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Locums: The Big Canary in the Emergency Medicine Coalmine

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oldtown

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So for the med students out there interested in the aforementioned “doomed specialities” (EM and anesthesia for me), what specialities are NOT doomed? Surgery? Primary care?

Also, is ACEP just propaganda? Their salary numbers this year still seem high and the number of FM/IM doctors working in EDs is shocking (>40% in many states). I scribed in the ED full-time for a year before med school and I definitely saw the...striking difference between FM/IM trained doctors and EM trained doctors. I guess that doesn’t matter if the public is naive and FM/IM is way cheaper?

I really loved my time in the ED but this website makes me already hesitant about choosing medicine :(


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The elements that make a specialty “not doomed” are

1) The aforementioned owning of patients. You bring referrals to the hospital, you have value. If the patients come whether you’re there or not, you have little value.

2) Generally procedure based- surgical sub specialties (ortho, Urg, ENT, CT, NSG etc.) are the best. Gen Surg and OB are ok, but less protected. Medicine wise, GI, cardiology. Basically, the more revenue you generate (billing for complicated procedures/surgeries), and the more specialized you are (I.e. the fewer people that can do your job), the safer you are.

3) Relative immunity from mid level encroachment. PA’s are not going to be doing brain surgery anytime soon. There is a push for more MLP’s in EM, IM, FP, Anesthesia, etc.

4) Are you outsourceable? Radiologists can read from anywhere. The lowest bidder may start winning those contracts. The US licensed radiologist who lives in India has a much lower cost of living than the one who lives in NYC. Pathologists can work for LabCorp in a central facility, and samples can be sent there. Neither have their own patients. (See #1)

5) can you charge cash for a relative “want” rather than a need? Derm and plastics for aesthetic procedures. Psych for therapy for rich folks who will pay cash etc.
 
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deleted859535

So for the med students out there interested in the aforementioned “doomed specialities” (EM and anesthesia for me), what specialities are NOT doomed? Surgery? Primary care?

Also, is ACEP just propaganda? Their salary numbers this year still seem high and the number of FM/IM doctors working in EDs is shocking (>40% in many states). I scribed in the ED full-time for a year before med school and I definitely saw the...striking difference between FM/IM trained doctors and EM trained doctors. I guess that doesn’t matter if the public is naive and FM/IM is way cheaper?

I really loved my time in the ED but this website makes me already hesitant about choosing medicine :(


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Agree with the post after yours that surgical subspecialties and "ownership" is protective.

Doesn't mean others are doomed, though. Medicine sucks in a lot of ways. That said, SDN is biased towards the negative.

Think of it like this: Patients will bitch and complain about whatever issue, real or perceived, and let patient relations / office staff / the internet know about how unhappy they are despite what is done for them. Big source of burnout, ironically. But do you think the ones who are happy about the experience overall are quite as vocal in general?

Same is true for emergency physicians.
 
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YCAGA

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The elements that make a specialty “not doomed” are

1) The aforementioned owning of patients. You bring referrals to the hospital, you have value. If the patients come whether you’re there or not, you have little value.

2) Generally procedure based- surgical sub specialties (ortho, Urg, ENT, CT, NSG etc.) are the best. Gen Surg and OB are ok, but less protected. Medicine wise, GI, cardiology. Basically, the more revenue you generate (billing for complicated procedures/surgeries), and the more specialized you are (I.e. the fewer people that can do your job), the safer you are.

3) Relative immunity from mid level encroachment. PA’s are not going to be doing brain surgery anytime soon. There is a push for more MLP’s in EM, IM, FP, Anesthesia, etc.

4) Are you outsourceable? Radiologists can read from anywhere. The lowest bidder may start winning those contracts. The US licensed radiologist who lives in India has a much lower cost of living than the one who lives in NYC. Pathologists can work for LabCorp in a central facility, and samples can be sent there. Neither have their own patients. (See #1)

5) can you charge cash for a relative “want” rather than a need? Derm and plastics for aesthetic procedures. Psych for therapy for rich folks who will pay cash etc.

