Future job market

[jaffri1]

I’m posting this in hopes I don’t get only doom and gloom responses, however how this is SDN so I’d be dreaming if I didn’t get any.

That being said, as someone who is interested in EM but constantly hears “there are too many residencies opening”, “job market is going to suffer” etc etc, I can’t help but think there’s tons of merit in those predictions.

for anyone in the field right now, what are your perspectives? How was the job market when you entered the field, how is it now, and what way do you think it’s heading with regards to location, supply and demand of pay.

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[thegenius]

Well.....there is not a single industry in any sector that is immune to supply and demand.

In general though we don’t have enough doctors, and as long as people can go to the ER for free anytime for any reason, ER doctors will be paid well.

It’s not unreasonable think though that in-demand places-to-live will probably show a slight reduction in pay over the next several years.

That being said, I continue to make slightly more / year and I work in Northern CA.

 

[BoardingDoc]

I’m posting this in hopes I don’t get only doom and gloom responses, however how this is SDN so I’d be dreaming if I didn’t get any.

That being said, as someone who is interested in EM but constantly hears “there are too many residencies opening”, “job market is going to suffer” etc etc, I can’t help but think there’s tons of merit in those predictions.

for anyone in the field right now, what are your perspectives? How was the job market when you entered the field, how is it now, and what way do you think it’s heading with regards to location, supply and demand of pay.

I live in a geographically desirable location. Job market is tight. Most jobs around me pay substantially less than places 1-2 hrs outside the city as is the case with other popular geographic regions. Getting a job in the city itself is fairly difficult. Getting one of the few jobs in the city that pays well is impossible without inside connections.

There are shops in the middle of nowhere and in undesirable cities which are paying well. I do moonlighting at some of them from time to time as the rates are still pretty good, though they certainly aren't the 300-350/hr that people used to get.

Short answer: My job is pretty good, but it's also rare and only getting more rare. You can still make good money without extreme difficulty if you're willing to sacrifice location.

 

[DocEspana]

I’m posting this in hopes I don’t get only doom and gloom responses, however how this is SDN so I’d be dreaming if I didn’t get any.

That being said, as someone who is interested in EM but constantly hears “there are too many residencies opening”, “job market is going to suffer” etc etc, I can’t help but think there’s tons of merit in those predictions.

for anyone in the field right now, what are your perspectives? How was the job market when you entered the field, how is it now, and what way do you think it’s heading with regards to location, supply and demand of pay.

Will point out that this whole covid thing has REALLY screwed over a lot of the income price points. It was a rube goldberg machine of driving down physician payments. Massive pandemic *actually* kept people home. Visits per day to the ED (particularly among worried well with insurance) dropped while the length of stay for admitted patients skyrocketed. This lead to massive costs for the hospital not being offset by shaking down the worried well for every penny insurance will give. Also elective surgery shut down so the hospitals other major source of income dried up. In areas *not quite* as hard hit, the hospitals laid off physicians or "asked" them to work fewer hours per month and/or at lower rates. In terribly hard hit areas, righteous white knights flew across the country to voluntarily work for little pay or free - leading to companies wondering what the point of paying the locals was when the out of towners wanted to do it for pennies on the dollar or simply for housing alone. As stuff has started to normalize the hospitals now dont want to raise the incomes and hours back to what they were before. The places that previously wanted traveling physicians now dont want them at all (the locums market is the hardest hit place in all of EM by all of this) because they realize that if the need gets really bad, people will volunteer.

All the while, new graduates who dont know what incomes they should be requesting (I know I didnt a few years ago) accept lower pay rates that their older coworkers would never dreamed of accepting and drive down the market price for the region.

optimistic silver lining: if you want to work rurally, the pay is still pretty great. And the good paying jobs still exist - but you're going to literally have to kill me or one of my coworkers in a fight to the death to get it. I am in a highly desired major city that also happens to pay well by any standard. I left a job paying (x +/- 15%) dollars a month in an incentive based model. I took this job making essentially exactly x dollars a month as well but now on a flat hourly model. This was just before covid by a few months. The old job 1) cut the hours per shift from twelve to ten. 2) they cut the number of physician shifts per day from five to four. and 3) they cut the average number of shifts per month from fourteen to ten; which is sort of an extension of having #2 occur. My current job still gives us the same hourly rate but we (lucky SOBs we are) got asked to work EXTRA shifts because our ICU cant recruit enough intensivists to cover its needs so we are doing extra shifts to cover some of the needs there.

