EM's Fatal Design Flaw (How To Use This Knowledge To Your Benefit)

[Birdstrike]

It was a catastrophic failure of foresight and planning, to build the specialty Emergency Medicine into a form where 65% feel burned out, feel the need to exit and can't. Whether it was planned, or by accident is not important. It was terrible mistake by the Founding Mothers and Fathers, of EM.

If EM was a subspecialty of other base specialties, every EM physician career would have a second specialty, built in. If you can stay in love with EM for a 30 year career, it works. If you fall out of love on the way, you have a second specialty you can practice that can coexist with a normal lifestyle, as well as countless other fellowship options. It's likely too late to change this, but you can use this information to your benefit.

How can this information help you?

On a personal level: Realize the first half of your EM career won't feel anything like the second half. Plan ahead for the second half of your EM career, now. Have a built in exit plan. Don't wait for burnout to hit, then scramble. Realize the problem isn't you. The problem is a fatal design flaw, in your noble, chosen field. EM may not change much in the second half of your working life, but you and your life will.

On a macro-level: Take a leadership role. Advocate for adding exit pathways (and partial exit pathways) to EM. Any fellowships (or other mechanism) that allow one to earn a comparable salary outside of an emergency department, during normal waking hours, Mon-Fri, qualifies. These pathways should be built in to EM, an expected part of the EM doctor's career cycle, and supported by the specialty. Emergency Physicians should not be left alone tattered, flapping in the wind, grasping at straws mid-career.

Be creative. Change the paradigm. We owe this to the great people who dedicate their lives to EM.

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[JacobMcCandles]

I don't think anyone imagined how "I want it now" American society would become. Not to mention the people with expectations not set in reality along with the general ability of the average person having no clue how to navigate the healthcare system.

 

[The Knife & Gun Club]

My opinion is the way we staff EDs needs to change drastically. Staffing to target one pph/hr. Then we could do a proper workup, have time for head to not be explode, eat lunch, pee, etc.

I’m not sure when the decision was made to have EM target 2+ pph but I think that’s a disservice to the patients needing proper resuscitation and emergency care.

Soveirgn immunity or similar for all EM providers. If you’re going to be compelled by the government to perform an MSE and determine if an emergency condition exists regardless of payor status, then the government should pick up the bill for insuring you too.

Oh, and discharge from triage for people who don’t have emergencies. I’ve covered one hospital that did this somewhat and it was glorious.

 

[Torsion]

My opinion is the way we staff EDs needs to change drastically. Staffing to target one pph/hr. Then we could do a proper workup, have time for head to not be explode, eat lunch, pee, etc.

I’m not sure when the decision was made to have EM target 2+ pph but I think that’s a disservice to the patients needing proper resuscitation and emergency care.

Soveirgn immunity or similar for all EM providers. If you’re going to be compelled by the government to perform an MSE and determine if an emergency condition exists regardless of payor status, then the government should pick up the bill for insuring you too.

Oh, and discharge from triage for people who don’t have emergencies. I’ve covered one hospital that did this somewhat and it was glorious.

Certainly wouldn't be feasible with our current productivity based reimbursement model.

 

[FlaminHotER]

My opinion is the way we staff EDs needs to change drastically. Staffing to target one pph/hr. Then we could do a proper workup, have time for head to not be explode, eat lunch, pee, etc.

I’m not sure when the decision was made to have EM target 2+ pph but I think that’s a disservice to the patients needing proper resuscitation and emergency care.

Soveirgn immunity or similar for all EM providers. If you’re going to be compelled by the government to perform an MSE and determine if an emergency condition exists regardless of payor status, then the government should pick up the bill for insuring you too.

Oh, and discharge from triage for people who don’t have emergencies. I’ve covered one hospital that did this somewhat and it was glorious.

It’s absolutely sickening to hear and read about the dangerous levels of patients some our colleagues are juggling on shifts.

 

[GonnaBeADoc2222]

It was a catastrophic failure of foresight and planning, to build the specialty Emergency Medicine into a form where 65% feel burned out, feel the need to exit and can't. Whether it was planned, or by accident is not important. It was terrible mistake by the Founding Mothers and Fathers, of EM.

