How much time do we have?

[GonnaBeADoc2222]

Whenever a patient is sent to the ED by a PLP at some urgent care for nonsense, I inform (and apologize to) them that their time / money was wasted by said PLP, and next time try to seek the care of a physician.

Doing my small part.

We need to figure out how to market ourselves to patients better. There's ample evidence on poorer outcomes and increased resource utilization with midlevels. If most reasonable people knew that with midlevels they'd have to sit through more tests and have lower odds of doing well, they'd want a doc.

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[CoolDoc1729]

Patients want tests and pills.
Admins want tests and cheap labor; they don't care about the actual medicine.
PLPs want to order ALL the tests, because "look at me, I can do the medicines".

Then, they hand the hot mess that they created to us once they get results and have no idea what they're looking at and say: "*Giggle* now do your job."

The way our PIT setup works, basically for the patients who hang around for dispo the midlevels are acting as scribes. I talk to the patient and examine them and look over their test results and go over everything with them, and I just have to write two sentence reeval/mdm instead of a whole note. They’re pretty good as scribes. The patients who leave before dispo or who get a bunch of pointless tests .. idk. A couple months ago the PLP didn’t know what to do with a patient whose feeding tube fell out, so she ordered a covid test, basic labs and a cxr (?) that was a shame and it was difficult to get the tube back in 5 hours later.

I think with current staffing the only way to safely utilize the midlevels is as scribes - when the doc has to deal with something urgent in the back they could continue seeing wr people but then have to present everyone to us so there’s a physician actually overseeing their care. At my site we had to argue back and forth for them to need to talk to us before admitting people !

I think for the next few years most of us are not ready to retire, cannot just move to avoid working for a cmg and they are playing crazy games with staffing, so I’m trying to figure out the safest way to deliver care with this current setup tbh

 

[Arcan57]

Patients want tests and pills.
Admins want tests and cheap labor; they don't care about the actual medicine.
PLPs want to order ALL the tests, because "look at me, I can do the medicines".

Then, they hand the hot mess that they created to us once they get results and have no idea what they're looking at and say: "*Giggle* now do your job."

That was my first thought, that if you marketed docs as testing less that would drive people to non physicians. The only people that care about testing utilization are docs and insurance companies. And in terms of outcomes, most people that come to the ED don’t think they’re really sick. If they were really sick they would have gone to the hospital. They went to the ED to have tests run, be told they’re going to be ok and to get some meds to allow them to ignore their symptoms until they go away or see a real doctor in a real office.

 

[CoolDoc1729]

That was my first thought, that if you marketed docs as testing less that would drive people to non physicians. The only people that care about testing utilization are docs and insurance companies. And in terms of outcomes, most people that come to the ED don’t think they’re really sick. If they were really sick they would have gone to the hospital. They went to the ED to have tests run, be told they’re going to be ok and to get some meds to allow them to ignore their symptoms until they go away or see a real doctor in a real office.

My question is why don’t the insurance companies push back ? Patients, hospital and cmgs are not fiscally harmed by over utilization so it would have to come from the payor.

 

[Arcan57]

My question is why don’t the insurance companies push back ? Patients, hospital and cmgs are not fiscally harmed by over utilization so it would have to come from the payor.

They’ve tried but keep losing. They have to cover emergency care and they’ve been unsuccessful in retrospectively declaring something non emergent when it’s been challenged in court. Probably ACEP’s biggest impact on the average doc.

 

[EthylMethylMan]

Patients want tests and pills.
Admins want tests and cheap labor; they don't care about the actual medicine.
PLPs want to order ALL the tests, because "look at me, I can do the medicines".

Then, they hand the hot mess that they created to us once they get results and have no idea what they're looking at and say: "*Giggle* now do your job."

