Locums appears dead

[emergentmd]

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BFE 45 min away from a BFE City, TX
8,500 annual visits
Level 4 trauma
24 hr MD/DO (8a-8a)
24 hr MLP (8a-8a)
ATLS, ACLS, PALS, NRP – Required (can be taken there)
Any boards – no AAPS
EMR : Meditech
$3,480/shift

Less than $150/hr. 23ppd. When its time to sleep, do you have to flip a coin? Terrible, just Terrible job.

 

[Fox800]

And the wonder why they can't get filled.

 

[Apollyon]

Exactly. Pay bottom wages, get bottom workers.

 

[emergentmd]

Why would anyone do these shifts when they can work in a major Tx city at 250+ or 170+ at a FSER with half the volume?

 

[Alvarez13]

Locums has taken a hit over the last year. Combination of a lot of factors:
- I've ran into several doctors at other sites in the south and even up in WI that have fled TX now that those rates have plummeted.
- Envision and TeamHealth are expanding left and right and trying hard to use internal locums. My internal locum agreement with a group in St Louis got devoured by TeamHealth who states I was property in their buyout and now I'm stuck with D&Y if I want to work at that site. Rate unchanged for time being, but this CMG has been known to drop pay by $30/hr when they feel like it. They won't negotiate with outside docs like they used to.
- Will probably have more EM specialized residencies than general colleges in FL if HCA keeps funding residency expansion to flood the market
- Another Envision site I'm at has 2 MDs covering 5-6 PA/NPs at a time to cover their 70k/year site. Who cares if someone dies because the ***** midlevel can't read an ECG or have sense to maybe tell the MD about "ACUTE STEMI" in all CAPS at the top of it. They're cheap and can bill at MD levels if we take on their liability. Another hit to our demand.

 

[gamerEMdoc]

At 23 patients per day, that's 0.5 patients per hour (assuming the work is split between the MLP and the MD/DO. So if you are only seeing 0.5 PPH, I wouldn't call that a terrible job. Personally I'd rather work harder and make more. But on the other hand, we can't see 1/2 the number of PPH that my interns see and expect to make 300/hr either.

 

[MechEDoc]

How did this field go so wrong? Take a small hospital that can't afford much. If they offer general surgery, they have a general surgeon. If they offer cardiology, they have a cardiologist. If they offer emergency medicine… They might have a NP, a PA, a family medicine doctor, a moonlighting neurologist, or possibly someone who never was board-certified in anything.

We have no professional standards.

Lawsuits against these facilities should be like shooting fish in a barrel.

 

[RustedFox]

How did this field go so wrong. Take a small hospital that can't afford much. If they offer general surgery, they have a general surgeon. If they offer cardiology, they have a cardiologist. If they offer emergency medicine… They might have a NP, a PA, a family medicine doctor, a moonlighting neurologist, or possibly someone who never was board-certified in anything.

We have no professional standards.

Lawsuits against these facilities should be like shooting fish in a barrel.

Four letters, man.

A. C. E. P.

 

[Fox800]

How did this field go so wrong? Take a small hospital that can't afford much. If they offer general surgery, they have a general surgeon. If they offer cardiology, they have a cardiologist. If they offer emergency medicine… They might have a NP, a PA, a family medicine doctor, a moonlighting neurologist, or possibly someone who never was board-certified in anything.

We have no professional standards.

Lawsuits against these facilities should be like shooting fish in a barrel.

They don't get an eff about properly staffing the ED, because we don't bring money in like a surgeon does. We're an expendable widget.

 

[Boatswain2PA]

BFE 45 min away from a BFE City, TX
8,500 annual visits
Level 4 trauma
24 hr MD/DO (8a-8a)
24 hr MLP (8a-8a)
ATLS, ACLS, PALS, NRP – Required (can be taken there)
Any boards – no AAPS
EMR : Meditech
$3,480/shift

Less than $150/hr. 23ppd. When its time to sleep, do you have to flip a coin? Terrible, just Terrible job.