If EM was a subspecialty of other base specialties, every EM physician career would have a second specialty, built in. If you can stay in love with EM for a 30 year career, it works. If you fall out of love on the way, you have a second specialty you can practice that can coexist with a normal lifestyle, as well as countless other fellowship options. It's likely too late to change this, but you can use this information to your benefit.

How can this information help you?

On a personal level: Realize the first half of your EM career won't feel anything like the second half. Plan ahead for the second half of your EM career, now. Have a built in exit plan. Don't wait for burnout to hit, then scramble. Realize the problem isn't you. The problem is a fatal design flaw, in your noble, chosen field. EM may not change much in the second half of your working life, but you and your life will.

On a macro-level: Take a leadership role. Advocate for adding exit pathways (and partial exit pathways) to EM. Any fellowships (or other mechanism) that allow one to earn a comparable salary outside of an emergency department, during normal waking hours, Mon-Fri, qualifies. These pathways should be built in to EM, an expected part of the EM doctor's career cycle, and supported by the specialty. Emergency Physicians should not be left alone tattered, flapping in the wind, grasping at straws mid-career.

Be creative. Change the paradigm. We owe this to the great people who dedicate their lives to EM.

What's the point of posts like this?

You arent even EM anymore but spend everyday making posts like this, I don't get it.

Like we all get it, the job ranges from terrible to meh w occasional great cases and people, but it pays well and it's consistent.

There isn't some big conspiracy to trap people in EM. No, I wouldn't advise going into it now, but ita not like the grass is greener.

People love to be like "but IM can fall back on their internal medicone training and be a Hospitalist or a PCP." No burnt out cardiologist is gping back to be straight IM.

It's just a job. Show up, do what you can, get paid, go home.

 

[psychemdoc]

It was a catastrophic failure of foresight and planning, to build the specialty Emergency Medicine into a form where 65% feel burned out, feel the need to exit and can't. Whether it was planned, or by accident is not important. It was terrible mistake by the Founding Mothers and Fathers, of EM.

If EM was a subspecialty of other base specialties, every EM physician career would have a second specialty, built in. If you can stay in love with EM for a 30 year career, it works. If you fall out of love on the way, you have a second specialty you can practice that can coexist with a normal lifestyle, as well as countless other fellowship options. It's likely too late to change this, but you can use this information to your benefit.

How can this information help you?

On a personal level: Realize the first half of your EM career won't feel anything like the second half. Plan ahead for the second half of your EM career, now. Have a built in exit plan. Don't wait for burnout to hit, then scramble. Realize the problem isn't you. The problem is a fatal design flaw, in your noble, chosen field. EM may not change much in the second half of your working life, but you and your life will.

On a macro-level: Take a leadership role. Advocate for adding exit pathways (and partial exit pathways) to EM. Any fellowships (or other mechanism) that allow one to earn a comparable salary outside of an emergency department, during normal waking hours, Mon-Fri, qualifies. These pathways should be built in to EM, an expected part of the EM doctor's career cycle, and supported by the specialty. Emergency Physicians should not be left alone tattered, flapping in the wind, grasping at straws mid-career.

Be creative. Change the paradigm. We owe this to the great people who dedicate their lives to EM.

I, for one, find this post (and others from Birdstrike) to be helpful and informative as far using this to help guide a career for prospective applicants to EM and current residents and attendings to look for ways to make their own careers more fulfilling in EM and outside of it. Yes, the grass isn’t greener on the other side. But it is still helpful to learn about options instead of more griping and moaning. And I look at this to be a fairly positive post overall.

 

[DeadCactus]

I don't think EM wants to be fixed unless the fix is a magical fantasy. Fixing the majority of EM complaints means decreasing salaries and the reality is the majority would rather grind themselves into burnout for the extra income. There's a weird cubicle around medicine that has convinced physicians they're trapped in something they hate. People aren't trapped, they're just unwilling to give up 98th percentile income for 94th percentile.

 

[Arcan57]

I don't think EM wants to be fixed unless the fix is a magical fantasy. Fixing the majority of EM complaints means decreasing salaries and the reality is the majority would rather grind themselves into burnout for the extra income. There's a weird cubicle around medicine that has convinced physicians they're trapped in something they hate. People aren't trapped, they're just unwilling to give up 98th percentile income for 94th percentile.