I'm not as experienced as you are, so I know my data points are fewer, but I don't think that's what I'm seeing most of the time. At least with the patient populations I've seen. For sure there are plenty of patients who want pan-MRI and get pissed when you try to be judicious, but I feel like more of my patients want a reasonably confident rule-out of badness and some symptom control. The people who want everything are usually more annoying and certainly memorable in that regard.
More often my pissy patients are mad about wait times as opposed to not getting their obscure rheumatologic assay that Dr. Google recommended. But I'm only a few months out and in a different region than you are so idk.

 

[RustedFox]

I'm not as experienced as you are, so I know my data points are fewer, but I don't think that's what I'm seeing most of the time. At least with the patient populations I've seen. For sure there are plenty of patients who want pan-MRI and get pissed when you try to be judicious, but I feel like more of my patients want a reasonably confident rule-out of badness and some symptom control. The people who want everything are usually more annoying and certainly memorable in that regard.
More often my pissy patients are mad about wait times as opposed to not getting their obscure rheumatologic assay that Dr. Google recommended. But I'm only a few months out and in a different region than you are so idk.

I remember feeling the same way when I was first out. In fact, I looked thru my early posts on here not long ago and was appalled at myself.

I work in a far better place now, but it's still not going to solve the problems at large. The biggest piece of the problem lies in those (and this is a significant percentage) of people who are completely misinformed about what test to use in what situation, and then they're pissy when you try to explain to them: "that's not how that works; you're making a big mistake by concluding that 'the test would show this or that, and if it's negative, then I'm reassured". On top of that, there are those who want the wrong test altogether to explain their symptoms (wants CT, needs endoscopy), and those who are unsatisfiable because their symptoms are entirely supratentorial in nature.

That last one... that's 90% of America for you.

 

[EctopicFetus]

Incoming new attendings or existing attendings?

Everyone. No one cares about your experience.

 

[PikminOC]

We need to figure out how to market ourselves to patients better. There's ample evidence on poorer outcomes and increased resource utilization with midlevels. If most reasonable people knew that with midlevels they'd have to sit through more tests and have lower odds of doing well, they'd want a doc.

People just want their drugs

 

[PikminOC]

The way our PIT setup works, basically for the patients who hang around for dispo the midlevels are acting as scribes. I talk to the patient and examine them and look over their test results and go over everything with them, and I just have to write two sentence reeval/mdm instead of a whole note. They’re pretty good as scribes. The patients who leave before dispo or who get a bunch of pointless tests .. idk. A couple months ago the PLP didn’t know what to do with a patient whose feeding tube fell out, so she ordered a covid test, basic labs and a cxr (?) that was a shame and it was difficult to get the tube back in 5 hours later.

I think with current staffing the only way to safely utilize the midlevels is as scribes - when the doc has to deal with something urgent in the back they could continue seeing wr people but then have to present everyone to us so there’s a physician actually overseeing their care. At my site we had to argue back and forth for them to need to talk to us before admitting people !

I think for the next few years most of us are not ready to retire, cannot just move to avoid working for a cmg and they are playing crazy games with staffing, so I’m trying to figure out the safest way to deliver care with this current setup tbh

When I started practice 10 years ago admin looked at me like I was crazy when I said they should be in the extender role like you have set up.

 

[CoolDoc1729]

They’ve tried but keep losing. They have to cover emergency care and they’ve been unsuccessful in retrospectively declaring something non emergent when it’s been challenged in court. Probably ACEP’s biggest impact on the average doc.

I mean, covering midlevel visits at a much lower rate than physician visits in their network contracts .. urgent, ED, office follow ups, etc. they can’t not cover ED visits but they could pay 60% for the PA visit and I bet they’d suddenly want us to see more of the esi 2/3

 

[EctopicFetus]

I mean, covering midlevel visits at a much lower rate than physician visits in their network contracts .. urgent, ED, office follow ups, etc. they can’t not cover ED visits but they could pay 60% for the PA visit and I bet they’d suddenly want us to see more of the esi 2/3

Medicare does this. pays 85% someinsurers are following suit. BCBS in alabama is doing this.

 

[CoolDoc1729]

Medicare does this. pays 85% someinsurers are following suit. BCBS in alabama is doing this.

