Has Emergency Medicine Residency Lost Its Appeal for Good?

[Groove]

Has Emergency Medicine Residency Lost Its Appeal for Good?

Drs Glatter, McNamara, and Ho discuss the high number of unmatched emergency medicine positions, what's behind it, and whether it can be fixed.

www.medscape.com

Pretty good watch. I don't think anyone has posted it yet on here.

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[bravotwozero]

If McNamara is there, probably worth a watch. Will try to check it out

 

[Fpg1245]

Has Emergency Medicine Residency Lost Its Appeal for Good?

Drs Glatter, McNamara, and Ho discuss the high number of unmatched emergency medicine positions, what's behind it, and whether it can be fixed.

www.medscape.com

Pretty good watch. I don't think anyone has posted it yet on here.

I saw it. They kind of talked about it but in a mildly serious way I thought. The bottom line is it’s not going to get better. Asking CMS for more money never works. The bottom line is Al thought medicine is noble and being on the front line is hard…nobody cares.

 

[miacomet]

Yes.
I am not having a problem getting offers for $300/hour plus, but the work has become so onerous, there are so few (no?) off-ramps unless one is as uniquely talented as @emergentmd (and in Texas) or @Birdstrike. It's not worth it.

I looked at an (employed) position at a great hospital I worked at in 2010. Night and day. Wouldn't take the job under any circumstances today. Would literally rather leave the country.

Things that are better than EM:

Basically any field of clinical medicine
CRNA
Psych NP (gold mine)
Leaving the country

 

[Groove]

Yes.
I am not having a problem getting offers for $300/hour plus, but the work has become so onerous, there are so few (no?) off-ramps unless one is as uniquely talented as @emergentmd (and in Texas) or @Birdstrike. It's not worth it.

I looked at an (employed) position at a great hospital I worked at in 2010. Night and day. Wouldn't take the job under any circumstances today. Would literally rather leave the country.

Things that are better than EM:

Basically any field of clinical medicine
CRNA
Psych NP (gold mine)
Leaving the country

300/hr locums gigs or local? I'm starting to see locums rates going up but local has remained fairly static in my area.

 

[miacomet]

300/hr locums gigs or local? I'm starting to see locums rates going up but local has remained fairly static in my area.

Finishing up a $315 an hour locums job in a formerly functional facility. They also provided a night/weekend differential. Would only have been worth it if they had offered sovereign immunity, no nights or swings or weekends. And...that's not EM.

I don't think, if you have a decent CV (something that makes it pop- director, great residency, particularly good work history) that you would have a problem making well north of $300. Ignore the offer and just state your price.

But, not worth it to me. Have decided working EM/UC clinically is simply not worth it.

 

[Birdstrike]

Yes.
I am not having a problem getting offers for $300/hour plus, but the work has become so onerous, there are so few (no?) off-ramps unless one is as uniquely talented as @emergentmd (and in Texas) or @Birdstrike. It's not worth it.

For the record, I have no unique talent, that the rest of you don't have.

 

[Tenk]

For the record, I have no unique talent, that the rest of you don't have.

Your unique talent is making everyone but Tom Hanks panic.

 

[GonnaBeADoc2222]

Yes.
I am not having a problem getting offers for $300/hour plus, but the work has become so onerous, there are so few (no?) off-ramps unless one is as uniquely talented as @emergentmd (and in Texas) or @Birdstrike. It's not worth it.

I looked at an (employed) position at a great hospital I worked at in 2010. Night and day. Wouldn't take the job under any circumstances today. Would literally rather leave the country.

Things that are better than EM:

Basically any field of clinical medicine
CRNA
Psych NP (gold mine)
Leaving the country

Lord. I'm all for doom and gloom, but this is just ridic. None of these are better than EM.

 

[BoardingDoc]

Lord. I'm all for doom and gloom, but this is just ridic. None of these are better than EM.

Seriously. "any other field of clinical medicine?" Most surgical specialists work at least 2x the hours I do and don't get paid 2x the salary. Internal medicine? Hell no. Obgyn? I would sooner quit medicine than work that field. Peds? Triple the salary and we can talk.

EM has a lot of flaws and it burns a lot of people out. Thinking that the grass is greener elsewhere is borne from depression though, not because it's actually better.

