Hot Off the Press: AEM E&T Article, EM Physician Supply on Track to Outpace Demand

[longtimelurker2015]

Hot off the press today (at least today based on the email alert I got, looks like first publication was October so apologies if there's already a thread on SDN discussing this) of AEM A&T's SAEM Proceedings: Error - Cookies Turned Off

Too Big Too Fast? Potential Implications of the Rapid Increase in Emergency Medicine Residency Positions
Mary R. C. Haas MD

Laura R. Hopson MD

Brian J. Zink MD

Obviously, we all knew and saw this coming from a mile away.

But distressing for us about to start residency training (and currently practicing docs too, I'm sure, but I think for different reasons).

What should soon-to-be-residents or recent grads do, if anything?

Do a 3-year residency to GTFO into practice ASAP? (Not looking to start a debate on 3- vs 4-year, just saying)

Focus on academics to develop a specific skillset?

Do a pain fellowship?

Move to and practice EM in Dubai?

I'm being facetious to an extent, I realize there are no easy solutions, and it's not like that's going to change my or any of my gen's choice to go into EM, but curious if there are thoughts on or if this points to a need to differentiate oneself within the landscape of EM long-term.

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[gamerEMdoc]

Is this just an opinion piece? As far as I can tell it is, but I'm not an SAEM member, so I can't read the entire article. If it isn't a study on the effect of the rising workforce then it doesn't really add anything to the opinions of doom and gloom that are on here if it is just another opinion piece.

 

[namethatsmell]

Agree with Gamer, would be helpful if you could post the article.

From my limited experience interacting with the last author, he doesn't strike me as a preacher of doom and gloom but rather a pragmatist.

Of course, it still won't change anything as there's nothing to stop the HCAs of this country from continuing to fund their own residencies while the ACGME keeps giving them all participation medals and hugs and kisses of approval. Maybe 40 new residencies ago this could have been somewhat helpful, but now nothing short of ACGME rule changes and revoking residency accreditations will solve this. And it's hard to imagine that happening at this point.

 

[deleted941485]

Agree with Gamer, would be helpful if you could post the article.

From my limited experience interacting with the last author, he doesn't strike me as a preacher of doom and gloom but rather a pragmatist.

Of course, it still won't change anything as there's nothing to stop the HCAs of this country from continuing to fund their own residencies while the ACGME keeps giving them all participation medals and hugs and kisses of approval. Maybe 40 new residencies ago this could have been somewhat helpful, but now nothing short of ACGME rule changes and revoking residency accreditations will solve this. And it's hard to imagine that happening at this point.

HCA is part of the problem but residents need willing doctors to train them and part of that blame lies with them.

I have no qualms discouraging medical student from entering EM.

 

[longtimelurker2015]

Agree with Gamer, would be helpful if you could post the article.

From my limited experience interacting with the last author, he doesn't strike me as a preacher of doom and gloom but rather a pragmatist.

Of course, it still won't change anything as there's nothing to stop the HCAs of this country from continuing to fund their own residencies while the ACGME keeps giving them all participation medals and hugs and kisses of approval. Maybe 40 new residencies ago this could have been somewhat helpful, but now nothing short of ACGME rule changes and revoking residency accreditations will solve this. And it's hard to imagine that happening at this point.

@gamerEMdoc @namethatsmell

Happy to copy paste the article here, or attach as a PDF, just not sure I can if that violates some copyright cuz behind the journal's pay wall?

It seems pretty well researched. Uses some past articles as references about future demand-supply EM projections and looks at trends of EM program residency spots over time. Anesthesiology in the late 1990s is offered as cautionary tale of increased residency spots --> recent grads struggling to find jobs.

And indeed, authors' suggestions include for the ACGME to switch to not just accrediting programs but also regulating whether new programs should be approved in the first place based on demand (I'm simplifying here, their argument is more reasoned).

 

[Angry Birds]

I think this time will come (most likely in our lifetimes) ... but I find it hard to believe that it is here now.

 

[erdoc00]

Could you imagine that one day you would go to work and see a manageable patient volume and treat actual medical emergencies and have time to take an lunch break and also go to the bathroom? Such a terrible future this will be.