WOW. I work in a 9000+ annual visit shop, also a level 4 trauma center, with single coverage PA/NP.

How did this field go so wrong? Take a small hospital that can't afford much. If they offer general surgery, they have a general surgeon. If they offer cardiology, they have a cardiologist. If they offer emergency medicine… They might have a NP, a PA, a family medicine doctor, a moonlighting neurologist, or possibly someone who never was board-certified in anything.

We have no professional standards.

Lawsuits against these facilities should be like shooting fish in a barrel.

A question I have is ARE THERE DIFFERENCES in outcomes between EDs who staff with BC/BE EPs, EDs who staff with non BC/BE EPs, and EDs who staff with PA/NPs? I know the NPs have poorly done research inferring no differences, but has ACEP/AAEM done any research on this?

If there are no differences in outcomes, then perhaps we should do things differently....

 

[anon6134]

If there are no differences in outcomes, then perhaps we should do things differently....

I am an M4 on a school mandated FM rotation during my last weeks of school and the PA working in the office just today asked if I could interpret the EKG she ordered on her chest pain patient because she "sucks at EKGs" and didn't know what to do with this lady.

I don't need a study to tell me what to think about my limited experiences with you guys but congrats on your single coverage

 

[Boatswain2PA]

And congrats on your upcoming graduation.

There are lots of FM docs (along with peds, rads, orthos, urologists, neurologists, dermatologists, etc ad nauseum) who suck at EKGs. I've had several FM docs send me an EKG to look at because they know I'm highly competent in reading them.

Worse yet, some (many?) CMG staffed EDs require all EKGs to be signed off by the EP/MD, so some Emergency PA/NPs don't feel the need to become EKG experts.

But the question remains, WHAT IF all of the training and specialization an EP gets does not lead to better patient outcomes? I would imagine it would, but what if it doesn't?

 

[Rekt]

And congrats on your upcoming graduation.

There are lots of FM docs (along with peds, rads, orthos, urologists, neurologists, dermatologists, etc ad nauseum) who suck at EKGs. I've had several FM docs send me an EKG to look at because they know I'm highly competent in reading them.

Worse yet, some (many?) CMG staffed EDs require all EKGs to be signed off by the EP/MD, so some Emergency PA/NPs don't feel the need to become EKG experts.

But the question remains, WHAT IF all of the training and specialization an EP gets does not lead to better patient outcomes? I would imagine it would, but what if it doesn't?

The fact that "patient outcomes" is the only metric you mentioned means you really don't have any clue.

 

[Boatswain2PA]

So clue me in? What other metric should I use? Patient satisfaction??

When I say "patient outcomes" I mean morbidity and mortality outcomes. Does a patient presenting with STEMI, stroke, hypertensive encephalopathy, appendicitis, shoulder dislocation, psychiatric distress, rash, runny nose, or (you pick your presentation) have a better outcome when they see a BC/BE EP than when they see a non BC/BE EP, or a PA/NP.

 

[namethatsmell]

But the question remains, WHAT IF all of the training and specialization an EP gets does not lead to better patient outcomes? I would imagine it would, but what if it doesn't?

From your posts on here, you sound like a PA of rare talent and ability. I commend you for this.

I would estimate that I'm a fairly average physician, but I'll attempt to answer your question.

If the training and experience of an EP doesn't lead to better patient care and outcomes compared with that of a PA/NP then we should have cessna pilots flying commercial 787s, paralegals arguing in court instead of lawyers, the bartenders make the food at restaurants instead of the chefs, mall security officers do the job of swat teams, people good at math should replace accountants, and I should be playing on the PGA tour since I can golf.

WHAT IF all of the training and specialization an EP gets does lead to better patient outcomes when compared to PA/NPs? If there is a difference in outcomes, then perhaps we should do things differently....

 

[Boatswain2PA]

Taking the last one (you playing PGA) because it's probably the easiest to quantify outcomes...

Yeah, if you had the same outcomes as a PGA golfer, you should do that. Fortunately it's easy to measure those outcomes.