It needs to be much lower to incentivize using physicians though

 

[Groove]

5-8 years. I think we'll see a gradual push of all IM/FM out of ERs and a change of hospital bylaws requiring ABEM with greater standardization of training backgrounds and clinical management among EM physicians. I'm already seeing it in my city. Lots of IM/FM guys (good ones too) getting pushed out and finding slim pickings for alternate EM jobs. One FM EM doc who was on the career admin path with different CMGs played it smart and managed to bag a CMO role at a local hospital rather than try to transition back to traditional FM after being out of it for so many years and also realizing that any future EM admin role without ABEM would be increasingly difficult to attain.

 

[EctopicFetus]

It needs to be much lower to incentivize using physicians though

I agree but for hospitals specifically who run in single digit margins it will be interesting what they do. I know of a local hospital system that fired all their "hospitalist" MLPs because the new rules made it nearly impossible to use MLPs. they delayed the start of the rules until 2024. Dont underestimate the impact of this though. Docs will ahve to have spent over half of the time on these patients not just doing the MDM. Game changer. Personally i think MLPs should be reimbursed at 30-50% of what they pay docs.

 

[finalpsychyear]

It needs to be much lower to incentivize using physicians though

Insurers are probably going to do this soon once they realize the midlevels are exploding and no way can they pay the same to physicians as that would suddenly not be right... Then maybe the pendulum will swing back.

 

[EctopicFetus]

Insurers are probably going to do this soon once they realize the midlevels are exploding and no way can they pay the same to physicians as that would suddenly not be right... Then maybe the pendulum will swing back.

Not that. it is the cost thing for insurers. I would rather pay a doc $250/hr than an MLP $100/hr if the MLP is gonna order an extra $500 on average in tests on my customer (errr patients).

 

[wholeheartedly]

I'm not as experienced as you are, so I know my data points are fewer, but I don't think that's what I'm seeing most of the time. At least with the patient populations I've seen. For sure there are plenty of patients who want pan-MRI and get pissed when you try to be judicious, but I feel like more of my patients want a reasonably confident rule-out of badness and some symptom control. The people who want everything are usually more annoying and certainly memorable in that regard.
More often my pissy patients are mad about wait times as opposed to not getting their obscure rheumatologic assay that Dr. Google recommended. But I'm only a few months out and in a different region than you are so idk.

N=1 but I was just on another social media site and reg ppl were discussing the AMAs post. Lots of my NPs have been really nice and really listened and spend more time and saved my life and docs are jerks and just trying to protect their turf. There were a few dissenters in that mix, several nurses interestingly. And some did point out that the training and experience of todays NPs is far different from historical. But yeah, patients don’t seem to care until they have a bad outcome themselves.

 

[Mount Asclepius]

5-8 years. I think we'll see a gradual push of all IM/FM out of ERs and a change of hospital bylaws requiring ABEM with greater standardization of training backgrounds and clinical management among EM physicians. I'm already seeing it in my city. Lots of IM/FM guys (good ones too) getting pushed out and finding slim pickings for alternate EM jobs. One FM EM doc who was on the career admin path with different CMGs played it smart and managed to bag a CMO role at a local hospital rather than try to transition back to traditional FM after being out of it for so many years and also realizing that any future EM admin role without ABEM would be increasingly difficult to attain.

Where in the world of small to medium to large cities are there still IM/FM physicians in the ED. All the cities and EDs that I know well have required ABEM certification for over a decade.

 

[EthylMethylMan]

Where in the world of small to medium to large cities are there still IM/FM physicians in the ED. All the cities and EDs that I know well have required ABEM certification for over a decade.

I think it's mainly in the boonies, though I did work with an FM doc while in my large urban academic hospital residency who did EM at the VA. That guy is a pretty old doc though and I think he was grandfathered in. But yeah, seems like the really rural/undesirable places continue to be a bit more desperate. I've gotten like 3 emails in the past month from FM recruiters in Alaska offering what sounds like a pretty good deal for primary care. Beggars can't be choosers.

