How much time do we have?

[The Knife & Gun Club]

There are logistical and payment issues with your model:
1. Would need an extra EM physician on shift 24 hours to cover these "extras". Who pays that salary when idle? Sure they can see patients in the ED when not busy but it would still drive salaries down.
2. Need to get RVUs and paid for procedures upstairs. Right now Envision forces many docs to cover upstairs intubations/resuscitations, but the RVUs for these never get included on the spreadsheet. Who gets that money?
3. Other specialties would become increasingly lazy, and just tell the nurse "Call the on-call EM doctor to handle X".

The way we have it done now is that some of the things are set up as dedicated extra shifts for those things separate from ED shifts.

And that’s fine if other specialities become lazy and want to give your group RVUs.

With regards to people not getting paid by CMGs for in house procedures - that sucks but anyone doing any significant volume of these should be asking for payment in some form.

I’ve only ever worked one place where EM docs were required to respond to emergencies in some other areas of the hospital, and was a resident at the time but the attendings were pretty clear they were capturing that billing.

To be clear I’m not talking about some EM doc on shift doing lines on the floor. Here we have a “procedure team” which works M-F (but not EM based) who will take any urgent procedures and do them within 12 hours of request.

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[The Knife & Gun Club]

Like imagine if you see an arthritic knee pain patient in the ED. It’s like a level 4 at best. But instead of giving them a shot of toradol and sending them on their way you say “hey let’s have you follow up within 72h in our clinic”. Refer to the EM or sports doc who’s got clinic for this type of thing during business hours. Check follow up of the treatment, do some films, maybe some joint injections and prescribe some PT, then they follow up again in a month.

You’ve now converted some nonsense level 4 joint pain into a recurring customer getting procedures and care from your group, during business hours, generating $$$ for you and your hospital

 

[Birdstrike]

Like imagine if you see an arthritic knee pain patient in the ED. It’s like a level 4 at best. But instead of giving them a shot of toradol and sending them on their way you say “hey let’s have you follow up within 72h in our clinic”. Refer to the EM or sports doc who’s got clinic for this type of thing during business hours. Check follow up of the treatment, do some films, maybe some joint injections and prescribe some PT, then they follow up again in a month.

You’ve now converted some nonsense level 4 joint pain into a recurring customer getting procedures and care from your group, during business hours, generating $$$ for you and your hospital

I do tons of this (outpatient, non-op ortho-ish stuff).

 

[TooMuchResearch]

Like imagine if you see an arthritic knee pain patient in the ED. It’s like a level 4 at best. But instead of giving them a shot of toradol and sending them on their way you say “hey let’s have you follow up within 72h in our clinic”. Refer to the EM or sports doc who’s got clinic for this type of thing during business hours. Check follow up of the treatment, do some films, maybe some joint injections and prescribe some PT, then they follow up again in a month.

You’ve now converted some nonsense level 4 joint pain into a recurring customer getting procedures and care from your group, during business hours, generating $$$ for you and your hospital

But we already have this. It's called orthopedics and sports medicine clinic.

 

[JacobMcCandles]

Like imagine if you see an arthritic knee pain patient in the ED. It’s like a level 4 at best. But instead of giving them a shot of toradol and sending them on their way you say “hey let’s have you follow up within 72h in our clinic”. Refer to the EM or sports doc who’s got clinic for this type of thing during business hours. Check follow up of the treatment, do some films, maybe some joint injections and prescribe some PT, then they follow up again in a month.

You’ve now converted some nonsense level 4 joint pain into a recurring customer getting procedures and care from your group, during business hours, generating $$$ for you and your hospital

Maybe it’s how EM has molded my mind but seeing these atraumatic elderly joint pains in a clinic is not how I want to spend my day. It takes 2 seconds to x-ray these in the department, give a shot of Toradol, and send home to follow up with PCP/Ortho/PT.

 

[Siggy]

For example a dynamic EM department could provide ICU coverage, floor procedure coverage, have clinics for MSK/ortho stuff, opioid treatment/ED diversion, wound care services, urgent care coverage, and staff a well run obs unit.

I was under the impression that most EM docs are doing EM to avoid clinic. Now you want EM to do followup clinics?

How much training does EM get for outpatient wound care? Are you planning on doing hyperbarics also?

You're going to staff the ICU overnight? If the ICU overnight was busy enough for intensivist coverage then there would be an intensivist scheduled for the night shift. If there isn't enough business overnight, how are you planning on justifying an EM doc instead? Are you planning on being available for the ICU to place central lines, arterial lines, dialysis catheters, transvenous pacemakers, throas, paras (thoras and paras are often kicked to the night team if the day team runs out of time)?

