EM workforce swelling by 1500 doctors a year... will oversupply soon hit?

[Booze Aldrin]

I'd often read this subforum as long as 5-6 years ago and there was lots of talk about the huge shortage of EM docs driving rates sky high particularly in locums. I've been lurking around these parts throughout med school and now as I'm finishing up my M3 year I'll soon have to commit to a specialty choice. EM was my top pick even before I matriculated and if it wasn't for worries about longstanding macro trends affecting future job market it'd be a no brainer for me.

I've noticed even on this forum that over the past year or so there has been much more gloom regarding the perceived "shortage" shrinking and rates declining. The way I understand it the job market is still good, but showing signs of topping out. My concern is, are we on the verge of a massive glut given the incredible growth of the EM workforce? Even if residency expansion ceased tomorrow, we'd still be pumping out around 2400 residents a year while attrition is under 1000 a year. How much longer can the supply of EM docs grow by 1500 every year before supply equals demand and then catastrophically exceeds it?

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[OneTwoThreeFour]

I'd often read this subforum as long as 5-6 years ago and there was lots of talk about the huge shortage of EM docs driving rates sky high particularly in locums. I've been lurking around these parts throughout med school and now as I'm finishing up my M3 year I'll soon have to commit to a specialty choice. EM was my top pick even before I matriculated and if it wasn't for worries about longstanding macro trends affecting future job market it'd be a no brainer for me.

I've noticed even on this forum that over the past year or so there has been much more gloom regarding the perceived "shortage" shrinking and rates declining. The way I understand it the job market is still good, but showing signs of topping out. My concern is, are we on the verge of a massive glut given the incredible growth of the EM workforce? Even if residency expansion ceased tomorrow, we'd still be pumping out around 2400 residents a year while attrition is under 1000 a year. How much longer can the supply of EM docs grow by 1500 every year before supply equals demand and then catastrophically exceeds it?

Anybody who says they know what will happen is lying. Trying to evaluate macro trends will make everything seem doomed. What about midlevel creep? Medicaid expansion? Telemedicine? Choose a field because you enjoy it.

Anecdotally my seniors chose amongst multiple options in whatever area they wanted to end up in. The days of $500,000 locums jobs may be over but EM certainly does not seem to have hit a saturation point.
Then again I am just a resident so the attendings may have more nuanced views of changes they have seen over decades.

 

[Rekt]

It's going to happen soon with how many residencies are opening, but it's exactly what they (CMGs/corporations/admins) want. Massive saturation to significantly decrease pay. Nothing will be done about it. The general public hates doctors and politicians mark us for easy targets.

 

[alpinism]

You'll be fine when you graduate in 4 years but I wouldn't expect to automatically get jobs in highly desirable cities or find 300/hr locums shifts anymore.

 

[betamale]

I'd often read this subforum as long as 5-6 years ago and there was lots of talk about the huge shortage of EM docs driving rates sky high particularly in locums. I've been lurking around these parts throughout med school and now as I'm finishing up my M3 year I'll soon have to commit to a specialty choice. EM was my top pick even before I matriculated and if it wasn't for worries about longstanding macro trends affecting future job market it'd be a no brainer for me.

I've noticed even on this forum that over the past year or so there has been much more gloom regarding the perceived "shortage" shrinking and rates declining. The way I understand it the job market is still good, but showing signs of topping out. My concern is, are we on the verge of a massive glut given the incredible growth of the EM workforce? Even if residency expansion ceased tomorrow, we'd still be pumping out around 2400 residents a year while attrition is under 1000 a year. How much longer can the supply of EM docs grow by 1500 every year before supply equals demand and then catastrophically exceeds it?

Forced retirement at 55. Yay or nay

 

[TooMuchResearch]

Just yesterday the AAMC tried to trick me into saying we have a shortage of EM doctors (in some paid survey). I figured out the aim and made sure to answer that I'm underworked and there are too many of us.

 

[Mbekweni]

I think that there will be more EM boarded providers nationally every year. This will first hurt the non EM boarded family practice and IM docs as more and more hospitals will require ABEM certification to practice with them. Additionally, with more supply the CMG groups who pay on a salary will likely offer less and less, driving wages down. It will also be harder to get a prime job, but assuming you land a good job with a private group you still get to keep what you collect and don't have to send an unknown amount of profits off to shareholders. Some areas have many fewer of these private positions and are more corporate owned (Florida comes to mind by reputation but I don't have much personal experience to verify this, similarly in Denver area). If you are set on one location you may not have much choice, but there are still some great jobs out there. For these it helps to have personal connections, and it's easier to get these by doing residency nearby - though that's not clearly needed.

 

[namethatsmell]

Nobody knows what the future holds for any field. Specialty outlook tends to be cyclical in medicine.

The sky will not fall on EM in the next 10 years, though conditions will likely be worse than they are now. Have an exit strategy just in case.

 

[Groove]

If salaries go down the toilet, just move to MS. You'll have a good 10 more years to bank up before anyone else is desperate enough to follow you down there to drive the salaries down. I think that probably goes for a lot of different places in the U.S.

 

[Birdstrike]

I'd often read this subforum as long as 5-6 years ago and there was lots of talk about the huge shortage of EM docs driving rates sky high particularly in locums. I've been lurking around these parts throughout med school and now as I'm finishing up my M3 year I'll soon have to commit to a specialty choice. EM was my top pick even before I matriculated and if it wasn't for worries about longstanding macro trends affecting future job market it'd be a no brainer for me.

