Resident ITE scores have plummeted 25% in the last 5 years

[sylvanthus]

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As I previously stated, the data in the EM News piece was incorrect and a retraction has been reported. Data matters and we should care about using it appropriately. Fake news won't help fix our specialty's problems.

EM Resident Test Performance Declines Over Past Year : Emergency Medicine News

An abstract is unavailable.

journals.lww.com

You point out that data matters, are you able to step back and look at the overall trends pointing in the wrong direction, or are you biased by being a PD?

 

[TooMuchResearch]

You are correct that the initial data reported was inaccurate.


That being said, the revised data isn't that much better to be honest. The median PGY-1 in 2019 scoring almost a high as the median PGY-3 in 2024 is deeply concerning.

Wow that's really worrisome

 

[TooMuchResearch]

Honestly, seems like a fairly significant difference to me. Scores are obviously still embarrassingly low though. I seem to recall hearing that an ITE score of 75 or 80 correlated w/ passing the written exam?

I don't really get it. Does the current crop of residents just not give a ****? Or are they intentionally throwing it?

Maybe it's the test's fault or whatever people want to blame this week

 

[JacobMcCandles]

Any bets that the "fix" for this won't be to actually educate, teach, and provide constructive feedback to residents but it will be to make the test easier?

This should be a wakeup call to program directors to get back to teaching EM in the ED.

 

[MechEDoc]

Any bets that the "fix" for this won't be to actually educate, teach, and provide constructive feedback to residents but it will be to make the test easier?

This should be a wakeup call to program directors to get back to teaching EM in the ED.

Maybe it's a wakeup call that our specialty is really dying. Gone are the days of well trained physicians seeing patients in the ER. Now it's PAs, NPs, FPs, and poorly trained ER physicians.

🙁

 

[JacobMcCandles]

Maybe it's a wakeup call that our specialty is really dying. Gone are the days of well trained physicians seeing patients in the ER. Now it's PAs, NPs, FPs, and poorly trained ER physicians.

🙁

I take the opposite approach. Never will the need be greater for good EM docs. If you’re good and can manage a department then you’ll do well.

 

[MechEDoc]

I take the opposite approach. Never will the need be greater for good EM docs. If you’re good and can manage a department then you’ll do well.

True, but there will be a much lower need. One physician with 3 midlevels vs 2-3 physicians covering the same department.

 

[HemorrhagicShock]

Maybe it's a wakeup call that our specialty is really dying. Gone are the days of well trained physicians seeing patients in the ER. Now it's PAs, NPs, FPs, and poorly trained ER physicians.

🙁

This fact supports my thought that the gap between newly trained ER docs and "well-trained" midlevels will continue to shrink, especially with AI help.

The system does not value the expertise and skillset of a well-trained experienced EM physician. As far as a health organization is concerned, it doesn't matter who is seeing the patient as long as metrics and reimbursement are coming in hot.

 

[xaelia]

True, but there will be a much lower need. One physician with 3 midlevels vs 2-3 physicians covering the same department.

Standard academic and/or UK-style model – supervising physician surrounded by a range of lower-skilled minions.

Wouldn't work for every hospital's patient population and acuity, obviously, but 60% of the time, it works every time.

 

[WhatJobDoIPick]

Guys. The test is obviously racist.

 

[SeekerOfTheTree]

What happened to this whole longer residency to make better doctors push for EM?

 

[EctopicFetus]

What happened to this whole longer residency to make better doctors push for EM?

I hear it is pending but ACGME (or whoever) is reconsidering cause major push back.

 

[Arcan57]

This fact supports my thought that the gap between newly trained ER docs and "well-trained" midlevels will continue to shrink, especially with AI help.

The system does not value the expertise and skillset of a well-trained experienced EM physician. As far as a health organization is concerned, it doesn't matter who is seeing the patient as long as metrics and reimbursement are coming in hot.

Students feel like they can AI search anything and so are less motivated to really imprint the information since imprinting takes a lot more time and effort than filtering ChatGPT results. Why memorize hard things when you can look up the info in seconds for almost any clinical scenario?