I got the sense that most EM docs hate working urgent care... and the sense I get from this forum was that it gets tolerated when the EM doc owns the urgent care instead of just staffing it (we can ignore the FSEDs that are often just glorified overpriced urgent cares).

 

[ScepticSkeksis]

I was under the impression that most EM docs are doing EM to avoid clinic. Now you want EM to do followup clinics?

How much training does EM get for outpatient wound care? Are you planning on doing hyperbarics also?

You're going to staff the ICU overnight? If the ICU overnight was busy enough for intensivist coverage then there would be an intensivist scheduled for the night shift. If there isn't enough business overnight, how are you planning on justifying an EM doc instead? Are you planning on being available for the ICU to place central lines, arterial lines, dialysis catheters, transvenous pacemakers, throas, paras (thoras and paras are often kicked to the night team if the day team runs out of time)?

I got the sense that most EM docs hate working urgent care... and the sense I get from this forum was that it gets tolerated when the EM doc owns the urgent care instead of just staffing it (we can ignore the FSEDs that are often just glorified overpriced urgent cares).

Most of us would love to avoid a clinic with scheduled, chronic, recurrent patients. The other issue with clinic visits is pay. Are you going to maintain $250/hr pay for ED physicians staffing a clinic with low reimbursement patients?

 

[thegenius]

Maybe it’s how EM has molded my mind but seeing these atraumatic elderly joint pains in a clinic is not how I want to spend my day. It takes 2 seconds to x-ray these in the department, give a shot of Toradol, and send home to follow up with PCP/Ortho/PT.

It's the way it should be too. I don't think there is a financially solvent model to give patients what they want, when they want it 24 x 7 x 365.

We need more docs, they need to be reimbursed a little better and some of that money should come from admin who are hired to take money away from docs. And we need patients to not be as needy and be more realistic. Second part is harder to do when they are paying an arm and a leg for insurance and health care.

 

[RustedFox]

It's the way it should be too. I don't think there is a financially solvent model to give patients what they want, when they want it 24 x 7 x 365.

We need more docs, they need to be reimbursed a little better and some of that money should come from admin who are hired to take money away from docs. And we need patients to not be as needy and be more realistic. Second part is harder to do when they are paying an arm and a leg for insurance and health care.

That last sentence.
"So much truth" he said, as he paid more than his mortgage for his monthly premium.

 

[Birdstrike]

Maybe it’s how EM has molded my mind but seeing these atraumatic elderly joint pains in a clinic is not how I want to spend my day. It takes 2 seconds to x-ray these in the department, give a shot of Toradol, and send home to follow up with PCP/Ortho/PT.

Knee steroid injection, d/c home - Bye

if no relief...

Knee hyaluronic injections- Bye

if no relief...

Off to ortho, d/c home - Bye

If still not better...

Genicular nerve block and ablation - Bye

 

[endo]

VAs can be a gem in the rough…

For context, I’m mid-career (4 year residency and on my 17th year in private practice) and recently left my SDG. At my SDG I was working no nights, making $400/hr @ 2pts/hr, moderate to high acuity setting. I was burned out. I had been for some time but hadn’t acknowledged it consciously. I made the switch to the VA which I’m quite happy with.

For starters, I would recommend getting your foot in the door as a per diem / part timer. I have always had a side gig and had established relationships at the local VA over the years. If you just go to usajobs and don’t know anyone on the inside it’s going to be more difficult to craft something you like. When you work there, don’t be a lazy bum and do nothing - if you only work at 60% speed you’ll look like a rock star. When you’re ready to make the jump there’s a good chance they’ll work with you to set something up.

Most VA jobs are 40hrs/wk for full time. However, some VA ER gigs will have “admin time” attached to your shift, such that a 12 hour shift is really 10. In addition, you need to factor in paid holidays (13/yr), AL (160 hrs/yr), and sick leave (104 hrs/yr). Where I’m at, the hourly becomes approximately $250/hr when you factor all that in. Also, I see 1 pt/hr average, and I’m seeing more than most docs there just because I’m used to seeing more. I also am a permanent part-timer, which gives you all the benefits of full time (pro-rated) but allows you to work whatever fraction of the 40hr week you are willing to work. Can’t likely arrange that however if you’re an outsider - need to get to know the director to make that happen IMHO.

Other benefits: FTCA - never worry about lawsuits again. Nicer, more respectful patients. Better job security. No Press Ganey. Don’t have to sign NP charts.

