M3 applying aways- reconsidering if I fit in this speciality

[EMmed2026]

Hi I am at the end of my 3rd year and after finishing all the rotations it has become clear to me I want to do EM. I enjoy the acuity, fast pace, variety of cases, and working with my hands (suturing). I currently go to a medical school that does not have an EM rotation. I was able to do a 2 week elective in the ER and another 2 weeks in a rural ER. I thoroughly enjoyed both but I am having a crisis while applying for aways. I don't know how I'll fit in this specialty I am on the quieter side but mainly because I felt like I was under a microscope the whole time. But this worries me. I am also not sure what I have to offer. I am an average student idk how competitive I'll be and I am just struggling all around to get myself to write a personal statement for my aways. What should I do?

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[Apollyon]

Acuity - no. Fast pace - no. Variety of cases - no. Using your hand - no.

I say "no", because these things, variously, aren't.

Acuity is hit or miss, but, very usually, miss. Much less acuity. Even "high acuity" cases lose their allure. Fast pace gets tiring. Variety of cases is slanted or biased. A plurality of pts have some psych component, and that's not usually what brings them in. If you had bugs in your house, would you marvel at the variety? It's like that.

And, show me an EM doc, more than 10 years out of training, who looks forward to the time suck of a lac repair. No one wants to do a bad job. And lacs can take time.

Whatever you think you found, it's not really there. If all you have are STEMIs and intracranial bleeds, that will wear you down. At the same time, if all you have are younger 20s URIs, that will also wear you down. And, even if you get a big save, you are the only one that will care. And that also means another trivial case to see.

 

[endo]

Doing an EM rotation as a med student is not going to prepare you for the ultra-marathon grind of an EM career. And it is less attractive (by far) now than when I matched into EM 23 years ago. Pick something better. Most anything will be better. Sorry to be a downer but you need to listen to your elders here.

 

[EMmed2026]

I just don't see myself doing something managing chronic care. I do not want to just be like we will "follow up in a few months and adjust your medications." Every other rotation I went home so drained and not looking forward to going in the next day. I was only excited during the times in the ER and ICU setting.

 

[Apollyon]

I just don't see myself doing something managing chronic care. I do not want to just be like we will "follow up in a few months and adjust your medications." Every other rotation I went home so drained and not looking forward to going in the next day. I was only excited during the times in the ER and ICU setting.

Suck it up, do 3 years of IM, then a Pulm/CC fellowship. You'll thank us in 10+ years.

 

[endo]

Then do pulm/cc or anesth/cc. You need an out from EM / ICU when you’re cooked at 45.

 

[AlmostAnMD]

op it's such a ****ty job, I did it as an attending for 5 years and I thought the same as you. Hell you could probably go through my posting history and find a similar post.

On one of my last shifts before I left EM I was at a freestanding. 3 lacs and an abscess checked in within 10 minutes of each other at 4a and I'm single coverage. Nearly cried. The banality of these procedures is punishing over time.

I can completely see why other countries don't even have EM.

It's also dropped off the list entirely of being competitive outside of a few Midwestern programs. So as long as you passed step one your entire personal statement could be, "I have a heart beat" and you'd still get interviews.

But also as others said pick something with a future. One where you can actually be valued. Don't be the hotdog vendor at the NFL stadium, be the quarterback. Hell even plain IM then cards would make you much less irreplaceable than any em doc.

 

[AlmostAnMD]

And, even if you get a big save, you are the only one that will care.

Just saw that comment. Deeply underappreciated take.

I had a few good saves that were acknowledged even by family in the form of letters and gifts, which was really sweet of them (not that I did this for that kind of ego boost, but people actually going out of their way to thank me was deeply appreciated). But that was so incredibly rare among the main drudgery it still didn't make it worth it

 

[EMmed2026]

Is it possible that after a few years, you can go part-time?

I've also heard some EM docs go on to open urgent cares or stand-alone ERs when they are older. How likely is that?

 

[WhatJobDoIPick]

Is it possible that after a few years, you can go part-time?

I've also heard some EM docs go on to open urgent cares or stand-alone ERs when they are older. How likely is that?

Do you have kids? Do you want kids?

Do you have loans?

You can easily go part-time and make 200k/year. If you have a partner that also makes 200k, that's a very comfortable life, especially if you don't have kids.

 

[EMmed2026]

Do you have kids? Do you want kids?

Do you have loans?

You can easily go part-time and make 200k/year. If you have a partner that also makes 200k, that's a very comfortable life, especially if you don't have kids.

I definitely have loans. I eventually do want kids. My partner makes around 120k

 

[WhatJobDoIPick]

op it's such a ****ty job, I did it as an attending for 5 years and I thought the same as you. Hell you could probably go through my posting history and find a similar post.