It's more difficult to measure ED outcomes, but it shouldnt be impossible. Why hasn't ACEP or AAEM studied and published this?

If the outcomes ARE different. I'm still not sure what we could/should do differently. Half the posters here complain about too many residency programs driving down wages, and the other half complain about the damn mudbloods (non-boarded docs, PAs and NPs) who are taking over shops they would never want to work in anyway.

 

[namethatsmell]

Taking the last one (you playing PGA) because it's probably the easiest to quantify outcomes...

Yeah, if you had the same outcomes as a PGA golfer, you should do that. Fortunately it's easy to measure those outcomes.

It's more difficult to measure ED outcomes, but it shouldnt be impossible. Why hasn't ACEP or AAEM studied and published this?

If the outcomes ARE different. I'm still not sure what we could/should do differently. Half the posters here complain about too many residency programs driving down wages, and the other half complain about the damn mudbloods (non-boarded docs, PAs and NPs) who are taking over shops they would never want to work in anyway.

If we were measuring happiness outcomes I can assure you my happiness would outweigh that of the current PGA pros.

As to your second point, why haven't we rigorously studied what's better for a human: jumping out of an airplane with or without a parachute?

For your last point, I partly agree--the majority of us complain about the supply of people hired to see patients in the ED. The part I don't agree with is the PAs/NPs "taking over shops" EPs woundn't want to work in anyway. One of my old groups was bought out by a CMG. Within 6 months the CMG had replaced 33% of the doc hours with PA/NP hours, so there'd be times I was only doc working alongside 2-5 PAs/NPs. The ED was profitable before the CMG made this change. They CMG just wanted more profit and didn't mind compromising patient care (it was a high acuity shop with few resources). I really like working there before this change and would have never left that shop.

There are many other options to meet ED staffing needs other than increasing NP/PA coverage or for-profit hospital chains creating new EM residencies at shops that may not have the clinical pathology to merit them.

 

[RPedigo]

As to your second point, why haven't we rigorously studied what's better for a human: jumping out of an airplane with or without a parachute?

Off topic but the PARACHUTE trial in the BMJ is a randomized controlled trial that studied this and is a fun joke journal club article to sprinkle in.

 

[namethatsmell]

Off topic but the PARACHUTE trial in the BMJ is a randomized controlled trial that studied this and is a fun joke journal club article to sprinkle in.

Actually I'd say that's about on topic. Good to know about the PARACHUTE trial.

I posed my question with this older study in mind: Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomised controlled trials

 

[plick]

BFE 45 min away from a BFE City, TX
8,500 annual visits
Level 4 trauma
24 hr MD/DO (8a-8a)
24 hr MLP (8a-8a)
ATLS, ACLS, PALS, NRP – Required (can be taken there)
Any boards – no AAPS
EMR : Meditech
$3,480/shift

Less than $150/hr. 23ppd. When its time to sleep, do you have to flip a coin? Terrible, just Terrible job.

No, not dead. But it is getting more difficult to find good paying jobs. I can still find places that will pay around $300, but it takes more time and negotiation.

There’s always agencies or “staffing consultants” that will try to lowball you. Just for kicks I wanted to know what the rates some locums companies were offering for a site where I work at part time (where the CMG pays its docs $240/hr). What I found was that some locums companies were actually offering less at around $200-$220 per hour... lol. Others offered more. So the rates doesn’t always make sense. Whoever they’ll sucker into working for less than market rate, they’ll be more than happy to sign you on.

 

[Boatswain2PA]

As to your second point, why haven't we rigorously studied what's better for a human: jumping out of an airplane with or without a parachute?

If we suddenly have a bunch of people jumping out of airplanes without parachutes, and apparently surviving, then the parachute makers should probably do a study to see if parachutes actually DO help.

I agree with you and others here that there certainly SHOULD be differences, but are there? And if so, what are they?

There are many other options to meet ED staffing needs other than increasing NP/PA coverage or for-profit hospital chains creating new EM residencies at shops that may not have the clinical pathology to merit them.