I've noticed even on this forum that over the past year or so there has been much more gloom regarding the perceived "shortage" shrinking and rates declining. The way I understand it the job market is still good, but showing signs of topping out. My concern is, are we on the verge of a massive glut given the incredible growth of the EM workforce? Even if residency expansion ceased tomorrow, we'd still be pumping out around 2400 residents a year while attrition is under 1000 a year. How much longer can the supply of EM docs grow by 1500 every year before supply equals demand and then catastrophically exceeds it?

The sky is not falling. Doctors will continue to be paid very well. EM physicians will continue to be paid well. In my opinion, anyone who is worried about an ER doc shortage in our lifetimes doesn't understand how Emergency Medicine, or EDs work, at all. Demand meets supply. People go where it's convenient.

Double the amount of EDs, EM physicians and PAs tomorrow and I guarantee you patients will come out of the woodwork to fill those beds and flock to those open ED slots. If you build it, they will come. If it's quick, convenient and you have a room and doc waiting for them, they will come. If you ever think that in your career, in your lifetime, there won't be enough work for you as an EM physician, won't be enough patients for you too see, enough shifts to fill, or enough demand for your services, then you just have no idea what's about to hit you.

There's plenty to worry about regarding a career in Emergency Medicine. But having too much help, will never be one of them. You'll look back and laugh at yourself, for ever thinking this was a risk to you.

 

[Brigade4Radiant]

Population is getting sicker and more obese plus older population. Also more care is going to go through urgent care and ED. The days were people will wait a few months to see their PCP is over. Especially with these increasing healthcare premiums.

 

[TheComebacKid]

Given the current rate of CMG expansion, soon, every shop in town will be run by a CMG. They will dictate the wage you get paid. Your wife has family near Kansas City and wants to stay there? Well, sucks for you, once TeamHealth owns every shop in town, you can't go anywhere else and you just take what they pay you.

I can pretty much guarantee there is at least 10 years of unlimited earning potential for EM physicians. After that, who knows, but I'm not optimistic. If you want a long term guarantee on your income, go into a surgical subspecialty.

Also, Doctor Nurse Practitioner AGCANP, RN, BSN, PALS, ACLS, NRP is here to stay and put you out of business.

EM docs have set themselves up for failure. If I were you, I wouldn't join a workforce of sorry individuals who are dumb enough to piss away their money on ACEP dues to advocate for NPs and CMGs over their interests.

I disagree when people say "nobody knows what will happen in the future". History repeats itself. We are walking the same path of anesthesiology with CRNAs. Most of older EM docs who are close to retiring don't give a s*** about you as an MS3 going into EM, because after all, they already cashed in on their crazy high locums rates and high hourly wages from their CMG, time for them to get out and purchase that boat they wanted.

The "doom and gloom" version you hear on SDN is not just a bunch of whiny EM docs. The truth of the matter is, medical schools and many people who are practicing in EM and drinking the kool aid, will lie to you constantly by saying "EM job demand is higher than ever! You will always be desired!" When an NP will do your job for a fraction of the price and ACEP will openly support their education/training without openly opposing independent practice, it's easy to see how you may not fare very well in this specialty.

EM docs should understand basic supply and demand economics. Shortage IS GOOD. Yet for some reason, our specialty is insistent on increasing our available numbers so we can become less desirable. Lets get MORE board certified EM docs so ALL of our wages can go down. Seriously, wtf? If you want to get paid and be considered valuable, you need to be a commodity.

That being said, emergency medicine... i.e. the actual art of practicing emergency medicine, is amazing. Hopefully you aren't a sorry fool like me who couldn't do anything else.

 

[gro2001]

I'd often read this subforum as long as 5-6 years ago and there was lots of talk about the huge shortage of EM docs driving rates sky high particularly in locums. I've been lurking around these parts throughout med school and now as I'm finishing up my M3 year I'll soon have to commit to a specialty choice. EM was my top pick even before I matriculated and if it wasn't for worries about longstanding macro trends affecting future job market it'd be a no brainer for me.

I've noticed even on this forum that over the past year or so there has been much more gloom regarding the perceived "shortage" shrinking and rates declining. The way I understand it the job market is still good, but showing signs of topping out. My concern is, are we on the verge of a massive glut given the incredible growth of the EM workforce? Even if residency expansion ceased tomorrow, we'd still be pumping out around 2400 residents a year while attrition is under 1000 a year. How much longer can the supply of EM docs grow by 1500 every year before supply equals demand and then catastrophically exceeds it?

The Doom and Gloom on this forum has been around for as long as I remember. I don't want to completely discount it, as of course there are serious issues in the specialty and medicine at large that we have to work on, but just bear in mind that the sky has been falling for quite some time now and we are all still here.

In terms of your specific concern of more docs graduating than ever before, the actual math is a little more complicated. You also have to consider:
-What's happening to ED visits over all? If they are going up, we need more docs to keep things the same.
-What's happening to non EM residency trained docs working in EDs? Are they being pushed out or are those numbers about the same and the new grads are all fighting for the urban/desirable jobs?
-What's happening with career longevity? Are "millennials" going to be burning out (or leaving the specialty for other reasons) faster or slower than previous cohorts?
-What's happening with workload? Certainly on this forum a lot of folks seem to be aiming to work fewer and fewer hours. My gestalt is that this is part of a larger national trend. If that's true, then we need more physicians to provide the same number of hours.
-What's happening with fellowships? Seems more EM physicians are doing fellowships than in the past and leaving the specialty (completely or partially).