Thank you. Do you believe Gen surg and OBGYN are less protected because they are less specialized? I can’t speak for OBGYN, but it seems like most general surgery residents are doing a fellowship these days.
 
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Fox800

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I don’t trust the ACEP salary survey. There are some wild inaccuracies on there. That’s all I’m gonna say.
 

YCAGA

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Think of it like this: Patients will bitch and complain about whatever issue, real or perceived, and let patient relations / office staff / the internet know about how unhappy they are despite what is done for them. Big source of burnout, ironically. But do you think the ones who are happy about the experience overall are quite as vocal in general?

Same is true for emergency physicians.
I definitely take what I read on here with a grain of salt for exactly that reason. But, some of it seems pretty objective (more residencies, lower locums pay) which is what has me worried. I do still see a lot of positives in EM, otherwise I would probably just give up on my interest in the specialty.
 

oldtown

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Thank you. Do you believe Gen surg and OBGYN are less protected because they are less specialized? I can’t speak for OBGYN, but it seems like most general surgery residents are doing a fellowship these days.

Yes. There are just more of them out there than there are other surgical sub-specialists. What they do is difficult and technically challenging, but there are a lot of surgeons and OB’s out there, so they’re more easily replaced than a CT surgeon.
 
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deleted109597

Are Oz and CA paying American wages?
My pick would be PEM- that's growing, fast, and salaries are beating out EM if you can stand it.
Oz pays ok, if you're from the Oz system. It's certainly less than here, and the market is dwindling rapidly. Sadly, my physician spouse won't let me move to Melbourne for the job I was offered, and it won't be there in 5-10 years, guaranteed. Not sure NZ won't be in the same boat soon.

Canada? Most of us can't practice in most provinces, as we aren't 5 year graduates.

Europe, nonstarter. Part of the Oz problem is all the UK docs moving there. Also, the rest of Australasia moving there to leave their dirtpoor nations.


PEM. Laughable. Sure, if you're at an academic site you can "supervise" the residents seeing your 4-5 pph. But in the private sector, seeing 2x more patients for 50% of the pay gets old really, really fast. Even if you aren't admitting most of them. And expect the CMS ax to fall on peds soon with regards to DRGs. They're simply not going to pay emergency rates for sore throats anymore.
 

TooMuchResearch

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I'm told we (a biggish DG) have been approached in the fairly recent past and we told the approacher to pound sand. Our hospital systems are still offering us lucrative opportunities, so I don't think we're at high risk of contract loss. Maybe we're a unicorn.
Ya and before you know it you can get some VC buy in and become another CMG!

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ace_inhibitor111

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Interestingly enough, the surgical subspecialties (ortho, urology, ENT, neurosurg) are getting screwed the hardest in Canada in terms of job market, partly due to limited OR resources.

IMO, it really is all about supply and demand. Salary is also not the best indicator of the job market. Pharmacists still get paid a lot, even though their job market is pretty bad.
 

aberkovi

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Got a call a few days ago offering 75/hr in Northern Montana. No joke.
 

Birdstrike

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Interesting to read that locums rates have decreased since I left the day to day practice of EM. It's certainly a sign that the labor supply is coming closer to meeting demand, finally. Whether it's good or bad, depends on your perspective, I suppose. If hourly pay is most important to you, it's a bad thing. If wanting adequate staffing so you don't have to constantly be pressured to work an amount of hours past your breaking point, then it's a good thing.
 

miacomet

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Yes. There are just more of them out there than there are other surgical sub-specialists. What they do is difficult and technically challenging, but there are a lot of surgeons and OB’s out there, so they’re more easily replaced than a CT surgeon.

I think Gen Surg and OB will alway be in demand because they are not only difficult and technically challenging, but PITA lifestyles. They are essential...and painful.
 
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John Red

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So, aside from the ever-optimistic @gamerEMdoc, it looks like EM is in the beginning of a death spiral, along with anesthesia, rads, rad onc, and maybe ICU. The party never lasts unless you have your own patients.

What's an early to mid-career doc to do? Palli? Occ Med? Pain? There just aren't a bunch of great escape strategies, no? This isn't IM with cards, GI, and even ID as outs.