Agreed

 

[GonnaBeADoc2222]

From your posts on here, you sound like a PA of rare talent and ability. I commend you for this.

I would estimate that I'm a fairly average physician, but I'll attempt to answer your question.

If the training and experience of an EP doesn't lead to better patient care and outcomes compared with that of a PA/NP then we should have cessna pilots flying commercial 787s, paralegals arguing in court instead of lawyers, the bartenders make the food at restaurants instead of the chefs, mall security officers do the job of swat teams, people good at math should replace accountants, and I should be playing on the PGA tour since I can golf.

WHAT IF all of the training and specialization an EP gets does lead to better patient outcomes when compared to PA/NPs? If there is a difference in outcomes, then perhaps we should do things differently....

K let's randomize patients to an all mid-level ED and an all physician MD and we will see who does better on the following:

-Speed
-Diagnostic accuracy
-Correct treatment
-Resource Utilization
-Bouncebacks

I don't need a randomized controlled trial to know who is going to win.

The NPs doing their own study is akin to the tobacco industry funding their nonsense studies.

 

[Boatswain2PA]

K let's randomize patients to an all mid-level ED and an all physician MD and we will see who does better on the following:

-Speed
-Diagnostic accuracy
-Correct treatment
-Resource Utilization
-Bouncebacks

I don't need a randomized controlled trial to know who is going to win.

The NPs doing their own study is akin to the tobacco industry funding their nonsense studies.

Well, a double blinded RCT might be a little difficult to design here, but yeah!

The NP studies were terribly done.

 

[crafted222]

If we suddenly have a bunch of people jumping out of airplanes without parachutes, and apparently surviving, then the parachute makers should probably do a study to see if parachutes actually DO help.

Because a bunch of people choose to jump out of airplanes, likely not surviving (i.e suicide) does not mean the parachute maker will take on the liability of making them jump.

You can't claim apparent survival with the outcomes in current practice where acuity and complexities are mostly lower for PA/NP. Your anecdotal experience does not apply either.

It is unlikely that any ethics committee will approve a study that randomizes patients of similar complexity and acuity between EPs and NP/PA.

 

[Boatswain2PA]

It is unlikely that any ethics committee will approve a study that randomizes patients of similar complexity and acuity between EPs and NP/PA

Sure. So how about just studying outcome differences between MD staffed and PA/NP staffed EDs of similar sizes.

Same thing with BC/BE EPs and other MD/DOs.

 

[TooMuchResearch]

Wait. To who exactly do I need to justify the existence of my specialty and value of my board certification?

 

[deleted547339]

Why do we have to keep doing this?

 

[deleted109597]

The counter argument is this. Some people want to see the studies showing we are superior. I argue that they're impossible to create in an RCT fashion, but should be doable in a retrospective observational standard.
More to the point, if we need the studies, then whey don't we let IM/FM/Peds/Disgraced whatever do everything in the hospital. Why only the ER (and in many cases, the ICU). I mean, I've done a few airways, why can't I run anesthesia some days. I'm a doctor too. While I'm at it, I did a surgical internship. I should be able to operate. Path? Rads? Cards?
It's ludicrous that they require BC/BE for literally every job but 2. They require extensive oversight for MLPs in every job but ours.

 

[Alvarez13]

Sure. So how about just studying outcome differences between MD staffed and PA/NP staffed EDs of similar sizes.

Same thing with BC/BE EPs and other MD/DOs.

My PA ordered a CTA of the knee to "rule out septic arthritis" last month. Not a new PA, 10 yrs experience.

Study not necessary.

 

[filhodeinferno]

My PA ordered a CTA of the knee to "rule out septic arthritis" last month. Not a new PA, 10 yrs experience.

Study not necessary.

I know anecdotes aren't great evidence, but they sure are fun to talk about. Just yesterday on of our mid levels asked me if she should order at CTA with runoff of an arm to rule out an artery injury. Went and looked at the limb and there was the spurting artery in question. Great mid level, but damn....I can't imagine some of these people out on their own.