 

[xaelia]

Students feel like they can AI search anything and so are less motivated to really imprint the information since imprinting takes a lot more time and effort than filtering ChatGPT results. Why memorize hard things when you can look up the info in seconds for almost any clinical scenario?

Why do anything at all?

 

[Pudortu]

I hear it is pending but ACGME (or whoever) is reconsidering cause major push back.

Oh geez I hope you’re wrong. Thought it was a great solution to poor new resident quality and possibly our oversupply.

 

[HemorrhagicShock]

Students feel like they can AI search anything and so are less motivated to really imprint the information since imprinting takes a lot more time and effort than filtering ChatGPT results. Why memorize hard things when you can look up the info in seconds for almost any clinical scenario?

You've hit the nail on the head - this is the path to similar outcomes, regardless of underlying education.

The vast amount of knowledge that a physician has only comes into play for the 2- and 3-sigma outlier cases, where their experience and expertise can shine.

Unfortunately, there's no incentive structure to reward this extra expertise within the current healthcare system as it is designed.

This is even less true in emergency medicine, where in most real emergency situations you take a fairly cookie-cutter approach that gets refined via extensive experiential training in residency. Repetition leads to mastery.

And for the 98% of cases we see in the ED that aren't real emergencies, well, I hate to say it, but a vast majority of the time it doesn't matter how competent or incompetent you are (from a systemic perspective), as "time heals all wounds" and "the art of medicine consists in amusing the patient while nature cures the disease." You don't need an MD/DO for the vast majority of these cases.

I've worked with amazing and capable PAs in this environment, and I truly believe there's no reason you need the entirety of a 4-year undergrad degree and a 4-year MD/DO as a context for entry into a 3- or 4-year EM residency.

All of medicine will be disrupted in the next 5 years, and there will be less and less high-reimbursing, low-effort volume-based work to bolster the historically high physician pay of today and yesteryear. The margins are thinning quickly.

 

[WhatJobDoIPick]

What makes you think there will be significant disruption in the next 5 years? I'm not saying you're wrong, just curious.

 

[Mount Asclepius]

There is a valid argument that with information so readily available and easily searchable we are going to be better off by learning to sort and find information rather than rotely memorize.

Previously (and still mostly currently), skilled EPs (probably applies to many specialties) are the ones who have a vast databank of medical knowledge that they can apply to pattern recognition. The latter of which is a very translatable skill to even those without medical degrees - triage nurses, experienced charge RNs, PAs and some NPs that didn’t take the path straight from pre-K to their online degree. 80+% of medical care is purely the basic patterns. The system doesn’t want us to pick needles out of haystacks, which requires medical knowledge and individualistic care. It wants standardized care. Bye bye physician autonomy.

The score issue is concerning, but I think it may be the tip of the spear of change that is coming. I hate to say that I won’t be able to adapt, but I think the concept of being a physician is going to fundamentally change and I’m not sure it’s what I signed up for.

 

[xaelia]

All of medicine will be disrupted in the next 5 years, and there will be less and less high-reimbursing, low-effort volume-based work to bolster the historically high physician pay of today and yesteryear. The margins are thinning quickly.

The key is that "high-reimbursing, low-effort volume-based work" – as soon as it seems apparent a lower-paid monkey with a computer can churn through the bulk of our patients, CMS will cut the RVUs for ED encounters to the point where reimbursement requires you to staff solely with lower-paid monkeys and their computers.

 

[WhatJobDoIPick]

The key is that "high-reimbursing, low-effort volume-based work" – as soon as it seems apparent a lower-paid monkey with a computer can churn through the bulk of our patients, CMS will cut the RVUs for ED encounters to the point where reimbursement requires you to staff solely with lower-paid monkeys and their computers.

The crux of the issue is that we actually need something like (just shooting random numbers here) 10% of the current number of ERs, and thus 10% of the current number of ER physicians. There's no reason to have 20 ERs open in a 20 mile radius at 3am, to deal with nonsense.

