Four Specialties Show A Decline In Applications

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2021Doctor

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Dying field… only answer is it crashes and burns so bad that private equity leaves because the profit succcccccks. But that will take us all down with it.
 
That doesn’t explain the decline in the FM or psych applications, they’re doing well as a whole with a decent job outlook.
 
southerndoc said:
So increased positions + decreasing applicants = plenty of unfilled positions in the future = not as much doom and gloom as people have projected?
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Those spots will fill with FMGs.

Honestly with the SLOE it makes EM a harder sell than FM. You can apply to several FM programs and get into a competitive city
 
bravotwozero said:
That doesn’t explain the decline in the FM or psych applications, they’re doing well as a whole with a decent job outlook.
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FM has always had a good job outlook but FM gets crapped on in med school prestige rankings as multiple failures of Steps and just graduating can get you into an academic FM residency. Also FM applicants know they can save their money and apply to 10 places and get a good match.

However you realize that FM can do outpatient, rural EM and hospitalist work as well so you have job options.

Unless those EM residencies close down it's just a slow bur
 
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bravotwozero said:
That doesn’t explain the decline in the FM or psych applications, they’re doing well as a whole with a decent job outlook.
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A deeper dive into psych shows a decrease in non USMD apps, which decreased the overall number despite the specialty actually being more competitive.
 
southerndoc said:
So increased positions + decreasing applicants = plenty of unfilled positions in the future = not as much doom and gloom as people have projected?
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Hardly. That % reduction in applicants wouldn't even account for the number of people who applied for EM and didn't match last year. Pretty unlikely in one year we'll see any dent. Even if there are positions open, there are so many people in the SOAP that don't match, they'll fill. I wouldn't bank on this being an answer, at least not this year.
 
Wasn’t the SLOE supposed to make matching tougher? You had to rotate at a real EM program with the ability to rate you among their history of rotating students.

Feels like something most FMGs won’t have.
 
Backpack234 said:
Wasn’t the SLOE supposed to make matching tougher? You had to rotate at a real EM program with the ability to rate you among their history of rotating students.

Feels like something most FMGs won’t have.
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It's easier than ever to get SLOEs now with CORD capping the amount of aways people can do to one (two if you have no home residency). A lot of residencies don't have a home medical school and likely saw a huge drop in rotators since these changes.
 
It's a start.

What I really want to know: how on earth did urology apps increase 40% in 2 years? New hotness among med studs + reasonably short residency + urologists know how to protect their turf and won't sell out to PE just yet?
 
sylvanthus said:
Like someone above said, the spots will still fill. There are plenty of applicants. Worst case, more FMG/IMGs jump on the spots if AMGs start to shun the specialty.
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On the plus side the sloe is a major barrier to getting into the general applicant pool. But you can still soap without a sloe.

I wonder how many EM spots will open up in the soap this year.
 
hundreddaysoff said:
It's a start.

What I really want to know: how on earth did urology apps increase 40% in 2 years? New hotness among med studs + reasonably short residency + urologists know how to protect their turf and won't sell out to PE just yet?
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Not sure a 5 year residency is in any way short lol
 
Dr Mantis Toboggan said:
Yup from what I’ve seen they work hard but it’s a guaranteed path to wealth.
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Seems like it. A friend of mine is a urologist. We started residency at the same time. He did a surgery prelim year and his PGY-2 schedule was brutal. The second years take "first call" and they do it like Q2. it's gross. But as time went on his chief year was baller, he was the "third call," the call made when the other two residents either didn't answer or it was so complicated they couldn't fix the problem. He also did Q4 call and mostly just operated and ran the clinic.

And now he has to check his bushes before he leaves his house because people keep jumping out at him to offer him jobs since they actually control their market.
 
You think HCA residencies care about SLOE letters? Bring on the FMGs.
 
Matthew9Thirtyfive said:
My wife’s uncle is a urologist and is loaded.
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When you
AlmostAnMD said:
Seems like it. A friend of mine is a urologist. We started residency at the same time. He did a surgery prelim year and his PGY-2 schedule was brutal. The second years take "first call" and they do it like Q2. it's gross. But as time went on his chief year was baller, he was the "third call," the call made when the other two residents either didn't answer or it was so complicated they couldn't fix the problem. He also did Q4 call and mostly just operated and ran the clinic.

