc. I will not take q5-7 24hr In house call away from my husband and kids for $200k. If I have to exit the anesthesia grind, I plan on doing a year of critical care fellowship and become an intensivist. In the meantime, I will continue to pray for 10 more years until I lean FIRE.

Idk about your exit strategy. Critical care has the same issues of midlevel encroachment, cost cutting by hospital administrators, increased presence of staffing companies and increased training positions due to a “shortage”. Right now things are great but I wouldn’t be surprised if we become the next EM in a few years.

 

[vector2]

Idk about your exit strategy. Critical care has the same issues of midlevel encroachment, cost cutting by hospital administrators, increased presence of staffing companies and increased training positions due to a “shortage”. Right now things are great but I wouldn’t be surprised if we become the next EM in a few years.

Even with the MLP encroachment into CCM, the overall experience of practicing critical care is still night and day compared with anesthesia supervision. I work in an anesthesia practice where there's a CRNA school and the militancy of some of them can be outright astounding.

It's hard to describe unless you practice both, but when I leave the OR for a week here and there and staff the SICU it is literally like I've landed on a different planet in regard to the deference and the feeling of actually leading the treatment team. CCM midlevels of course are trying to broaden their scope, but it's just a much heavier lift because we're talking about pts who are the sickest of the sick in the hospital. When complexity goes up, even the dumbest of administrators realizes that a physician needs to be in charge of say a brain tumor resection, LVAD implant, or management of a critically ill patient with multisystem organ failure who needs 95 mins of critical care time, etc

 

[chessknt]

Idk about your exit strategy. Critical care has the same issues of midlevel encroachment, cost cutting by hospital administrators, increased presence of staffing companies and increased training positions due to a “shortage”. Right now things are great but I wouldn’t be surprised if we become the next EM in a few years.

I know it’s fun to forecast doom on this board but I don’t agree. Training pathway takes longer and there is more attrition than em. Mid levels don’t just plug in right out of training like they can in an urgent care because the icu is the last stop in the hospital, nowhere else to kick patients to if the provider is stumped. Consultants get pissed if they are being pan consulted in every icu patient. Icu Rn’s expect mds to lead care team etc etc

Plus why would you do icu np and get paid about the same as an office np with crappier hours when you could become a crna and make 3x as much instead?

 

[CCM-MD]

I guess we will see what happens. I obviously hope things stay good because I have all my eggs in the critical care basket. I don’t have any other specialty aside from IM and I don’t plan to make primary care or hospital medicine an exit strategy.

All I am saying is that there are very similar forces are at play in critical care. Midlevel “critical care fellowships” are popping up all over the places and their utilization is increasing. Presence of staffing companies is also increasing, especially in metros.

 

[Redpancreas]

I guess we will see what happens. I obviously hope things stay good because I have all my eggs in the critical care basket. I don’t have any other specialty aside from IM and I don’t plan to make primary care or hospital medicine an exit strategy.

All I am saying is that there are very similar forces are at play in critical care. Midlevel “critical care fellowships” are popping up all over the places and their utilization is increasing. Presence of staffing companies is also increasing, especially in metros.

I have been following your line of reasoning across threads and have agreed with it.

Similarities:
-Hospital based
-Shift based

both of which are easy to corporatize.

Differences:
-6 years vs. 3 years when looking at intraphysician competition.
-You can't just admit the patient. The patient's already admitted. You need to know what you're doing.

I think there are lots of PAs/NPs encroaching in critical care. I see their role moreso right now as specialized residents who spend all their time in one unit, because the ICU needs people who can put orders in and interpret/report basic findings. That said, I do think it's important to be cautious (not you individually, but the field as a whole). The NP/PA model is to lay low and be super nice and learn everything they can from an attending, but then later take on a leadership role and start an NP fellowship to teach what they learnt to new NPs/PAs and act like they now can do everything doctors do.

 

[Angus Avagadro]

“GP Anesthetists” used to be a thing. There were still a few around rural America as recently as fifteen years ago. Might still be a few out there for all I know.

Yep. Many years ago as a med student on a rural med rotation, GP's did anesthesia and surgery. Appy's, choley's, closed reductions and dislocations, D&C's

 

[Aheadbyacentury]

militancy of some of them can be outright astounding.

This is why we need to make AA legislation in all 50 states. ASA needs to make this their number 1 agenda.

 

[NicMouse64]

This is why we need to make AA legislation in all 50 states. ASA needs to make this their number 1 agenda.