And to counter the "common sense" trope thrown around here that shortage is always good: that's not that simple either. The bigger the real or perceived shortage, the more incentive there is for midlevels to take over or look for other solutions. For example, the influx of midlevels into anesthesia, in my opinion, was driven by the extreme shortage of anesthesiologists in the preceding years. The longer and more severe the shortage is, the more acceptable then non ABEM/non MD option is.

 

[bronx43]

Population is getting sicker and more obese plus older population. Also more care is going to go through urgent care and ED. The days were people will wait a few months to see their PCP is over. Especially with these increasing healthcare premiums.

No established patient waits months to see their primary care. Also you do realize that for average non Medicaid (and Medicare Advantage) patient, an ED visit is more or less prohibitively expensive right? No one with private insurance is going to prefer the ED for a problem that could be taken care of by their pcp or urgent care.

 

[Moose A Moose]

Population is getting sicker and more obese plus older population. Also more care is going to go through urgent care and ED. The days were people will wait a few months to see their PCP is over. Especially with these increasing healthcare premiums.

This. You guys are the future model of primary care. You will definitely have work. ED for the uninsured/Medicare/Medicaid, and Urgent Care for the masses of insured.

 

[bronx43]

This. You guys are the future model of primary care. You will definitely have work.

Negative. Future model of primary care is legions of mid levels in clinics. By future I mean near future.

 

[Moose A Moose]

Negative. Future model of primary care is legions of mid levels in clinics. By future I mean near future.

Lol. Touché.

 

[Birdstrike]

Yes, history repeats itself. And anesthesiologists continue to make very good money, despite the arrival of CRNAs, and their residents also continue to predict the sky falling, when it's not.

I'm the very first to expose the warts and blemishes of EM, but in my opinion, the bottom dropping out on the need for EM physicians, just isn't one of them. At the same time I realize, there's nothing I can say to convince the doom n' gloomers of that. Also remember, there are feedback loops at work here, that keep this all in check. It's hard enough to stomach EM burnout more than 10 years at $300-$400K, let alone with dropping wages. You really think people are going to flock to EM at a $90K/year salary?

Lol. Hell no. Even if salaries dropped temporarily, people panic, stop going into EM, there's a critical shortage again, wages go up and shazam, here we are again. Supply and demand is a powerful force and it's there working, whether you see it or not.

Some of you all have this fear, this fantasy, that magically mid-career you look around, there's too much help, too many docs and PAs. There' not enough work to be done. There's so many of you that instead of being pressure to work 18-20 shifts and see 2 patients per hour, you're barely seeing a trickle of 1 - 1.2 patients per hour, only needed 9 or 10 shifts per month, and you're so unneeded, no one wants to pay you. You're so well rested, so far from burnout due to the tsunami of oversupply you're begging for patients, shifts and work. Burnout is extinct, like the Saber Tooth Tiger. People have heard of it, but it's gone and no one under 75 talks about it. This is just not true. It's false. It's fantasy land. You should hope it's true, but it's not. EM would be much better for it.

I've said it before, I'll say 1,000 more times. A shortage of demand for your services is not your long term career risk in EM. Your long term career risk is an overwhelming feeling of emotional exhaustion, combined with the sense you cannot withstand the acuity, pace, and circadian rhythm dysphoria for a whole career, starting in years 5-10. Your fear is the opposite of what's actually going to happen.

 

[anbuitachi]

Yes, history repeats itself. And anesthesiologists continue to make very good money, despite the arrival of CRNAs, and their residents also continue to predict the sky falling, when it's not.

I'm the very first to expose the warts and blemishes of EM, but in my opinion, the bottom dropping out on the need for EM physicians, just isn't one of them. At the same time I realize, there's nothing I can say to convince the doom n' gloomers of that. Also remember, there are feedback loops at work here, that keep this all in check. It's hard enough to stomach EM burnout more than 10 years at $300-$400K, let alone with dropping wages. You really think people are going to flock to EM at a $90K/year salary?

Lol. Hell no. Even if salaries dropped temporarily, people panic, stop going into EM, there's a critical shortage again, wages go up and shazam, here we are again. Supply and demand is a powerful force and it's there working, whether you see it or not.

Some of you all have this fear, this fantasy, that magically mid-career you look around, there's too much help, too many docs and PAs. There' not enough work to be done. There's so many of you that instead of being pressure to work 18-20 shifts and see 2 patients per hour, you're barely seeing a trickle of 1 - 1.2 patients per hour, only needed 9 or 10 shifts per month, and you're so unneeded, no one wants to pay you. You're so well rested, so far from burnout due to the tsunami of oversupply you're begging for patients, shifts and work. Burnout is extinct, like the Saber Tooth Tiger. People have heard of it, but it's gone and no one under 75 talks about it. This is just not true. It's false. It's fantasy land. You should hope it's true, but it's not. EM would be much better for it.