On one of my last shifts before I left EM I was at a freestanding. 3 lacs and an abscess checked in within 10 minutes of each other at 4a and I'm single coverage. Nearly cried. The banality of these procedures is punishing over time.

I can completely see why other countries don't even have EM.

It's also dropped off the list entirely of being competitive outside of a few Midwestern programs. So as long as you passed step one your entire personal statement could be, "I have a heart beat" and you'd still get interviews.

But also as others said pick something with a future. One where you can actually be valued. Don't be the hotdog vendor at the NFL stadium, be the quarterback. Hell even plain IM then cards would make you much less irreplaceable than any em doc.

OP, I would not recommend it.

Here's why:

You will be judged on three principal metrics

1) Be perfect, every time
2) Be fast
3) Satisfy the "customer"

I'm actually pretty good at all of these, however, they are all opposed to each other.

Even if you can perform well in all of these, payors will not pay you. There is constant downward pressure on pay from Medicaid, Medicare and private insurance. There's always some new game to play, some hurdle to jump, and then they still might not pay.

Add to this low resource environments, staff shortages, abusive patients, admin that needs to be pleased in this way or that.

Add to this the fact that 75% of your shifts will end after 11pm, or be on a weekend.

Don't get me wrong, there ARE legit wins to be had. There ARE thankful patients. There ARE fun procedures (intubation and chest tubes, for me). There ARE good days that I enjoy in the ED.

This is my advice to any student for specialty selection:

1) Protected against midlevel encroachment (think surgical)

2) If not #1, then something that's easy to sell in cash to rich people (derm, plastics, psych)

3) avoid having to be beholden to a hospital

4) if not #3, then something admin types love and will bend over backwards for you (Ortho, interventional cards)

 

[Pinner Doc]

Then do pulm/cc or anesth/cc. You need an out from EM / ICU when you’re cooked at 45.

Boy, does this comment resonate with me.

I turn 45 in August, and I'm leaving EM to start HPM fellowship on July 1.

I liked EM for a long time. I did. As a mom, I found it flexible (even though only ONE shift out of our 5 shifts on weekdays and NONE on weekends will get you home for dinner). But I got to the point where even working six shifts a month was painful. Driving in for these shifts filled me with dread and I'd be anxious days after.

For me, it truly felt like every time we had our monthly staff meeting, we'd be met with, "Here's another change happening in our health network that's going to make your life ****tier/harder." One month it was that we had to starting rounding on nearly all the APP patients (presumably to bill more for them) and there would be no increased pay or staffing to make up for it. Another was that the network decided to close inpatient psychiatry at our hospital, so we'd have nowhere to put the inevitable influx of patients. Oh, and all the psychiatrists left. These are just two examples.

You know, I always prided myself on EM and its "anywhere, any time, for any reason" ethos. But the writing is on the wall. Any cut to any aspect of the healthcare system? More patients end up coming to us. Any cut to social safety nets that have nothing to do with medicine? More patients come to us. It's getting harder and harder to the point its untenable. We are the canaries in the coal mine. We are all leaving. Something is going to break.

 

[TooMuchResearch]

op it's such a ****ty job, I did it as an attending for 5 years and I thought the same as you. Hell you could probably go through my posting history and find a similar post.

On one of my last shifts before I left EM I was at a freestanding. 3 lacs and an abscess checked in within 10 minutes of each other at 4a and I'm single coverage. Nearly cried. The banality of these procedures is punishing over time.

I can completely see why other countries don't even have EM.

It's also dropped off the list entirely of being competitive outside of a few Midwestern programs. So as long as you passed step one your entire personal statement could be, "I have a heart beat" and you'd still get interviews.

But also as others said pick something with a future. One where you can actually be valued. Don't be the hotdog vendor at the NFL stadium, be the quarterback. Hell even plain IM then cards would make you much less irreplaceable than any em doc.

Would rather own the football team.

 

[flextape]

OP, I would not recommend it.

Here's why:

You will be judged on three principal metrics

1) Be perfect, every time
2) Be fast
3) Satisfy the "customer"

I'm actually pretty good at all of these, however, they are all opposed to each other.

Even if you can perform well in all of these, payors will not pay you. There is constant downward pressure on pay from Medicaid, Medicare and private insurance. There's always some new game to play, some hurdle to jump, and then they still might not pay.

Add to this low resource environments, staff shortages, abusive patients, admin that needs to be pleased in this way or that.

Add to this the fact that 75% of your shifts will end after 11pm, or be on a weekend.

Don't get me wrong, there ARE legit wins to be had. There ARE thankful patients. There ARE fun procedures (intubation and chest tubes, for me). There ARE good days that I enjoy in the ED.