The moral of that story is that good work is out there. But you have to read the tea leaves. I could never have predicted covid. but i knew this incentive based model was ripe for something ****ing with it, and the opportunity to make exactly the same money (in a slightly less nice hospital in the same city) on an hourly basis just felt infinitely more safe. Don't be afraid to move around a bit as you get experience and find the job that makes the most sense to provide you with lasting security and income. Or as lasting as anything is in EM

 

[Apollyon]

if you want to work rurally, the pay is still pretty great.

I just want to put in here that, for UPMC, that is NOT true. To work in BFE, with no backup, they pay less than 10% MGMA. They screw the **** out of any dopes that might work there.

 

[DocEspana]

I just want to put in here that, for UPMC, that is NOT true. To work in BFE, with no backup, they pay less than 10% MGMA. They screw the **** out of any dopes that might work there.

Valid. Rural generally pays better, but state-wide trends also play into things as do system-wide trends. Your mileage may vary. This is only a very broad generalization.

Im literally a perfect example as I'm in the biggest city in my state and literally working in the dead center of that city and I get paid enough to out-earn anyone in any area (rural or otherwise) from the state I trained in. But thats because the state i'm in just pays everyone more than anyone would get in the state I left. I think I make essentially average for the state I'm in (and thats great for the city i'm in)

Good point

 

[Groove]

Supply and demand have palpably impacted where I live. I live in a semi-desirable Southern city with a population around 650K and surrounding area of ~1.3mill. We have several hospitals in the area. When I moved here, 7 yrs ago, huge sign ons were commonplace, on the order of 75-100K for 3yr commitments. You had pick of the litter with hospitals. There were not nearly enough ABEM docs to staff an entire dept. Half the ER docs in town were IM/FM. Well, since then we had a residency open up nearby and have had a palpable influx of interest from people in totally unrelated parts of the U.S. whom I assume are finding themselves in desperate straights in their local markets causing them to venture out to new areas.

The market now is quickly saturating. The job I recently took with TH...had a 15K sign on offer for 2 years, which I declined. (The first time in history that I can remember where TH in this particular area has not offered 50K for 2yr commit or 75K for 3yr.) There were 3 or even 4 applications for the same position. We now have enough ABEM to staff 3 of our local hospitals with 100% EM boarded docs and more are following suit. Salaries have fluctuated but luckily have not dropped precipitously except for during the pt volume decline d/t COVID.

I think the field is being flooded by too many new EM grads. I read next year that we'll have over 2K graduating residents each year for the foreseeable future. Will we feel the impact immediately? I'm not sure. I have a feeling that more and more hospitals will start employing ABEM only hospital bylaws for their ERs which will push the IM/FM crew further out to less desirable locations. That will likely buy us some time and might not be a bad thing insomuch as the future of our specialty is concerned. (Standardizing training and care....) I think the things we'll notice first are similar to what I'm seeing in the area... 1) Fewer available positions and harder work obtaining them. 2) Lower sign ons, paying for your own scribes, etc..

I get locums calls all the time. When I graduated, the rates were consistently >$300/hr, some even $350/$400/hr depending on the state. Nowadays, I can't find anything more than $250 and most are around $230 or $240/hr. (Which is good nationwide but historically low for my area.)

To the OP: Your question is like asking a bunch of people who had their salaries slashed 100K. Does that make us happy? Well, of course it doesn't. Does the job still pay 6 figures? Yes, it does.. Everything is relative. If you never lived through the "golden era" of EM, then you have less to be unhappy about. If you enjoy EM, by all means, jump in. Everyone else seems to be doing it. Just don't get your hopes up. You'll likely witness a slow erosion of your specialty throughout your career. The 3% average salary increase per year that just about everyone else enjoys in other industries will never apply to you.

 

[Rekt]

As someone actively scouting the market, it's very bad. Covid essentially made it significantly worse. All specialities are vulnerable to Covid, but EM essentially had no wiggle room for this type of issue. Also, the extreme expansion of EM residencies is actually very recent and the grads are just now entering the market in droves. I expect this next year is where we'll see significant strain. I already noticed some last year.