I've said it before, I'll say 1,000 more times. A shortage of demand for your services is not your long term career risk in EM. Your long term career risk is an overwhelming feeling of emotional exhaustion, combined with the sense you cannot withstand the acuity, pace, and circadian rhythm dysphoria for a whole career, starting in years 5-10. Your fear is the opposite of what's actually going to happen.

while i agree EM will be a great residency choice for a whil to come, im going to disagree with there'll be no one to fill those spots if salaries drop. there are a lot of foreign graduates with barely any loans, and would take any spot in any specialty they can get their hands on. its a plus that EM residency is only 3-4 years. they'll just treat it like a job.

And disagree with the anesthesiologist thing. I follow it closely since im in that field.. while the SKY hasn't fallen, you can see the slow decline. it's not a crash, its a recession. people in other fields might not notice, but compared to other fields, anesthesiologys average salary has barely budged in the past 5 years, while most fields have gone up by a significant amount. Per Merritt Hawkins 2018 review, EM salary average was 311k in 2013 358 in 2017, which is inline with increases in most other fields, i guess to keep up with inflation. Meanwhile anesthesiologist salary has gone DOWN 383k to 371k in the same time period. Couple that with increased workload, covering multiple ORs at a time, less vacation/benefits, and you can see how the field is in decline from an economic standpoint. Sure the sky is not crashing down, but its definitely getting lower year after year

like ive mentioned before in other threads, i am impressed at how you guys were able to get to where you are today. yes your job is busy, but there are plenty of EDs that aren't that busy, and to have your standard be working half the month as a field, and that the governing body/insurance/others accept that is amazing. good job. but i cant see it lasting forever. if neurosurgery can work 60 hours in a row, and somehow the hospital /governing body is OK with that, i cant imagine your situation to last for decades

if your field follows anesthesiologys footsteps, what will likely happen is once supply increases, employers/companies will SLOWLY increase shifts, maybe initially just 12 to 13 etc, while keeping salary in line. Before you know it 5 years later, your field as a whole will be working much more for the same money. B/c of the slow change, residents wont even know what hit them. From what i see, most anesthesiology residents arent even informed of recent history/changes. A lot of residents are simply happy going from 65+ hr work weeks making 60k to working 55 hr work weeks making 300k. Never did they know, 10 years ago, they were making more, working less, and had 3 times as much vacation.

 

[Brigade4Radiant]

No established patient waits months to see their primary care. Also you do realize that for average non Medicaid (and Medicare Advantage) patient, an ED visit is more or less prohibitively expensive right? No one with private insurance is going to prefer the ED for a problem that could be taken care of by their pcp or urgent care.

Yes they do my friend is a physician she tried to get a refill on her antidepressants but can’t see her PCP until May and she is established. So she has been weaning herself off them and going through withdrawal.

Also you insurance changes your PCP network often. The ED is more expensive but things are changing. A CBC can easily run 1k but with price transparency in a few years the cost will go down. Even then it’s urgent care is taking over

Also urgent cares are very popular and telemedicine is gaining. The days of seeing your PCP in weeks is over. Also you have to find one which can be a hassle.

 

[Brigade4Radiant]

while i agree EM will be a great residency choice for a whil to come, im going to disagree with there'll be no one to fill those spots if salaries drop. there are a lot of foreign graduates with barely any loans, and would take any spot in any specialty they can get their hands on. its a plus that EM residency is only 3-4 years. they'll just treat it like a job.

And disagree with the anesthesiologist thing. I follow it closely since im in that field.. while the SKY hasn't fallen, you can see the slow decline. it's not a crash, its a recession. people in other fields might not notice, but compared to other fields, anesthesiologys average salary has barely budged in the past 5 years, while most fields have gone up by a significant amount. Per Merritt Hawkins 2018 review, EM salary average was 311k in 2013 358 in 2017, which is inline with increases in most other fields, i guess to keep up with inflation. Meanwhile anesthesiologist salary has gone DOWN 383k to 371k in the same time period. Couple that with increased workload, covering multiple ORs at a time, less vacation/benefits, and you can see how the field is in decline from an economic standpoint. Sure the sky is not crashing down, but its definitely getting lower year after year

like ive mentioned before in other threads, i am impressed at how you guys were able to get to where you are today. yes your job is busy, but there are plenty of EDs that aren't that busy, and to have your standard be working half the month as a field, and that the governing body/insurance/others accept that is amazing. good job. but i cant see it lasting forever. if neurosurgery can work 60 hours in a row, and somehow the hospital /governing body is OK with that, i cant imagine your situation to last for decades

if your field follows anesthesiologys footsteps, what will likely happen is once supply increases, employers/companies will SLOWLY increase shifts, maybe initially just 12 to 13 etc, while keeping salary in line. Before you know it 5 years later, your field as a whole will be working much more for the same money. B/c of the slow change, residents wont even know what hit them. From what i see, most anesthesiology residents arent even informed of recent history/changes. A lot of residents are simply happy going from 65+ hr work weeks making 60k to working 55 hr work weeks making 300k. Never did they know, 10 years ago, they were making more, working less, and had 3 times as much vacation.

Foriegn grads in EM? They have been pushed out for years most top programs will not even interview them we are not internal or Family.

Residents are ignorant about somethings but they research a lot especially with the age of private doctor message boards on Facebook

ER isn’t a new speciality ER has been around since the olden days. Also Hospitalists are emerging so shift work is here to stay.