And now he has to check his bushes before he leaves his house because people keep jumping out at him to offer him jobs since they actually control their market.
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when you say urology make that much.. do you mean they re making $1mill +?
 
Urology residency is surprisingly brutal from the few people I know who have done it. You would think a bunch of folks who look at genitals all day would be low key, have a good time, be humorous etc but they really get worked in residency. Life after as a urologist isn't that peachy. The money is no doubt the best there is, but depending on the group they work for, can end up with A LOT of annoying calls. Busy clinic days. I think they mostly enjoy it and most of the people in the specialty are nice, but it's not a cake walk.

That being said, I'm not sure how urology as a specialty has managed so well to keep themselves protected, competitive, well compensated. They have done it better than anyone else by limiting residency spots despite insane demand. We all really should be taking a page from their book, although I fear for many of the other specialties including EM, that ship has sailed.
 
TheComebacKid said:
Urology residency is surprisingly brutal from the few people I know who have done it. You would think a bunch of folks who look at genitals all day would be low key, have a good time, be humorous etc but they really get worked in residency. Life after as a urologist isn't that peachy. The money is no doubt the best there is, but depending on the group they work for, can end up with A LOT of annoying calls. Busy clinic days. I think they mostly enjoy it and most of the people in the specialty are nice, but it's not a cake walk.

That being said, I'm not sure how urology as a specialty has managed so well to keep themselves protected, competitive, well compensated. They have done it better than anyone else by limiting residency spots despite insane demand. We all really should be taking a page from their book, although I fear for many of the other specialties including EM, that ship has sailed.
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I dunno, the program here is extremely chill. They all go surfing together Wednesday mornings and have no patients or cases scheduled that day. They surf in the morning, do conference until noon, and then have admin time the rest of the afternoon.
 
NRAI2001 said:
When you

when you say urology make that much.. do you mean they re making $1mill +?
Click to expand...
TheComebacKid said:
Urology residency is surprisingly brutal from the few people I know who have done it. You would think a bunch of folks who look at genitals all day would be low key, have a good time, be humorous etc but they really get worked in residency. Life after as a urologist isn't that peachy. The money is no doubt the best there is, but depending on the group they work for, can end up with A LOT of annoying calls. Busy clinic days. I think they mostly enjoy it and most of the people in the specialty are nice, but it's not a cake walk.

That being said, I'm not sure how urology as a specialty has managed so well to keep themselves protected, competitive, well compensated. They have done it better than anyone else by limiting residency spots despite insane demand. We all really should be taking a page from their book, although I fear for many of the other specialties including EM, that ship has sailed.
Click to expand...
Uro here. Residency is definitely long and tough. 5-6 years of surgical residency. Home call q4-5 where you’re never at home but have no post call day. Surgical residency hours. At my program, I felt the junior years were tougher then general surgery due to aforementioned call. The senior years were definitely easier though since there are fewer chief level surgical emergencies in Uro (I e the junior on call can do the stent for septic stones)

Many programs including my own are moving towards more humane schedules by instituting a night float system, but it’s still busy.

Post residency lifestyle is quite good. Typically a clinic schedule with one or two OR days. Mostly outpatient cases. Call is usually limited and compensated if you choose to take ER call. In a typical week of call at a busy hospital, I’ll come in 2-3 times which isn’t too bad.

Job market is great, but effected by the same issues as everyone else (consolidation, shift to employment rather then true PP, etc.) Most people I know were able to find jobs in the city they want, though that is less true as you get more sub specialized (ie Uro oncology is more saturated). The specialty has done a good job of limiting spots and keeping a high bar for programs adding new spots in terms of number of cases, resources, etc.

Most Uro’s are starting around 350-450k (less for academics) and may go up from there. anyone pulling over 7 figures is either working their a** off or generating a lot of revenues from ancillary services like surgery center ownership, ESWL machine ownership, etc.
 