This is my advice to any student for specialty selection:

1) Protected against midlevel encroachment (think surgical)

2) If not #1, then something that's easy to sell in cash to rich people (derm, plastics, psych)

3) avoid having to be beholden to a hospital

4) if not #3, then something admin types love and will bend over backwards for you (Ortho, interventional cards)

Sorry if this is off topic, but where does FM fall into any of these four? I know it's vulnerable to midlevel encroachment and all but what about the other three?

 

[WhatJobDoIPick]

Boy, does this comment resonate with me.

I turn 45 in August, and I'm leaving EM to start HPM fellowship on July 1.

I liked EM for a long time. I did. As a mom, I found it flexible (even though only ONE shift out of our 5 shifts on weekdays and NONE on weekends will get you home for dinner). But I got to the point where even working six shifts a month was painful. Driving in for these shifts filled me with dread and I'd be anxious days after.

For me, it truly felt like every time we had our monthly staff meeting, we'd be met with, "Here's another change happening in our health network that's going to make your life ****tier/harder." One month it was that we had to starting rounding on nearly all the APP patients (presumably to bill more for them) and there would be no increased pay or staffing to make up for it. Another was that the network decided to close inpatient psychiatry at our hospital, so we'd have nowhere to put the inevitable influx of patients. Oh, and all the psychiatrists left. These are just two examples.

You know, I always prided myself on EM and its "anywhere, any time, for any reason" ethos. But the writing is on the wall. Any cut to any aspect of the healthcare system? More patients end up coming to us. Any cut to social safety nets that have nothing to do with medicine? More patients come to us. It's getting harder and harder to the point its untenable. We are the canaries in the coal mine. We are all leaving. Something is going to break.

The comment about frog in boiling pot of water staff meetings rings true.

It's always a list of "Oh, just do this..." -isms in response to hospital deficiencies or operational problems:
-Just lean on the nurses to collect the urine
-Just call CT yourself to speed up the scan
-Just coordinate with XYZ person to do XYZ thing
-On Tuesdays when it's raining we refer to this group, but on Thursdays when it's partly cloudy we call this group

The encroachment of more and more tasks does not alleviate you of your primary metrics of:
-be perfect
-be fast
-satisfy the "customer"

 

[WhatJobDoIPick]

Boy, does this comment resonate with me.

I turn 45 in August, and I'm leaving EM to start HPM fellowship on July 1.

I liked EM for a long time. I did. As a mom, I found it flexible (even though only ONE shift out of our 5 shifts on weekdays and NONE on weekends will get you home for dinner). But I got to the point where even working six shifts a month was painful. Driving in for these shifts filled me with dread and I'd be anxious days after.

For me, it truly felt like every time we had our monthly staff meeting, we'd be met with, "Here's another change happening in our health network that's going to make your life ****tier/harder." One month it was that we had to starting rounding on nearly all the APP patients (presumably to bill more for them) and there would be no increased pay or staffing to make up for it. Another was that the network decided to close inpatient psychiatry at our hospital, so we'd have nowhere to put the inevitable influx of patients. Oh, and all the psychiatrists left. These are just two examples.

You know, I always prided myself on EM and its "anywhere, any time, for any reason" ethos. But the writing is on the wall. Any cut to any aspect of the healthcare system? More patients end up coming to us. Any cut to social safety nets that have nothing to do with medicine? More patients come to us. It's getting harder and harder to the point its untenable. We are the canaries in the coal mine. We are all leaving. Something is going to break.

What was your application process like?

Can you blindly apply or need research / letters from in field docs?

What's your sense of your local job market? Overrun with midlevels?

 

[WhatJobDoIPick]

Sorry if this is off topic, but where does FM fall into any of these four? I know it's vulnerable to midlevel encroachment and all but what about the other three?

FM folks can comment on specifics, but my general comments:

1) anytime you're running a business, you still need to pay attention to quality, speed and customer service

2) the key difference between that and EM (any any specialty where you are tied to a hospital) is that in the former YOU choose what your relative priorities are, how you want to meet them etc. you are your boss, not some idiot suit who has no idea how an ER works.

 

[Pinner Doc]

What was your application process like?

Can you blindly apply or need research / letters from in field docs?

What's your sense of your local job market? Overrun with midlevels?

I went through ERAS, which was a real trip because I had to find my old login from 2008! I put together the application, submitted in July (I think?) and interviewed in September. I only applied to my one local program. Match Day was December 4. I had three letters of recommendation - my director, the assistant director, and one of our ED care managers.

My healthcare network is small enough that I know a lot of folks in HPM locally that are part of the program. I'm a faculty member through VitalTalk and a lot of those folks with whom I teach are faculty in the Palliative Program to which I matched. One is the program director. I also have shadowed many of them in the past few years before deciding to make the leap. So I was a known entity, although I didn't get letters from any of them.

The local job market seems overwhelmingly physician-led, but there are APPs, chaplains, and social workers who also make up the care teams. It seems like a very multidisciplinary field.