Drawbacks: No peds, so hard to go back to the community setting if you’re away for too long. Procedural atrophy: intubations and central lines are less frequent. But in our shop, ERPs can go up to OR to practice intubations whenever, so ongoing practice there is a non-issue. Govt bureaucracy - will have to accept some of this…

I think as the CMGs worsen and the pay gap between community and the VA decreases, you’ll see people heading into the VA system. Especially mid-career I think it’s a viable option.

 

[BoardingDoc]

Most VA jobs are 40hrs/wk for full time. However, some VA ER gigs will have “admin time” attached to your shift, such that a 12 hour shift is really 10. In addition, you need to factor in paid holidays (13/yr), AL (160 hrs/yr), and sick leave (104 hrs/yr). Where I’m at, the hourly becomes approximately $250/hr when you factor all that in. Also, I see 1 pt/hr average, and I’m seeing more than most docs there just because I’m used to seeing more. I also am a permanent part-timer, which gives you all the benefits of full time (pro-rated) but allows you to work whatever fraction of the 40hr week you are willing to work. Can’t likely arrange that however if you’re an outsider - need to get to know the director to make that happen IMHO.

I'd be curious to know what the actual hourly rate is before you assign a value to benefits. Looking at the whole package is obviously important, but if you tell someone working a 1099 who is currently making 250/hr that their new rate (before benefit calcs) is $170/hr, you're going to see some people balk.

I also thought about how the workload at the VA would be MASSIVELY easier than my current job, but even for a super cush job, it would be a hard pill for me to swallow to have to work an extra 12 hours a week for roughly half the pay.

 

[TooMuchResearch]

VAs can be a gem in the rough…

For context, I’m mid-career (4 year residency and on my 17th year in private practice) and recently left my SDG. At my SDG I was working no nights, making $400/hr @ 2pts/hr, moderate to high acuity setting. I was burned out. I had been for some time but hadn’t acknowledged it consciously. I made the switch to the VA which I’m quite happy with.

For starters, I would recommend getting your foot in the door as a per diem / part timer. I have always had a side gig and had established relationships at the local VA over the years. If you just go to usajobs and don’t know anyone on the inside it’s going to be more difficult to craft something you like. When you work there, don’t be a lazy bum and do nothing - if you only work at 60% speed you’ll look like a rock star. When you’re ready to make the jump there’s a good chance they’ll work with you to set something up.

Most VA jobs are 40hrs/wk for full time. However, some VA ER gigs will have “admin time” attached to your shift, such that a 12 hour shift is really 10. In addition, you need to factor in paid holidays (13/yr), AL (160 hrs/yr), and sick leave (104 hrs/yr). Where I’m at, the hourly becomes approximately $250/hr when you factor all that in. Also, I see 1 pt/hr average, and I’m seeing more than most docs there just because I’m used to seeing more. I also am a permanent part-timer, which gives you all the benefits of full time (pro-rated) but allows you to work whatever fraction of the 40hr week you are willing to work. Can’t likely arrange that however if you’re an outsider - need to get to know the director to make that happen IMHO.

Other benefits: FTCA - never worry about lawsuits again. Nicer, more respectful patients. Better job security. No Press Ganey. Don’t have to sign NP charts.

Drawbacks: No peds, so hard to go back to the community setting if you’re away for too long. Procedural atrophy: intubations and central lines are less frequent. But in our shop, ERPs can go up to OR to practice intubations whenever, so ongoing practice there is a non-issue. Govt bureaucracy - will have to accept some of this…

I think as the CMGs worsen and the pay gap between community and the VA decreases, you’ll see people heading into the VA system. Especially mid-career I think it’s a viable option.

Nice option to keep in mind, thanks

 

[endo]

I'd be curious to know what the actual hourly rate is before you assign a value to benefits. Looking at the whole package is obviously important, but if you tell someone working a 1099 who is currently making 250/hr that their new rate (before benefit calcs) is $170/hr, you're going to see some people balk.

I also thought about how the workload at the VA would be MASSIVELY easier than my current job, but even for a super cush job, it would be a hard pill for me to swallow to have to work an extra 12 hours a week for roughly half the pay.

Before benefits (holidays, AL, SL) are calculated in, the hourly is $200/hr. In regards to the hourly equivalency, I also had to calculate that my SDG shifts run over 8hrs commonly, which decreases the hourly, maybe by $20/hr. Additionally, I used a scribe at the SDG (completely unnecessary at VA) which came out of my earnings too ($20/hr).

Health insurance is another benefit that likely is far cheaper / better at VA vs an SDG (as it is in my case). I didn’t factor that into the hourly.

I don’t think VA is the best option right out of residency, as you will see a more narrow subset of EM. Mid-career, I think there is more reason to give it a closer look. But there are still plenty of EM docs who want to make top dollar despite the added pressure / stress later in their career.