Even pre covid it was very common to see new grads take jobs 2-3 hours outside major cities. Essentially nothing left in Portland/Seattle area. DFW is locked out with a waiting list. Closest to Austin is probably 3hours. Maybe SA if you're lucky. CA coast if you're willing to commute significantly. PHX/metro almost nothing left and what does open is CMG scraps. Maybe can snag an outskirt job in Tucson or border town. Utah has always been impossible. CO if you're willing to work for 120/hr. Nashville is completely full. Florida is almost ground zero for over saturation due to HCA alone. Saw many "graduating from X University in FL and can't find anything" last year and this year so even going to the good programs doesn't save you. Few people in my recent class went SE/east coast and said similar things about difficulty. Luckily had good connections but still outside major city with commutes. Can't speak to NE, but they aren't shy to opening as many residencies as possible. Midwest probably has the majority of what's left and even then it's the less desirable spots in an already not desirable region.

Etc etc etc.

Is our speciality doing anything about it? Nope. Not until it will be irreversibly damaged.

 

[turkeyjerky]

Sorry, OP, all you're going to get is doom and gloom.

The job market is bad, and only going to get worse. In a few years, outside of a few unicorn positions (which will be inaccessible to anyone w/o inside connections), we'll be making the same hourly rates as hospitalists, with far less job security and location flexibility.

 

[alpinism]

Heh you want doom and gloom?

I know of a few newly graduated residents who had their contracts cancelled and are currently working for COVID disaster field hospitals for 60/hr while they’re looking for new jobs.

 

[namethatsmell]

Heh you want doom and gloom?

I know of a few newly graduated residents who had their contracts cancelled and are currently working for COVID disaster field hospitals for 60/hr while they’re looking for new jobs.

Yes but how are the turkey sandwiches?

 

[Frazier]

Yeah, it is bad in EM... and many specialties.
Most the big academic hospitals are on essentially hiring freezes.

There are jobs, but quality of those positions are questionable.

Guy I know just took a job in southern California... About 200/hr, has been seeing ~40 patients per 10 hour shift (single coverage doc, all levels acuity) AND has to respond to all codes in the hospital.

Sounded unbelievable, but true.

No thanks!

 

[CliveStaples]

I am a recent graduate and found a job 25min commute from my house in a 800k pop metro area in the south paying 240-250/hr with a 1y sign on bonus of >50k. All of my coresidents are currently in jobs that pay either similarly or slightly less but with added benefits I do not receive. Their jobs stretch from Oregon to the Carolinas. The "squeeze" that COVID has done to our current jobs are that the opportunity to work much more than 120-130 hours per month is a little limited in July and August. Our volumes are currently at about 90% of pre-COVID numbers and continuing to rise.

This is my n=~10 experience.

 

[sylvanthus]

Heh you want doom and gloom?

I know of a few newly graduated residents who had their contracts cancelled and are currently working for COVID disaster field hospitals for 60/hr while they’re looking for new jobs.

Jesus, is this real?

 

[sylvanthus]

Ill prob get flak for this, but it may be wise for some future EM residents to consider combined residency programs, EM/FM, EM/IM, EM/IM/CC, hell theres EM/anesthesia now, just the flexibility alone could be worth the extra time spent.

 

[GatorCHOMPions]

I’m hoping these job market trends are cyclical. In the not too distant past radiology and anesthesiology were hurting hugely and now they’re enjoying a pretty solid rebound all things considered. We’re probably in for rough seas ahead for the next few years and pay will drop, but then I’d expect interest/supply from students to drop a bit too.

Speaking for myself, it’s been stable for me and my friends in the northeast lately. Granted, we never really saw $300+/hour even several years ago so maybe the rest of the country is just catching up.

 

[Dr Mantis Toboggan]

I’m hoping these job market trends are cyclical. In the not too distant past radiology and anesthesiology were hurting hugely and now they’re enjoying a pretty solid rebound all things considered. We’re probably in for rough seas ahead for the next few years and pay will drop, but then I’d expect interest/supply from students to drop a bit too.

Speaking for myself, it’s been stable for me and my friends in the northeast lately. Granted, we never really saw $300+/hour even several years ago so maybe the rest of the country is just catching up.

Big difference is gas and rads didn’t have anything like the explosion of these community residencies. That will be our undoing, in my opinion, and it’s likely too late to stop it.

 

[Fox800]

Jesus, is this real?

Doubtful. LT jobs at $200/hr are still easy enough to find.

Unless this is an extreme example where you absolutely cannot travel or leave one particular area and there are no jobs locally. Jobs are there but this is a personal problem.

 

[CCM-MD]

Ill prob get flak for this, but it may be wise for some future EM residents to consider combined residency programs, EM/FM, EM/IM, EM/IM/CC, hell theres EM/anesthesia now, just the flexibility alone could be worth the extra time spent.