 

[bky3c]

Hi I am at the end of my 3rd year and after finishing all the rotations it has become clear to me I want to do EM. I enjoy the acuity, fast pace, variety of cases, and working with my hands (suturing). I currently go to a medical school that does not have an EM rotation. I was able to do a 2 week elective in the ER and another 2 weeks in a rural ER. I thoroughly enjoyed both but I am having a crisis while applying for aways. I don't know how I'll fit in this specialty I am on the quieter side but mainly because I felt like I was under a microscope the whole time. But this worries me. I am also not sure what I have to offer. I am an average student idk how competitive I'll be and I am just struggling all around to get myself to write a personal statement for my aways. What should I do?

In addition to the responses from others, which I agree with, this stood out to me. I'm also the quieter type and don't enjoy being in the spotlight for codes, traumas, etc. When you know what you're doing, which you will once you're an attending, it's not a big deal anymore, but it was hard during residency. Also, consider whether you're okay with being socially "on" for 8-12+ hours a day. I like people in general, and I enjoy chatting with coworkers and the handful of normal/nice patients, but all that people-ing is draining for me, and maybe for you, too. Especially when a lot of your social interactions on shift involve difficult conversations with difficult people (everyone from patients to nurses to other physicians, depending on the situation). Everyone else complains about charting, but I actually didn't mind it because it was a chance to sit quietly with my own thoughts. I hated having scribes because I was never alone. I retired early from EM after 9.5 years as an attending, and I couldn't be happier. (To answer the "how" which is the usual response to that... lived below my means, saved a ton.) And I was a person who was about as "informed" as possible. I did 3 months of ED rotations as a student, and before and during medical school, I volunteered as an EMT.

 

[throway134]

I went through ERAS, which was a real trip because I had to find my old login from 2008! I put together the application, submitted in July (I think?) and interviewed in September. I only applied to my one local program. Match Day was December 4. I had three letters of recommendation - my director, the assistant director, and one of our ED care managers.

My healthcare network is small enough that I know a lot of folks in HPM locally that are part of the program. I'm a faculty member through VitalTalk and a lot of those folks with whom I teach are faculty in the Palliative Program to which I matched. One is the program director. I also have shadowed many of them in the past few years before deciding to make the leap. So I was a known entity, although I didn't get letters from any of them.

The local job market seems overwhelmingly physician-led, but there are APPs, chaplains, and social workers who also make up the care teams. It seems like a very multidisciplinary field.

Not who was asked, but I had a letter from a local hpm person I shadowed, my ed medical director and assistant director.

If your director is a bit lazy you might want to just write it yourself and send it to them to submit.

There’s a lot of midlevels in the field, but there’s a lot of docs too. Hospice is mostly physicians as nps can’t certify terminal illness and pas can’t even do the maintenance face to face visits, but both sets are still used for things like call or last minute visits.

Palliative has some more midlevel presence but honestly even there it’s a lot of docs. Field doesn’t draw a lot of glory or money, so midlevel presence is mostly from people who belong in the field

I have never been happier with a career decision than I was with the one to leave the pit.

 

[EctopicFetus]

Don’t do EM if you can think of doing anything else. Beyond what is here.. getting a job will be a bear.. 3k grads each and every year.. You know what we dont have.. the need for 3k fresh docs every year.

It’s perhaps not as terrible as we thought because the new grads know it blows from residency and only want to work 100-120 hours a month.. you can make plenty good dough doing that.. I mean $200/hr X 120 hours is just under 25k a month and thats 300k a year.. Thats super not hard to find IMO.. You can find some decently simple jobs making 230 (sometimes more).. Suddenly it’s 350k for the 12 hours a month. Not shabby..

That being said pay will go down, due to a few items, a glut of EM docs.. 2) tremendous pressure is coming to hospitals. When I say that I mean they are looking at site neutrality which would cost hospitals about $20B / yr per estimates. That money will cause tremendous ripples with cardiology and not a small amount of financial strain for hospitals. What do you think that means to all the docs who work at hospitals? Pay cuts especially if you work in a semi decent area where docs want to live. The future is not very far away. I bet the employment landscape looks incredibly different (in a bad way) for grads who will finish in 2028,2029.

 

[Arcan57]

For me, it truly felt like every time we had our monthly staff meeting, we'd be met with, "Here's another change happening in our health network that's going to make your life ****tier/harder." One month it was that we had to starting rounding on nearly all the APP patients (presumably to bill more for them) and there would be no increased pay or staffing to make up for it. Another was that the network decided to close inpatient psychiatry at our hospital, so we'd have nowhere to put the inevitable influx of patients. Oh, and all the psychiatrists left. These are just two examples.