Instead, we created a commodity that's way too available and perceived as cheap (Medicaid/Medicare patients with way too little skin in the game).

When a resource is available and "cheap," it is abused. Value to the "consumer " is perceived as low and you get all sorts of bad behavior. Turns out, the resource is actually very expensive. The powers that be will then whip us and lower our pay, instead of create incentives for the "consumer" to alter behavior. Because we have 10x the EPs that we actually need in a rational society, we are all replaceable at the drop of a hat. Furthermore we have an army of pretenders (midlevels) that are even cheaper and easier to slot in.

EM is a failed paradigm. Not because it's not valuable. We need high trained and competent physicians in the ED. It failed because of the implementation

 

[Porfirio]

EM failed because we gave up all our power to Corp Medicine. Just get what you can, help the patients, and move on. You and I might be dinosaurs but we didn’t die immediately from the comet. We know before the comet, when the comet fell, and after. New EM docs/residents only know the after.

By the time I am old and gray, the world is going to be a very different place. Likely there will be no midlevels or physicians.

 

[EctopicFetus]

Oh geez I hope you’re wrong. Thought it was a great solution to poor new resident quality and possibly our oversupply.

While i think the time allows for more learning i think the issue is GIGO. Your applicant quality would tank and no amount of time would get these people to a level of practice that would be strong.

 

[EctopicFetus]

The issues discussed here are not just EM’s. Cardiology? Literally the same.. Any non procedural specialty literally the same. Risk stratification and a plan.. Do you need a human at all? Enter patient info into AI algo and spit out results but it would literally be better than the human because it can take into account their insurance and deal with pre-auths and be immune to drug reps and based on patients income help choose a medicine the will take and afford.

Many procedures are fairly simple. Don’t need a human for them either (soon). I do think that’s in the 5-10 years range. I mean if my car can drive me from point A to point B and deal with all the people and their decisions which are questionable do you think a robot cant do a colonoscopy? A simple appy? A knee replacement? Etc etc. Do we need human anesthesia docs?

EM will always require a human. We cant even begin to think about a world where a bunch of EDs close at night. It’s less about the medicare/medicaid $$ and more about the systems trying to funnel patients into their system. I think things will continue to go as is. Some markets will expand. Places with CONs will eventually remove them and an arms race will proceed. How it ends.. lots of shuttered EDs but short term gain for EM docs.

 

[alpinism]

So at the moment there's about 60,000 EM docs + 60,000 EM midlevels in the United States.

Do the math and it's 1 for 3,000 population on average if we have a normal distribution.

Which is completely insane and explains how most EM care is not EM level care.

 

[alpinism]

I'll add that based on studies we need 1 for 100,000 population on average for the actual emergency patients.

That means we currently have a surplus of 30x EM docs and midlevels if we exclude non emergency patients.

 

[WhatJobDoIPick]

I'll add that based on studies we need 1 for 100,000 population on average for the actual emergency patients.

That means we currently have a surplus of 30x EM docs and midlevels if we exclude non emergency patients.

I really just need this gravy train to chug along for another 5 years or so. After that, IDC what happens.

 

[Apollyon]

I really just need this gravy train to chug along for another 5 years or so. After that, IDC what happens.

Or, you could be on the "gravy train with biscuit wheels" like @EctopicFetus and @emergentmd !

 

[WhatJobDoIPick]

Or, you could be on the "gravy train with biscuit wheels" like @EctopicFetus and @emergentmd !

Nah I don't have the talent.

I foresee a lot of vacations to national parks and rounds of golf on municipal courses ..which I am VERY ok with.

 

[HemorrhagicShock]

What makes you think there will be significant disruption in the next 5 years? I'm not saying you're wrong, just curious.