 

[miacomet]

Seriously. "any other field of clinical medicine?" Most surgical specialists work at least 2x the hours I do and don't get paid 2x the salary. Internal medicine? Hell no. Obgyn? I would sooner quit medicine than work that field. Peds? Triple the salary and we can talk.

EM has a lot of flaws and it burns a lot of people out. Thinking that the grass is greener elsewhere is borne from depression though, not because it's actually better.

1. Plenty of surgical subspecialists barely take call and rarely work weekends. Lots of locums work, too. When was the last time you say ophtho or ENT at night?
2. Internal medicine has lucrative private-practice subspecialties- cards, GI, allergy etc
3. Peds does not pay aside from NICU, cards, and EM. Although in wealthy areas cash pay peds can be very lucrative if you own the practice. But no nights.
4. Ob-gyn- reproductive endocrinology is a great field

 

[WilcoWorld]

Your unique talent is making everyone but Tom Hanks panic.

Or a half in the bag Denzel.

 

[DocEspana]

Has Emergency Medicine Residency Lost Its Appeal for Good?

Drs Glatter, McNamara, and Ho discuss the high number of unmatched emergency medicine positions, what's behind it, and whether it can be fixed.

www.medscape.com

Pretty good watch. I don't think anyone has posted it yet on here.

<looks at title>

No.

 

[DocEspana]

<looks at title>

No.

If you want a more nuanced (but only a little bit more) take. The dip, for better or worse, is temporary. Either the ills befalling the specialty change dramatically for the better in the next 5-10ish years and we resemble what we used to resemble, or the entire medical community becomes private equity pawns like us in 5-10 years and everyone's problems are the same as the ones we have now. In either case, the playing field will be level again and all the stuff that *did* work for EM and make it appealing will be applicable again.

Obviously in the latter scenario, it might be because its the best option of many ****ty private equity run options - but it will still be the best!

 

[Rekt]

You’re just flat out wrong if you think EM is fine. The acep report was for 2030. I think you guys are forgetting this. Even if there was more attrition than expected (also a indicator of the poor health of our specialty), maybe the number is 6k unemployed/underemployed versus 10k. Still very bad.

If you haven’t been following along. Even since our disastrous match there’s been another 4-6 residencies approved this year alone. Not even including expansion.

 

[Brigade4Radiant]

I watched it

They both made good points
McNamara: was saying this hurts EM best and brightest are leaving. Me is full of corporate interests

Ho: this doesn’t hurt EM we have to be apart of the solution and board scores don’t really matter they will be board certified regardless.

 

[WildEMDoc]

Getting board certified isn't a requirement to work in an ER. HCA and CMG residencies can simply to continue to flood the market with "EM trained" docs that can't pass boards.

Even then passing boards is an exam, patients in the ER are far from the "ABEM general" standard patient, these for-profit residencies with sub-par EM unenthused docs will generate poor quality docs that will lead to missed/delayed diagnosis, death etc.

 

[emergentmd]

EM is not the worse specialty. Do you guys not remember all the surgeons, OB, internists wondering the halls like pissed off zombies? Alot of my old specialists friends are working to get out of medicine/slowing down. You will not see many docs working full time through past 50s in the future.

EM definitely is not the same as it was 20 yrs ago but all fields have gone down hill. As medicine has become corporate, docs become pawns without any control. Look at all the derm, allergist, cardiologists being bought out by VC/hospitals.

The way to branch out of medicine is to network and essentially be a pleasant hard working person with some luck thrown in.

I was director at a large hospital early in my career that allowed me to meet alot of people/network. I was offered multiple directors job at other hospitals including the VP of a national EM/hospitalists/anesthesiology CMG which I turned down. It helped me to get into opening a FSER. Helped me to get good property managers/contractors/loan brokers for my properties. Now I am going into finance through networking where the pay could dwarf my other current gigs.

 

[GonnaBeADoc2222]

You’re just flat out wrong if you think EM is fine. The acep report was for 2030. I think you guys are forgetting this. Even if there was more attrition than expected (also a indicator of the poor health of our specialty), maybe the number is 6k unemployed/underemployed versus 10k. Still very bad.