It's challenging to convey to an outsider how resource poor many EDs have become. TV and media can show the gore and the grief but never captures the concept that all of that is happening within a system where something goes wrong on almost every patient. Sometimes that's a rare reaction or a hidden disease. Usually, it's that the lab was short staffed so they never accessioned the labs on a no-risk chest pain and now they're hemolyzed and the patient who never had any possibility of pathology is leaving AMA after 6 hours while complaining loudly on a phone call to their friend how much the place you work at (and sometimes you personally) suck. That dissatisfied customer will be charged $7-15 thousand dollars for that experience and you will make ~$37.

I swear, someday I'm going to come to work and find out that we switched EMRs to a cheaper vendor that no longer allows you to use a base10 numeric system but instead all drug doses have to be inputted in hexadecimal. In a functional system this would cause catastrophic patient safety issues. Since the nurses never open the EMR because they're too busy apartment hunting on-shift to actually perform patient care, it's actually fine and the CEO that ordered the contract gets another 0 on the end of their bonus check.

 

[WhatJobDoIPick]

Don’t do EM if you can think of doing anything else. Beyond what is here.. getting a job will be a bear.. 3k grads each and every year.. You know what we dont have.. the need for 3k fresh docs every year.

It’s perhaps not as terrible as we thought because the new grads know it blows from residency and only want to work 100-120 hours a month.. you can make plenty good dough doing that.. I mean $200/hr X 120 hours is just under 25k a month and thats 300k a year.. Thats super not hard to find IMO.. You can find some decently simple jobs making 230 (sometimes more).. Suddenly it’s 350k for the 12 hours a month. Not shabby..

That being said pay will go down, due to a few items, a glut of EM docs.. 2) tremendous pressure is coming to hospitals. When I say that I mean they are looking at site neutrality which would cost hospitals about $20B / yr per estimates. That money will cause tremendous ripples with cardiology and not a small amount of financial strain for hospitals. What do you think that means to all the docs who work at hospitals? Pay cuts especially if you work in a semi decent area where docs want to live. The future is not very far away. I bet the employment landscape looks incredibly different (in a bad way) for grads who will finish in 2028,2029.

The financial pressure is immense and cannot be overstated. Medicare cuts every year, Medicaid in my state is in shambles, insurers playing games.

 

[EctopicFetus]

The financial pressure is immense and cannot be overstated. Medicare cuts every year, Medicaid in my state is in shambles, insurers playing games.

It’s gonna get worse. Regardless of where you fall politically they are gonna make some cuts. Some i think make total sense like site neutrality and PBM reform but also understand that outside of HCA most hospital systems are in the +/- 3% margin range.. that aint much.. cut out $20B and man oh man.

 

[WhatJobDoIPick]

It’s gonna get worse. Regardless of where you fall politically they are gonna make some cuts. Some i think make total sense like site neutrality and PBM reform but also understand that outside of HCA most hospital systems are in the +/- 3% margin range.. that aint much.. cut out $20B and man oh man.

Agree. Hospital margins are razor thin despite our kvetching about admin pay.

One could argue you could cut admin pay to widen those margins but that's another issue.

Also agree that the rape of medicine is apolitical:
-Under biden, every year we had a year on year Medicare physician cut
-Now Trump coming after Medicaid
-Democrats in my state want to dismantle healthcare

 

[Pinner Doc]

Agree. Hospital margins are razor thin despite our kvetching about admin pay.

One could argue you could cut admin pay to widen those margins but that's another issue.

Also agree that the rape of medicine is apolitical:
-Under biden, every year we had a year on year Medicare physician cut
-Now Trump coming after Medicaid
-Democrats in my state want to dismantle healthcare

What do you mean by dismantle healthcare?

 

[EctopicFetus]

Agree. Hospital margins are razor thin despite our kvetching about admin pay.

One could argue you could cut admin pay to widen those margins but that's another issue.

Also agree that the rape of medicine is apolitical:
-Under biden, every year we had a year on year Medicare physician cut
-Now Trump coming after Medicaid
-Democrats in my state want to dismantle healthcare

Margins are razor thin due to insane waste and in many ways this is related to CMS. Do you have a sepsis coordinator? Do you have people who have jobs simply to meet Joint Commission nonsense? Thats a cost to the hospitals. They generate $0 in revenue.

I know of systems who have great outcomes in sepsis, stroke, STEMI but the money spent to essentially meet documentation standards isnt tiny. My personal system has pretty craptastic numbers on meeting sepsis standards. Is it that we dont? Of course not. It’s that the CMS standards are dumb, and the number of hours our docs and the “coordinators” spend figuring out ways to meet “metrics” is insane. These people could be focused on patient centered outcomes instead of dumb metrics that dont impact patients or their outcomes at all. At one of my hospitals if we could quantify this I would bet it is well over $500k. We are solving stupid made up issues instead of focusing on throughput, lab issues, staffing issues etc. I get the patient safety aspect of some of the requirements but in my experience 90% of the stuff we deal with is completely stupid, costs a bunch of money (takes up peoples time) and adds literally nothing to patient experience, outcomes, or good quality medicine.