Neurosurgeons make 800k+ also they are on call mostly they are not constantly in surgery doing drains.
Also anesthesiologists have made more than general surgeons for decades so I don’t see why you brought up Neurosurgery

 

[anbuitachi]

Foriegn grads in EM? They have been pushed out for years most top programs will not even interview them we are not internal or Family.

Residents are ignorant about somethings but they research a lot especially with the age of private doctor message boards on Facebook

ER isn’t a new speciality ER has been around since the olden days. Also Hospitalists are emerging so shift work is here to stay.

Neurosurgeons make 800k+ also they are on call mostly they are not constantly in surgery doing drains.
Also anesthesiologists have made more than general surgeons for decades so I don’t see why you brought up Neurosurgery

you must have very quickly skimmed thru my post. i mentioned foreign grads because above poster mentioned large drop in salary, so that there wont be people going into the field. I'm not talking about EM now. If EM salary drops by 75%, it will definitely not be competitive.

Well i can tell you the anesthesiology forum is one if not the most active specialty forums on SDN, but most residents are still CLUELESS. there are a lot of discussions going on on these boards, but there are WAY more residents not on these discussions.

I dont know what you mean by ER is an old specialty or what that has to do with anything ive said. I didn't mention anything about EM being a young specialty??

Neurosurg was just an example. You can use other busy fields too. my point was i dont think the working half a month thing will stay in the next few decades.

 

[Perrin]

I wonder if the canary in the coal mine would be when the average step scores of students matching into EM plateaus and begins to drop?

In my area, the mid-level pay in the ED is far below that of many working in other specialties. Also, ED MLP’s have to work many of the same hours we do. Many of the ones we hire, in their late 20’s, gradually transition to other specialties where they can work regular hours M-F with weekends and holidays off, because they are starting families.

A lot of the FP and IM docs who were grandfathered in are reaching retirement age. Most of ours are going part time, doing weekends only to get a set schedule, or doing more admin. Some of our older EM folks are decreasing their shifts and adding side gigs by opening UCs and doing consulting. Some of the 35-45 y/o docs who’ve been here around 10 years, are now financially independent with school debts paid off and a large chunk of equity in their house. They’re looking for their dream location that doesn’t have to pay as much. Where I am, there seems to be a large cushion to take on more EM docs.

 

[s109442]

I wonder if the canary in the coal mine would be when the average step scores of students matching into EM plateaus and begins to drop?

In my area, the mid-level pay in the ED is far below that of many working in other specialties. Also, ED MLP’s have to work many of the same hours we do. Many of the ones we hire, in their late 20’s, gradually transition to other specialties where they can work regular hours M-F with weekends and holidays off, because they are starting families.

A lot of the FP and IM docs who were grandfathered in are reaching retirement age. Most of ours are going part time, doing weekends only to get a set schedule, or doing more admin. Some of our older EM folks are decreasing their shifts and adding side gigs by opening UCs and doing consulting. Some of the 35-45 y/o docs who’ve been here around 10 years, are now financially independent with school debts paid off and a large chunk of equity in their house. They’re looking for their dream location that doesn’t have to pay as much. Where I am, there seems to be a large cushion to take on more EM docs.

This is what I’m seeing also

 

[TXEMC344]

No established patient waits months to see their primary care. Also you do realize that for average non Medicaid (and Medicare Advantage) patient, an ED visit is more or less prohibitively expensive right? No one with private insurance is going to prefer the ED for a problem that could be taken care of by their pcp or urgent care.

 

[TXEMC344]

This is just not true. Established patient's do sometimes have to wait months to actually see their PCP. And, people with insurance have no issues with dropping by the ED to have their URI treated.

 

[TulaneUnderdog]

Edit

 

[gro2001]

you must have very quickly skimmed thru my post. i mentioned foreign grads because above poster mentioned large drop in salary, so that there wont be people going into the field. I'm not talking about EM now. If EM salary drops by 75%, it will definitely not be competitive.

Well i can tell you the anesthesiology forum is one if not the most active specialty forums on SDN, but most residents are still CLUELESS. there are a lot of discussions going on on these boards, but there are WAY more residents not on these discussions.

I dont know what you mean by ER is an old specialty or what that has to do with anything ive said. I didn't mention anything about EM being a young specialty??

Neurosurg was just an example. You can use other busy fields too. my point was i dont think the working half a month thing will stay in the next few decades.

The main thing I disagree with you is the idea that EM working "half a month" is light. Having worked a variety of schedules in different EDs, I can assure you that 32 hours/week in the ED feels very much full time and 40 hours a week is not sustainable in the long term for most people. So people working low 30s don't have it cush. 32 hours in the ED feels about like 50 on the floors or in the ICU. This is not a knock on the floors or ICU work at all, it's just that there is a lot more down time of some sort in those settings. There is a reason that full time has evolved to be the way it did in those specialties. Perhaps in your hypothetical model of future EM when income has dropped by 75% EM workload will look very different, but that's not at all related to EM reality today.

 

[gro2001]

I wonder if the canary in the coal mine would be when the average step scores of students matching into EM plateaus and begins to drop?

I disagree. EM PDs rely much less on step scores than PDs in other specialties when selecting candidates (Emergency Medicine Residency Selection Criteria: An Update and Comparison. - PubMed - NCBI). Only 10% mentioned steps; most important were SLOEs, EM rotation grades, and interview performance; single most important factor being away SLOE. Even PDs who use step scores relatively heavily in weighing their decision on candidate selection do so reluctantly due to a shortage of great metrics. If we come up with a metric that EM PDs feel more accurately predicts EM career success, the step scores will be even less predictive of EM match success than it is now and EM residency programs can end up being more selective (based on their new metric) while step scores drift down.