EM has been a bifurcated specialty for at least the last decade. There are the docs that want to be doing EM because they love the medicine and the vibe of being in the ED. There are the docs that don't love the medicine and went in because 3 years=$$$$. The 2nd group has their exit strategy already planned, which is to be FIRE at 5-8 years out and dump medicine completely. Things are never going to be ok because the groups' goals don't align.

Someone that is looking for a 20-30 yr career is going to be looking at things like low pph, fewer nights as you get older, and reasonable circadian shifts. Someone trying to bounce as quickly as possible is going to read that as low pay, too many nights starting out, and loss of flexibility to pad out their schedule with side gigs. Since most shops couldn't double the number of EM docs they employ simply due to there not being enough of us (for now), the live fast-die young crowd is going to be the dominant model. Tell your prospective employer you're aiming to see 1-1.5 pph and watch how many jobs you don't get.

 

[Birdstrike]

What's the point of posts like this?

See paragraphs 3 and 4.

 

[Mbekweni]

This is already possible. There is urgent care, and with a touch of reading EM can go into primary care (direct or concierge models…I have friends who have done it and have all the business they can handle). Management consulting, biotech drug development, US foreign service or Peace Corps, shady weight loss/ketamine clinic. Lots of options. Some might have an even worse schedule, some a pay cut or require small business acumen and a bit of risk taking to get ahead. All will likely be 6 figures at least and you won’t starve.

 

[TrailRun]

Thanks for this post. Current pain applicant with cold feet (stressed about the decreased income for a year, fellow work hours etc) but think it will all work out. Even urgent care nowadays has a lot of evenings and weekends for patient convenience. I could definitely be happy in the perfect EM or urgent care job (no nights, good coverage) but those are few and far between where I live. Hoping pain is a better fit

 

[emergentmd]

Anyone switching fields or doing a fellowship should want to do this due to the change in work. There is very little fields that can make as much as EM docs on an hourly basis. If you like pain as a field, like the bankers hours, like procedure, etc then its a good option. But giving up essentially 2 yrs and 1M is a big ask especially as you take a haircut when you start your practice.

The best EM fellowship is the income/hour and 32 hr work week. You have another 15 hrs/wk to specialize in something else like RE, finance, business owner, etc.

 

[ShockIndex]

Left EM for CCM. The opportunity costs of fellowship were mitigated by the fact that I was in training during COVID when my former EM colleagues were taking temporary pay cuts in the form of lost bonuses and suspended employer retirement contributions for some of that time.

Now, I make about $100K more per year in salary in the same region with similar employer benefits (better retirement package now). I do technically work more total hours, but the nature of the work is far more physician friendly. Most importantly, hardly any of my patients are full of sh!+ which is its own psychological relief. Second, I work 90% of my shifts between 7AM and 5-6PM and only 1.5 weekend per month averaged over the year. Of the shifts that start after 4PM, they are equally divided between evenings that end before midnight and overnights - a massive decrease in sleep schedule disruption and significant improvement in weekend availability with my family. Finally, I supervise an army of residents and APPs who absorb the lion share of note writing leaving me far more time at the bedside, doing procedures, teaching etc. I’m generally able to grab lunch in the lounge or a coffee without feeling like the waiting room is back-up with toe pain.

So, it’s an interesting situation. More hours for more pay but a more favorable work environment despite far more complex patients translates to more happiness. This type of situation is best for people placing an emphasis on what they are doing when they arrive at the office as opposed to those focusing on dollar/hr or looking to do the bare minimum from the moment they badge-in.

 

[Arcan57]

Anyone switching fields or doing a fellowship should want to do this due to the change in work. There is very little fields that can make as much as EM docs on an hourly basis. If you like pain as a field, like the bankers hours, like procedure, etc then its a good option. But giving up essentially 2 yrs and 1M is a big ask especially as you take a haircut when you start your practice.

The best EM fellowship is the income/hour and 32 hr work week. You have another 15 hrs/wk to specialize in something else like RE, finance, business owner, etc.

You realize that 2 yrs is /= 1M for the vast majority of EM docs? If it was, there'd be a lot fewer complaints on this board.

 

[TooMuchResearch]

You realize that 2 yrs is /= 1M for the vast majority of EM docs? If it was, there'd be a lot fewer complaints on this board.