I agree both parties want to cut us. You also forget how HHS/Biden/Becerra tried to weaponize the NSA/IDR process to screw EM docs.

 

[AlmostAnMD]

Margins are razor thin due to insane waste and in many ways this is related to CMS. Do you have a sepsis coordinator? Do you have people who have jobs simply to meet Joint Commission nonsense? Thats a cost to the hospitals. They generate $0 in revenue.

This has lead to the rise of my role as advisor at many healthcare systems. Virtually every, if not every hospital or hospital system with over 300 beds has at least one advisor.

With margins being so thin and insurance denying everything, my main role is to recoup money from insurance by flipping obs --> IP or, and this is where a lot of the money is, getting IP denials overturned to prevent downgrade. Insurance started overwhelming systems with denials, denials that take time to appeal so most without advisors don't appeal at all or rarely appeal.

Our group of advisors at our system bring in tens of millions of dollars a year that otherwise would have gone unpaid.

So it's a hell of a swing going from being a cog no one cares about (previous EM life) to someone the CEO personally talks to (rarely but happens) to make sure we have all the resources we need.

In an ideal system my current job wouldn't, or shouldn't, be necessary. However you play the game you HAVE to play, not the game you WANT to play. Thin margins means a bloodbath for the scraps.

 

[EctopicFetus]

This has lead to the rise of my role as advisor at many healthcare systems. Virtually every, if not every hospital or hospital system with over 300 beds has at least one advisor.

With margins being so thin and insurance denying everything, my main role is to recoup money from insurance by flipping obs --> IP or, and this is where a lot of the money is, getting IP denials overturned to prevent downgrade. Insurance started overwhelming systems with denials, denials that take time to appeal so most without advisors don't appeal at all or rarely appeal.

Our group of advisors at our system bring in tens of millions of dollars a year that otherwise would have gone unpaid.

So it's a hell of a swing going from being a cog no one cares about (previous EM life) to someone the CEO personally talks to (rarely but happens) to make sure we have all the resources we need.

In an ideal system my current job wouldn't, or shouldn't, be necessary. However you play the game you HAVE to play, not the game you WANT to play. Thin margins means a bloodbath for the scraps.

Yep. I know a few physician advisors locally. It’s further proof of the waste (denials and creating a system around it ) and abuse (by insurers) in our system.

In lieu of the money they spent on you and other advisors more patients could get care and generate money for them and have you care for patients. It’s clear it makes sense for insurers to deny claims and for the hospital to hire you to claw back some of the money.

 

[VA Hopeful Dr]

FM folks can comment on specifics, but my general comments:

1) anytime you're running a business, you still need to pay attention to quality, speed and customer service

2) the key difference between that and EM (any any specialty where you are tied to a hospital) is that in the former YOU choose what your relative priorities are, how you want to meet them etc. you are your boss, not some idiot suit who has no idea how an ER works.

Yes, but we develop long term relationships with our patients so they cut us way more slack than they do an EP who they met for the first time today.

 

[alpinism]

The average hospital profit margin in 2024 was 4% which isn't wonderful but not what I'd call "razor thin".

I'll add there are plenty of hospital chains especially the for profit ones like tenet healthcare that have consistently averaged 14% for many years.

 

[sloh]

This has lead to the rise of my role as advisor at many healthcare systems. Virtually every, if not every hospital or hospital system with over 300 beds has at least one advisor.

With margins being so thin and insurance denying everything, my main role is to recoup money from insurance by flipping obs --> IP or, and this is where a lot of the money is, getting IP denials overturned to prevent downgrade. Insurance started overwhelming systems with denials, denials that take time to appeal so most without advisors don't appeal at all or rarely appeal.

Our group of advisors at our system bring in tens of millions of dollars a year that otherwise would have gone unpaid.

So it's a hell of a swing going from being a cog no one cares about (previous EM life) to someone the CEO personally talks to (rarely but happens) to make sure we have all the resources we need.

In an ideal system my current job wouldn't, or shouldn't, be necessary. However you play the game you HAVE to play, not the game you WANT to play. Thin margins means a bloodbath for the scraps.

These positions and those like them in medicine are very underrated, regardless of specialty. One of the rare times you can be on the same team as the administrators and up the corporate chain.

 

[EctopicFetus]

The average hospital profit margin in 2024 was 4% which isn't wonderful but not what I'd call "razor thin".

I'll add there are plenty of hospital chains especially the for profit ones like tenet healthcare that have consistently averaged 14% for many years.

Thats one year. Look back over the past 10 years.. how has it looked. 4% margins arent much. The non profits are typically under the 4% you quote and HCA and the for profits are certainly pulling that up.