 

[Perrin]

I disagree. EM PDs rely much less on step scores than PDs in other specialties when selecting candidates (Emergency Medicine Residency Selection Criteria: An Update and Comparison. - PubMed - NCBI). Only 10% mentioned steps; most important were SLOEs, EM rotation grades, and interview performance; single most important factor being away SLOE. Even PDs who use step scores relatively heavily in weighing their decision on candidate selection do so reluctantly due to a shortage of great metrics. If we come up with a metric that EM PDs feel more accurately predicts EM career success, the step scores will be even less predictive of EM match success than it is now and EM residency programs can end up being more selective (based on their new metric) while step scores drift down.

I guess a more distinct measure would be the step scores of med students applying to EM, than those matching. Actually matching is a multifactorial endeavor. My PD, our chiefs, and the residents did weigh many factors in ranking applicants. A demonstrable measure in this would be step scores of those applying. It will not be specific to an individual candidate. If the step scores of those applying to EM drop consistently 5-10 points, it may be an indication of decreased confidence in the sustainability of that specialty’s current expectations.

When I applied for EM, people hinted that it should be included in the ROAD group. Since then, I’ve heard that the scores and requirements have increased significantly because of this. Perhaps this is not true.

 

[gro2001]

I guess a more distinct measure would be the step scores of med students applying to EM, than those matching. Actually matching is a multifactorial endeavor. My PD, our chiefs, and the residents did weigh many factors in ranking applicants. A demonstrable measure in this would be step scores of those applying. It will not be specific to an individual candidate. If the step scores of those applying to EM drop consistently 5-10 points, it may be an indication of decreased confidence in the sustainability of that specialty’s current expectations.

When I applied for EM, people hinted that it should be included in the ROAD group. Since then, I’ve heard that the scores and requirements have increased significantly because of this. Perhaps this is not true.

The panic among (primarily non EM) undergraduate medical education folks, starting about 5-8 years ago, about the competitiveness of EM was largely driven by them failing to understand how EM candidate selection works and that EM really is different from other specialties. Basically, medical school deans at prestigious schools were seeing students with good step scores not match in EM while they would normally have their choice of specialties and programs. They interpreted it as EM being way more competitive than previously thought, rather than realizing that the candidates who would be super desirable in other specialties (great school, great scores) might or might not be as desirable in EM (what does their SLOE say? can they rock climb?). So they spread the word that EM is crazy competitive, while mostly it was just more discriminant (we don't so much look for the "best" candidates, as for the best fitting candidates). I think it's true that EM has gotten more competitive in recent years without the scores reflecting it due to increasing ability of PDs to be discriminant (ie pick the best fitting candidates).

 

[anbuitachi]

The main thing I disagree with you is the idea that EM working "half a month" is light. Having worked a variety of schedules in different EDs, I can assure you that 32 hours/week in the ED feels very much full time and 40 hours a week is not sustainable in the long term for most people. So people working low 30s don't have it cush. 32 hours in the ED feels about like 50 on the floors or in the ICU. This is not a knock on the floors or ICU work at all, it's just that there is a lot more down time of some sort in those settings. There is a reason that full time has evolved to be the way it did in those specialties. Perhaps in your hypothetical model of future EM when income has dropped by 75% EM workload will look very different, but that's not at all related to EM reality today.

i wasnt referring to what i think, i was referring to the people taking over our fields, the guys and girls in the suits will think. i know you guys are busy, and i know you guys work full time, with different set of problems than other fields.
but it makes sense to me at least, for people in suits, they look at the difference in hours, and its HUGE. do they care about what you DO in the ED? maybe a little, but i dont think they will truly accept that you guys deserve a much lighter schedule hour wise because you guys work harder when you are there. but i hope im wrong. we'll see where the future goes in 10 years

 

[Brigade4Radiant]

i wasnt referring to what i think, i was referring to the people taking over our fields, the guys and girls in the suits will think. i know you guys are busy, and i know you guys work full time, with different set of problems than other fields.
but it makes sense to me at least, for people in suits, they look at the difference in hours, and its HUGE. do they care about what you DO in the ED? maybe a little, but i dont think they will truly accept that you guys deserve a much lighter schedule hour wise because you guys work harder when you are there. but i hope im wrong. we'll see where the future goes in 10 years

ER is so corporate because it makes a lot of money that’s it.

It’s productivity the ER. It makes far more money than clinic and inpatient. Also the ER is staffed 24/7 . What you are saying doesn’t make sense even with the shift work they deal with constant turnover have you worked in the ED or actually practiced in the community because your thoughts are way off base.

Most nurses leave to work more hours in a less stressful pace. You have docs working more hours in pain clinic and loving the lifestyle more

 

[hundreddaysoff]

The panic among (primarily non EM) undergraduate medical education folks, starting about 5-8 years ago, about the competitiveness of EM was largely driven by them failing to understand how EM candidate selection works and that EM really is different from other specialties. Basically, medical school deans at prestigious schools were seeing students with good step scores not match in EM while they would normally have their choice of specialties and programs. They interpreted it as EM being way more competitive than previously thought, rather than realizing that the candidates who would be super desirable in other specialties (great school, great scores) might or might not be as desirable in EM (what does their SLOE say? can they rock climb?). So they spread the word that EM is crazy competitive, while mostly it was just more discriminant (we don't so much look for the "best" candidates, as for the best fitting candidates). I think it's true that EM has gotten more competitive in recent years without the scores reflecting it due to increasing ability of PDs to be discriminant (ie pick the best fitting candidates).