Might as we just do a diff residency instead. IMO most people who do combined end up working only one of the fields.

 

[Fox800]

Might as we just do a diff residency instead. IMO most people who do combined end up working only one of the fields.

Correct. Difficult finding a mix of jobs to work both EM/IM and EM/FM. Most people end up only doing one - just means more years of lost attending pay.

 

[Brigade4Radiant]

Lots of doom and gloom in all filter messy though just asked the same question on the rads, surgery or anesthesia boards.

I knew GI docs who couldn’t find work after fellowship

 

[jaffri1]

Well so much for medicine having for one of the best job markets /s. Anywho I have a few years to decide things. Thanks to anyone and everyone who took the time to reply.

 

[alpinism]

Jesus, is this real?

Doubtful. LT jobs at $200/hr are still easy enough to find.

Unless this is an extreme example where you absolutely cannot travel or leave one particular area and there are no jobs locally. Jobs are there but this is a personal problem.

These were California residents with local jobs cancelled at the last minute in June. They couldn’t find any locums positions available in the state and they ended up taking out of state positions which can take 3-6 months before they get a license.

 

[ace_inhibitor111]

I’m hoping these job market trends are cyclical. In the not too distant past radiology and anesthesiology were hurting hugely and now they’re enjoying a pretty solid rebound all things considered. We’re probably in for rough seas ahead for the next few years and pay will drop, but then I’d expect interest/supply from students to drop a bit too.

Speaking for myself, it’s been stable for me and my friends in the northeast lately. Granted, we never really saw $300+/hour even several years ago so maybe the rest of the country is just catching up.

Gas was hurting because they had a huge increase in residency positions sometime between 1995-2005 (don’t remember when). There’s a bit of a lag before the effects of an increase presents itself. They’ve stabilized now with very few new positions in the past decade.

 

[Fox800]

These were California residents with local jobs cancelled at the last minute in June. They couldn’t find any locums positions available in the state and they ended up taking out of state positions which can take 3-6 months before they get a license.

Okay, so...fairly unusual circumstances.

 

[RustedFox]

Gas was hurting because they had a huge increase in residency positions sometime between 1995-2005 (don’t remember when). There’s a bit of a lag before the effects of an increase presents itself. They’ve stabilized now with very few new positions in the past decade.

I'm willing to bet that none of these new GAS positions were HCA related or financed.

 

[namethatsmell]

While job security isn't the only thing you should think about when picking a specialty, it should be some part of your decision making. In the long run, a med student's best protection probably comes from either:
a) pursuing a surgical specialty with a grueling residency (ie neurosurgery) that drives away most students from going into it and keeps supply low or
b) going into something that you could do purely as an outpatient with the option to hang your own shingle.

While a specialty that fits either of these two attributes still isn't immune from forces like market saturation and private equity involvement, being in one of these specialties will generally allow for much more control over your own destiny. The job market and opportunities for other specialties (ie EM/radiology/anesthesia/hospitalist/CC etc) will be much more dependent on external forces you can never hope to control.

 

[EctopicFetus]

Ill prob get flak for this, but it may be wise for some future EM residents to consider combined residency programs, EM/FM, EM/IM, EM/IM/CC, hell theres EM/anesthesia now, just the flexibility alone could be worth the extra time spent.

Will never recover the opportunity cost. If you like it because it is interesting that's one thing. but if you think that will somehow open up job opportunities I think you are mistaken. Lets be honest as EM makes more than FM or IM I'm not sure how that helps you financially. For CC or anesthesia that's job dependent but much of the CC big money is in pulm clinic of which you don't train in. Anesthesia is another version of EM when you consider job opportunities and pay. It is heavily controlled by CMGs and Private equity.

 

[EctopicFetus]

To the OP.. The more flexible you are or think you can be the better off you will be. The market has most definitely tightened in bigger cities. Most educated people are pessimistic by nature and worry about the negative effects of market changes.

Between new EM residencies and the use of MLPs it is definitely scary. That being said jobs will open up. Yes its not as good as before where you could walk into a great situation right out of residency. Now it seems like people will bide their time at a CMG job while they wait for a good job to open up. As someone else mentioned there is a lead time to the troubled waters.

As long as big business is running the show in medicine the only fields that arent facing rough seas are those who are outside of hospital/cmg control. As of today that is ortho, ENT and other surgical subspecialties.

On the bright side of EM is an aging and ever more sickly population. Older folks drive our volumes and our population is aging quickly with the baby boomers.