I'm still complaining and I have what seems to be a near unicorn job. But it's not all puppies and roses, I assure you

 

[RustedFox]

You realize that 2 yrs is /= 1M for the vast majority of EM docs? If it was, there'd be a lot fewer complaints on this board.

Guy has a lot of good things to say, but is so out of touch with EM in 202X.

What Birdstrike is missing from his thesis here is similar. The "founders" existed in an entirely different EM landscape altogether. They never predicted a metrics and CMG-laden hellscape.

 

[Kryptocoin]

The major flaw in EM design was creating an ER in EVERY single hospital in the US. A lot of hospitals have no business having an ER. Only real ERs should have EMTALA mandates since they are the last resort for patients. ER designations should only be given to hospitals with at least a Level 2 identification.

All other hospitals should function like an urgent care: no EMTALA mandates, no ambulance dropoffs (unless direct admit), no psych.

 

[alpinism]

That's what many people don't realize about EM in the USA vs in other countries.

In most countries 500K cities have 1-5 EDs while here its often 5-10 EDs.

 

[TooMuchResearch]

The major flaw in EM design was creating an ER in EVERY single hospital in the US. A lot of hospitals have no business having an ER. Only real ERs should have EMTALA mandates since they are the last resort for patients. ER designations should only be given to hospitals with at least a Level 2 identification.

All other hospitals should function like an urgent care: no EMTALA mandates, no ambulance dropoffs (unless direct admit), no psych.

Are you kidding? That wouldn't fly in our system as it exists. There are plenty of people I can see (from an ambulance) and admit to an outlying hospital and our tertiary hospitals are overwhelmed. Your level two trauma certification argument is very arbitrary.

 

[Arcan57]

Guy has a lot of good things to say, but is so out of touch with EM in 202X.

What Birdstrike is missing from his thesis here is similar. The "founders" existed in an entirely different EM landscape altogether. They never predicted a metrics and CMG-laden hellscape.

Everyone thinks it's the same game because it still has the same name. Sure chess is easy if you start up a queen and 2 rooks, but that's not what most people mean when they talk about chess. For perspective, Emergent was in the best time and place to be an entrepreneurial EM doc that has ever existed. His path is not repeatable today.

 

[ScepticSkeksis]

The major flaw in EM design was creating an ER in EVERY single hospital in the US. A lot of hospitals have no business having an ER. Only real ERs should have EMTALA mandates since they are the last resort for patients. ER designations should only be given to hospitals with at least a Level 2 identification.

All other hospitals should function like an urgent care: no EMTALA mandates, no ambulance dropoffs (unless direct admit), no psych.

You are correct in a sense, but the greedy hospitals want to bill an ER facility charge for every patient. If you designate it urgent care, the money is a lot less. They are happy to sacrifice us on the Altar of EMTALA.

 

[Kryptocoin]

Are you kidding? That wouldn't fly in our system as it exists. There are plenty of people I can see (from an ambulance) and admit to an outlying hospital and our tertiary hospitals are overwhelmed. Your level two trauma certification argument is very arbitrary.

Yes, of course, it won't work in the current system. Hence the need for a total revamp. At so many hospitals today, the ER physician is all things at once. Many facilities have no ortho, cards, OB, psych, ENT, optho or trauma coverage. Heck, some don't even have hospitalists. The ER doc admits the pt and then rounds on them in the morning. In my ideal world, hospitals without appropriate sub-specialty coverage have no business calling themselves an ER.

I can diagnose and treat many things out of a makeshift tent. That doesn't mean I should call my tent an ER.

 

[Kryptocoin]

You are correct in a sense, but the greedy hospitals want to bill an ER facility charge for every patient. If you designate it urgent care, the money is a lot less. They are happy to sacrifice us on the Altar of EMTALA.

Bingo.

 

[Birdstrike]

What Birdstrike is missing from his thesis here is similar. The "founders" existed in an entirely different EM landscape altogether. They never predicted a metrics and CMG-laden hellscape.

I'm aware EM is very different from the early '70s. I'm aware EM is different from when I chose to go into it in the late '90s. But that doesn't change the fact that the design flaw exists. I'm not saying they should have been psychic, in the '70s, when starting EM or foresee every change in healthcare, 10 years before they happened. What happened, happened.

My goal is for people, particularly young people, to know about this inherent flaw in the design of EM as early as possible, so they can plan for when it affects them.