1) Speed of AI developments (just look at how things have advanced since ChatGPT hit the scene in 2022)
2) An unhealthier population getting more unhealthy and older, the massive need for more "provider" labor
3) Deregulation on a Federal and State level, leading to more open doors for non-physician players
4) If the techbros want to disrupt it, they will disrupt it, they all see the trillions of TAM within the healthcare space
5) Physicians are cuc|<s administratively, legislatively, and love nothing more than fighting amongst themselves rather than focusing on protecting the entire profession (like lawyers have done)
6) Look at your day-to-day in a hospital or clinic or any other healthcare space, and compare it to any modern profitable company. It's wild how many opportunities there are to streamline processes and workflows. We are still using FAX machines for god sake, all because of regulatory burden and tradition.

I could go on, but you get the idea

 

[EctopicFetus]

Nah I don't have the talent.

I foresee a lot of vacations to national parks and rounds of golf on municipal courses ..which I am VERY ok with.

You can be on the gravy train AND take lots of vacations.

 

[RustedFox]

You can be on the gravy train AND take lots of vacations.

Those are inexpensive vacations and rounds of golf, bro.

Municipal courses are fun AF, too. You hit shots that you would otherwise never normally take.

 

[WhatJobDoIPick]

Sitting here gathering the strength to see someone for the same complaint they've been seen for 7x this year.

 

[RustedFox]

Sitting here gathering the strength to see someone for the same complaint they've been seen for 7x this year.

Is it TSH testing that isn't indicated?

Please tell me "yes".

@CajunMedic

 

[RustedFox]

Sitting here gathering the strength to see someone for the same complaint they've been seen for 7x this year.

Zen, bro.
Zen.

Think about that 45 yard pitch shot into a par 4 with a laser-level'ed flat green that you would never otherwise hit.

Slippery when you think about it, right?

 

[RustedFox]

Sitting here gathering the strength to see someone for the same complaint they've been seen for 7x this year.

Zen, bro.
Zen.

Think about that 45 yard pitch shot into a par 4 with a laser-level'ed flat green that you would never otherwise hit.

Slippery when you think about it, right?

 

[HemorrhagicShock]

Sitting here gathering the strength to see someone for the same complaint they've been seen for 7x this year.

I actually found solace in these patients, knowing that I could go in and just do whatever, acquiesce to whatever, click whatever they want (within reason after talking to them about how this kind of excessive workup could cause harm long term), and know that the outcome would be exactly the same as the last 7 times.

These patients were autopilot mode. I'd prep their discharge stuff the second I got back to my computer, and would just let their superfluous workup cook for the 1-5 hours (depending on what I ordered).

Hell, sometimes you WOULD find some incidental or something of import, maybe it gave them something to chase with their PCP, or perhaps just added to their anxiety for the upcoming 9th visit to the ED. Who knows (and I hate to say it, but who cares).

Once I found these kinds of patients more enjoyable than an undifferentiated train wreck/mega-code resuscitation, or a gnarly high-acuity multi-system trauma patient who was actively dying, or any of the other "reasons people go into EM" that's when I knew it was time to get the F out of the specialty.

 

[CajunMedic]

Is it TSH testing that isn't indicated?

Please tell me "yes".

@CajunMedic

lol. or chest pain, dyspnea, anxiety..... God help me if they come back and there is no one else to see them

 

[xaelia]

Sitting here gathering the strength to see someone for the same complaint they've been seen for 7x this year.

The simple problem is that patients have all the power. They bring the $$$ with them, for the most part. No patients, no $$$ for us. All the incentives on our side are to see and do whatever the patients want. U.S. medicine is addicted to high salaries and this is the only way to fuel them.

Go overseas, you get to tell people "no" because the power belongs with the expertise.

 

[WhatJobDoIPick]

The simple problem is that patients have all the power. They bring the $$$ with them, for the most part. No patients, no $$$ for us. All the incentives on our side are to see and do whatever the patients want. U.S. medicine is addicted to high salaries and this is the only way to fuel them.

Go overseas, you get to tell people "no" because the power belongs with the expertise.

I mean...I'll take 400k USD to see the chronic back pain... I'm good lol

 

[Porfirio]

I mean...I'll take 400k USD to see the chronic back pain... I'm good lol

Start a pain clinic?

