Bittersteel
Full Member
Ofc we have midlevels. What profitable group doesn't?
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Leaving EM
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Ofc we have midlevels. What profitable group doesn't?
This begs the question
Is the improvement of patient outcomes for ED trained docs over non ED trained docs worth the cost of having ED trained docs?
This may be the fatal flaw with the EM specialty where 80% of our patients don't need to be there at all. 80% of the remaining 20% are simple cases that could be easily taken care of by a 1st year NP. 80% of the remaining 4% are complicated and really need a skilled emergency clinician, but not one who did four years of medical school and then 4 years of EM residency. Of the remaining 0.8%, the cases where it is the advanced skills of the EM doc which MIGHT make or break the case....how many of those are going to have a poor outcome regardless?
It is as the margins where the differences are made, like the early administration of antibiotics in sepsis. But really, how much better is 10 minutes versus 40 minutes?
But what is the cost to the healthcare system to apply that margin (a BC EM doc) to every ED compared to other ED providers (EM fellow trained FM, EM trained PAs, etc), and are the marginal benefits worth that cost?
Bittersteel
Full Member
Most elective cholecystectomies don't need to happen.
Of those that do most could be done by a PA.
Of those that can't, they certainly cant be done by a new grad attending.
Does society need to bear the cost of training general surgeons?
See what I did there?
Yeah, ridiculous argument.
“Most people use the ER inappropriately. Therefore, the few people that REALLY need the ER should have to see people of lesser training.”
“Most radiology reads are simple and can be done by PAs. Therefore, the complicated and subtle findings should just be missed since it’s not worth it to have a radiologist find the needle in the haystack.”
You either want a system of excellence, or you don’t.
Bittersteel
Full Member
From your posts it seems like your a fellow SDG enjoyer.
Most people here have been so kucked by CMG / hospital employment that they're at the point where they think FM belongs in the ED, EM training is unnecessary, snd slinging z packs for $25 a pop is worthwhile work.
Yeah, you asked a slightly different question, and turned it into an argument.
What IS the difference in patient outcomes between a BCEM physician and other EM providers (Fellow trained FM, FM, EM trained PA, EM trained NP, dermatologist moonlighting, etc)?
I'm not arguing. Just asking a question.
Perhaps asking the same question on a slightly different but related topic: What IS the difference in patient outcomes between a 4 year EM resident trained doc and a 3 year EM resident trained doc?
If there isn't a difference, or isn't much of a difference, then I would argue that we should indeed consider we are overtraining for EM.
We all love Ketamine. But the outcomes show etomidate should be our go-to for intubation in sepsis, despite our concerns for adrenal suppression.
We should follow the data.
Bittersteel
Full Member
Great research question.
Lets do the same for Neurosurgery, plastics and cardiology. Whats the difference?
I can only tell you what I see from FM/other types of docs doing EM. They have problems with volume, acuity, balancing multiple critical patients at the same time, understanding Emergency conditions first then benign conditions later, and going the additional mental step to why did something happen.
I am not sure any of this could be quantified in a reasonable way. It would require an immense study (design, sample number, $$$). It would also be seen as inflammatory in the House of Medicine as well.
As for why 4 year vs 3 year, the majority of the 4th year is “elective” style education or ER leadership style education in the setting of a very advanced level ER. The majority of ERs in America are not this advanced. I see no need to “waste” a year of economic output for a doctor in this way. But that is my personal belief.
Your sarcasm is late compared to real life:
NPs doing TAVRs now
Interventional cardiology up in arms but no one will do anything
Again, when the dollar is god, the worshipper is irrelevant
Bittersteel
Full Member
I'm sure your hospital system would benefit.
Will more money flow to the docs because of the savings?
Will you sign up for an NP to do your TAVR?
Just giving you real answers here from the perspective of someone looking out for the interests of a very, very large pie with many stakeholders, both docs and non-docs
"Will more money flow to the docs?" is not a question any healthcare executive asks, ever, in the history of healthcare. Anyone in an admin role can step in and tell me I'm wrong there, I'd love to be challenged on this.
the actual question is, and always will be, "will more money flow?" Of course, ensuring doctors are paid is a proper priority, but you're fully delusional if you think it's anyone's #1 priority.
And the answer to that question is what decides the future.