TheComebacKid said:
Urology residency is surprisingly brutal from the few people I know who have done it. You would think a bunch of folks who look at genitals all day would be low key, have a good time, be humorous etc but they really get worked in residency. Life after as a urologist isn't that peachy. The money is no doubt the best there is, but depending on the group they work for, can end up with A LOT of annoying calls. Busy clinic days. I think they mostly enjoy it and most of the people in the specialty are nice, but it's not a cake walk.

That being said, I'm not sure how urology as a specialty has managed so well to keep themselves protected, competitive, well compensated. They have done it better than anyone else by limiting residency spots despite insane demand. We all really should be taking a page from their book, although I fear for many of the other specialties including EM, that ship has sailed.
Click to expand...
The AUA is very good at protecting the specialty
 
Matthew9Thirtyfive said:
A deeper dive into psych shows a decrease in non USMD apps, which decreased the overall number despite the specialty actually being more competitive.
Click to expand...
I wonder if FMGs are self selecting out as psych is more competitive. Psychiatry also sucks, because you make barely any money and have to see psych patients all day.
 
nexus73 said:
I wonder if FMGs are self selecting out as psych is more competitive. Psychiatry also sucks, because you make barely any money and have to see psych patients all day.
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Lol wut? They make great money for the hours worked.
 
sylvanthus said:
Tons of NPs doesnt help.
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You're right that NPs doing psych doesn't help. But if you read the psych forums it doesn't seem to really hurt either.

Psych a fairly nuanced cognitive specialty. Since there's not much in the way of truly objective pysch testing, the likes of Bob McBoberson and Jenny McJennerson can't fake their (lack of) training/knowledge/abilities as easily as they can in other fields.

All the psychiatrists I know couldn't be happier with their job market as they're in huuuge demand. Add in their ability to do tele-psych and/or have a solo cash-only practice with nearly no overhead and they're positioned very well to survive despite the best efforts of private equity and hospitals to capture their market.
 
I don't understand how psych is as lucrative as it is. There are no procedures other than maybe ECT which I heard bills well? A huge percentage of patients with mental health issues have no insurance. Hospital systems vastly underfund psychiatric care.

I'm not denying its true, it just doesn't add up for me. I'm guessing the solo cash practice, low overhead costs etc are where the money comes in? I can say though from observing on the inpatient side, psych seems to be not optimally positioned to do well financially.
 
TheComebacKid said:
I don't understand how psych is as lucrative as it is. There are no procedures other than maybe ECT which I heard bills well? A huge percentage of patients with mental health issues have no insurance. Hospital systems vastly underfund psychiatric care.

I'm not denying its true, it just doesn't add up for me. I'm guessing the solo cash practice, low overhead costs etc are where the money comes in? I can say though from observing on the inpatient side, psych seems to be not optimally positioned to do well financially.
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Agreed. And let me add that it's a field that's SO easily infiltrated by midlevels, and even clinical psychologists, licensed therapists, and even "psychiatric" pharmacists who can prescribe.

I think this golden age of psychiatry won't be long-lived at all for all of the above reasons. I'd love to be wrong, but I just cannot see financially motivated MBAs, CEOs, and leaders of private equity taking this aspect of medicine seriously. Payors don't want to pay for mental health, and even the ethos of our country skews away from taking mental health seriously.

Again, it's ethically wrong in my opinion. However mental health patients on average are less "productive" (as defined by a capitalist system) and are often cost burdens on communities and societies.

So yea, I just don't see the money continuing to flow except for the few psychiatrists that can command a high cash-based hourly rate. And as more and more people are earning less, inflation continues to spiral out of control, and other cost pressures continue to mount... nobody is going to be able to pay that cash rate except for those at the very top.

Just my two cents...
 
2021Doctor said:
View attachment 344653
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Just going to point out that this doesn't mean what the posters above think it does. It's applications received per program, the number of programs in EM has increased (as best I can tell) by 32 between 2019 and 2021. EMRA lists 278 EM programs under their current EMRA Match list. So the number of programs increased by >10%, which means that the total number of applicants in EM didn't fall by 10% but probably increased by a point or two.
 
TheComebacKid said:
I don't understand how psych is as lucrative as it is. There are no procedures other than maybe ECT which I heard bills well? A huge percentage of patients with mental health issues have no insurance. Hospital systems vastly underfund psychiatric care.