One indirect effect of Step 1 score I saw when applying was ability to land an away rotation in the first place. At least as of 2014 when I was applying, I found most of them pretty competitive, and many places had initial step cutoffs of 220--225 or so. This was annoying as mine was 217, taken in 2009 and right at the national mean back then, just before the ~10-point national mean bump that I imagine was caused by increased focus on QBanks rather than textbooks the first 2 years of med school.

I hope this situation has changed in the past 5 years so that getting an away reflects "best fit", but I don't know how else to screen hundreds of med studs applying for a couple dozen away slots at most.

 

[gro2001]

One indirect effect of Step 1 score I saw when applying was ability to land an away rotation in the first place. At least as of 2014 when I was applying, I found most of them pretty competitive, and many places had initial step cutoffs of 220--225 or so. This was annoying as mine was 217, taken in 2009 and right at the national mean back then, just before the ~10-point national mean bump that I imagine was caused by increased focus on QBanks rather than textbooks the first 2 years of med school.

I hope this situation has changed in the past 5 years so that getting an away reflects "best fit", but I don't know how else to screen hundreds of med studs applying for a couple dozen away slots at most.

Having a higher step score is obviously better than having a lower score. I didn't mean to imply there was absolutely no utility to an EM applicant having a higher score, just that specialty level trends of median step scores are not a good reflection of specialty competitiveness and don't predict individual candidate success nearly as well as they do in some other specialties.

 

[deleted480308]

Yes they do my friend is a physician she tried to get a refill on her antidepressants but can’t see her PCP until May and she is established. So she has been weaning herself off them and going through withdrawal.

Also you insurance changes your PCP network often. The ED is more expensive but things are changing. A CBC can easily run 1k but with price transparency in a few years the cost will go down. Even then it’s urgent care is taking over

Also urgent cares are very popular and telemedicine is gaining. The days of seeing your PCP in weeks is over. Also you have to find one which can be a hassle.

Your friend has a bad pcp. It shouldn’t take that long

 

[Booze Aldrin]

Quick update, there were 2488 PGY1 spots in the match this year, up from 2278 last year, an increase of 9.2%.

65% were filled by US grads, down from 71% last year. As several people noted above, I don't think people running residency programs and those planning new ones would lose much sleep if EM became predominantly FMG manned.

 

[mmmnmmm]

Quick update, there were 2488 PGY1 spots in the match this year, up from 2278 last year, an increase of 9.2%.

65% were filled by US grads, down from 71% last year. As several people noted above, I don't think people running residency programs and those planning new ones would lose much sleep if EM became predominantly FMG manned.

65% were filled by U.S. allopathic 4th year medical student applicants. This number omits D.O. aplicants, re-applicants, and IMGs. This is largely reflective of the MD/DO residency merger and not a tide shift in EM away from US MDs.

 

[gutonc]

65% were filled by U.S. allopathic 4th year medical student applicants. This number omits D.O. aplicants, re-applicants, and IMGs. This is largely reflective of the MD/DO residency merger and not a tide shift in EM away from US MDs.

Also, simple math will tell you that this is the exact same # of USMD 4th years matching to EM this year as last.

 

[gro2001]

Quick update, there were 2488 PGY1 spots in the match this year, up from 2278 last year, an increase of 9.2%.

65% were filled by US grads, down from 71% last year. As several people noted above, I don't think people running residency programs and those planning new ones would lose much sleep if EM became predominantly FMG manned.

And what exactly is the concern if EM did become "predominantly FMG manned"?

 

[GeneralVeers]

And what exactly is the concern if EM did become "predominantly FMG manned"?

We can import nearly an unlimited number of FMGs to fill residency spots. It would enable an even more rapid expansion of programs.

 

[gro2001]

We can import nearly an unlimited number of FMGs to fill residency spots. It would enable an even more rapid expansion of programs.

https://www.cordem.org/globalassets.../applying-guide---international-applicant.pdf

If you look at table 1 you will see that last year non US IMGs ammounted to a whopping 29 people. Over the last 10 years it's been 4-36 people per year. I doubt that is fueling program expansion or leading to EM being "predominantly FMG manned". But sure, blame the foreigners.

 

[InternistDO]

https://www.cordem.org/globalassets.../applying-guide---international-applicant.pdf

If you look at table 1 you will see that last year non US IMGs ammounted to a whopping 29 people. Over the last 10 years it's been 4-36 people per year. I doubt that is fueling program expansion or leading to EM being "predominantly FMG manned". But sure, blame the foreigners.

I think what people are saying is, in the hypothetical worst case scenario of dramatic EM oversupply causing poor salaries/job market/conditions/famine/whatever, if US MD/DO students stop applying to EM, the programs will at that point likely begin to relax their standards and take IMG/FMGs in their place, which would cause the oversupply issue to continue instead of correcting with time.