 

[Mount Asclepius]

I think it's mainly in the boonies, though I did work with an FM doc while in my large urban academic hospital residency who did EM at the VA. That guy is a pretty old doc though and I think he was grandfathered in. But yeah, seems like the really rural/undesirable places continue to be a bit more desperate. I've gotten like 3 emails in the past month from FM recruiters in Alaska offering what sounds like a pretty good deal for primary care. Beggars can't be choosers.

Yeah, I know of several rural sites where IM/FM still practice in the ED and perhaps always will given less desirable. I just am surprised there are any cities that are still employing FM/IM in the ED. Even the small cities that I’m familiar with have required ABEM certification for a long time. I think Groove is in the SE. Perhaps it’s still common there. I’m the least familiar with that region.

 

[Groove]

Where in the world of small to medium to large cities are there still IM/FM physicians in the ED. All the cities and EDs that I know well have required ABEM certification for over a decade.

S and SE. Not everyone is exactly climbing over themselves to move down here. Prob around 11 hospitals in my greater city area and only 3 that have ABEM bylaws. Pretty common in my neck of the woods though rapidly changing.

I find it interesting that this is less common everywhere else. Maybe we don’t have as much time as I thought.

The unusual part is that a lot of our new grads have been transplants from all over the US which is really uncommon for this area traditionally. Prob due to the tightening job market. At this pace, I anticipate more local shops will soon follow suit on ABEM bylaw changes. Luckily, I haven’t seen wages decrease…yet.

 

[alpinism]

There was just a post on the EM docs Facebook Group for a job in SoCal that was accepting FM trained Physicians.

They’re paying 200/hr for 2 PPH nocturnist.

 

[Mbekweni]

I wish there was a better path to work WITH FM/IM in the ER as double coverage or extender. I would love to have double coverage with another doc than a PA but then you enter issues with pay equity etc. No reason an FM doc with 20 years of experience can’t do as well as a fresh grad out of PA school but there just isn’t a path for that. Although that FM doc would probably want to make the same as EM rather than $100-125/hr all in including benefits that PA is getting.

 

[Pudortu]

After today’s match day misery, I can see that we are going to really get screwed sooner than what most people think. In fact, I would say 90% of my colleagues have their heads buried in the sand. “What acep jobs report?” Is what I heard today. All these unfilled spots will fill with garbage quality residents further devaluing us in the eyes of our peers and the hospital. My assumption is these people are saddled with debt and will do anything for that “sweet $100/hour” job.

 

[Mount Asclepius]

The nostalgic idea of an EP is a failed paradigm.

EM is a thing. It’s just no longer actually Emergency Medicine. It’s ACM. Acute Care Medicine. EPs value isn’t in ACM. We’re pretty good at it, but most of our prior training was for EM. We were line slinging, tube dunking saviors of the critically ill (for a few hours).

The system doesn’t need or want the EPs that we want to be. They want metric-focused docs that want to be hourly, not run a physician business/practice, and are fine with decreased pay. It’s not a whole lot different than the concept of a midlevel. It’s move through the herds of worried well and dish out consults to sub-specialists who manage actual problems.

Ride the last of the gravy train. It’s circling the toilet.

Feeling a little cynical after a run of shifts, and also after I transferred a trauma to a tertiary trauma center with complex injuries only to see an EM midlevel see the transfer in the ED, admit the transfer to the trauma surgery service where seen by a midlevel, and then have consults by orthopedic surgery and neurosurgery midlevels. Our surgeons couldn’t “handle” the injuries at our lower level trauma center, and so we sent it out to have PLPs save the day. End rant.

 

[xaelia]

 

[RustedFox]

After today’s match day misery, I can see that we are going to really get screwed sooner than what most people think. In fact, I would say 90% of my colleagues have their heads buried in the sand. “What acep jobs report?” Is what I heard today. All these unfilled spots will fill with garbage quality residents further devaluing us in the eyes of our peers and the hospital. My assumption is these people are saddled with debt and will do anything for that “sweet $100/hour” job.