I'm not denying its true, it just doesn't add up for me. I'm guessing the solo cash practice, low overhead costs etc are where the money comes in? I can say though from observing on the inpatient side, psych seems to be not optimally positioned to do well financially.
Click to expand...
So schizo and bipolar tend to be un-insured, but the anxiety/depression/somatic symptom disorder/etc population tends to skew towards the more well-insured demographic.

Also lots of families of psych patients are very invested in getting their family member well and will pay quite a bit of cash for a good psychiatrist who is easily reachable and takes the necessary time to keep tabs on the patients mental health/prevent decompensation. I say this from experience with a family member with one of the “bad” psych conditions. Our family will happily pay the $500/hour ($1000/30 min after hours) for a private psych so we can have someone to intervene ASAP if the person begins to show signs of decompensation. Of course this is the population we rarely if ever see in the ED.
 
TheComebacKid said:
I don't understand how psych is as lucrative as it is. There are no procedures other than maybe ECT which I heard bills well? A huge percentage of patients with mental health issues have no insurance. Hospital systems vastly underfund psychiatric care.

I'm not denying its true, it just doesn't add up for me. I'm guessing the solo cash practice, low overhead costs etc are where the money comes in? I can say though from observing on the inpatient side, psych seems to be not optimally positioned to do well financially.
Click to expand...


The Knife & Gun Club said:
So schizo and bipolar tend to be un-insured, but the anxiety/depression/somatic symptom disorder/etc population tends to skew towards the more well-insured demographic.

Also lots of families of psych patients are very invested in getting their family member well and will pay quite a bit of cash for a good psychiatrist who is easily reachable and takes the necessary time to keep tabs on the patients mental health/prevent decompensation. I say this from experience with a family member with one of the “bad” psych conditions. Our family will happily pay the $500/hour ($1000/30 min after hours) for a private psych so we can have someone to intervene ASAP if the person begins to show signs of decompensation. Of course this is the population we rarely if ever see in the ED.
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Exactly.

There are a few reasons these guys can thrive...

Due to perpetual demand (which was quietly there long before the pandemic), they don't need to take insurance so many don't. But those that do generally get decent rates...since the insurers want any shrink who will sign up with them. And many psych patients don't want the stigma of their visits being tracked by a 3rd party so patients with insurance may prefer to pay cash for mental health (the stigma's not a good thing, but it is what it is).

Psych overhead to go solo is literally as small as it gets in medicine. So they can start a practice on the side of an inpatient W2 gig and then leave then their pp is big enough. I know several who've done this or they just keep doing both in perpetuity.

Since there's basically no "fat" (ie excess overhead) for the PE groups to cut from a psych practice, it basically leaves them the options of paying docs less or increasing staffing with midlevels. Neither of which are appealing to most pyschiatrists. And many shrinks, being kinda brainy, have little patience for babysitting a midlevel unless they are employing said midlevel.

While psychiatrists certainly have competition from LCSWs, counselors, clinical psychologists and midlevels...most people who pay cash and may need meds usually want to see a boarded psychiatrist. These are your anxious, sad/depressed, +/- bipolar middle class and wealthy people. And it turns out there's LOTS of them. And the child psychs can absolutely crush it -- it's not uncommon for them to charge 300-600+/hr. I once worked with a guy whose dad was a kiddie psych in a popular coastal city whose rate approached $1000/hr and the uber-wealthy would fly their kids in for appointments with him.

But ultimately, what really protects them is that they are not procedural or a heavy test-ordering field that "AI" or a midlevel can easily mimic. Their protection lies in that they're a thinking specialty that requires observation, analysis, and time which can't be as easily commoditized in a way that allows middlemen to get their hooks into the specialty.
 
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namethatsmell said:
Their protection lies in that they're a thinking specialty that requires observation, analysis, and time which can't be as easily commoditized in a way that allows middlemen to get their hooks into the specialty.
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When we lost this as physicians in other specialities, we lost what made us unique due to our higher level training. The proliferation of testing replaced the physical exam and medical deduction, while the world of medical knowledge also became readily available at anyone’s fingertips. The only hope that we have in maintaining our value and corresponding compensation is to find a way to better differentiate ourselves from those that can willy-nilly order any test or google any symptom.
 