As far as the pay goes, it's about time for physicians and especially ER physicians to unionize. The fire department and law enforcement should be our model. 20 years and then eligible for a pension. This job cannot be done long term safely and the intensity and nature of the work leads to burnout and ptsd. Also no other emergency service operates in such a poorly staffed fashion. If fire departments were staffed like ERs, youd have 2 firemen covering 24 hour shifts and then buildings would be burning down whenever there was more than one active fire. Same with the police department. The ER is the only emergency service that is so chronically understaffed that everyday is essentially disaster protocol.

 

[Fox800]

Could you imagine that one day you would go to work and see a manageable patient volume and treat actual medical emergencies and have time to take an lunch break and also go to the bathroom? Such a terrible future this will be.

As far as the pay goes, it's about time for physicians and especially ER physicians to unionize. The fire department and law enforcement should be our model. 20 years and then eligible for a pension. This job cannot be done long term safely and the intensity and nature of the work leads to burnout and ptsd. Also no other emergency service operates in such a poorly staffed fashion. If fire departments were staffed like ERs, youd have 2 firemen covering 24 hour shifts and then buildings would be burning down whenever there was more than one active fire. Same with the police department. The ER is the only emergency service that is so chronically understaffed that everyday is essentially disaster protocol.

Sounds nice if you’re okay making $150 an hour with $300,000 worth of student loans coming out of residency. Go for it.

 

[cyanide12345678]

Any one know how to go about finding a job in Dubai/qatar/kuwait?

Curious to see what they are offering for a two physician couple.

 

[TooMuchResearch]

I wouldn't entrust my money (pension) to someone else.

Could you imagine that one day you would go to work and see a manageable patient volume and treat actual medical emergencies and have time to take an lunch break and also go to the bathroom? Such a terrible future this will be.

As far as the pay goes, it's about time for physicians and especially ER physicians to unionize. The fire department and law enforcement should be our model. 20 years and then eligible for a pension. This job cannot be done long term safely and the intensity and nature of the work leads to burnout and ptsd. Also no other emergency service operates in such a poorly staffed fashion. If fire departments were staffed like ERs, youd have 2 firemen covering 24 hour shifts and then buildings would be burning down whenever there was more than one active fire. Same with the police department. The ER is the only emergency service that is so chronically understaffed that everyday is essentially disaster protocol.

 

[Rekt]

I don't really understand how people can't see this as an issue? I guess if you've been in your same job forever not thinking about residencies/jobs then it might not be obvious. But to anyone that has recently gone through the match, it should be incredibly obvious we're in for a massive oversaturation in the next 2-5 years.

 

[sylvanthus]

Anyone really set on EM should highly consider having another avenue to make money. Subspecialize, have a niche, do palliative, pain, critical care, something that gives you another job in addition. Then you are not quite as hosed when the market crashes and can pickup ED shifts as you see fit at the higher paying areas.

 

[homebaseddad112818]

Could you imagine that one day you would go to work and see a manageable patient volume and treat actual medical emergencies and have time to take an lunch break and also go to the bathroom? Such a terrible future this will be.

As far as the pay goes, it's about time for physicians and especially ER physicians to unionize. The fire department and law enforcement should be our model. 20 years and then eligible for a pension. This job cannot be done long term safely and the intensity and nature of the work leads to burnout and ptsd. Also no other emergency service operates in such a poorly staffed fashion. If fire departments were staffed like ERs, youd have 2 firemen covering 24 hour shifts and then buildings would be burning down whenever there was more than one active fire. Same with the police department. The ER is the only emergency service that is so chronically understaffed that everyday is essentially disaster protocol.

Far chance of that ever happening. “I’ll sacrifice myself for my patients!!!” Would be the common sentiment

 

[miacomet]

Terrifying and true.
We all need an escape route.

 

[GeneralVeers]

I don't really understand how people can't see this as an issue? I guess if you've been in your same job forever not thinking about residencies/jobs then it might not be obvious. But to anyone that has recently gone through the match, it should be incredibly obvious we're in for a massive oversaturation in the next 2-5 years.

We all see it as an issue, but there's nothing we can do. How do we lobby ACGME to stop approving these programs? Are they getting bribes from Envision and HCA?

Where is ACEP and why aren't they doing something about it?