Im fairly negative on EM long term but its all about perspective. There were an abundance of $300+/hr jobs that were stable when I graduated residency about a decade ago. Now it is hard to find and I know many residents who are "settling" for total comp around $250/hr. Is $250/hr bad? No. Is it more than I thought I would ever make yes. Can you still make $400k per year absolutely.

Are you going to be taken advantage of by CMGs, hospitals and other employers? You better believe it.

Many of us on here are pessimistic but if you read between the lines many of the posters are saying things equivalent to "the job market sucks BUT I have a really special job". If everyone has a special job maybe they arent quite as hard to find as we think?

Flexibility will be key. If you say I need to be in [Insert Large metro city here] then you will likely end up in a crap ass job. If you say I would like to be within 4 hours of X then you can likely find something good.

Also remember pay isn't everything. It has always mattered a lot to me but high pay in a crap environment wont be worth it for long.

 

[sylvanthus]

Will never recover the opportunity cost. If you like it because it is interesting that's one thing. but if you think that will somehow open up job opportunities I think you are mistaken. Lets be honest as EM makes more than FM or IM I'm not sure how that helps you financially. For CC or anesthesia that's job dependent but much of the CC big money is in pulm clinic of which you don't train in. Anesthesia is another version of EM when you consider job opportunities and pay. It is heavily controlled by CMGs and Private equity.

It definitely opens up job opportunities, absolutely disagree with that. Currently making similiar pay in both the ICU and ED. The flexibility to get the heck out of the ED and work in a generally less hectic environment is a godsend at times. I think people need to also look at burnout. Working both ICU and ED allows some recovery from the nonsense of both specialities. When I get sick of the gomers in the ICU, I can work ED, when Im sick of the drug seekers, press ganey BS, etc etc I can work ICU. This could allow me to work longer, and burnout less, and recover that income that was lost due to extra training length. I think it is oversimplifying things to purely look at length of residency/fellowship. I took a pay cut in the ED recently, made up for it with extra ICU shifts that ended up paying more per hour.

 

[DoctwoB]

Well so much for medicine having for one of the best job markets /s. Anywho I have a few years to decide things. Thanks to anyone and everyone who took the time to reply.

To be honest it may have been unrealistic expectations from the getgo. All the old timers ive spoken with always said location, hours, pay, if you’re lucky you can pick 2. Some fields may have it better or worse then others in some areas, (eg primary care you can pick your location and hours at the cost of low salary), but there also may be nostalgia goggles on.

Likewise any relatively new field was going to have a honeymoon phase where demand far outstrips supply. EM, CCM, neuroIR, etc are all fields that only really came into being as the “standard” relatively recently. It follows there would be a time period where demand would far outstrip supply, and supply would catch up eventually. To be blunt the field of EM hasn’t reached an equilibrium and it’s hard to say why that equilibrium will be.

I do think our generation is more focused on urban/suburban locations then before and we have a lot more working spouses that have their own geographic restrictions so it feels more restrictive

 

[emergentmd]

Eh, EM is still one of the best jobs out there. Best? Probably not. Worst? Definitely not. Are we past our Hayday? Definitely. Will we get back to the hayday? Likely not.

But you can replace almost every specialty above, save a few super competitive fields that None of us can get into or would want to sacrifice 5+ yrs of residency.

Did Covid hurt EM? Absolutely. Lower volume = decreased hrs +/- decrease in rate. But look at the other fields that got decimated.

Almost all outpt clinics got decimated and essentially shut down. Anesthesia = no elective surgery. Rad=less things to read. Atleast most EM docs had a regular paycheck. I know private IM docs that took out loans just to pay the rent b/c they had essentially zero patients.

Move out of medicine? Dentist did zero work. Most jobs either had decreased pay, no pay, or threatened furlough.

I am glad I am doing all FSER now, working 5-8 dys a month, and making more than I did in my golden days of medicine working 140hr/mo.

 

[bravotwozero]

Eh, EM is still one of the best jobs out there. Best? Probably not. Worst? Definitely not. Are we past our Hayday? Definitely. Will we get back to the hayday? Likely not.

But you can replace almost every specialty above, save a few super competitive fields that None of us can get into or would want to sacrifice 5+ yrs of residency.

Did Covid hurt EM? Absolutely. Lower volume = decreased hrs +/- decrease in rate. But look at the other fields that got decimated.