Okay.

I've been a doomer on here for awhile. I am (was) King Ashtray of Burnout.

If these spots don't fill...

... increased demand for EPs?

I mean... They can't all just fill with crazypants applicants from East Uruguay school of medicine....

 

[GonnaBeADoc2222]

Okay.

I've been a doomer on here for awhile. I am (was) King Ashtray of Burnout.

If these spots don't fill...

... increased demand for EPs?

I mean... They can't all just fill with crazypants applicants from East Uruguay school of medicine....

Oh but they can.

I'm in full doomsday mode.

Culture at my shop is toxic AF and getting worse.

I'm working on multiple escapes.

 

[JacobMcCandles]

After today’s match day misery, I can see that we are going to really get screwed sooner than what most people think. In fact, I would say 90% of my colleagues have their heads buried in the sand. “What acep jobs report?” Is what I heard today. All these unfilled spots will fill with garbage quality residents further devaluing us in the eyes of our peers and the hospital. My assumption is these people are saddled with debt and will do anything for that “sweet $100/hour” job.

I don’t really see today as helping or hurting the future. There was 3000 EM spots yesterday and there’s still 3000 EM spots today. For those who are already out or who go to real programs, they should have an advantage. I don’t think these residencies getting filled by SOAPers is necessarily a bad thing compared to getting filled with rockstars since the number of EPs won’t change. Hopefully interest remains low and the HCA residencies at Bum**** Regional will crater.

 

[Boatswain2PA]

What will really be interesting is what happens to physician supply when Envision/TeamHealth/USACS tries to implement national wage controls. The unintended consequence might be thousands of physicians opting out of clinical work altogether, which may push wages back up.

I don't see them implementing formal wage controls, but rather controlling other "industry standards" like pph, LWBS, paying for own scribe, etc that puts more money in their pocket.

The wage controls were happening organically as they took larger and larger swaths of the industry. Of course, they will add in dishonesty as well (UNLIMITED RVU POTENTIAL!!!!!...but we count RVU's wayyyyy differently than the company we bought out so you have zero chance of getting any bonus).

 

[RustedFox]

I don't see them implementing formal wage controls, but rather controlling other "industry standards" like pph, LWBS, paying for own scribe, etc that puts more money in their pocket.

The wage controls were happening organically as they took larger and larger swaths of the industry. Of course, they will add in dishonesty as well (UNLIMITED RVU POTENTIAL!!!!!...but we count RVU's wayyyyy differently than the company we bought out so you have zero chance of getting any bonus).

This already happens at my shop.

 

[Boatswain2PA]

This already happens at my shop.

Mine too. Was promised possibility of 20% raise, wound up with a 20% cut despite doing EVERYthing I could do to improve my RVUs. That's when I said Fck y'all, I'm out. (stayed part time because I love the team, and makes me better at my low-volume rural jobs).

Now they are losing docs, and the experienced ones who remain are crispy. I mean....REALLY crispy. New ones young with tons of energy, but walk out of every shift looking like they got their a$$ beat. Don't see the emotional fortitude in them to last long doing this, but I could be wrong.

 

[xaelia]

The NSA is crushing EM – playing right into the hands of payors:

Opinion | The Surprise Effect of the 'No Surprises Act' on Emergency Physicians

Doctors and facilities are bearing the excess burden

www.medpagetoday.com

And then you have all the pandemic carve out extra funding drying up, among others ...

It's definitely not getting *better* for hospitals and those who depend on hospital revenue to pay their wages.

 

[Boatswain2PA]

The NSA is crushing EM – playing right into the hands of payors:

Opinion | The Surprise Effect of the 'No Surprises Act' on Emergency Physicians

Doctors and facilities are bearing the excess burden

www.medpagetoday.com

And then you have all the pandemic carve out extra funding drying up, among others ...
View attachment 367625

It's definitely not getting *better* for hospitals and those who depend on hospital revenue to pay their wages.