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TheComebacKid said:
I don't understand how psych is as lucrative as it is. There are no procedures other than maybe ECT which I heard bills well? A huge percentage of patients with mental health issues have no insurance. Hospital systems vastly underfund psychiatric care.

I'm not denying its true, it just doesn't add up for me. I'm guessing the solo cash practice, low overhead costs etc are where the money comes in? I can say though from observing on the inpatient side, psych seems to be not optimally positioned to do well financially.
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ECT bills well for the hospital OR and anesthesiologist. But we do other "procedures". Yes, therapy is coded, and has been reimbursed, as an add-on procedure for quite awhile. It's common for patients to schedule follow ups q1-4 weeks. Hence, small panels and long waitlists. It's not necessary to do cash psychiatry or have wealthy patients because insurances have raised rates in response to our willingness to walk away and go on the open market where patients value us. Ironically, if Mr. Insurance CEO offers us poor rates, we won't see his patients, and if Mr. Insurance CEO offers us good rates, we work less.

Also, "psych" patients in the ED are different than most private practice psychiatry outpatients. The stuff you see in the ED is not reflective. I am going to assume ED attendings like you guys live in nice neighborhoods. If you live in such neighborhoods, I will bet you a large sum of money there are a bunch of really nice psychiatry clinics (with zero openings) within 1-2 miles of your home that treat your friends, neighbors, and families.

Depression and anxiety disorders are rampant among educated, high functioning, high achieving people with real stressors, demanding jobs, and good health insurance. You know, like doctors. These people want to better themselves and not just get psych meds thrown at them like PCPs, NPs, and EM docs will. These aren't the drunkards who have been trained to stop by the ED once a month to yell at docs and spit at nurses to score a few opioids or benzos to numb themselves. As someone said above, psych is a cognitive specialty and educated people can sense whether you are slinging pills vs. trying to actually understand them and tease out a diagnosis.
 
TheComebacKid said:
I don't understand how psych is as lucrative as it is. There are no procedures other than maybe ECT which I heard bills well? A huge percentage of patients with mental health issues have no insurance. Hospital systems vastly underfund psychiatric care.

I'm not denying its true, it just doesn't add up for me. I'm guessing the solo cash practice, low overhead costs etc are where the money comes in? I can say though from observing on the inpatient side, psych seems to be not optimally positioned to do well financially.
Click to expand...

I imagine it's a highly lucrative outpatient field for the psychiatrists that treat the 125M Americans who make over 100K / year. Or the ~50M people who make 150K / year. For the rest of the nation it's piss-poor coverage and they all wander around psychotic listening to space messages from their radio transmitter embedded in their tooth
 
NRAI2001 said:
When you

when you say urology make that much.. do you mean they re making $1mill +?
Click to expand...

They aren't. The hospital employed urologists I was working with in 2015 were making 30% less than a private practice urologist in the 1990s. Unless something has changed, their salaries were about equal to EM (working a sane number of hours) at its peak.

I'm curious as to what happened to Rad Onc. You would think that would be a competitive field.
 
Old_Mil said:
They aren't. The hospital employed urologists I was working with in 2015 were making 30% less than a private practice urologist in the 1990s. Unless something has changed, their salaries were about equal to EM (working a sane number of hours) at its peak.

I'm curious as to what happened to Rad Onc. You would think that would be a competitive field.
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The PP urologist in the 1990s was making the equivalent of almost a million dollars a year in today’s dollars.
 
rokshana said:
The PP urologist in the 1990s was making the equivalent of almost a million dollars a year in today’s dollars.
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True, but if you start factoring that in then everything in medicine looks pretty dismal...from the percentage drop in urology compensation to EM's hourly rates.
 
I'm Family Medicine. A very large portion of my patient population includes mental health, and my town is hurting for good psychiatrists. I'd say 70% of these patients are employed with good insurance, and not very demanding whatsoever. Think nurses, docs, physical therapists, lawyers, cops, IT people, and probably half the teachers in the county. It's almost all garden variety stuff.

The visits are very rewarding when we get the always wanted "thank you doc, I'm feeling much better, I'm arguing with my spouse less and I'm spending more time with my family."

If you're good, personable and responsible, they'll come beating down your door and you can name your price.
 
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