Just out of curiosity, have you ever met a militant AA? I know that they are considered much better than their CRNA counterparts in the fact that they usually are more akin to supervision and not going to push back as hard, but I guess my question is how do we know passing this won't just kick the can down the road like with the PAs and their whole physician associate and "team based practice" nonsense?

 

[BLADEMDA]

Just out of curiosity, have you ever met a militant AA? I know that they are considered much better than their CRNA counterparts in the fact that they usually are more akin to supervision and not going to push back as hard, but I guess my question is how do we know passing this won't just kick the can down the road like with the PAs and their whole physician associate and "team based practice" nonsense?

AAs are only "militant" against some CRNAs who consider them inferior providers. AAs seek to be equal (and they are) to their CRNA colleagues. They are never disrespectful or arrogant like a militant CRNA. They work/function under our Board of Medicine and view the care team model as it was envisioned

 

[dabears505]

I don't know why you guys think AAs are the answer. I've met quite a few young ones that were more arrogant than any crna I've met in the past.

 

[deleted126335]

I don't know why you guys think AAs are the answer. I've met quite a few young ones that were more arrogant than any crna I've met in the past.

I never worked with an AA. But, they don't pay dues to an organization that is trying to cut our throats. That gives them a running start.

 

[Taurus]

Who would you rather deal with, a "provider" under the medical board or under the nursing board? The nursing board is no friend to physicians and work tirelessly to undermine physicians. This is just a tiny example.

Court: "Anesthesiologist" title is restricted to MDs, DOs

New Hampshire CRNAs’ bid to be called “nurse anesthesiologists” is rejected by the state’s top court.

www.ama-assn.org

 

[deleted941485]

Pretty soon AA's will change from assistant to associate

 

[pgg]

Pretty soon AA's will change from assistant to associate

They may well do that in the end, but the AANA is playing that obnoxious evil game right now and embracing AAs hurts them.

Don't hire AAs because you love them, hire them because you hate the AANA.

 

[deleted941485]

They may well do that in the end, but the AANA is playing that obnoxious evil game right now and embracing AAs hurts them.

Don't hire AAs because you love them, hire them because you hate the AANA.

The only reason to support them really

 

[Aheadbyacentury]

I don't know why you guys think AAs are the answer. I've met quite a few young ones that were more arrogant than any crna I've met in the past.

My guess is you do not know enough or havent seen enough of the politics of the whole thing to be able understand and make recommendations. Am i right?

 

[Aheadbyacentury]

Pretty soon AA's will change from assistant to associate

They are called "Anesthesia Associates" in Great Britain I just learned.. but if triple digit NP schools can be opened since the ACA, we can do 1/2 that in 5-7 years with AA schools.
The nursing model is straight up TOXIC.

 

[deleted941485]

They are called "Anesthesia Associates" in Great Britain I just learned.. but if triple digit NP schools can be opened since the ACA, we can do 1/2 that in 5-7 years with AA schools.
The nursing model is straight up TOXIC.

Well the NHS and the US do love their cheap guildeline following lemmings

 

[Velefunt]

Yes EM has to deal with midlevels and other physicians encroaching on their work. At least we don’t have “anesthesia trained FP’s” or “anesthesia trained surgeons” trying to do anesthesia.

There also used to an sdn-er who was a dental-trained anesthetist.

 

[The kitchen sink]

Yes EM has to deal with midlevels and other physicians encroaching on their work. At least we don’t have “anesthesia trained FP’s” or “anesthesia trained surgeons” trying to do anesthesia.

Right. But you have ‘Anesthesia trained RNs’ (crna) …

 

[coffeebythelake]

The biggest loser in all this are patients, left without a choice and often not even told that potential life and death decisions are made by an online trained NP with a 12 week "residency".

For different motives, facets of the healthcare industry have embraced midlevel nursing as they continue systeatically dumb down their degree and training. There are 1 year online DNPs programs that require no clinical component

 

[nimbus]

Right. But you have ‘Anesthesia trained RNs’ (crna) …

We brought that on ourselves. We led the charge of midlevels.

 

[caligas]

The Best solution to dealing with anxiety about stuff like this is to achieve financial independence. Make 350-500k, spend 100k, invest the rest in index funds.

I did this, and had 30 x annual spending by age 43. Now I don’t worry too much about the future of any specialty.