Current resident and thinking the same thing. With all the current supply/demand gloom started thinking about which EM fellowships could change my job perspectives / where I work and the only ones I can think of are CCM, PEM, Pain, Tox. The majority of the rest might give you an academic niche but don't think they change your job perspectives outside of academia. Thinking EMS, US, SIM, MedEd, Disaster, Global Health, etc
 
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GatorCHOMPions

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Current resident and thinking the same thing. With all the current supply/demand gloom started thinking about which EM fellowships could change my job perspectives / where I work and the only ones I can think of are CCM, PEM, Pain, Tox. The majority of the rest might give you an academic niche but don't think they change your job perspectives outside of academia. Thinking EMS, US, SIM, MedEd, Disaster, Global Health, etc

Agree with your thinking there. However, don't discount the role of an academic niche. If you have a specific interest and can carve out a specific role for yourself, you will be valuable and not seen as a commodity as much. That's the name of the game in today's health care market, be seen as valuable to your employer or the patient (and thereby valuable to the employer). Having that academic niche that very few other people do is seen as attractive to most Chairs in academia. If your main objective is job security, this is something to consider. As others have alluded to, one of the main reasons we are so vulnerable in EM is because we're not "special enough" - we don't bring patients into the hospital system or generate large revenue with highly reimbursed procedures. Our supply is also meeting demand, at least in popular areas to live. We are simply cogs in the hospital-based healthcare machine.

In terms of your specific list of possibilities for the fellowships to change one’s practice, all of them are a losing effort financially except for possibly Pain. PEM fits the bill for job security, although you are still stuck working in an emergency department and susceptible to the same stuff which affects all hospital employees. Tox will give you an automatic niche, but it's two years whereas most of the fellowships available to us are one so you better like it a lot. I know nothing of the CCM market, but I imagine they are threatened by very similar things as we are in the pit. In fact, I keep hearing more and more of ICU's being staffed solely with MLP's following protocols under the guise of physician supervision.
 
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miacomet

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Current resident and thinking the same thing. With all the current supply/demand gloom started thinking about which EM fellowships could change my job perspectives / where I work and the only ones I can think of are CCM, PEM, Pain, Tox. The majority of the rest might give you an academic niche but don't think they change your job perspectives outside of academia. Thinking EMS, US, SIM, MedEd, Disaster, Global Health, etc

If I were still in training, I'd consider a second residency. PEM and Pain would be my other picks. Not so much call for tox, and I agree CCM is facing the same issues we are. Palli and Occ Med will go 100% midlevel pretty soon, I think.
 

Frazier

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    Fellowships are great for the right person.

    However...

    A great proportion of EM docs would not be satisfied being a pain doc. They dont have an interest in the science of pain/research, running their own business, they hate clinic, they seem to have an distaste for chronic pain patients, "they get bored", etc.

    Many pit docs don't have the IM-esque fascination for biochem pathophys to truly enjoy toxicology as an enriching academic career.

    While features of primary palliative care are (...well, should) be practiced by all EM docs. Great majority have no interest in its tenets. Hell, there was a big whining movement at my shop when the docs were encouraged to simply ask patients about goals of care. The most basic of stuff, "let someone else do it inpatient, too busy here in the ED". "Hospice patient in my ED? Lets go! let's go, people! DC or admit. Move the meat!" Bad match for interests and personalities.

    CCM? "40 bed ICU pushing capacity? I could never do rounds again. I'd pull out all my hair. No thanks!"

    It appears large proportion of EM docs (whether from interests, personality, ADHD, whatever) are best suited to do exactly what they do -- pure EM.

    Yet, again, for others fellowships are blessings.
     
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    GatorCHOMPions

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    Fellowships are great for the right person.

    However...

    A great proportion of EM docs would not be satisfied being a pain doc. They dont have an interest in the science of pain/research, running their own business, they hate clinic, they seem to have an distaste for chronic pain patients, "they get bored", etc.

    Many pit docs don't have the IM-esque fascination for biochem pathophys to truly enjoy toxicology as an enriching academic career.