This is because I went from being a 26-year-old, bright eyed and idealistic EM intern who was excited about EM and felt certain I could stay that way my whole career, to becoming very burned out, emotionally exhausted and certain I couldn't be happy in EM over the long haul, in less than 5 years. Then I dragged my feet for another 5 years convincing myself somehow I could make it work. Not being pro-active sooner, was a mistake.

I want to help people in similar positions, shave a few years and some unhappiness off of that timeline. For those "born to do EM" it doesn't matter. But for the 65% who feel burnout, I think it's worth considering all options and wasting as little time as possible.

 

[TooMuchResearch]

Yes, of course, it won't work in the current system. Hence the need for a total revamp. At so many hospitals today, the ER physician is all things at once. Many facilities have no ortho, cards, OB, psych, ENT, optho or trauma coverage. Heck, some don't even have hospitalists. The ER doc admits the pt and then rounds on them in the morning. In my ideal world, hospitals without appropriate sub-specialty coverage have no business calling themselves an ER.

I can diagnose and treat many things out of a makeshift tent. That doesn't mean I should call my tent an ER.

Man if I could own my own tent, call it an ER, and then just transfer everyone that needs more than an istat and portable xray elsewhere, I would totally do it.

 

[JacobMcCandles]

Man if I could own my own tent, call it an ER, and then just transfer everyone that needs more than an istat and portable xray elsewhere, I would totally do it.

Except it’s like pulling teeth trying to find an open bed to transfer someone these days.

 

[Dr Mantis Toboggan]

You are correct in a sense, but the greedy hospitals want to bill an ER facility charge for every patient. If you designate it urgent care, the money is a lot less. They are happy to sacrifice us on the Altar of EMTALA.

Yup and now they don’t even have to hire a doctor at the truly small places. They can’t or won’t pay a doc to staff it, and apparently they don’t have to.

 

[RustedFox]

I'm aware EM is very different from the early '70s. I'm aware EM is different from when I chose to go into it in the late '90s. But that doesn't change the fact that the design flaw exists. I'm not saying they should have been psychic, in the '70s, when starting EM or foresee every change in healthcare, 10 years before they happened. What happened, happened.

My goal is for people, particularly young people, to know about this inherent flaw in the design of EM as early as possible, so they can plan for when it affects them.

This is because I went from being a 26-year-old, bright eyed and idealistic EM intern who was excited about EM and felt certain I could stay that way my whole career, to becoming very burned out, emotionally exhausted and certain I couldn't be happy in EM over the long haul, in less than 5 years. Then I dragged my feet for another 5 years convincing myself somehow I could make it work. Not being pro-active sooner, was a mistake.

I want to help people in similar positions, shave a few years and some unhappiness off of that timeline. For those "born to do EM" it doesn't matter. But for the 65% who feel burnout, I think it's worth considering all options and wasting as little time as possible.

I hear you, amigo - but the way it sounds; your first paragraph reads like EM is/was deliberately built like a leghold trap by the cartoonishly evil Tintinalli (an evil Penelope Pitstop) and Rosen (Snidely Whiplash).

For the record, I find it bizarre that autocomplete spit "Penelope Pitstop" right out for me.

 

[allantois]

That's what many people don't realize about EM in the USA vs in other countries.

In most countries 500K cities have 1-5 EDs while here its often 5-10 EDs.

In other countries uninsured do not inundate the ED system

 

[WorkNoteEmergency]

Man if I could own my own tent, call it an ER, and then just transfer everyone that needs more than an istat and portable xray elsewhere, I would totally do it.

That is just a couple of notches below what my (former) hospital system does at my rural hospital, hoping the transfers will come to the mother ship.

I don’t think it’s necessarily a design flaw but a concept failure on the part of the people writing the checks. In the current underinsured, EMTALA’ed environment there is no way a proper ED can function as a legitimate profit center. They only way it can, which we see daily, is squeeze the staff and other overhead since the customers aren’t paying their own bills and the insurance companies set the prices of services.

Thats not to say however that the ED concept is flawed. I think a high functioning department with smart, motivated well paid physicians carrys way more value than just the RVU’s generated. Think of all the crappy primary care referrals, Friday afternoon garbage referrals we deal with, complex problem solving we take care of. All this allows a health system to skimp on specialists, skimp on inpatient throughput, skimp on quality primary care. You tally up all that we should be getting $500/hr.