If you haven’t been following along. Even since our disastrous match there’s been another 4-6 residencies approved this year alone. Not even including expansion.

I didn't say it was good. Everything else sucks too though.

 

[thegenius]

Has Emergency Medicine Residency Lost Its Appeal for Good?

Drs Glatter, McNamara, and Ho discuss the high number of unmatched emergency medicine positions, what's behind it, and whether it can be fixed.

www.medscape.com

Pretty good watch. I don't think anyone has posted it yet on here.

High level discussion about EM. I have no problem with it and my views are somewhere between an intersection of all the participants.
I have pie in the sky ideas about how to change EM and health care, but in reality what would help us the most allowing patients to go back to their PCP when they have acute problems. It seems like, although I'm jaded by my ER cohort and what I read here, is just about all acute care, no matter what the symptom, is handled by the ER. PCP's no longer see acute abdominal pain, chest pain, headache, leg swelling, etc. These all get sent to the ER.

We also need to figure out a way to keep old people out of the hospital. They are too complex for PCPs, they are not emergencies for the ER, but they have 46 problems, on 18 drugs, and have 5 different specialists managing all their pulm, cardiac, GI, neuro, and vascular issues. Invariably...they all end up in the ER because "they don't feel good" and are basically too complex for any one single doctor to figure them out. We need a better system for these folks. Until that happens, they will get sent to the ER and we will admit them because all their specialists will need to chime in, or they will need 24-48 hour obs by a hospitalist to make sure their symptoms don't get worse.

 

[RustedFox]

High level discussion about EM. I have no problem with it and my views are somewhere between an intersection of all the participants.
I have pie in the sky ideas about how to change EM and health care, but in reality what would help us the most making patient go back to their PCP when they have acute problems. It seems like, although I'm jaded by my cohort and what I read here, is just about all acute care, no matter what the symptom, is handled by the ER. PCP's no longer see acute abdominal pain, chest pain, headache, leg swelling, etc. These all get sent to the ER.

We also need to figure out a way to keep old people out of the hospital. They are too complex for PCPs, they are not emergencies for the ER, but they have 46 problems, on 18 drugs, and have 5 different specialists managing all their pulm, cardiac, GI, neuro, and vascular issues. Invariably...they all end up in the ER because "they don't feel good" and are basically too complex for any one single doctor to figure them out. We need a better system for these folks. Until that happens, they will get sent to the ER and we will admit them because all their specialists will need to chime in, or they will need 24-48 hour obs by a hospitalist to make sure their symptoms don't get worse.

These old people would just love to live IN the hospital in my neck of the woods. Really, really would.
I hate them.

 

[PianoMedic]

These old people would just love to live IN the hospital in my neck of the woods. Really, really would.
I hate them.

We had someone try to do that. Was escorted out by security at least twice. Wasn’t that old either, just didn’t want to take care of themselves anymore and wanted someone else to do it for them.

 

[FlaminHotER]

You’re just flat out wrong if you think EM is fine. The acep report was for 2030. I think you guys are forgetting this. Even if there was more attrition than expected (also a indicator of the poor health of our specialty), maybe the number is 6k unemployed/underemployed versus 10k. Still very bad.

If you haven’t been following along. Even since our disastrous match there’s been another 4-6 residencies approved this year alone. Not even including expansion.

Exactly

It seems every month I read on here and elsewhere about another freakin community level 3 hospital getting acgme approval to open up a em residency

Absolute disgrace what is happening to our field

 

[emergentmd]

EM is not terrible but not really a field you can do full time for more than 20 yrs. I thought I was one of the lucky ones and even after 15 yrs thought I would die in the ER. Once a CMG took over, I quickly looked for a way out.

Everyone in EM, should look for a way out but this goes for most in the house of medicine. Even if you think you have a great job now, changes will be coming for you that is out of your control.

Never hurts to look for side gigs, non medical fields, and other passive income so you can go part time. Most Er docs are smart/risk takers, have many days off, have high income. Its a good recipe to get other streams of income..

 

[thegenius]

We had someone try to do that. Was escorted out by security at least twice. Wasn’t that old either, just didn’t want to take care of themselves anymore and wanted someone else to do it for them.

Every town and city in the US has hundreds of people just like this.