Bittersteel
Full Member
I'm fully aware that "will more money flow to the docs" is neither your's or administration's priority.
You're still not getting it
It's no one's priority. But yours. Only docs advocate for docs, in the same way nursing unions advocate for nurses--they don't care about you--and you don't care about them, unless I'm wrong and you go to their union meetings.
I'm not trying to antagonize you, it's just how things work. Be cautious of the hubris of "I'm an irreplicable part of the system", because that's the fastest way to get replaced.
If you feel you have irreplaceable value, you've got to show it.
I say that because I do worry about a future where cost-minded systems DO actually try to fully replace their ED docs with cheaper midlevels/AI and just eat the 0.1% zebra lawsuits along the way. There's a reeeeeal route to that happening, and it worries me.
BTW the best way to demonstrate value is to do what most ED docs would never want to do, and do some admin work/get involved with hospital work outside of ED dynamics/financials. I think one of the biggest weaknesses of EM, having seen it from both sides, is that EM docs love to be so invisible to things outside of their shiftwork they literally become exactly that--invisible
It's no one's priority. But yours. Only docs advocate for docs, in the same way nursing unions advocate for nurses--they don't care about you--and you don't care about them, unless I'm wrong and you go to their union meetings.
I'm not trying to antagonize you, it's just how things work. Be cautious of the hubris of "I'm an irreplicable part of the system", because that's the fastest way to get replaced.
If you feel you have irreplaceable value, you've got to show it.
I say that because I do worry about a future where cost-minded systems DO actually try to fully replace their ED docs with cheaper midlevels/AI and just eat the 0.1% zebra lawsuits along the way. There's a reeeeeal route to that happening, and it worries me.
BTW the best way to demonstrate value is to do what most ED docs would never want to do, and do some admin work/get involved with hospital work outside of ED dynamics/financials. I think one of the biggest weaknesses of EM, having seen it from both sides, is that EM docs love to be so invisible to things outside of their shiftwork they literally become exactly that--invisible
Bittersteel
Full Member
No. I get it.
I'm aware that everyone except pit physicians are tirelessly attempting to erode the perceived value of our work.
The funny thing is, the second any of these people find themselves in a situation where they need care, they demand a board certified physician, and want it NOW.
Rules for thee but not for me.
I refuse to participate in any effort that further cheapens our value.
That's excellent. Because I strongly encourage you--and anyone reading this--to do everything they can to have as much demonstrated value as possible.
I gotta be honest, when I first went into EM the "clock in, clock out" part was a huge sell. But I sincerely didn't know that when you become a cog, you have the value of a cog. When you leave, you don't take a huge patient panel with you. You don't take the entire ED with you in the same way a transplant doctor leaving might shut down the transplant service. They just find a new warm body to fill that chair, or an entire other group to do it if done en masse
So it's incumbent on everyone to show value, because you are 1,000% right that there is very active effort to erode the value of your work.
Of course, I'm well past the "bitch and moan" phase of my life. I'm very much in a "what can I do?" phase. Long term, getting ED physicians off the island that could sink any moment (with few noticing) and join the mainland--where we ALL sink or swim, together--is a priority for me
I gotta be honest, when I first went into EM the "clock in, clock out" part was a huge sell. But I sincerely didn't know that when you become a cog, you have the value of a cog. When you leave, you don't take a huge patient panel with you. You don't take the entire ED with you in the same way a transplant doctor leaving might shut down the transplant service. They just find a new warm body to fill that chair, or an entire other group to do it if done en masse
So it's incumbent on everyone to show value, because you are 1,000% right that there is very active effort to erode the value of your work.
Of course, I'm well past the "bitch and moan" phase of my life. I'm very much in a "what can I do?" phase. Long term, getting ED physicians off the island that could sink any moment (with few noticing) and join the mainland--where we ALL sink or swim, together--is a priority for me
You see a conspiracy to "erode the value of your work." Could it instead be a simple matter of those around you trying to maximize their own profits while being agnostic to the value of your work?
UPMC did it at my old hospital - NPs with no doctor in house. They have medical direction available 100 miles away. Honestly, I don't know what they do when a pt needs a tube or a chest tube, or need a joint reduced.
I'm guessing they intubated, put in the chest tube, and reduced the joint.