 

[TooMuchResearch]

Except it’s like pulling teeth trying to find an open bed to transfer someone these days.

What? If all I have is istat and portable xray, that means basically everywhere has more ability to treat the patient than I would, which means they'll take it. It's a win win. For me. Not anyone else.

 

[JacobMcCandles]

What? If all I have is istat and portable xray, that means basically everywhere has more ability to treat the patient than I would, which means they'll take it. It's a win win. For me. Not anyone else.

Do you work somewhere now that has to transfer routinely? They won’t take it if they don’t have any staffed beds. Calling multiple hospitals over the course of hours to find an accepting facility has been the norm in my area for awhile.

 

[RustedFox]

Do you work somewhere now that has to transfer routinely? They won’t take it if they don’t have any staffed beds. Calling multiple hospitals over the course of hours to find an accepting facility has been the norm in my area for awhile.

Mobile phone and unit clerk (you), and we're G2G, amigo.

 

[ShockIndex]

I think a high functioning department with smart, motivated well paid physicians carrys way more value than just the RVU’s generated.

Is now a good time for the daily reminder to do the bare minimum?

There is a saying - it’s easier to change individuals than systems.

EM’s fatal flaw is a manifestation of healthcare system issues. Specifically, the shifting of unscheduled care (especially advanced imaging and admissions) to the ED, coupled with cost containment efforts that allocate inpatient resources to perioperative patients at the ED’s expense. The system isn’t going to change until it collapses because we do not have the money to fix it.

It sounds like the OP made the wise choice to change the individual rather than waiting for the system to change. On the other hand, I completely understand the desire to do the bare minimum for those choosing to wait for the system to change…gotta pace yourself.

 

[Birdstrike]

I hear you, amigo - but the way it sounds; your first paragraph reads like EM is/was deliberately built like a leghold trap by the cartoonishly evil Tintinalli (an evil Penelope Pitstop) and Rosen (Snidely Whiplash).

For the record, I find it bizarre that autocomplete spit "Penelope Pitstop" right out for me.

No one person (or two or three) built EM single handedly. However, if one or two are going to accept the credit for the good that came out of it, then they need to accept the bad along with the good.

Mistakes can be intentional. They can also be accidental. Lack of intent, doesn't absolve one of responsibility for a failure. That's especially true if they're putting their self in a position to take credit.

I didn't bring up names. You (an others) named names. I'm not interested in pointing fingers. What I'm interested in, is shining light on what I think is true about EM, and what's false about it. There are still too many falsehoods being use to sell the specialty to unsuspecting recruits, in my opinion.

 

[TooMuchResearch]

Do you work somewhere now that has to transfer routinely? They won’t take it if they don’t have any staffed beds. Calling multiple hospitals over the course of hours to find an accepting facility has been the norm in my area for awhile.

"I want to send to your ED. I do not have the ability to care for this patient."

 

[ShockIndex]

The speciality of emergency medicine was created 50 years ago. It’s interesting that the current and recent generations of emergency physicians (ie the ones most directly responsible for the current mess) are talking about mistakes that were supposedly made 50 years ago that are responsible for the problems of today.

Here is a thought - perhaps there was no fatal flaw 50 years ago. Maybe the fatal flaws came from poor leadership and mismanagement over the past 15-20 years.

 

[ScepticSkeksis]

The speciality of emergency medicine was created 50 years ago. It’s interesting that the current and recent generations of emergency physicians (ie the ones most directly responsible for the current mess) are talking about mistakes that were supposedly made 50 years ago that are responsible for the problems of today.

Here is a thought - perhaps there was no fatal flaw 50 years ago. Maybe the fatal flaws came from poor leadership and mismanagement over the past 15-20 years.

Like most of medicine, the problems arose from physicians abdicating responsibility over the financial decisions, and general management of the hospital.

 

[RustedFox]

The speciality of emergency medicine was created 50 years ago. It’s interesting that the current and recent generations of emergency physicians (ie the ones most directly responsible for the current mess) are talking about mistakes that were supposedly made 50 years ago that are responsible for the problems of today.

Here is a thought - perhaps there was no fatal flaw 50 years ago. Maybe the fatal flaws came from poor leadership and mismanagement over the past 15-20 years.