 

[southerndoc]

Hearing these horror stories makes me glad that our NP's and PA's are good. Seriously, they accurately apply clinical decision rules, have appropriate workups, etc. One last night told me "I know they're PERC negative and their Wells is 0, but something tells me they have a PE. Can you go see them?" I saw them, agreed, and told him to order the CTA. Large bilateral PE's.

 

[Boatswain2PA]

Wait. To who exactly do I need to justify the existence of my specialty and value of my board certification?

I think I've heard NPs say the same thing.

 

[Brigade4Radiant]

Wait. To who exactly do I need to justify the existence of my specialty and value of my board certification?

I think I've heard NPs say the same thing.

Ok have NPs work independently and don’t sign on doctors charts

 

[emergentmd]

Sure. So how about just studying outcome differences between MD staffed and PA/NP staffed EDs of similar sizes.

Same thing with BC/BE EPs and other MD/DOs.

Please don't derail my thread. Can't you start your own in the PA forum?

Seriously move this troll/asinine to the PA forum and you will find your own ridiculing you.

I will admit that if you took the top 5% PA, they could hold their own with the bottom 5% of EM trained docs.

But if you grab 10 Random ER trained PAs and 10 Em trained docs, the difference would be night and day.

I work in places with good PAs and I would say they are in the top 25% for PAs but I still get questions that No MD would ever ask me or do. Case in point

Minor MVC and ordered a CT head and neck. I asked him/her why b/c there had to be a good reason. Answer, "I have been taught to always order CT rather than 3View xray" - WTF?

5 yr old with pneumonia with 93% sat resting. "Should I admit this patient". I went over and the kid was drinking, well appearing, no resp compensation. WTF, the pedi floor would be riddled with admissions

I do not blame them for these questions. They do not have the same amount of training and they never care for sick patients by themselves. Thus their knowledge will ALWAYS be inferior. When you are on your own, taking care of the patients on your own, and the final decisions falls on your shoulder - ONLY then will you be a good Practitioner. Confidence can only be learned when you are willing to bear the consequences which a PA never will do.

 

[emergentmd]

WOW. I work in a 9000+ annual visit shop, also a level 4 trauma center, with single coverage PA/NP.



A question I have is ARE THERE DIFFERENCES in outcomes between EDs who staff with BC/BE EPs, EDs who staff with non BC/BE EPs, and EDs who staff with PA/NPs? I know the NPs have poorly done research inferring no differences, but has ACEP/AAEM done any research on this?

If there are no differences in outcomes, then perhaps we should do things differently....

I have worked with some really good 1st yr nursing students. I am sure PAs know more but are we sure that the nursing student will have just as good of outcomes as a PA? Have the PA society done a study that shows PAs truly know more than nursing students and the outcomes are better?

I know this is a stupid question just as your question is stupid.

But in all honesty, I am quite confident that I can train a Brand new Grad nurse in 6 months to better manage an Er than what a PA has learned in 2 yrs.

Let a New grad nurse follow me around for 6 months, I bet they can handle 95% of what comes through an ER which is not true for any PAs I have worked with.

 

[deleted109597]

Just make sure and keep this discussion civil. It's worthwhile, but no need for it to get out of control.

 

[Boatswain2PA]

Seriously move this troll/asinine to the PA forum and you will find your own ridiculing you.

If you need a safe space from my postings there is an ignore feature on these boards.

Have the PA society done a study that shows PAs truly know more than nursing students and the outcomes are better?

If PAs start to feel that nursing students are "taking all the jobs" then that's exactly what I would hope we would do.

As to the rest of your postings, I generally agree with you. Especially your comment about REAL learning taking place when YOU are responsible for the outcomes, not your attending. I also think that is one reason many of you EPs work with the PAs you do. If they never care for the sick patients, and always have to run things by you, they will never be responsible enough to reach that level of learning.

 

[miacomet]

Yes. EM is trending south salary-wise. We are already grossly underpaid for the hours we do, but as long as residency slots keep increasing and students are sucked in, I don't see it changing. If you love it, go for it, of course.