 

[miacomet]

So glad I have saved every penny. It's not enough, but at least I'm debt-free with savings.

 

[longtimelurker2015]

We all see it as an issue, but there's nothing we can do. How do we lobby ACGME to stop approving these programs? Are they getting bribes from Envision and HCA?

Where is ACEP and why aren't they doing something about it?

If I recall correctly, I believe that was part of the article, e.g. ACEP is starting to look into it and putting task forces together to "study" the effects of such rapid EM residency spots expansion and what not... But it does feel like too little, too late.

 

[deleted941485]

Far chance of that ever happening. “I’ll sacrifice myself for my patients!!!” Would be the common sentiment

I always resented that sentiment because it usually comes from doctors that don’t spend much time in clinic anyway.

 

[ShockIndex]

We all see it as an issue, but there's nothing we can do. How do we lobby ACGME to stop approving these programs? Are they getting bribes from Envision and HCA?

Where is ACEP and why aren't they doing something about it?

An effort by a professional medical society to limit the labor pool at a time of soaring medical costs and supply shortages across the healthcare industry is political suicide. ACEP leadership would get hauled before Congress to testify why they were supporting rent controls and anti-competitive practices. You can bet your ass it would be the impetus for draconian balance/surprise billing legislation as well as statewide efforts to allow APPs to “practice at the top of their licenses” which we all know is code for independent practice.

I agree that the market is getting flooded. I’m also aware that physician compensation accounts for only 8% of healthcare costs. But step back and look at it from the perspective of healthcare consumers who are being told by the media that physician groups are screwing them. This whole surprise billing fiasco is not playing well in the press for physicians. There have been articles in the left and right wing press pointing fingers at both insurance and physician groups. When private equity-backed groups like Doctor Patient Unity go on a media blitz, we get a black eye in the press because we work for these bastards.

Mystery Solved: Private-Equity-Backed Firms Are Behind Ad Blitz on ‘Surprise Billing’ (Published 2019)

Two doctor-staffing companies are pushing back against legislation that could hit their bottom lines.

www.google.com

 

[sum dude]

We all see it as an issue, but there's nothing we can do. How do we lobby ACGME to stop approving these programs? Are they getting bribes from Envision and HCA?

Where is ACEP and why aren't they doing something about it?

1) You can't lobby ACGME...it's its own independent body. As mentioned above, that would be a huge anti-trust lawsuit if ACEP intevened.
2) No bribes, but they get paid every visit they do. Some people brought up issue of multiple new programs in FL to ACGME, and their response was "it's our job to make sure they are on track once they open" or something to that effect, meaning they're collecting checks to open programs, won't stop them from opening programs, but if there are issues, they won't hesitate to put programs on probation.
3) You guys completely misunderstand the role of ACEP. It's an educational college, not a trade organization. We've had hard enough time collecting data on insurers before lawyers get antsy about anti-trust issues. Huge anti-trust issues if it suddenly limits residencies, even if intentions are good.

For all you going into EM--we reached high water mark for pay. You will be getting paid less (even w/o accounting for inflation) in 5 years than we made in mid 2010's. Know that going in. It's still a great field and way more interesting than other specialties, but you will not be paid $300+/hr as people on this forum used to brag about ($200/hr will probably be top 10% of pay.) Burnout is high, and yes, the expectations for EM will get worse even though pay doesn't increase. It is what it is--would have been nice if groups didn't sell out to CMG's, or doctors cared as much about advocacy, donating to PACS, and advancing medicine through innovation as they do Telsa stock or FIRE, but here we are, get used to the new normal.

 

[DoctwoB]

The move isn’t to lobby to have fewer programs which is neither legal nor defensible. The move is to push for stricter requirements to open a program, higher numbers, fewer sites, etc. That way You’re not arguing against expansion, you’re arguing for quality which has the side benefit of curtailing expansion.

 

[Dr Mantis Toboggan]

yeah the CMGs just have to play the long game at this point. we are fairly dumb as a specialty in this regard, I’m sure many organizations would love to increase the supply of ortho, neurosurgery, urology docs to drive down their reimbursement. But you don’t see a bunch of podunk hospitals opening up those programs.