    While features of primary palliative care are (...well, should) be practiced by all EM docs. Great majority have no interest in its tenets. Hell, there was a big whining movement at my shop when the docs were encouraged to simply ask patients about goals of care. The most basic of stuff, "let someone else do it inpatient, too busy here in the ED". "Hospice patient in my ED? Lets go! let's go, people! DC or admit. Move the meat!" Bad match for interests and personalities.

    CCM? "40 bed ICU pushing capacity? I could never do rounds again. I'd pull out all my hair. No thanks!"

    It appears large proportion of EM docs (whether from interests, personality, ADHD, whatever) are best suited to do exactly what they do -- pure EM.

    Yet, again, for others fellowships are blessings.

    Who’s arguing most of us aren’t best suited to practice EM? Ignoring market and political forces out there is foolish, though. In 10 years the run of the mill new grad may not be able to get a job within 50 miles of “name your desirable city”. A fellowship diversifies one’s skill set. Even if said fellowship does not align with one’s passion or personality, it may be the thing that guarantees they have a job in the future.

    To circle back to the intent of the thread, the locums market being so dry is a testament to how much the general EP has been devalued recently.
     
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    MechEDoc

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    Going to necrobump a thread. For the near term it looks like locums has fully tanked. Was a FT locums physician for 4+ years. TH, CompHealth, etc. fed me and paid the bills. Currently have no true locums contracts. Income has been as follows:
    1. 2016 (second half) - $296/hr.
    2. 2017 - $264/hr.
    3. 2018 - $278/hr.
    4. 2019 - $242/hr.
    5. 2020 - $231/hr.
    Above are averages and include a stint of W2 at a slightly lower rate.
     
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    cyanide12345678

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    Because the pay is so low it devalues our profession. $90/hr would not be enough to pay off the cost of becoming a physician.

    Plus Im pretty sure a NP/PA makes 80-90/hr working in an urgent care -_-

    For a EM residency trained doc taking 90/hr is just ridiculous.

    Though at the same time, I did once work at a place that paid $130/hr. I saw 6-8 patients in 24 hours there. Always slept 8 hours at night. 8 patients a day meant roughly $400/patient. I was definitely okay with that.

    But 90/hr is just low. Unless maybe if you saw 2-4 patients in 24 hours?
     

    skougess

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    Going to necrobump a thread. For the near term it looks like locums has fully tanked. Was a FT locums physician for 4+ years. TH, CompHealth, etc. fed me and paid the bills. Currently have no true locums contracts. Income has been as follows:
    1. 2016 (second half) - $296/hr.
    2. 2017 - $264/hr.
    3. 2018 - $278/hr.
    4. 2019 - $242/hr.
    5. 2020 - $231/hr.
    Above are averages and include a stint of W2 at a slightly lower rate.
    Have to ask, why even do locums at that rate?
     

    GeneralVeers

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    Have to ask, why even do locums at that rate?

    I have no idea why anyone would do it. The travel burns you out quick.

    I did 5 years at 350/hour plus bonuses. I couldn't imagine doing it for less than $300 even if that was slightly above the local rate.
     
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    MechEDoc

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    Have to ask, why even do locums at that rate?

    2016 through 2018 was pretty good.

    2019 was watered down by some 1099 work (which likely is under valued in my calculations as I didn't include some low value benefits).

    2019 (second half) and 2020 the trade off was worth it to me to allow for a move, travel, and lifestyle issues. Long term, it isn't worth it anymore.
     

    Mbekweni

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    So much benefit in getting a stable independent physician group job where you eat what you kill, and once you have the job the influx of new grads makes little difference since they are the ones struggling to get a job in the prime spot you are already at. Add in getting bonus etc and you are way ahead when it comes to a long term career, even if it means a few years of sweat equity and making a little bit less than locums. Good interactions and working with hospital admin can go a long way towards establishing yourself as a non replaceable cog in the wheel. UNLESS your group gets a stipend, then that is up for cost cutting and review every year. Lots of comments about fellowship, second residency etc. What about the opportunity cost of 1-3 years of attending level income? Things are uncertain for sure...all the more reason to live simply, save as much as possible as early as possible and then have more flexibility down the line. I'm diversifying into hospital admin and telemedicine in addition to regular EM for additional income streams and job security.
     