I think the other low- to mid- paid fields are a better ROI than EM, though, since they mainly work a regular schedule. If they volunteered for nights and weekends, their salaries might well exceed EM with lower liability.

 

[Porfirio]

If they never care for the sick patients, and always have to run things by you, they will never be responsible enough to reach that level of learning.

You mean like EM residency? Maybe they should go to medical school then EM residency if they want to do that.

 

[TooMuchResearch]

I think I've heard NPs say the same thing.

Sure, but they have no specialty or medical board certification.

 

[Boatswain2PA]

Sure, but they have no specialty

But they do. They claim specialization, including a new Emergency Nurse Practitioner. Requires them to do their 500 clinical hours in an ED, thus "specializing".

 

[cyanide12345678]

But they do. They claim specialization, including a new Emergency Nurse Practitioner. Requires them to do their 500 clinical hours in an ED, thus "specializing".

I'm sorry but 500 hours is about 8 weeks of residency training. I sure as hell do not trust a September intern with ANYTHING, even if they have had 500 clinical hours. They would be watched like a hawk, because they still don't know anything. And this is after thousands more clinical hours in medical school.

 

[miacomet]

Back to the original topic- I can't imagine taking any of these: https://smartphysicianrecruiting.com/find-a-job/#s=1

Note the anesthesia gigs look WAY better.

 

[GonnaBeADoc2222]

You mean like EM residency? Maybe they should go to medical school then EM residency if they want to do that.

Generalization for sure but most midlevels I encounter and students that want to be midlevels lack a desire for lifelong inprovement. They repeat the same errors (partly out of ignorance and sometimes I think out of active defiance). When I ask the students who want to be midlevels the reason for their choice they say "it's faster and I want to make money sooner."

The midlevels I work with do not ask intellectual questions about physiology and pathophysiology. They graduate from midlevel school and think they have it figured out. They present at the level of an MS2 at best (subjective and objective without any assessment or plan).

If that's what we want to say is equivalent to a physician that's fine but you should know what you're buying.

 

[miacomet]

Most physicians are woefully uneducated, but at least know medicine. Midlevels miss the mark on both, and also refuse to work nights/weekends/holidays, which would be their main useful function. Smarter career choice, though.

 

[cyanide12345678]

Back to the original topic- I can't imagine taking any of these: https://smartphysicianrecruiting.com/find-a-job/#s=1

Note the anesthesia gigs look WAY better.

Unfortunately smart offers better rates than comp health and the big locum companies.

 

[Splenda88]

From your posts on here, you sound like a PA of rare talent and ability. I commend you for this.

I would estimate that I'm a fairly average physician, but I'll attempt to answer your question.

If the training and experience of an EP doesn't lead to better patient care and outcomes compared with that of a PA/NP then we should have cessna pilots flying commercial 787s, paralegals arguing in court instead of lawyers, the bartenders make the food at restaurants instead of the chefs, mall security officers do the job of swat teams, people good at math should replace accountants, and I should be playing on the PGA tour since I can golf.

WHAT IF all of the training and specialization an EP gets does lead to better patient outcomes when compared to PA/NPs? If there is a difference in outcomes, then perhaps we should do things differently....

The NP/PA argument is: You don't need all these educations to practice primary care, emergency medicine, etc...

 

[miacomet]

Unfortunately smart offers better rates than comp health and the big locum companies.

Yup. And that's what's concerning. I don't like UC or telehealth, but they are so much lower risk and so much more circadian and family friendly that it may soon be worth jumping ship.

 

[betamale]

Listen new grads

Texas is a terrible place but especially for new grads...recommend going to any of the other 49 states, Guam, Saipan, Puerto, US Virgin Islands

Make >$500/hr anywhere but in Texas...stay away

 

[Alvarez13]

Listen new grads

Texas is a terrible place but especially for new grads...recommend going to any of the other 49 states, Guam, Saipan, Puerto, US Virgin Islands

Make >$500/hr anywhere but in Texas...stay away

What are you talking about?