Over the last 65 years healthcare has expanded and expanded, with our ability to "save" those who were once on the margins of survival growing tremendously. This is PART of the ever-growing expense of healthcare which now stands at $5.3 TRILLION (18% of our GDP) , including $2.18 TRILLION paid directly by Uncle Sam. And to remind you, Uncle Sam's credit card has a $40.5 Trillion balance.
We all know something is going to give somewhere at some time.
Bittersteel
Full Member
Lol sure they did
NPs? I think you are giving too much credit!
Most of them I would agree with you as they haven't had training/education to do that.
But I know a few who are competent ED providers.
Paramedics do a lot of field intubations.
Uh, yeah, I know that. After all, I have talked at length on SDN how I was a paramedic before med school!
NPs don't get any experience tubing or placing chest tubes. And, I don't think (strongly) that they get any Ortho training.
In a world full of absolutely useless NP programs, there are a couple of good ENP (emergency nurse practitioner) programs with reasonably good education.
Only a fraction of MD/EM education, but still pretty good.
Watch out! A few folks here will flame you into submission!
I don't see any mention of NPs actually performing TAVRs. Only that they need to be aware of treatment options for AS and refer to structural heart team when appropriate.
got wires crossed, here you go
Nurse Practitioners Doing TAVI? What’s Gained and Lost
(UPDATED) Cardiology orgs were caught flat-footed after a world-renowned TAVI program tweeted out its congrats to an ANP lead operator.
TAVI=TAVR
If this can be done by a NP (not trying to start anything here) does it then highlight that maybe our medical education needs to be redone?got wires crossed, here you go
Nurse Practitioners Doing TAVI? What’s Gained and Lost
(UPDATED) Cardiology orgs were caught flat-footed after a world-renowned TAVI program tweeted out its congrats to an ANP lead operator.www.tctmd.com
TAVI=TAVR
Wasn't there a place NPs were doing scopes? Give a 16 year COD player chat GPT and train him/her on scopes for a week at this point. My argument isn't that NPs or PAs are bad; I just wonder is all this training necessary for us then? I think the answer is no. I'd love to retrain into a different specialty because I am bored of EM but the road is long and hard to change track.
Honestly not trying to be edgy, sarcastic, or witty...just thinking about this alot.
NPs in ICU at night here, respiratory intubates, NPs ran SICU at residency did tubes and lines.
Bro the cog part hit deep. That was the draw for me and is now the curse. I thought cool this will be great; how I realize what my position/value is.
Most physicians believe they are special because they spend 11+ years in school.
Medical education is overkill IMO. It should be 2 yrs of prereqs after HS, 3 yrs (18 + 18 months) of med school and 2-6 yrs of residency.
Eh, to my thinking its not the actual hours that matter (although that makes an easy talking point). Its that as a result of that time we know way more and have much more experience.
The knowing more part might not matter for outcomes, that can be tricky to study. The experience is what really matters. We've seen more of the bread and butter and more of the zebras. That matters. Or, it would if we weren't such a litigious society and refer everything to specialists.
I agree. Back in the day I could understand the need to be there to see it all but with all the resources at our fingertips do you need to be in the hospital to see every complication? I think this mentality of living at the hospital went back to the old days but doesn't make sense anymore. In the real world most complications get referred out. Why can't we learn from the NP/CRNA model and make changes.
I don't see any meaningful changes made by our end; however, I do think the NPs will continue to close the gap with more autonomy and procedures. NPs doing diagnostic caths was studied decades ago with surprisingly better times https://pubmed.ncbi.nlm.nih.gov/9326997/. Old studies I know but just a safe space to have these discussions. Apparently Nurse endoscopists are firmly established in the UK, with 350 nurses currently in practice as of 2009.
Could I with my MD work with a cardiologist and get trained on diagnostic caths and do this if I wanted to? Just rambling here but thinking about my MD experience and training yet I can't leave to do anything other than urgent care or go get a fellowship to waste more time. My NP left from the ER and now works in cardiology. Doesn't do caths obviously. Did it in a couple of weeks.
Bittersteel
Full Member
Way too much academic gate keeping in the physician world.
An EM physician cant easily leave the ED to be trained to do endoscopy or cardiac caths but some Jenny McJennerson can go from adult primary care to ortho to oncology to pediatrics.