 

[Booze Aldrin]

I think what people are saying is, in the hypothetical worst case scenario of dramatic EM oversupply causing poor salaries/job market/conditions/famine/whatever, if US MD/DO students stop applying to EM, the programs will at that point likely begin to relax their standards and take IMG/FMGs in their place, which would cause the oversupply issue to continue instead of correcting with time.

Very much this. People don't really think about this much but there is a veritably inexhaustible supply of physicians in developing countries who enter medical school at 18, graduate at 24 with no debt, and for whom even the 60k salary of a resident in the US is a multiple of what they could make as a senior attending in their home country. Granted, only a small fraction of them could pass US Boards but even a small fraction of a very large number is still a large number.

Physicians are the only profession in this country that is completely unprotected in the visa regime (H1Bs are not capped for foreign physicians) so the only thing standing between this huge potential influx of cheap labor and prevailing salaries is the limited number of residency spots. I guess there was someone further up the thread trying to police our ability to talk about this topic but there is nothing bigoted about discussing the effects of supply and demand on price. Now that large corporations like HCA have gotten into the Residency Program game, I'm afraid this residency spot barrier will eventually cease to be the bulwark it has traditionally been.

 

[Arcan57]

https://www.cordem.org/globalassets.../applying-guide---international-applicant.pdf

If you look at table 1 you will see that last year non US IMGs ammounted to a whopping 29 people. Over the last 10 years it's been 4-36 people per year. I doubt that is fueling program expansion or leading to EM being "predominantly FMG manned". But sure, blame the foreigners.

Don’t confuse @MAGAdoc with facts.

 

[GeneralVeers]

Very much this. People don't really think about this much but there is a veritably inexhaustible supply of physicians in developing countries who enter medical school at 18, graduate at 24 with no debt, and for whom even the 60k salary of a resident in the US is a multiple of what they could make as a senior attending in their home country. Granted, only a small fraction of them could pass US Boards but even a small fraction of a very large number is still a large number.

Physicians are the only profession in this country that is completely unprotected in the visa regime (H1Bs are not capped for foreign physicians) so the only thing standing between this huge potential influx of cheap labor and prevailing salaries is the limited number of residency spots. I guess there was someone further up the thread trying to police our ability to talk about this topic but there is nothing bigoted about discussing the effects of supply and demand on price. Now that large corporations like HCA have gotten into the Residency Program game, I'm afraid this residency spot barrier will eventually cease to be the bulwark it has traditionally been.

I know it sounds protectionist, but ultimately we are in a business (yes I said THAT and it was naughty). It is all our responsibility to ensure the viability of the business, which means we try to prevent oversupply of physicians. We can do this by limiting the number of residency spots, while PDs can refuse to take foreign medical grads. Community doctors please start saying a big fat NO, when your hospital/group wants to start a new program and ask you to be "clinical faculty". No one knows what the future holds, but rest assured hospitals and CMGs are working very hard towards a future where they can employ us for $80-$100/hour.

 

[turkeyjerky]

I know it sounds protectionist, but ultimately we are in a business (yes I said THAT and it was naughty). It is all our responsibility to ensure the viability of the business, which means we try to prevent oversupply of physicians. We can do this by limiting the number of residency spots, while PDs can refuse to take foreign medical grads. Community doctors please start saying a big fat NO, when your hospital/group wants to start a new program and ask you to be "clinical faculty". No one knows what the future holds, but rest assured hospitals and CMGs are working very hard towards a future where they can employ us for $80-$100/hour.

My feeling is that the CMGs and big hospital systems see 2 future preferable practice models for the future:

1. Staffing heavily tilted to midlevels, with physicians in a primarily supervisory role. Something like 3-4:1, with the docs just basically signing off on the patients. We get paid the same as we do now, but basically just show up and sit on the computer all day to cash checks. This is doomed to fail, absent a much higher level of training for midlevels, since most tend to decrease throughput and increase costs due to over ordering. In addition, quality of care goes down. This model would probably be financially successful in the short term, but will fail in the long term once reimbursement if fully bundled.

2. Docs and midlevels are used basically interchangeably, we get paid 20/hr more than them. Most people don't work very hard, burnout and turnover are high. Staffing resembles ED nursing with constant shortages, turnover, and lazy people getting by without any issues.

 

[SterlingMaloryArcher]

No established patient waits months to see their primary care. Also you do realize that for average non Medicaid (and Medicare Advantage) patient, an ED visit is more or less prohibitively expensive right? No one with private insurance is going to prefer the ED for a problem that could be taken care of by their pcp or urgent care.

Oh yes they do. After I get seen I better schedule a followup at the checkout window on the spot because if I wait to get closer the time the doc wants to see me back hes booked months out.

ER isn't cost prohibitive to abusers who don't care and will never pay the bills anyway.

 

[TooMuchResearch]

Oh yes they do. After I get seen I better schedule a followup at the checkout window on the spot because if I wait to get closer the time the doc wants to see me back hes booked months out.

ER isn't cost prohibitive to abusers who don't care and will never pay the bills anyway.

Really? I think I'm surrounded by good health systems. I can get my patients near immediate primary or subspecialty follow-up within the week. My family can get near immediate appointments in a different health system.

 

[GeneralVeers]

Really? I think I'm surrounded by good health systems. I can get my patients near immediate primary or subspecialty follow-up within the week. My family can get near immediate appointments in a different health system.

So the median wait times published in Canadian media are not factual?