    Groove

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    Going to necrobump a thread. For the near term it looks like locums has fully tanked. Was a FT locums physician for 4+ years. TH, CompHealth, etc. fed me and paid the bills. Currently have no true locums contracts. Income has been as follows:
    1. 2016 (second half) - $296/hr.
    2. 2017 - $264/hr.
    3. 2018 - $278/hr.
    4. 2019 - $242/hr.
    5. 2020 - $231/hr.
    Above are averages and include a stint of W2 at a slightly lower rate.

    That has been my observation also. I used to scalp shifts in my region for premium pay but I haven't been able to find anything worth taking in well over 2 years. My CMG flies in these travelers that are making less than the local FT docs. Given...their rate might be decent for the area they live but there really should be a premium for someone willing to leave home for a week at a time and fill empty shifts at the drop of a hat. Learning a new hospital, EMR, etc.. ad infinitum.

    Does anyone know what the TH Strike guys make these days? A few years back they were making $300/hr in this region. I suppose it might still be worth it for some at that rate. Personally, I loathe locums work. I would do it if I had to...but I'd gladly take a pay cut to be able to sleep in my own bed at night.

    Veers, I'm glad you finally came to your senses before one of your coronaries needed stenting. You used to be the poster boy on here for locums companies.

    We've got this traveler with us who's fresh out of residency and has been doing it for the past year and already I can see the circles forming under his eyes.
     
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    bravotwozero

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    yeah i think locums is a short term deal for most people. That said, given where our profession is headed, part of me just wants to work my butt off for the next 6-7 years at 140+ hrs per month, sock away 20k a month, and then peace out.
     
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    CliveStaples

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    It has been about two years in my region since locums paid any kind of premium over regular full time work. Now the pendulum has swung to where the people with contracts have much more guaranteed work than the people making a locums living. The regional locums people I know are having to travel further and credential at more hospitals in order to make their hours and the ones that come to my shop make the same as the rest of us.
     

    Alvarez13

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    Interesting to read that locums rates have decreased since I left the day to day practice of EM. It's certainly a sign that the labor supply is coming closer to meeting demand, finally. Whether it's good or bad, depends on your perspective, I suppose. If hourly pay is most important to you, it's a bad thing. If wanting adequate staffing so you don't have to constantly be pressured to work an amount of hours past your breaking point, then it's a good thing.
    You're delirious if you think this oversupply is going to equal adequate staffing. These private equity-backed middle men will run the dept at bare bones. The only difference is their cost will go down when it's desperate docs supervising 4 midlevels.

    Refuse to supervise midlevels.
    Refuse to train these BS HCA residents.
    Refuse to work for corporations and become employees.

    Suck it up and learn a little bit about business to manage your own group. Ownership for our specialty and most importantly for our patient's safety and well-being.
     
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    TheSingularity

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    That has been my observation also. I used to scalp shifts in my region for premium pay but I haven't been able to find anything worth taking in well over 2 years. My CMG flies in these travelers that are making less than the local FT docs. Given...their rate might be decent for the area they live but there really should be a premium for someone willing to leave home for a week at a time and fill empty shifts at the drop of a hat. Learning a new hospital, EMR, etc.. ad infinitum.

    Does anyone know what the TH Strike guys make these days? A few years back they were making $300/hr in this region. I suppose it might still be worth it for some at that rate. Personally, I loathe locums work. I would do it if I had to...but I'd gladly take a pay cut to be able to sleep in my own bed at night.

    Veers, I'm glad you finally came to your senses before one of your coronaries needed stenting. You used to be the poster boy on here for locums companies.

    We've got this traveler with us who's fresh out of residency and has been doing it for the past year and already I can see the circles forming under his eyes.

    When I did TH special ops / strike force / seals, the rate was $260 / hr IC for the NE and SE groups.

    Something really interesting happened with the West group. They recruited a TON of people out there for $300 / hr. Soon after, they were like PSYCH! and lowered the rate to $260 / hr. Really sketchy shyt.
     
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    Buckeye1992

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    What is the schedule like for those internal locums groups. Do you have much say over where you go/ when you work?
     