Can't argue with the article after a quick read....

...but written by two docs from USUCS and one from Summa....

 

[xaelia]

Can't argue with the article after a quick read....

...but written by two docs from USUCS and one from Summa....

Big CMGs want their money for corporate jet retreats just as much as the little guy wants it for his mortgage.

 

[cyanide12345678]

Where in the world of small to medium to large cities are there still IM/FM physicians in the ED. All the cities and EDs that I know well have required ABEM certification for over a decade.

Lol hell no.

I’m technically affiliated with a power house residency program consistently considered one of the best in the country.

Their system has some 16 or so hospitals i think. Other than the main residency shop in downtown and the children’s hospital in downtown, every other hospital has a large proportion of FM docs. One of their level 3s where i work has >50 percent FM docs. Their rural sites have a couple of younger ER docs, everyone else is FM.

 

[GonnaBeADoc2222]

CMG land sounds horrid.

Don't worry, hospital employed land is just as bad.

All responsibility, no authority, zero support.

 

[Mount Asclepius]

Lol hell no.

I’m technically affiliated with a power house residency program consistently considered one of the best in the country.

Their system has some 16 or so hospitals i think. Other than the main residency shop in downtown and the children’s hospital in downtown, every other hospital has a large proportion of FM docs. One of their level 3s where i work has >50 percent FM docs. Their rural sites have a couple of younger ER docs, everyone else is FM.

If I remember correctly this is in the Midwest. Also not as familiar with this region. Historically not as desirable. Certainly a good fit for some though.

Also a little misleading as EM residents have to staff with EM attendings. Maybe affiliated with the university system, but I’m guessing all those outlying sites are smaller and not in decent sized cities. Most Midwest states are only going to have a handful of what I’d consider small to medium sized cities.

 

[Franzd'Epinay]

The nostalgic idea of an EP is a failed paradigm.

EM is a thing. It’s just no longer actually Emergency Medicine. It’s ACM. Acute Care Medicine. EPs value isn’t in ACM. We’re pretty good at it, but most of our prior training was for EM. We were line slinging, tube dunking saviors of the critically ill (for a few hours).

The system doesn’t need or want the EPs that we want to be. They want metric-focused docs that want to be hourly, not run a physician business/practice, and are fine with decreased pay. It’s not a whole lot different than the concept of a midlevel. It’s move through the herds of worried well and dish out consults to sub-specialists who manage actual problems.

This is how it is in many other countries.

In parts of Europe, the equivalent of ALS will have an intensivist (usually an anesthesiologist) on-board. Truly sick people start getting high-level care on-scene and en-route. Once they get to the hospital, these patients fully bypass the ED to go to the relevant ICU directly. The ED is fully staffed with FM (or IM) docs and there is an understanding that anyone remotely ill gets immediately moved upstairs.

 

[endo]

Acgme keeps approving and allowing new EM
Residencies to open. I hear about it all the time with the EMRA emails.

I also have it on good authority that usacs is even trying to open their own EM residency in Cincinnati. Wtf

A USACS residency in Cinci? As a Cinci residency graduate I find this highly offensive. Cinci is EM sacred ground…

 

[thegenius]

Test 'n' Pills

 

[RustedFox]

Test 'n' Pills

I remember this joke.
It's still funny.

 

[The Knife & Gun Club]

So now that I’m technically employed by an anesthesia department I have seen some interesting trends from their side as they’ve survived the mid level onslaught decently well especially in the last few years.

It was all doom and gloom for them a decade ago, then their departments started to diversify and add a much larger toolbox of things to offer to the hospital systems that CRNAs alone could not. You hire one anesthesiologist and you get someone who can provide general OR coverage, do peri-op nerve blocks, post op and inpatient pain consults, pre-operative clinics and a whole slew of other things that you just can’t use a CRNA for. Train that anesthesiologist out with one extra year of fellowship in something fancy like pain or cardiac or critical care and they can cover the unit, a procedure clinic, do TEEs, bronchs, Trachs, pugs etc.