 

[miacomet]

EM is not terrible but not really a field you can do full time for more than 20 yrs. I thought I was one of the lucky ones and even after 15 yrs thought I would die in the ER. Once a CMG took over, I quickly looked for a way out.

Everyone in EM, should look for a way out but this goes for most in the house of medicine. Even if you think you have a great job now, changes will be coming for you that is out of your control.

Never hurts to look for side gigs, non medical fields, and other passive income so you can go part time. Most Er docs are smart/risk takers, have many days off, have high income. Its a good recipe to get other streams of income..

I mean I think cash pay, non CMS practices can be lucrative. Those psych NPs charging $400 first visit/$200 follow up for med management are probably fine for the foreseeable future. Otherwise, yes, I agree everyone needs a way out, but especially EM.

 

[RustedFox]

We had someone try to do that. Was escorted out by security at least twice. Wasn’t that old either, just didn’t want to take care of themselves anymore and wanted someone else to do it for them.

Every shift.
Some senior WITH chronic medical issues that can't be bothered to take care of themselves or (worse) family that doesn't understand and says things like: "you can't just send her back to that nursing home, what if she gets a UTI like she did the last x number of times?!" (Lady, your mom is gonna get UTIs no matter where she is because she forgets to clean herself correctly. Cope.)

 

[miacomet]

Every shift.
Some senior WITH chronic medical issues that can't be bothered to take care of themselves or (worse) family that doesn't understand and says things like: "you can't just send her back to that nursing home, what if she gets a UTI like she did the last x number of times?!" (Lady, your mom is gonna get UTIs no matter where she is because she forgets to clean herself correctly. Cope.)

Sounds like in this case the patient needs a higher level of care, it doesn't sound like she can't be bothered, but that she needs help. WTAF?

 

[Birdstrike]

The #1 problem is how Emergency Medicine does absolutely nothing stop abuse of it's physicians, and nothing to ensure or demand job satisfaction among its physicians. Don't let them call it "moral injury." Don't them them call it "burnout." It's abuse. EM physicians are abused. Call it what it is.

And what has been done in the past 20 years to stop that abuse and improve job satisfaction among Emergency Physicians?

Nothing.

What they've done instead, is the most aggressive and offensive thing they could possibly every do. Ignore the effects to their abuse on you, blame you for it, and just make new bodies to replace the "burned out" ones. Increased residency spots aren't so they can pay you less. Its their insurance policy to be able to continue the abuse and easily replace you when you can't withstand it anymore. They have enough money to pay you 3 times what you make, if they wanted to.

Don't lie to yourself by saying, "It's just as bad everywhere else." Not all specialties of medicine are "destroyed." There are plenty where you can live a normal life, work normal hours, avoid shift work that causes chronic circadian-rhythm depression and not be abused on a daily, hourly basis. It may not be perfect everywhere, but it's not just as bad, everywhere.

Telling yourself "it's just as bad everywhere," is just as excuse to accept the abuse. It's just an excuse to avoid your fear of change. It's an excuse to stay miserable, because that's less scary, and safer feeling, than change. Sometimes grass is brown. And sometimes grass is greener on the other side of the street. Not always. But sometimes.

I made the decision to get out a decade ago and have never regretted it for one minute.

Get out, before you stroke out.

 

[TooMuchResearch]

High level discussion about EM. I have no problem with it and my views are somewhere between an intersection of all the participants.
I have pie in the sky ideas about how to change EM and health care, but in reality what would help us the most making patient go back to their PCP when they have acute problems. It seems like, although I'm jaded by my cohort and what I read here, is just about all acute care, no matter what the symptom, is handled by the ER. PCP's no longer see acute abdominal pain, chest pain, headache, leg swelling, etc. These all get sent to the ER.

We also need to figure out a way to keep old people out of the hospital. They are too complex for PCPs, they are not emergencies for the ER, but they have 46 problems, on 18 drugs, and have 5 different specialists managing all their pulm, cardiac, GI, neuro, and vascular issues. Invariably...they all end up in the ER because "they don't feel good" and are basically too complex for any one single doctor to figure them out. We need a better system for these folks. Until that happens, they will get sent to the ER and we will admit them because all their specialists will need to chime in, or they will need 24-48 hour obs by a hospitalist to make sure their symptoms don't get worse.

