How much time do we have?

[Siggy]

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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.