Future Possibility of EM Saturation?

[ScarletRMD]

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There's been a slew of current job market/salary threads recently in this forum. Has anyone speculated the job market for EM in the 5,10, 20 years?

I ask because while healthcare demand is constantly rising across all specialties, and actually set to supposedly surge with the impending retirement of the baby boomers, there are some unique aspects to EM that may or may not effect future demand (vs. say primary care, cardio, ortho, or oncology for example, each of which have there own nuances of course).

Firstly, its a relatively young specialty. New residencies are opening yearly, popularity is surging, and I think this year nearly every spot was filled pre-SOAP. While the amount of yearly American grads is increasing drastically to meet future demand, its often said it will make little difference if congress doesn't expand medicare to fund more residency spots (which does not seem likely).

However in EM, new residencies are opening every year, several in my state alone over the last few years. Also more osteopaths are choosing EM than every before and AOA is also accommodating them with new residencies.

There are already markets that are hard to crack or getting saturated, as mentioned in several recent threads, including NYC/ North Jersey where I'm from. Is it possible as this pace we can train too many EM doctors for our own good?

Second, ACA will effect EM physicians differently than other specialties. While more people insured will mean less patients covered by EMTALA showing up in EDs, isn't it also possible that better access to primary care will reduce ED volume in the future? While such a reduction is unlikely, I read a paper recently about future physician demand by specialty and EM is not projected to grow as fast as other specialties (highest future growth was in primary care, cardio, ortho, and oncology.) Also EM was projected to meet that increased demand much better than these specialties.

However that being said, there are many things EM has in its favor, too. A large portion of EDs are still staffed by primary care-trained docs and over time EDs will try to replace them with the EM trained docs coming out of these new residencies. New EM business models, like free standing EDs, have expanding popularity. Also while midlevel creep threatens a lot of the nonsurgical specialties, most EM doctors I've talked to welcome midlevels as it makes their jobs that much easier.

Also, doctors are retiring later than ever, probably in order to maintain the lavish lifestyles they expected to have entering medicine only to see reimbursement cuts throughout their career. This is especially evident in radiology, which is relatively chill work, making it even harder for new grads to find desirable jobs. EM doctors tend to value free time more than others, however, and also retire younger (maybe due to burnout?).

I apologize for the long post, but with all of these confounding factors unique to EM, where do you think the job market will be in 5, 10, 20 years? It's impossible to predict, but we can have some fun speculating...

 

[RustedFox]

None of it will matter when the robot overlords arrive in 2042 anyways.

I will embrace our new robot masters.

 

[Birdstrike]

There's been a slew of current job market/salary threads recently in this forum. Has anyone speculated the job market for EM in the 5,10, 20 years?

I ask because while healthcare demand is constantly rising across all specialties, and actually set to supposedly surge with the impending retirement of the baby boomers, there are some unique aspects to EM that may or may not effect future demand (vs. say primary care, cardio, ortho, or oncology for example, each of which have there own nuances of course).

Firstly, its a relatively young specialty. New residencies are opening yearly, popularity is surging, and I think this year nearly every spot was filled pre-SOAP. While the amount of yearly American grads is increasing drastically to meet future demand, its often said it will make little difference if congress doesn't expand medicare to fund more residency spots (which does not seem likely).

However in EM, new residencies are opening every year, several in my state alone over the last few years. Also more osteopaths are choosing EM than every before and AOA is also accommodating them with new residencies.

There are already markets that are hard to crack or getting saturated, as mentioned in several recent threads, including NYC/ North Jersey where I'm from. Is it possible as this pace we can train too many EM doctors for our own good?

Second, ACA will effect EM physicians differently than other specialties. While more people insured will mean less patients covered by EMTALA showing up in EDs, isn't it also possible that better access to primary care will reduce ED volume in the future? While such a reduction is unlikely, I read a paper recently about future physician demand by specialty and EM is not projected to grow as fast as other specialties (highest future growth was in primary care, cardio, ortho, and oncology.) Also EM was projected to meet that increased demand much better than these specialties.

However that being said, there are many things EM has in its favor, too. A large portion of EDs are still staffed by primary care-trained docs and over time EDs will try to replace them with the EM trained docs coming out of these new residencies. New EM business models, like free standing EDs, have expanding popularity. Also while midlevel creep threatens a lot of the nonsurgical specialties, most EM doctors I've talked to welcome midlevels as it makes their jobs that much easier.

Also, doctors are retiring later than ever, probably in order to maintain the lavish lifestyles they expected to have entering medicine only to see reimbursement cuts throughout their career. This is especially evident in radiology, which is relatively chill work, making it even harder for new grads to find desirable jobs. EM doctors tend to value free time more than others, however, and also retire younger (maybe due to burnout?).