Almost all outpt clinics got decimated and essentially shut down. Anesthesia = no elective surgery. Rad=less things to read. Atleast most EM docs had a regular paycheck. I know private IM docs that took out loans just to pay the rent b/c they had essentially zero patients.

Move out of medicine? Dentist did zero work. Most jobs either had decreased pay, no pay, or threatened furlough.

I am glad I am doing all FSER now, working 5-8 dys a month, and making more than I did in my golden days of medicine working 140hr/mo.

Do you own the FSED you work at?

 

[emergentmd]

Do you own the FSED you work at?

yup. Unless FSED dies, never going back to the hospital.

 

[BoardingDoc]

yup. Unless FSED dies, never going back to the hospital.

I thought various states/insurance companies were pushing back on FSEDs so that you could no longer charge the same facility fees as a regular ED... thus making the FSED proposition no longer valuable. That not the case?

 

[bravotwozero]

There are still some that are doing quite well.

 

[solitarius]

There are some rad oncs that are doing extremely well. Doesn't negate the fact that their field is in a world of hurt.

 

[emergentmd]

No one is saying EM is rocking it at this moment. But look at all the other forums on here (That most could actually get into) and you hear the same.

Radiology, Anes, IM, etc.

EM is better than many fields and you can find jobs in most areas of the country at a decent rate. You are not going to get 300/hr but 200/hr is not difficult.

 

[EctopicFetus]

It definitely opens up job opportunities, absolutely disagree with that. Currently making similiar pay in both the ICU and ED. The flexibility to get the heck out of the ED and work in a generally less hectic environment is a godsend at times. I think people need to also look at burnout. Working both ICU and ED allows some recovery from the nonsense of both specialities. When I get sick of the gomers in the ICU, I can work ED, when Im sick of the drug seekers, press ganey BS, etc etc I can work ICU. This could allow me to work longer, and burnout less, and recover that income that was lost due to extra training length. I think it is oversimplifying things to purely look at length of residency/fellowship. I took a pay cut in the ED recently, made up for it with extra ICU shifts that ended up paying more per hour.

Well opportunity cost isn't made up unless you make it up on the backend. If you actually were to invest the delta in fellow pay vs EM attending pay you gotta put in a lot of years. Now happiness, burnout etc is a interrelated discussion but goes beyond finance. As a quick math exercise.. Lets say an EM attending makes 400k, a fellow makes 50k. Lets say that 350k is worth 250k post tax. For 2 years that's 500k. Now we invest the money, assuming a 7.2% return on your money which isn't crazy and using the rule of 72 it would double every decade. If you worked in EM for 30 years that 500k in opportunity cost is $4m. How many years at the end of your career do you have to tack on to make that up? Can figure out with inflation etc. But those 2 years of fellowship cost likely add 5-8 years to the end of your career (inflation dependent).

I know its not remotely that simple but yeah the opportunity cost is very very high. That doesn't mean its not worth it but from a purely $$$ standpoint the cost is huge.

 

[CCM-MD]

Well opportunity cost isn't made up unless you make it up on the backend. If you actually were to invest the delta in fellow pay vs EM attending pay you gotta put in a lot of years. Now happiness, burnout etc is a interrelated discussion but goes beyond finance. As a quick math exercise.. Lets say an EM attending makes 400k, a fellow makes 50k. Lets say that 350k is worth 250k post tax. For 2 years that's 500k. Now we invest the money, assuming a 7.2% return on your money which isn't crazy and using the rule of 72 it would double every decade. If you worked in EM for 30 years that 500k in opportunity cost is $4m. How many years at the end of your career do you have to tack on to make that up? Can figure out with inflation etc. But those 2 years of fellowship cost likely add 5-8 years to the end of your career (inflation dependent).

I know its not remotely that simple but yeah the opportunity cost is very very high. That doesn't mean its not worth it but from a purely $$$ standpoint the cost is huge.

The time value of money is a real thing. From a purely financial standpoint additional training is not worth it for EM, and nowadays even for IM/hospitalists. But obviously specialty selection is not a purely financial decision.

One thing you said earlier is not correct, ccm piece is typically more lucrative than the pulm part. Office based pulm uses the same codes as primary care/any other office based specialty. PFTs and bronchs don’t pay as much as one thinks. Typically 100 bucks and change for bronchs even some of the more complicated ones don’t result in more reimbursement. But outpt pulm comes with bankers hours and having both does give one an eventual “way out” of crit care which is the major advantage of having both.