I think an hour with a good pharmacist every 3-6 months to go over all meds and allowing the pharmacist to change doses or potentially discontinue conflicting meds would go a long way here.

 

[VA Hopeful Dr]

High level discussion about EM. I have no problem with it and my views are somewhere between an intersection of all the participants.
I have pie in the sky ideas about how to change EM and health care, but in reality what would help us the most allowing patients to go back to their PCP when they have acute problems. It seems like, although I'm jaded by my ER cohort and what I read here, is just about all acute care, no matter what the symptom, is handled by the ER. PCP's no longer see acute abdominal pain, chest pain, headache, leg swelling, etc. These all get sent to the ER.

We also need to figure out a way to keep old people out of the hospital. They are too complex for PCPs, they are not emergencies for the ER, but they have 46 problems, on 18 drugs, and have 5 different specialists managing all their pulm, cardiac, GI, neuro, and vascular issues. Invariably...they all end up in the ER because "they don't feel good" and are basically too complex for any one single doctor to figure them out. We need a better system for these folks. Until that happens, they will get sent to the ER and we will admit them because all their specialists will need to chime in, or they will need 24-48 hour obs by a hospitalist to make sure their symptoms don't get worse.

I'm always shocked to hear how bad PCPs are in other areas.

 

[EMhawkeye]

I'm always shocked to hear how bad PCPs are in other areas.

As a former primary care doc you have no idea the pain the bad primary care in the ed causes me. I wonder if these guys have done any cme in decades.

 

[Brigade4Radiant]

As a former primary care doc you have no idea the pain the bad primary care in the ed causes me. I wonder if these guys have done any cme in decades.

The thing is you can be a bad PCP and nothing will be done it’s rare to have a doctor ran out of clinic

 

[JacobMcCandles]

As a former primary care doc you have no idea the pain the bad primary care in the ed causes me. I wonder if these guys have done any cme in decades.

It’s almost like the patient shouldn’t come to the ED for primary care.

 

[TooMuchResearch]

It’s almost like the patient shouldn’t come to the ED for primary care.

The number of times a patient has asked me to add a fourth antihypertensive med... Please call the cardiology clinic tomorrow. And PRN nitro is not for hypertension.

 

[EMhawkeye]

Prn lisinopril prescriptions makes my head explode

 

[RustedFox]

Prn lisinopril prescriptions makes my head explode

Maaaan.

Look, I don't know any primary care guidelines, but I know that this is dumb.

Radical idea, instead of adding a "fourth med", increase dose on a med and keep your head about you for contraindications (don't increase B blocker dose with low HR, etc).

 

[Ubba]

Maaaan.

Look, I don't know any primary care guidelines, but I know that this is dumb.

Radical idea, instead of adding a "fourth med", increase dose on a med and keep your head about you for contraindications (don't increase B blocker dose with low HR, etc).

Data reportedly show that the lion's share of a med's benefits are manifest on the standard dose and that dose increases from there have high AE/benefit ratios. But your point has validity. Lots of unnecessary polypharmacy.

 

[Dr.LeoSpaceman]

Most surgical specialists work at least 2x the hours I do and don't get paid 2x the salary.

Admittedly I'm an interloper here, but came across this thread after seeing the NRMP stats on matches this year and the change in match rate/unmatched from a few years ago struck me, and so was trying to figure out what's going on.

However to this point of working longer and not getting paid substantially more, I think the one graphic in the original article is interesting. While (some) surgeons may get paid the same and work more hours, their burnout rate is lower and their satisfaction may be higher.

And I think there's a quote later that may be relevant to this:

We're filling huge numbers with the SOAP. Some of them are going to be real high-quality people who didn't match in ENT or whatever but are in love with emergency medicine; they just didn't apply to us first. You have to be in love with the specialty these days to survive in it.

This has always been true for surgery (and many surgical subspecialties). It's the thing everyone thinking of applying gets told. If you don't love it, don't do it because you won't make it. It's the only way to survive the dead-eyed zombie phase of residency. The potential benefit of that is that people that make it through are primed to generally find satisfaction in it, even if there are parts others would find intolerable.