I apologize for the long post, but with all of these confounding factors unique to EM, where do you think the job market will be in 5, 10, 20 years? It's impossible to predict, but we can have some fun speculating...

It's not hard to predict at all. EPs will remain in very high demand.


1-All jobs are more competitive in desirable or crowded locations such as NYC. EM is no different. That has no bearing on anywhere else. In most places, EPs are in demand.

2-Greater numbers of people with insurance (ie, Medicaid expansion, which is what Obamacare depends on to cover the uninsured) does NOT equal greater access to care. For greater access you need more doctors, doctors offices and hospitals, and LESS patients. Obamacare does nothing to increase such entities to match the needs of 40+ million newly ensured. In fact, it tips the scales in the opposite direction, and it certainly will mean LESS access with greater numbers of insured patients trying to get into the same number of physicians offices. They'll have no choice but to pile into EDs, which is what the uninsured do now for their primary care anyways. Demand will continue go up for ED man hours.

3- As the baby boomers grow older and sicker they will drastically strain the system. Since outpatient PCPs will not start keeping their offices open around the clock, EDs will be the only places able or willing to attempt picking up the slack. All the while, immigration will keep the population growing greatly, during and even after the baby boomers are gone. Population will not decrease, it will grow through immigration. There are no (viable) plans to stop immigration. EDs will remain packed to the gills.

4. With continued hospital closures, remaining EDs will have many, many, many more customers.

http://www.kevinmd.com/blog/2012/03/onethird-hospitals-close-2020.html


5. I get multiple daily emails and phone calls from recruiters calling looking for people to come staff EDs in need. I can't even delete them fast enough. I haven't heard of any 9-4, no-call cosmetic dermatology spots having a tough time filling. ED jobs, however = plentiful.

Emergency Medicine as an industry will be as alive and well as ever, with EPs in greater demand than ever. You can argue over what effect these changes will have on EP job satisfaction, but what is not in doubt is that you will be needed, grasshopper. You will be needed much more than you know.

 

[Groove]

You wanna prognosticate 15 to 20 years in the future and come to some semblance of a conclusion that might dissuade you from pursuing EM in the present? Really, dude?

The specialty is in greater need than it ever has been. Primaries are closing up shop, new EDs proliferate and the masses continue (more so under our new health care plan) to pack into the ED waiting rooms like sardines. If there is any specialty that has a promising outlook at being in continued demand for years to come, it's definitely EM.

Just do what you enjoy and let the cards fall where they may in 15 or 20 years. Hell, I plan to be more concerned with planning my retirement at that point than worrying about the state of the specialty or shedding tears in my coffee over not becoming a proctologist.

 

[John Lannister]

You wanna prognosticate 15 to 20 years in the future and come to some semblance of a conclusion that might dissuade you from pursuing EM in the present? Really, dude?

The specialty is in greater need than it ever has been. Primaries are closing up shop, new EDs proliferate and the masses continue (more so under our new health care plan) to pack into the ED waiting rooms like sardines. If there is any specialty that has a promising outlook at being in continued demand for years to come, it's definitely EM.

Just do what you enjoy and let the cards fall where they may in 15 or 20 years. Hell, I plan to be more concerned with planning my retirement at that point than worrying about the state of the specialty or shedding tears in my coffee over not becoming a proctologist.

Even if, no specialty is going to have a perfect 20 year run. FM 20 years ago was among the best and ortho was among the worst. Did anyone know what would happen 20 years later? Nope.

 

[Chip N Sawbones]

None of it will matter when the robot overlords arrive in 2042 anyways.

I will embrace our new robot masters.

Far from being a joke, that actually is a valid point. As computers get smarter they will take over a lot of physician jobs, making some doctors obsolete. Computers have already been able to diagnose heart attacks from EKGs better than experienced cardiologists since 1997. IBM's Watson is busy reviewing medical records, and by the time its done it will probably be better at diagnostics than any internist. How long will it be until someone engineers software that can spot anomalies on an x-ray better than a radiologist, and do it 24 hours a day, never needing a paycheck or a bathroom break? Computers still have trouble with mechanical skills, so the procedures necessary in emergency medicine will probably keep that specialty around for awhile, but I'd be very worried about the long-term prospects of any career in medicine that is based on gathering and processing information.

Either that or the computers will get smart enough to quit doing our dirty work and we will need lots of EM doctors and trauma surgeons to deal with the casualties incurred in the coming war against the Cylons.