 

[Torsion]

Well opportunity cost isn't made up unless you make it up on the backend. If you actually were to invest the delta in fellow pay vs EM attending pay you gotta put in a lot of years. Now happiness, burnout etc is a interrelated discussion but goes beyond finance. As a quick math exercise.. Lets say an EM attending makes 400k, a fellow makes 50k. Lets say that 350k is worth 250k post tax. For 2 years that's 500k. Now we invest the money, assuming a 7.2% return on your money which isn't crazy and using the rule of 72 it would double every decade. If you worked in EM for 30 years that 500k in opportunity cost is $4m. How many years at the end of your career do you have to tack on to make that up? Can figure out with inflation etc. But those 2 years of fellowship cost likely add 5-8 years to the end of your career (inflation dependent).

I know its not remotely that simple but yeah the opportunity cost is very very high. That doesn't mean its not worth it but from a purely $$$ standpoint the cost is huge.

Depending on what fellowship someone does they may be able to make far more than a PGY salary by working attending shifts in some shops. I know that our U/S, Sim, and EMS fellows are able to work attending shifts through the SDG and are paid the hourly rate but just can't bill for RVUs. This wouldn't make up for the opportunity cost entirely but probably significantly narrows it. This is probably less possible with fellowships like CC though.

 

[EctopicFetus]

The time value of money is a real thing. From a purely financial standpoint additional training is not worth it for EM, and nowadays even for IM/hospitalists. But obviously specialty selection is not a purely financial decision.

One thing you said earlier is not correct, ccm piece is typically more lucrative than the pulm part. Office based pulm uses the same codes as primary care/any other office based specialty. PFTs and bronchs don’t pay as much as one thinks. Typically 100 bucks and change for bronchs even some of the more complicated ones don’t result in more reimbursement. But outpt pulm comes with bankers hours and having both does give one an eventual “way out” of crit care which is the major advantage of having both.

Im not gonna pretend I know Pulm reimbursement except one group locally that I have a good relationship with. They do Pulm clinic, sleep medicine etc. They are making good money there. CCM makes about the same as EM. That much I know for a fact. Like you said it is not all financial but as I pointed out you will never make that money back (which is fine) cause we all make plenty.

 

[EctopicFetus]

Depending on what fellowship someone does they may be able to make far more than a PGY salary by working attending shifts in some shops. I know that our U/S, Sim, and EMS fellows are able to work attending shifts through the SDG and are paid the hourly rate but just can't bill for RVUs. This wouldn't make up for the opportunity cost entirely but probably significantly narrows it. This is probably less possible with fellowships like CC though.

Well I would just state the obvious question. Does it really narrow it. For example (I'm totally making up the numbers here) if that fellowship pays 50k and they work 1800 hours a year for fellowship then moonlight another 200 hours over that year that's not the same as working 1800 hours as an attending. You would have to compare it to working 2000 attending hours. I would also venture to guess from speaking to people I know who did fellowships that much of their internal moonlighting didn't pay market rate. it was often 10-15% below market.

 

[CCM-MD]

Im not gonna pretend I know Pulm reimbursement except one group locally that I have a good relationship with. They do Pulm clinic, sleep medicine etc. They are making good money there. CCM makes about the same as EM. That much I know for a fact. Like you said it is not all financial but as I pointed out you will never make that money back (which is fine) cause we all make plenty.

Don't doubt your colleagues are making good money. But "big money" is not in pulm clinic.

MGMA 2019 Means
EM $375,916
CCM (intensivist) $432,163
Pulm/CC $425,896

 

[Hercules]

Im not gonna pretend I know Pulm reimbursement except one group locally that I have a good relationship with. They do Pulm clinic, sleep medicine etc. They are making good money there. CCM makes about the same as EM. That much I know for a fact. Like you said it is not all financial but as I pointed out you will never make that money back (which is fine) cause we all make plenty.

Ectopic is correct. My father-in-law is a very business-savvy pulmonologist in a high functioning large pulmonary group. We have open conversations about the business side of medicine, and he has been one of my main mentors in that area. He has always said that the reimbursement from a well run pulmonary clinic greatly outweighs the reimbursement from hospital critical care. It makes sense—imagine how much more you would make in EM if one could schedule the patient flow while matching staffing to it (not to mention prescreening them for insurance)...

 

[CCM-MD]

Ectopic is correct. My father-in-law is a very business-savvy pulmonologist in a high functioning large pulmonary group. We have open conversations about the business side of medicine, and he has been one of my main mentors in that area. He has always said that the reimbursement from a well run pulmonary clinic greatly outweighs the reimbursement from hospital critical care. It makes sense—imagine how much more you would make in EM if one could schedule the patient flow while matching staffing to it (not to mention prescreening them for insurance)...