This is what I was trying to say.

 

[JacobMcCandles]

"I want to send to your ED. I do not have the ability to care for this patient."

Sure, if you’ve got area hospitals that will accept ED to ED transfers. Ours typically don’t when the ED is also full with inpatient holds, etc.

 

[CoolDoc1729]

"I want to send to your ED. I do not have the ability to care for this patient."

The closest tertiary center that can handle Xcritical diagnosisX recently said no - they had 200 patients in their waiting room, 50-60 were admitted. So did everywhere else in the state. The guy died waiting for the helicopter to come from the next state’s quaternary center. (Not my case)

I’m a little jealous if your area isn’t like this - it’s been most of the time since late 2020 here 😬 thankfully I don’t have to transfer almost anything , but people are coming to my hospital from 2-400 miles away for GI or cardiology coverage !

 

[aafisahar]

Like most of medicine, the problems arose from physicians abdicating responsibility over the financial decisions, and general management of the hospital.

The problem is that there are enough bad actors to sour the system. For example there was a doc who falsely diagnosed patients with multiple myeloma in order to refer to his infusion center.

 

[Arcan57]

The speciality of emergency medicine was created 50 years ago. It’s interesting that the current and recent generations of emergency physicians (ie the ones most directly responsible for the current mess) are talking about mistakes that were supposedly made 50 years ago that are responsible for the problems of today.

Here is a thought - perhaps there was no fatal flaw 50 years ago. Maybe the fatal flaws came from poor leadership and mismanagement over the past 15-20 years.

The problem today is the environment in which decisions are made. Late stage capitalism makes it really difficult for companies and organizations to successfully defend against ideas that increase short term profit. At the same time, consumers are conditioned to accept innumerable trade-offs in the name of greater convenience. The interaction of these two forces explains almost everything that has happened in EM in the last 30 years. The rise of CMGs (convenient for both docs and hospitals), the role of PE, the rise of midlevels, etc all spring from these wells.

 

[emergentmd]

You realize that 2 yrs is /= 1M for the vast majority of EM docs? If it was, there'd be a lot fewer complaints on this board.

I am estimating, but if you are doing a fellowship then you are likely doing 50-60 hrs/wk. Do this in EM and you mostly would be above 500k/yr.

Even when you are done with 2 yrs of pain, you will likely start off making less your first few years out while building your practice so yea, I beat the monetary cost will be over 1M.

 

[Birdstrike]

Even when you are done with 2 yrs of pain

Pain Fellowships are 1 year, not 2.

 

[emergentmd]

I stand corrected, I always thought it was 2 yrs.

 

[greatnt249]

I am estimating, but if you are doing a fellowship then you are likely doing 50-60 hrs/wk. Do this in EM and you mostly would be above 500k/yr.

Even when you are done with 2 yrs of pain, you will likely start off making less your first few years out while building your practice so yea, I beat the monetary cost will be over 1M.

The difference I would wager is that in fellowship, tough rotations are often broken up with somewhat more relaxed rotations. I think this would be somewhat different than a constant 50-60 hour/week grind in the ED; then again, I'm not an ED physician, but I can imagine 50-60 hours/week would make me somewhat crispy after a while.

 

[Boatswain2PA]

Mobile phone and unit clerk (you), and we're G2G, amigo.

That's an expense that was cut from many EDs because covid.

 

[Birdstrike]

EM physicians should be trained in a way that they’re equally capable of earning a living outside of an Emergency Department as they are in one.

Exit plans shouldn’t be an afterthought, like a pilot hitting the eject button as a last ditch effort. It should be part of the plan and training.

EPs should be able to seamlessly move from ED-based careers to non-ED based careers. If EPs could easily do this, they’d have leverage, as opposed to now, where they’re at the mercy of the whims of administrators, CMGs and contract gain/loss.

If this was the case, EPs would have the leverage to easily walk away. They wouldn’t be at the mercy of contract loss, hospital based politics or administrators whims.

It would also be an incredible Insurnace policy against burnout if those non-ED based options avoided circadian-disruption dysphoria.

This should be a part of normal EM training. EPs should not be forced to reinvent the wheel, mid career in a scattered way or out of desperation.

EM training should take as much responsibility for the EPs exit from EM, as they it does entry into EM.