 

[EctopicFetus]

The average hospital profit margin in 2024 was 4% which isn't wonderful but not what I'd call "razor thin".

I'll add there are plenty of hospital chains especially the for profit ones like tenet healthcare that have consistently averaged 14% for many years.

A look at hospital operating margins in the United States

Explore hospital operating margins in the U.S. Discover the average operating margin and the yearly trends for hospital operating margins in U.S. hospitals.

www.definitivehc.com

 

[RustedFox]

The average hospital profit margin in 2024 was 4% which isn't wonderful but not what I'd call "razor thin".

I'll add there are plenty of hospital chains especially the for profit ones like tenet healthcare that have consistently averaged 14% for many years.

3.6 roentgen.
Not great, not terrible.

 

[alpinism]

Thats one year. Look back over the past 10 years.. how has it looked. 4% margins arent much. The non profits are typically under the 4% you quote and HCA and the for profits are certainly pulling that up.

True but that's always been the case since technically "nonprofit hospitals" shouldn't have any profits and should be reinvesting everything in the hospital to cover the uninsured their community. I mean if all the nonprofits where regularly at 10%+ profit margins then it would make no sense classifying them as nonprofit since they're essentially a for profit company. That's why its such a stupid excuse for admin to cut costs since they're quite literally supposed to be reinvesting all that money to fund their downtown EDs and not to build tons of suburban FSEDs.

 

[dozitgetchahi]

Sorry if this is off topic, but where does FM fall into any of these four? I know it's vulnerable to midlevel encroachment and all but what about the other three?

By my reasoning, FM (or primary care focused IM) is not half bad in these categories.

You’re not necessarily beholden to a hospital. You can open a cash only, concierge/DPC primary care practice.

 

[EctopicFetus]

True but that's always been the case since technically "nonprofit hospitals" shouldn't have any profits and should be reinvesting everything in the hospital to cover the uninsured their community. I mean if all the nonprofits where regularly at 10%+ profit margins then it would make no sense classifying them as nonprofit since they're essentially a for profit company. That's why its such a stupid excuse for admin to cut costs since they're quite literally supposed to be reinvesting all that money to fund their downtown EDs and not to build tons of suburban FSEDs.

We all know thats a scam,.. that being said the majority of hospitals in the US are non profits. The tenets, HCA CHS are a powerful minority.

 

[RustedFox]

We all know thats a scam,.. that being said the majority of hospitals in the US are non profits. The tenets, HCA CHS are a powerful minority.

Gee.

Wonder who has all the money, then?
The docs don't have it.
The hospitals don't have it.
The patients don't have it.

What's that I hear in the distance?
The Super Mario theme?
Nah. Can't be.

 

[dozitgetchahi]

Gee.

Wonder who has all the money, then?
The docs don't have it.
The hospitals don't have it.
The patients don't have it.

What's that I hear in the distance?
The Super Mario theme?
Nah. Can't be.

The hospitals have it, as do the drug companies, the medical device makers, and the multiple layers of rent seeking middlemen (Change Healthcare).

The “nonprofit” hospitals get away with this via creative accounting.

 

[RustedFox]

The hospitals have it, as do the drug companies, the medical device makers, and the multiple layers of rent seeking middlemen (Change Healthcare).

The “nonprofit” hospitals get away with this via creative accounting.

Well with all this crying poor about razor thin margins and all but a few hospitals going to war over scraps or else it's bankruptcy for them, there's gotta be a party with fat stacks of cash.

 

[AlmostAnMD]

Well with all this crying poor about razor thin margins and all but a few hospitals going to war over scraps or else it's bankruptcy for them, there's gotta be a party with fat stacks of cash.

Oh sure. That pic makes perfect sense. They've all really upped their crazy denials game. Ive had straightforward cases get denied on purely administrative grounds. Just had a case yesterday about an acute dx of AML in a young girl getting transfusions daily since her body is essentially shutting down fully denied by UHC on laughable grounds. Now we need to work through the appeals process.

Some guy just got threatened by UHC, (made national news, I forget his name but he's some stock guru) he basically insinuated that these companies are only profitable by denying necessary medical care. I think in many cases this is true.

The less you spend, the more you keep. And they're testing new grounds every year to see how far they can push it. Sometimes they go a bridge too far, like the anesthesia billing hours cap. Doesn't mean they won't try again later.

 

[RustedFox]

Oh sure. That pic makes perfect sense. They've all really upped their crazy denials game. Ive had straightforward cases get denied on purely administrative grounds. Just had a case yesterday about an acute dx of AML in a young girl getting transfusions daily since her body is essentially shutting down fully denied by UHC on laughable grounds. Now we need to work through the appeals process.

Some guy just got threatened by UHC, (made national news, I forget his name but he's some stock guru) he basically insinuated that these companies are only profitable by denying necessary medical care. I think in many cases this is true.