I can share my anecdotes too. But numbers from a large respected sample are above.

 

[Hercules]

I can share my anecdotes too. But numbers from a large respected sample are above.

Fair enough. Obviously my sample size is severely limited and doesn’t take into account any model other than a private group made up of all partners. It’s probably similar to comparing how the top 5% of EM SDGs function/reimburse compared to the whole of EM which is predominantly employee based positions.

 

[EctopicFetus]

Fair enough. Obviously my sample size is severely limited and doesn’t take into account any model other than a private group made up of all partners. It’s probably similar to comparing how the top 5% of EM SDGs function/reimburse compared to the whole of EM which is predominantly employee based positions.

I think that's a big part. Many of the CCM docs are hospital employees. The ones I know that run these clinics are private groups. As hercules said we are probably comparing apples and oranges perhaps. He and I work for high functioning SDGs.

In the end the jobs on average pay similarly as noted above. There are many other variables in EM (and surely in CCM). I know of docs who work 50 hours a month.. they work into those averages.

ALl the salary surveys are also somewhat inaccurate because most docs cant figure out their total comp which is more valuable to know than "salary". If you work for a place that matches 5% of your salary for retirement I would argue 25% of EM docs would include that in salary or total comp.

 

[ConfusedAboutEverything]

Ill prob get flak for this, but it may be wise for some future EM residents to consider combined residency programs, EM/FM, EM/IM, EM/IM/CC, hell theres EM/anesthesia now, just the flexibility alone could be worth the extra time spent.

M2 here. Can I get some more advice on this?

I was thinking of doing just FM since it covers both EM, IM, Peds and OB and can get some of those positions in rural areas. Even OB jobs and hospitalist and ED and urgent care job opening have specific statements that they accept FM applicants. So FM appeals to me because of the security and wide-job market. Is this a bad idea to choose FM? I want to be a generalist because I don't like uncertainty and FM offers the most flexibility (and the international recognition of FM is massive compared to other specialties).

My interests: I love acute care, but I also love chronic care (I have experience being a scribe in both). So I can't exactly tell you I'm leaning EM. In fact, the appeal to EM for me was that I could work part time (a 7 shift stretch a month), have massive hobbies and still be pulling more than a full-time PCP/Hospitalist? Is this no longer true? Should I not consider EM?

 

[turkeyjerky]

M2 here. Can I get some more advice on this?

I was thinking of doing just FM since it covers both EM, IM, Peds and OB and can get some of those positions in rural areas. Even OB jobs and hospitalist and ED and urgent care job opening have specific statements that they accept FM applicants. So FM appeals to me because of the security and wide-job market. Is this a bad idea to choose FM? I want to be a generalist because I don't like uncertainty and FM offers the most flexibility (and the international recognition of FM is massive compared to other specialties).

My interests: I love acute care, but I also love chronic care (I have experience being a scribe in both). So I can't exactly tell you I'm leaning EM. In fact, the appeal to EM for me was that I could work part time (a 7 shift stretch a month), have massive hobbies and still be pulling more than a full-time PCP/Hospitalist? Is this no longer true? Should I not consider EM?

Your username certainly checks out.

Don't do an FM residency if you want to practice EM. Train in FM if you want to practice FM. Generally this means 9-5 outpatient clinic work. Occasionally it includes caring for your patients who are admitted to the hospital as well. While you are correct that certain ER jobs accept FM applicants (typically bottom of the barrel or very low volume sites) I would not expect this to continue. More and more hospitals are requiring specialty-specific board certification and this will likely become nearly universal with the increased supply of EM residency grads.

You won't be able to make as much as a full time hospitalist working 1 week/month in EM. Salaries in the two specialties are rapidly approaching equivalence (hourly still greater in EM). FM and HM certainly do seem to have much wider open job markets, seems like there are openings in pretty much every area, which is far better than the situation in EM.

But seriously dude, you're at the beginning of your 2nd year in med school. I'm sure all your classmates seem ready to commit to a certain specialty based on some inane preconceived notion or previous experience (which universally don't mean jack--including yours), but most people change their minds at least 3 times during 3rd year and (and those that don't never had their minds made up to begin with).

Focus on your studies, keep your doors open and, if you have spare time, shadow in some specialties that you have no prior experience in or knowledge about.