    TheSingularity

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    For TH, you have little say, except for general region. The Northeast group runs from Ohio all the way up to Maine. You license and credential wherever they tell you to. They do have a pretty well oiled admin machine and they prefill all applications and you pretty much just sign away. Schedule flexibility depends on individual site. You will work nights/weekends/holidays. You will be at dysfunctional sites.

    Pros: Learned a lot straight out of residency; made good co-attending friends that I still talk to; good pay relative to the market in the city I was forced to live in at the time.

    Cons: Travel sucks, high stress dysfunctional sites, no one cares about you

    TL/DR: Glad I did it. Glad to never do it again.
     

    scoopdaboop

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    Average team health hourly is 231 and a bit less than 500k a year, based on glassdoor. Isnt that reasonable for a full time doc. Don’t see the hate on team health. One of the attendings I scribed for said he didn’t really have a problem working for them.
     
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    TheSingularity

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    Average team health hourly is 231 and a bit less than 500k a year. Isnt that reasonable for a full time doc. Don’t see the hate on team health. One of the attendings I scribed for said he didn’t really have a problem working for them.

    Ok. So....it's VERY site dependent.

    If you're working at a money making site with a good payor mix, you will make good money. With a crap payor mix / worse local market, you will make less.

    You will NOT be at a desirable site if you work for their travel team.

    The range of sites I worked at for them were:

    "This is OK...I could work here for a bit."

    to

    Tolerable...with intermittent intense spurts of panic and maybe wanting to cry a little

    to

    "OMFG THIS IS INSANELY DANGEROUS WHY WOULD ANYONE CHOOSE TO WORK HERE?!?!"

    Working for TH is very transactional. You are a cog, make no mistake. They do not care about you as a person. This is not necessarily a bad thing depending on your mindset / what you want out of a job., but I couldn't do it forever.
     
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    TheSingularity

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    Average team health hourly is 231 and a bit less than 500k a year. Isnt that reasonable for a full time doc. Don’t see the hate on team health. One of the attendings I scribed for said he didn’t really have a problem working for them.

    Also, your math is way off here.

    The average monthly number of clinical hours that I think most people would say is healthy would be probably about 120-130. 140 is pushing it. Go above 140 and you are seriously risking burnout.

    I'll even assume 140 hrs for this calculation:

    140 hrs/month * 231 dollars/hour * 12 months = $386,400.

    And with TH, this figure is quite possibly paid as a 1099, increasing your tax burden, and with paltry, if any, benefits.
     
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    scoopdaboop

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    Also, your math is way off here.

    The average monthly number of clinical hours that I think most people would say is healthy would be probably about 120-130. 140 is pushing it. Go above 140 and you are seriously risking burnout.

    I'll even assume 140 hrs for this calculation:

    140 hrs/month * 231 dollars/hour * 12 months = $386,400.

    And with TH, this figure is quite possibly paid as a 1099, increasing your tax burden, and with paltry, if any, benefits.

    I assumed it was all the bonuses etc. leading to that range. But that's not my math; it's what I saw on glassdoor. But now I just checked glassdoor again and saw 181 at 380k a year...so it's all over the place.

    https://www.glassdoor.com/Hourly-Pa...ine-Physician-Hourly-Pay-E11221_D_KO11,39.htm

     

    CliveStaples

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    Working for a CMG is all about recognizing what you are paying to them for the service they provide you.

    I work for a CMG, contracted for x dollars an hour for 120 hours per month with +y dollars for night shift hours. I got a bonus for signing with them which I basically think of as +z dollars per hour for the year length of the contract.

    The amount that I'm paid (x+z or y+z) is less than I'm billing for, but not by much. I naturally don't know exactly how much I'm billing for, but I know how many patient's I see per hour, how many RVUs is billed per average patient, and how much on average ER physicians collect per RVU (there are other threads on this forum that breaks it down. Now many people would tell you that I'm a lemming or whatever for accepting this. That said, even if I were in an independent practice, I would not be able to keep everything I bill for. I'd need to pay for the administrative costs of being a private group, paying the medical director for the work they do, paying for whatever service we use for billing and coding, etc. This is what the CMG does.