 

[Socrates25]

Far from being a joke, that actually is a valid point. As computers get smarter they will take over a lot of physician jobs, making some doctors obsolete. Computers have already been able to diagnose heart attacks from EKGs better than experienced cardiologists since 1997. IBM's Watson is busy reviewing medical records, and by the time its done it will probably be better at diagnostics than any internist. How long will it be until someone engineers software that can spot anomalies on an x-ray better than a radiologist, and do it 24 hours a day, never needing a paycheck or a bathroom break? Computers still have trouble with mechanical skills, so the procedures necessary in emergency medicine will probably keep that specialty around for awhile, but I'd be very worried about the long-term prospects of any career in medicine that is based on gathering and processing information.

Either that or the computers will get smart enough to quit doing our dirty work and we will need lots of EM doctors and trauma surgeons to deal with the casualties incurred in the coming war against the Cylons.

If there are 2 clinics, one staffed by a computer and one staffed by a human, patients will choose the one staffed by a human 10 times out of 10, even if the computer is "smarter" than the human doctor.

 

[John Lannister]

Far from being a joke, that actually is a valid point. As computers get smarter they will take over a lot of physician jobs, making some doctors obsolete. Computers have already been able to diagnose heart attacks from EKGs better than experienced cardiologists since 1997. IBM's Watson is busy reviewing medical records, and by the time its done it will probably be better at diagnostics than any internist. How long will it be until someone engineers software that can spot anomalies on an x-ray better than a radiologist, and do it 24 hours a day, never needing a paycheck or a bathroom break? Computers still have trouble with mechanical skills, so the procedures necessary in emergency medicine will probably keep that specialty around for awhile, but I'd be very worried about the long-term prospects of any career in medicine that is based on gathering and processing information.

Either that or the computers will get smart enough to quit doing our dirty work and we will need lots of EM doctors and trauma surgeons to deal with the casualties incurred in the coming war against the Cylons.

What fields are you talking about speficially? I can't think of one other than diagnostic radiology. Which would probably still need a person to look over.

 

[Apollyon]

What fields are you talking about speficially? I can't think of one other than diagnostic radiology. Which would probably still need a person to look over.

Pathology.

 

[Chip N Sawbones]

If there are 2 clinics, one staffed by a computer and one staffed by a human, patients will choose the one staffed by a human 10 times out of 10, even if the computer is "smarter" than the human doctor.

Patients won't know what is going on in the background. How many patients would care that the clinic that used to employ three internists, a radiologist and a cardiologist now has one doctor to be the human face patients interact with and computers to do the work of the other four doctors? Obviously not everything a doctor does can be done by a machine, but if you can teach a computer to do 25% of what a doctor does, that means Management can fire one out of four doctors, reduce payroll expenses and still bring in the same number of patients.

What fields are you talking about speficially? I can't think of one other than diagnostic radiology. Which would probably still need a person to look over.

Every field of medicine requires gathering and processing information to some degree. EM doctors gather information in the form of patient histories, lab values and imaging, and then process that data to provide a diagnosis and a treatment plan. Pathologists gather data by looking at frozen sections and then process the data to decide if cells are malignant or not. As you said, diagnostic radiology is nothing but data processing. If you can teach a computer to read films and make fewer mistakes than a radiologist, why would you even need a person to look over the computer's work? If the radiologist and the computer disagree, the computer would be more likely to be correct, and the EM attending who is relying on the read would be better off listening to the computer. Like I said, no computer can do 100% of what a doctor does. However, if computers can be taught to do a certain percentage of what a doctor does in any given specialty, and do it better, faster and cheaper, then you can eliminate that many doctors and still obtain the same results in patient care.

 

[John Lannister]

Patients won't know what is going on in the background. How many patients would care that the clinic that used to employ three internists, a radiologist and a cardiologist now has one doctor to be the human face patients interact with and computers to do the work of the other four doctors? Obviously not everything a doctor does can be done by a machine, but if you can teach a computer to do 25% of what a doctor does, that means Management can fire one out of four doctors, reduce payroll expenses and still bring in the same number of patients.



Every field of medicine requires gathering and processing information to some degree. EM doctors gather information in the form of patient histories, lab values and imaging, and then process that data to provide a diagnosis and a treatment plan. Pathologists gather data by looking at frozen sections and then process the data to decide if cells are malignant or not. As you said, diagnostic radiology is nothing but data processing. If you can teach a computer to read films and make fewer mistakes than a radiologist, why would you even need a person to look over the computer's work? If the radiologist and the computer disagree, the computer would be more likely to be correct, and the EM attending who is relying on the read would be better off listening to the computer. Like I said, no computer can do 100% of what a doctor does. However, if computers can be taught to do a certain percentage of what a doctor does in any given specialty, and do it better, faster and cheaper, then you can eliminate that many doctors and still obtain the same results in patient care.