They market one anesthesiologist as far more versatile and able to provide a much larger umbrella of services than several CRNAs.

I could see EM doing something similar with an enterprising department in the hospital. Get a few EM docs with advanced training of some sort in areas outside of the ED and suddenly one EM physician can provide a much wider variety of services than a MLP ever could.

Of course this would require EPs to supplement their training and be OK with not necessarily being the doc just grinding away in the pit but that seems like a reasonable trade to me.

 

[The Knife & Gun Club]

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.

Heck One of our EM docs just got credentialed to do procedures under flouro on admitted patients.

One of the EM ultrasound peeps is working on getting a “resuscitative TEE” program off the ground - where just popping in the TEE probe and looking at the heart during cardiac arrest generates several RVUs.

 

[RustedFox]

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.

Heck One of our EM docs just got credentialed to do procedures under flouro on admitted patients.

One of the EM ultrasound peeps is working on getting a “resuscitative TEE” program off the ground - where just popping in the TEE probe and looking at the heart during cardiac arrest generates several RVUs.

... but be sure to be in that emergency department to greet the patient within 5 minutes, optimizing throughout and turnover.

 

[Birdstrike]

I could see EM doing something similar with an enterprising department in the hospital. Get a few EM docs with advanced training of some sort in areas outside of the ED and suddenly one EM physician can provide a much wider variety of services than a MLP ever could.

Of course this would require EPs to supplement their training and be OK with not necessarily being the doc just grinding away in the pit but that seems like a reasonable trade to me.

Yes!

I’ve talked for years on here about adding diverse skills to your stack of skills then using them creatively. Skills useful OUTSIDE of the ED are likely to be a much more powerful combination than those only usefully on the inside.

Don’t look at a fellowship as throwing away one thing and replacing it with another. Look at it as adding a second especially, a second skill, that gives you a unique and powerful combination of skills. Add a touch of creative thinking, refusal to quit and the sky is the limit.

 

[deuist]

One of our biggest failures in medical training is to silo the various disciplines. There's no reason emergency physicians can't do a cardiology fellowship anymore than an internist can't do hyperbarics or toxicology.

 

[psychemdoc]

One of our biggest failures in medical training is to silo the various disciplines. There's no reason emergency physicians can't do a cardiology fellowship anymore than an internist can't do hyperbarics or toxicology.

Totally agreed. I think PEM is interesting because it’s an example of a fellowship that is available with separate curriculums from both Peds and EM. Peds does it in 3 and EM does it in 2. Now why isn’t anesthesia and EM like that? Make that pipeline easier. 2 year fellowship? How many EM docs would switch to that after 10-15 years in the pit and they just want outpatient surgical center to sit and blow away their savings while stock trading?

I have been in agreement entirely with Birdstrike from the moment I started med school that EM just seems so narrow. It should have been a fellowship off of family or something. Because the skills are very handy in other specialties and there would be even more career longevity. I hate to see docs stop working because of burnout when they desire to continue working otherwise. Additionally, by it being so siloed it gets no respect as other specialties don’t know what happens there. It also doesn’t offer a way out of the ER without a primary specialty in something clinic based. Anyway the fragmented system plus the RVU system leads to a lot of unnecessary physician infighting and turf wars for no reasons. Don’t get me started on IM vs FM fellowship options. Like why in the world are some of these fellowships that are almost entirely outpatient clinic based not available to FM docs? Endocrine? Infectious? Rheumatology? ALLERGY??? When’s the last time you saw an allergist in the hospital? I double dog dare you to name one minus an ivory tower.

Rant over.

 

[ScepticSkeksis]

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.

Heck One of our EM docs just got credentialed to do procedures under flouro on admitted patients.

One of the EM ultrasound peeps is working on getting a “resuscitative TEE” program off the ground - where just popping in the TEE probe and looking at the heart during cardiac arrest generates several RVUs.

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".