    I made the decision looking at the math that it was the best decision in my region. My options were other CMG sites that paid less for similar work, a job in academics where the work and compensation would both be very different but did not align with what my current career goals are, and a private group that has a predatory pre-partner track where I would be paid significantly less for two years, would then "eat what I kill" while still paying for the administrative costs of the practice, and worst still would require me to work exclusively nights. Honestly my job choice felt like a no-brainer after doing my homework. In addition, I have a medical director who advocates well for us and I get to make my own schedule.

    I do not like what CMGs mean for the future of our profession. I would love to be able to make a bid and work at this site as a private group and handle the administrative costs ourselves. But I do not feel like I am paying an egregious amount to CMG to do this, so I don't think I'm a lemming for working this job.

    Seeing what "firefighters" are paid to work at much worse sights than mine for almost no difference in pay (or less pay) in return for having to constantly travel makes me thankful for my job.
     
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    MechEDoc

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    For TH, you have little say, except for general region. The Northeast group runs from Ohio all the way up to Maine. You license and credential wherever they tell you to. They do have a pretty well oiled admin machine and they prefill all applications and you pretty much just sign away. Schedule flexibility depends on individual site. You will work nights/weekends/holidays. You will be at dysfunctional sites.

    Pros: Learned a lot straight out of residency; made good co-attending friends that I still talk to; good pay relative to the market in the city I was forced to live in at the time.

    Cons: Travel sucks, high stress dysfunctional sites, no one cares about you

    TL/DR: Glad I did it. Glad to never do it again.

    Same. Western TH special ops.
     
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    miacomet

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    I have former residents practicing all over the country. Pacific NW. Appalachia. New England. Long Island. Texas. Carolinas. California, Florida, etc. They still sign contracts as early as their second year. I have yet to have a resident want a job in some state and not land a reasonable contract in that state. I look at their contracts. Most make way more than I do. Im not saying that their isnt tight markets in some places, but my experiences with residents in the job market is not reflected in all the doom and gloom I see. That doesnt mean we may not get there, we may see a big downturn, and I definitely get the fear. I just dont believe its as bad as many make it out to be based on my own experiences and the actual data and reports published on EM compensation.

    I am impressed- do you have grads in Portland, OR and SLC, UT? Those seem to be two of the hardest markets.
     

    EctopicFetus

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    Working for a CMG is all about recognizing what you are paying to them for the service they provide you.

    I work for a CMG, contracted for x dollars an hour for 120 hours per month with +y dollars for night shift hours. I got a bonus for signing with them which I basically think of as +z dollars per hour for the year length of the contract.

    The amount that I'm paid (x+z or y+z) is less than I'm billing for, but not by much. I naturally don't know exactly how much I'm billing for, but I know how many patient's I see per hour, how many RVUs is billed per average patient, and how much on average ER physicians collect per RVU (there are other threads on this forum that breaks it down. Now many people would tell you that I'm a lemming or whatever for accepting this. That said, even if I were in an independent practice, I would not be able to keep everything I bill for. I'd need to pay for the administrative costs of being a private group, paying the medical director for the work they do, paying for whatever service we use for billing and coding, etc. This is what the CMG does.

    I made the decision looking at the math that it was the best decision in my region. My options were other CMG sites that paid less for similar work, a job in academics where the work and compensation would both be very different but did not align with what my current career goals are, and a private group that has a predatory pre-partner track where I would be paid significantly less for two years, would then "eat what I kill" while still paying for the administrative costs of the practice, and worst still would require me to work exclusively nights. Honestly my job choice felt like a no-brainer after doing my homework. In addition, I have a medical director who advocates well for us and I get to make my own schedule.

    I do not like what CMGs mean for the future of our profession. I would love to be able to make a bid and work at this site as a private group and handle the administrative costs ourselves. But I do not feel like I am paying an egregious amount to CMG to do this, so I don't think I'm a lemming for working this job.

    Seeing what "firefighters" are paid to work at much worse sights than mine for almost no difference in pay (or less pay) in return for having to constantly travel makes me thankful for my job.
    A few things with your math. Some do keep everything they bill. The admin is covered by stipends from the hospital or MLPs.