The less you spend, the more you keep. And they're testing new grounds every year to see how far they can push it. Sometimes they go a bridge too far, like the anesthesia billing hours cap. Doesn't mean they won't try again later.

Insufficient Luigi.

 

[BoardingDoc]

Insufficient Luigi.

Honestly surprised there aren't a bunch of copycats.

 

[HemorrhagicShock]

Don’t do EM if you can think of doing anything else. Beyond what is here.. getting a job will be a bear.. 3k grads each and every year.. You know what we dont have.. the need for 3k fresh docs every year.

It’s perhaps not as terrible as we thought because the new grads know it blows from residency and only want to work 100-120 hours a month.. you can make plenty good dough doing that.. I mean $200/hr X 120 hours is just under 25k a month and thats 300k a year.. Thats super not hard to find IMO.. You can find some decently simple jobs making 230 (sometimes more).. Suddenly it’s 350k for the 12 hours a month. Not shabby..

That being said pay will go down, due to a few items, a glut of EM docs.. 2) tremendous pressure is coming to hospitals. When I say that I mean they are looking at site neutrality which would cost hospitals about $20B / yr per estimates. That money will cause tremendous ripples with cardiology and not a small amount of financial strain for hospitals. What do you think that means to all the docs who work at hospitals? Pay cuts especially if you work in a semi decent area where docs want to live. The future is not very far away. I bet the employment landscape looks incredibly different (in a bad way) for grads who will finish in 2028,2029.

This post should be required reading.

I have foreseen the same economic conditions plaguing hospitals for the next decade. More like the next 5 years.

Already, I'm hearing about it in the rural areas of my state (CA), and it's only a matter of time before these constraints reach more urban healthcare enterprises and organizations.

Add in the anticipated lack of support from Federal sources, and you're now sitting on an unmistakable powder keg that will obliterate the system as we know it.

And guess who gets to deal with the fall-out as the only specialty that can't say no (EMTALA)?

That's right.

Emergency Medicine.

This is why I don't practice it anymore, and I fully made use of the fact that you could FIRE with less than 10 years of practice if you were diligent about investing.

After 8 years of full-time high-acuity, high-volume practice, the only lives I have TRULY saved are those of the medical students I convinced to avoid EM at all costs.

At this point in the timeline no MD at a middle or high-tier school should be wasting their time with EM. It was suitable for a minute there during the Golden Era of EM, but the specialty is dying quickly. If you're a trash tier DO or IMG and don't have many other options, sure. It's still a job, and will allow for a middle-class lifestyle.

But if you made your way into a good MD school, it would be such a tragic waste of time to do EM when you have so many other better options available to you.

ROAD, PMR, Neurology (if you can cash pay practice) or surgical specialty, don't look back.

 

[WhatJobDoIPick]

This post should be required reading.

I have foreseen the same economic conditions plaguing hospitals for the next decade. More like the next 5 years.

Already, I'm hearing about it in the rural areas of my state (CA), and it's only a matter of time before these constraints reach more urban healthcare enterprises and organizations.

Add in the anticipated lack of support from Federal sources, and you're now sitting on an unmistakable powder keg that will obliterate the system as we know it.

And guess who gets to deal with the fall-out as the only specialty that can't say no (EMTALA)?

That's right.

Emergency Medicine.

This is why I don't practice it anymore, and I fully made use of the fact that you could FIRE with less than 10 years of practice if you were diligent about investing.

After 8 years of full-time high-acuity, high-volume practice, the only lives I have TRULY saved are those of the medical students I convinced to avoid EM at all costs.

At this point in the timeline no MD at a middle or high-tier school should be wasting their time with EM. It was suitable for a minute there during the Golden Era of EM, but the specialty is dying quickly. If you're a trash tier DO or IMG and don't have many other options, sure. It's still a job, and will allow for a middle-class lifestyle.

But if you made your way into a good MD school, it would be such a tragic waste of time to do EM when you have so many other better options available to you.

ROAD, PMR, Neurology (if you can cash pay practice) or surgical specialty, don't look back.

EM is great is you want to work really hard to do 99% of the things right, but only hear about the 1%; and get paid less and less each year for the 99%.

 

[AlmostAnMD]

EM is great is you want to work really hard to do 99% of the things right, but only hear about the 1%; and get paid less and less each year for the 99%.

I posted this before but it's still funny. Well, sad-funny.

I joined a (malignant) SDG in 2019. I made partner in 2022. I made more money as a partner but when you factor in inflation I actually made less /hr than I did in 2019 lolololol

Reason #293183 to leave

 

[WhatJobDoIPick]

I posted this before but it's still funny. Well, sad-funny.

I joined a (malignant) SDG in 2019. I made partner in 2022. I made more money as a partner but when you factor in inflation I actually made less /hr than I did in 2019 lolololol

Reason #293183 to leave

What made it malignant?