Making the argument that we all process and assimilate data is true - but it's hard to apply. Someone comes into an ED and then they use touch screens to tell what the problem is, then the computer diagnoses and creates a treatment plan... ok. What happens when someone dies? Who's medical license is on the line in malpractice. Can the computer prescribe drugs? Every computer program in history makes mistakes, what happens when these do?

I'm very pro-tech, and while I do agree that computers will absolutely change the field of medicine, it's pretty far fetched to believe that they will BE the doctors. Even the automated checkout at the grocery store needs a person to oversee the 4 machines when things go awry.

And sure, I'll buy your conclusion that many physicians jobs can be eliminated with amazing technology. How many in a field like EM? I'd have a hard time buying more than 1/3 or 1/4 of the field.

Hey, welcome to the real world. Medicine is one of the few fields that has been super insulated from competition. You have always been guaranteed a job and great income. In the future, it may be more normal - only the top 80% of the docs have jobs while the bottom 20% are hurting. That's certainly possible.

 

[Postictal Raiden]

👍

If there are 2 clinics, one staffed by a computer and one staffed by a human, patients will choose the one staffed by a human 10 times out of 10, even if the computer is "smarter" than the human doctor.

👍

Until today, people prefer to be put on hold for 45mins to talk to a human being rather than listening to the automated system, pay $150 to an accountant to have their income tax done than doing on their own using TurboTax, pay mechanics $200 to change the breaks on their cars instead of doing it themselves, and the list goes on and on forever. The last thing people will do is to have their sick children checked out by Dr. Watson.

 

[FatherOblivion]

Once computers/machines are doing the work of doctors they will be good enough to do almost everything else as well and none of our patients will have jobs anyway. Worrying about a future where doctors are obsolete is the same as worrying about a future where people are obsolete. Probably best not to factor this too heavily into career planning.

 

[WilcoWorld]

Once computers/machines are doing the work of doctors they will be good enough to do almost everything else as well and none of our patients will have jobs anyway. Worrying about a future where doctors are obsolete is the same as worrying about a future where people are obsolete. Probably best not to factor this too heavily into career planning.

what he said

 

[Arcan57]

Hey, welcome to the real world. Medicine is one of the few fields that has been super insulated from competition. You have always been guaranteed a job and great income. In the future, it may be more normal - only the top 80% of the docs have jobs while the bottom 20% are hurting. That's certainly possible.

Given the amount of debt we go into to become doctors, 20% unemployment would be enough to make most rationally acting pre-meds find another field.

 

[Chip N Sawbones]

👍

👍

Until today, people prefer to be put on hold for 45mins to talk to a human being rather than listening to the automated system, pay $150 to an accountant to have their income tax done than doing on their own using TurboTax, pay mechanics $200 to change the breaks on their cars instead of doing it themselves, and the list goes on and on forever. The last thing people will do is to have their sick children checked out by Dr. Watson.

People prefer to be put on hold rather than talk to the automated system because so far, the automated system sucks. It isn't intelligent enough to be as useful as a human yet. It can't answer complex questions and it can't understand me when I've got a cold. In another twenty years, automated phone systems will be much, much more usable--voice recognition technology hardly existed twenty years ago, and look where it is today. Computer power, and therefore intelligence, doubles roughly every eighteen months.

People will certainly have their sick children checked out by Dr. Watson if they don't know he's the one doing the diagnosis. In any hospital with electronic charts, patient data gets entered into a computer by nurses and doctors doing exams, lab workers running tests, and imaging techs taking pictures. At this point, computers aren't smart enough to take that data and determine how to treat the patient, but someday they will be. The computer can generate a list of treatments to be run and drugs to be prescribed by the doctor. Because the doctor no longer has to spend time trying to diagnose patients, the hospital can increase his patient load that much more. The patients will still see themselves as being served by a real doctor, and it'll never enter their innocent little heads that the treatment was dictated by a box of silicon and plastic assembled in Taiwan.

Like I said earlier, EM won't be affected quite as much by improvements in artificial intelligence. Computers may be better at reading EKGs than a cardiologist, but they aren't very good at intubating patients, reducing dislocated joints or any of the other hands-on procedures that are an essential part of emergency medicine. This is also a minor reason why I want to be an surgeon when I grow up. Orthopod jokes aside, it takes a lot of smarts to know how to swing a hammer with exactly the right amount of force for any given situation, or how to use a scalpel to cut to exactly the right depth. You spent years developing those skills when you were a child, and computers still have a long way to go before they can match humans in mechanical skills.