1) You can't lobby ACGME...it's its own independent body. As mentioned above, that would be a huge anti-trust lawsuit if ACEP intevened.
2) No bribes, but they get paid every visit they do. Some people brought up issue of multiple new programs in FL to ACGME, and their response was "it's our job to make sure they are on track once they open" or something to that effect, meaning they're collecting checks to open programs, won't stop them from opening programs, but if there are issues, they won't hesitate to put programs on probation.
3) You guys completely misunderstand the role of ACEP. It's an educational college, not a trade organization. We've had hard enough time collecting data on insurers before lawyers get antsy about anti-trust issues. Huge anti-trust issues if it suddenly limits residencies, even if intentions are good.

For all you going into EM--we reached high water mark for pay. You will be getting paid less (even w/o accounting for inflation) in 5 years than we made in mid 2010's. Know that going in. It's still a great field and way more interesting than other specialties, but you will not be paid $300+/hr as people on this forum used to brag about ($200/hr will probably be top 10% of pay.) Burnout is high, and yes, the expectations for EM will get worse even though pay doesn't increase. It is what it is--would have been nice if groups didn't sell out to CMG's, or doctors cared as much about advocacy, donating to PACS, and advancing medicine through innovation as they do Telsa stock or FIRE, but here we are, get used to the new normal.

 

[ShockIndex]

The move isn’t to lobby to have fewer programs which is neither legal nor defensible. The move is to push for stricter requirements to open a program, higher numbers, fewer sites, etc. That way You’re not arguing against expansion, you’re arguing for quality which has the side benefit of curtailing expansion.

Then, we better make sure that we can show these stricter requirements translate to improved quality. That means studies need to be started...like...yesterday.

 

[Torsion]

For all you going into EM--we reached high water mark for pay. You will be getting paid less (even w/o accounting for inflation) in 5 years than we made in mid 2010's. Know that going in. It's still a great field and way more interesting than other specialties, but you will not be paid $300+/hr as people on this forum used to brag about ($200/hr will probably be top 10% of pay.) Burnout is high, and yes, the expectations for EM will get worse even though pay doesn't increase. It is what it is--would have been nice if groups didn't sell out to CMG's, or doctors cared as much about advocacy, donating to PACS, and advancing medicine through innovation as they do Telsa stock or FIRE, but here we are, get used to the new normal.

If $300+/hr is top 10% pay right now, and you are predicting that in a few short years $200/hr will be top 10% pay, what you are saying is that new grads will be facing a >33% , >$100k pay cut from current numbers. As I've mentioned on other threads, that is quite catastrophic and has no recent precedent. Considering most on here state they would refuse to work for under $200/hr, it seems like the glut of new EM grads would be balanced against the glut of disillusioned, retiring veteran docs.

 

[GeneralVeers]

If $300+/hr is top 10% pay right now, and you are predicting that in a few short years $200/hr will be top 10% pay, what you are saying is that new grads will be facing a >33% , >$100k pay cut from current numbers. As I've mentioned on other threads, that is quite catastrophic and has no recent precedent. Considering most on here state they would refuse to work for under $200/hr, it seems like the glut of new EM grads would be balanced against the glut of disillusioned, retiring veteran docs.

When you are making ~$45K as a resident, suddenly making $300K seems like a ton of money. Not so fun when you are used to 500K and told you have to take a 40% pay cut. There will definitely be new grads willing to work for that amount of money

 

[hundreddaysoff]

If $300+/hr is top 10% pay right now, and you are predicting that in a few short years $200/hr will be top 10% pay, what you are saying is that new grads will be facing a >33% , >$100k pay cut from current numbers. As I've mentioned on other threads, that is quite catastrophic and has no recent precedent. Considering most on here state they would refuse to work for under $200/hr, it seems like the glut of new EM grads would be balanced against the glut of disillusioned, retiring veteran docs.

In addition to what Veers wrote, remember that SDN is not a representative sample. The average ER doc I talk to about this stuff IRL has no clue that, eg, all these new residencies are being opened. They have no clue about these potential oversupply issues. They just want to pay off their loans and take care of their families and otherwise enjoy their wealth and if pressed, I suspect most of them would take a pay cut from $200/h to $150/h because it's hard for most to conceive an alternative.