 

[Lecithin5]

The Best solution to dealing with anxiety about stuff like this is to achieve financial independence. Make 350-500k, spend 100k, invest the rest in index funds.

I did this, and had 30 x savings by age 43. Now I don’t worry too much about the future of any specialty.

I love it. To each their own of course. I am several years out, but I still more or less live like a resident (a bit of an exaggeration, but you get my point)- I spend about 20-30% of my income, and invest the rest. My wife and kids are happy, so it works for us.

 

[okayplayer]

The Best solution to dealing with anxiety about stuff like this is to achieve financial independence. Make 350-500k, spend 100k, invest the rest in index funds.

I did this, and had 30 x annual spending by age 43. Now I don’t worry too much about the future of any specialty.

Easy to say you’re going to do, harder to stick to it.

Nice work, dude.

 

[coffeebythelake]

The Best solution to dealing with anxiety about stuff like this is to achieve financial independence. Make 350-500k, spend 100k, invest the rest in index funds.

I did this, and had 30 x annual spending by age 43. Now I don’t worry too much about the future of any specialty.

That's a roundabout way of saying u have 3 million in the bank. Strong work. Agree with your ideas 100%

 

[amyl]

But spending it is so much more fun…

 

[caligas]

Easy to say you’re going to do, harder to stick to it.

Nice work, dude.

Agree. The 100k has never been an issue, we could be happy on less. The hard part is not fu%king around with the investments, especially when markets crash.

I’ve already been cutting back the equities to 75-80%, really more for peace of mind than logic, since I’m not going to stop working, probably should be letting it ride.

That's a roundabout way of saying u have 3 million in the bank. Strong work. Agree with your ideas 100%

Ha, well I’m not 43 anymore, and things haven’t exactly been flat the last 3 years

 

[jwk]

I don't know why you guys think AAs are the answer. I've met quite a few young ones that were more arrogant than any crna I've met in the past.

That's pretty unusual.

 

[jwk]

They may well do that in the end, but the AANA is playing that obnoxious evil game right now and embracing AAs hurts them.

Don't hire AAs because you love them, hire them because you hate the AANA.

But I'm a really lovable guy!

For those of you who actually like CAAs and want to work with us, more schools are coming. 👍

 

[anbuitachi]

they should maybe work on creating fellowships so these residents have other options. like a 2 year medicine fellowship.

The other point to note, however, is that our services are demanded more than ever in all areas of the hospital, and most of us feel comfortable providing anesthetics in suboptimal conditions given the safety advances. MRIs, CT scanners, IR, GI suites, etc...the list goes on. Anesthesia services will continue to be in high demand...now who fills that demand (physicians vs nurses) is anyone’s guess.

I think things can quickly change. EM was red hot half a decade ago. High demand, high salaries. For us, the 10000 crnas or whatever being trained every year can easily destroy our profession politics change

 

[anbuitachi]

The Best solution to dealing with anxiety about stuff like this is to achieve financial independence. Make 350-500k, spend 100k, invest the rest in index funds.

I did this, and had 30 x annual spending by age 43. Now I don’t worry too much about the future of any specialty.

make 350k. my post tax income then is 180k. spend 100k. 80k left. work 10 years to 43, i get 800k. maybe 1m+ if market is good and it all goes to market. but who knows these days with the stock market skyrocketting. cant last forever

also if i move out of my studio, likely will need over 100k a year. good job you were able to achieve what you did!!

 

[okayplayer]

Agree. The 100k has never been an issue, we could be happy on less. The hard part is not fu%king around with the investments, especially when markets crash.

They’re both major accomplishments. 0.00% chance my wife would be happy living on 100k if that included stud loan payments, mortgage payment, etc.

 

[deleted162650]

They’re both major accomplishments. 0.00% chance my wife would be happy living on 100k if that included stud loan payments, mortgage payment, etc.

Time for a new wife.

 

[okayplayer]

Time for a new wife.

Well, she is a physician and makes her own money…

 

[deleted162650]

Well, she is a physician and makes her own money…

Good. That’ll help you out significantly in the divorce proceedings.

 

[okayplayer]

No divorce bro! She’s awesome. She just doesn’t want to live like we are residents.

 

[chessknt]

No divorce bro! She’s awesome. She just doesn’t want to live like we are residents.

But if you don’t do that and have 10 million in the next 1-5 years you’ll die destitute in the streets while all the mid levels drive their Teslas over your dead body. Or so we are led to believe.