 

[xaelia]

Obviously, any relatively "hands on" specialty will have some element of irreplaceability – although, it's completely feasible for a lower-paid mid-level to replace a highly paid physician for even the more technical procedural skills: see CRNAs or non-inferior outcomes with colonoscopies by NPs.

As for the function of our future digital overlords –*is there a day that goes by in the Emergency Department where we don't see a referral or follow-up from a PCP who is clearly practicing some sort of tragicomedy medicine? I guarantee an expert diagnostic engine or predictive tool will raise the standard of care in many settings. Patients/families will still need a healthcare professional with some level of training to double-check, communicate, etc. but, yet again, it may not be a physician.

Bottom line – medicine is a slow-moving colossus. You'll see the end coming plenty far enough to course correct, so you might as well just try and do something where you find joy and excel.

 

[gro2001]

Computers would be able to replace doctors in the very near future if most people were even half decent at actually reporting crucial information. A lion's share of clinical education is learning to tease out the information from the data, such a figuring out why are they really here?

I am sure Dr Watson could probably soon risk stratify the chest pains better than most ER doctors, but how long will it be till he figures out that of the 3 kids this mother brought in with the same chief complaint, she is actually only concerned about one and the other 2 are only here because there was no babysitter? That this person eating a burger is not actually having the worst headache of their life? That the home health aide that just provided your history has no idea whats going on?

 

[Arcan57]

Computers would be able to replace doctors in the very near future if most people were even half decent at actually reporting crucial information. A lion's share of clinical education is learning to tease out the information from the data, such a figuring out why are they really here?

I am sure Dr Watson could probably soon risk stratify the chest pains better than most ER doctors, but how long will it be till he figures out that of the 3 kids this mother brought in with the same chief complaint, she is actually only concerned about one and the other 2 are only here because there was no babysitter? That this person eating a burger is not actually having the worst headache of their life? That the home health aide that just provided your history has no idea whats going on?

The human aspect (in addition to the data gathering issue) is important in terms of setting parameters around what risk level to accept when doing a work-up. In general, people seem much happier with a person making the decision rather than some institutional (national?) fiat. If you held Watson to the same standard as EM docs in the most dangerous medicolegal climes, it's work-up would be legion. If you held it the same miss rate as an NP at a critical access hospital, then I bet it would do just fine.

 

[Birdstrike]

When are computers and robots going to replace patients? That would actually make things interesting.

 

[deleted547339]

When are computers and robots going to replace patients? That would actually make things interesting.

You mean, like, simulators?

 

[dfib slim]

.

 

[John Lannister]

Obviously, any relatively "hands on" specialty will have some element of irreplaceability – although, it's completely feasible for a lower-paid mid-level to replace a highly paid physician for even the more technical procedural skills: see CRNAs or non-inferior outcomes with colonoscopies by NPs.

As for the function of our future digital overlords –*is there a day that goes by in the Emergency Department where we don't see a referral or follow-up from a PCP who is clearly practicing some sort of tragicomedy medicine? I guarantee an expert diagnostic engine or predictive tool will raise the standard of care in many settings. Patients/families will still need a healthcare professional with some level of training to double-check, communicate, etc. but, yet again, it may not be a physician.

Bottom line – medicine is a slow-moving colossus. You'll see the end coming plenty far enough to course correct, so you might as well just try and do something where you find joy and excel.

Great point.

 

[Chip N Sawbones]

When are computers and robots going to replace patients? That would actually make things interesting.

Pretty soon. When I interviewed at Nova they showed us a simulator that could pee on the floor, complain and ask for drugs. If they can teach the simulator to eat free sandwiches and throw up on the doctor's shirt it'll be almost impossible to tell it from the real thing.

 

[med2UCC]

With a realistic odour of listerine,of course! All of our customers with the above attributes drink listerine. Cheers,
M

 

[Birdstrike]

Pretty soon. When I interviewed at Nova they showed us a simulator that could pee on the floor, complain and ask for drugs. If they can teach the simulator to eat free sandwiches and throw up on the doctor's shirt it'll be almost impossible to tell it from the real thing.

I was hoping for much more polite, and better behaved robots to replace patients, sort of like futuristic versions of the sensitive and preppy cavemen on the Geico commercials. Hmm....Per your estimate, the future is not so bright. I may have to reconsider this whole plan. Well...a man can always dare to dream. Thank you Sawbones. Now, back to the drawing board.....

 

[HunterGatherer]

I'm not sensitive!

sort of like futuristic versions of the sensitive and preppy cavemen on the Geico commercials...