Heck, if I ever had the choice of going down to $150/h vs just quitting, I'd probably take the $150/h, although it would also depend on how much crappier the job was getting at the same time. At the end of the day, although I do have some marketable skills, I doubt any of them besides medicine could net me $150/h without a huge amount of unpaid work up-front. And that work would have to include lots of time-consuming and emotionally painful management of my family's expectations of how much time I would still need to carve out to spend with them.

 

[Dr Mantis Toboggan]

Indeed. That’s why we are in trouble.

In addition to what Veers wrote, remember that SDN is not a representative sample. The average ER doc I talk to about this stuff IRL has no clue that, eg, all these new residencies are being opened. They have no clue about these potential oversupply issues. They just want to pay off their loans and take care of their families and otherwise enjoy their wealth and if pressed, I suspect most of them would take a pay cut from $200/h to $150/h because it's hard for most to conceive an alternative.

Heck, if I ever had the choice of going down to $150/h vs just quitting, I'd probably take the $150/h, although it would also depend on how much crappier the job was getting at the same time. At the end of the day, although I do have some marketable skills, I doubt any of them besides medicine could net me $150/h without a huge amount of unpaid work up-front. And that work would have to include lots of time-consuming and emotionally painful management of my family's expectations of how much time I would still need to carve out to spend with them.

 

[deleted941485]

In addition to what Veers wrote, remember that SDN is not a representative sample. The average ER doc I talk to about this stuff IRL has no clue that, eg, all these new residencies are being opened. They have no clue about these potential oversupply issues. They just want to pay off their loans and take care of their families and otherwise enjoy their wealth and if pressed, I suspect most of them would take a pay cut from $200/h to $150/h because it's hard for most to conceive an alternative.

Heck, if I ever had the choice of going down to $150/h vs just quitting, I'd probably take the $150/h, although it would also depend on how much crappier the job was getting at the same time. At the end of the day, although I do have some marketable skills, I doubt any of them besides medicine could net me $150/h without a huge amount of unpaid work up-front. And that work would have to include lots of time-consuming and emotionally painful management of my family's expectations of how much time I would still need to carve out to spend with them.

And everyone including CMG, mega health system and the govt knows that which is why 200 will become 150 and in a few years will become 125 then 115 and eventually the people stuck in the system will be demanding that the govt pay their loans off which will probably embolden payers to keep cutting because well now they own you because they paid for your education.

 

[miacomet]

If we went down to $150 I'd probably work a few days a month just to keep my toe in the water, but no more. I'd be off volunteering and enjoying my leisure time.

 

[GeneralVeers]

If we went down to $150 I'd probably work a few days a month just to keep my toe in the water, but no more. I'd be off volunteering and enjoying my leisure time.

At 150, I'd work for a bit while trying to figure out an alternative employment. There are lots of options, and at $150 those options start to become financially competitive.

 

[sum dude]

can show these stricter requirements translate to improved quality. That means stu

If $300+/hr is top 10% pay right now, and you are predicting that in a few short years $200/hr will be top 10% pay, what you are saying is that new grads will be facing a >33% , >$100k pay cut from current numbers. As I've mentioned on other threads, that is quite catastrophic and has no recent precedent. Considering most on here state they would refuse to work for under $200/hr, it seems like the glut of new EM grads would be balanced against the glut of disillusioned, retiring veteran docs.

20% is literally being voted on by Congress in the surprise billing legislation. It "saves" $20+ Billion by cutting MD salaries. B/c EM is more sensitive to commercial payor changes b/c of EMTALA, most industry experts predict 30-40% revenue cuts. Unprecedented, yes, but easily accomplished by Congress passing one bill with bad language.

https://www.cbo.gov/system/files/2019-09/hr2328.pdf

 

[Torsion]

20% is literally being voted on by Congress in the surprise billing legislation. It "saves" $20+ Billion by cutting MD salaries. B/c EM is more sensitive to commercial payor changes b/c of EMTALA, most industry experts predict 30-40% revenue cuts. Unprecedented, yes, but easily accomplished by Congress passing one bill with bad language.

https://www.cbo.gov/system/files/2019-09/hr2328.pdf

Provider-friendly solutions with IDR are gaining momentum in some states and the Ways and Means bill has some traction as well I believe. I don't think the Energy and Commerce bill will become law in its current form. We shall see.