    Also when you say you know your RVUs do you really? Are they wRVUs or total RVUs. There is a fair bit of bloat in the delta there. Like $50/patient.

    In the end we all have to do what is best for us and our families But if you dont think they are making At least $50/hr off of you you haven’t been paying attention.
     
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    GeneralVeers

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    I don't have a problem paying CMGs a fee so that I don't have to do billing/coding/HR and admin. Often they are extremely helpful with hospital credentialing, and save me hours of time by pre-filling out the paperwork. I think 20% is a reasonable amount to pay for these services.

    When I see some jobs paying $150/hour in desirable locations (Austin TX) but know that the CMGs are collecting $400/hour, it makes me sad for those doctors.
     
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    CliveStaples

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    A few things with your math. Some do keep everything they bill. The admin is covered by stipends from the hospital or MLPs.

    Also when you say you know your RVUs do you really? Are they wRVUs or total RVUs. There is a fair bit of bloat in the delta there. Like $50/patient.

    In the end we all have to do what is best for us and our families But if you dont think they are making At least $50/hr off of you you haven’t been paying attention.

    I think 50/hr is probably spot on. Less than 20% at least. Would I love to work a little hard, take ownership of the group, and make that money (or potentially even more)? I would jump at the opportunity. Do I think that if we all left the group today and made a bid for the contract ourselves and lost, that CMG would have trouble replacing us? No, which is why we haven't done so yet. The hope would be that we eventually build enough collateral with the hospital that we become 'indispensable' and win that bid. A pipe dream, I know. In the meantime do I think that I'm being taken to the cleaners? Not at all. Like I said, they are providing a service and I have to think about my job no more than the hours that I am there. That last 50/hr more is going to cost me my time outside of work to keep the group running well.
     
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    thegenius

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    I don't have a problem paying CMGs a fee so that I don't have to do billing/coding/HR and admin. Often they are extremely helpful with hospital credentialing, and save me hours of time by pre-filling out the paperwork. I think 20% is a reasonable amount to pay for these services.

    20% is an awful lot...maybe half that is the real cost. But OK.
     

    Groove

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    I think I posted a locums email chain awhile back where I could see the recruiters haggling with the hospital/group client and if memory serves, it was roughly $40/hr on top of most of the physician fees. Of course, this was 8 or 9 years ago. When you factor in malpractice costs, travel costs, business expenses, etc.. I doubt their profit margin is as massive as one might think.

    Another time, they were paying the docs around $300/hr but I know for a fact the hospital was billed at $400/hr. That's the largest profit that I've been aware of personally.

    Weatherby for both of those.
     

    EctopicFetus

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    I think 50/hr is probably spot on. Less than 20% at least. Would I love to work a little hard, take ownership of the group, and make that money (or potentially even more)? I would jump at the opportunity. Do I think that if we all left the group today and made a bid for the contract ourselves and lost, that CMG would have trouble replacing us? No, which is why we haven't done so yet. The hope would be that we eventually build enough collateral with the hospital that we become 'indispensable' and win that bid. A pipe dream, I know. In the meantime do I think that I'm being taken to the cleaners? Not at all. Like I said, they are providing a service and I have to think about my job no more than the hours that I am there. That last 50/hr more is going to cost me my time outside of work to keep the group running well.
    I think you look at it all wrong. I don't know how big your shop is but most SDGs just pay their admin docs to do the work and plenty can do as you say. The difference is instead of paying $50/hr you end up at either $0/hr or maybe $10/hr. You also have control, upside and get to keep the MLP money. The 20% or so is really excluding MLP money. You are willing to pay $400/shift (assuming 8s or $600/shift for 12s.

    If you work 100 shifts a year that's 40-60k or enough to fund your retirement on a light workload. I have come around to the realization that few people will ever make the necessary moves to get away from the CMGs.

    The last public filings showed profit margins of 28% for the CMGs. Thats after their admin bloat.

    I am just happy to be in the position I am. I hope you are too. in the end our primary duty is to provide for our families.
     
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