 

[WhatJobDoIPick]

Start a pain clinic?

You're misunderstanding. I'm saying I'll deal with the US nonsense for money rather than go abroad and make 50% of what I do now for some perceived notion of autonomy lol.

 

[Zebra Hunter]

Nah I don't have the talent.

I foresee a lot of vacations to national parks and rounds of golf on municipal courses ..which I am VERY ok with.

Bruh, I just played a round at our local boujee resort course for a friend’s birthday. $200 for me to have the pleasure of shanking into the woods 8+ times lol. I’ll definitely be sticking to the municipal courses.

 

[RustedFox]

Bruh, I just played a round at our local boujee resort course for a friend’s birthday. $200 for me to have the pleasure of shanking into the woods 8+ times lol. I’ll definitely be sticking to the municipal courses.

RustedFox Rants: Miniature edition.

So I played today.

I was reminded why I don't play golf in Florida hardly at all.

I can play. If I actually played regularly, I would be a single-digit handicapper. I keep it in the shortgrass.

I'm not gonna pay for a membership at any private course. Not worth it.

So I live in this subdivision where there's a public and a private course. The public course is closed for renovations (okay), so I went over to the private side and said: "Hey I live here and just wanna hit some golf balls on the range to kill time. Here's my ten bucks; sound good?"

"Can't do that, neighbor - but you know we're open to non-members in the subdivision during summer afternoons."

"Cool. Let's play. Pair me with whoever, idc."

90 degrees. Feels like 105. Sauna warning. Okay. I'll hydrate.

"Dickerson Woods Golf and Country Club" (that's not it's real name) should REALLY be called "Dickerson Woods Golf and Assisted Living Facility".

After 3 hours and 11 holes behind people who really should have ambulatory assist devices, I straight up left and went home. 6 HOUR PACE OF PLAY.

Shot 5 over par on the front 9 with a birdie. Soaked 4 golf gloves thru-and-thru.

The land before time.

 

[BoardingDoc]

RustedFox Rants: Miniature edition.

So I played today.

I was reminded why I don't play golf in Florida hardly at all.

I can play. If I actually played regularly, I would be a single-digit handicapper. I keep it in the shortgrass.

I'm not gonna pay for a membership at any private course. Not worth it.

So I live in this subdivision where there's a public and a private course. The public course is closed for renovations (okay), so I went over to the private side and said: "Hey I live here and just wanna hit some golf balls on the range to kill time. Here's my ten bucks; sound good?"

"Can't do that, neighbor - but you know we're open to non-members in the subdivision during summer afternoons."

"Cool. Let's play. Pair me with whoever, idc."

90 degrees. Feels like 105. Sauna warning. Okay. I'll hydrate.

"Dickerson Woods Golf and Country Club" (that's not it's real name) should REALLY be called "Dickerson Woods Golf and Assisted Living Facility".

After 3 hours and 11 holes behind people who really should have ambulatory assist devices, I straight up left and went home. 6 HOUR PACE OF PLAY.

Shot 5 over par on the front 9 with a birdie. Soaked 4 golf gloves thru-and-thru.

The land before time.

Just ask the gomers if you can play through. Or if they're a**holes, just skip a hole and jump ahead of them.

 

[RustedFox]

Just ask the gomers if you can play through. Or if they're a**holes, just skip a hole and jump ahead of them.

I would have, but what do you think was in front of those gomers... and the gomers in front of those gomers... and the gomers in front of the gomers in FRONT of those gomers?

And it's like that in Florida most of the time. During season? 120 bucks for a six hour round? ForGET it.

 

[BoardingDoc]

I would have, but what do you think was in front of those gomers... and the gomers in front of those gomers... and the gomers in front of the gomers in FRONT of those gomers?

And it's like that in Florida most of the time. During season? 120 bucks for a six hour round? ForGET it.

Yeah, kinda sounds like you either need to have the first tee time of the day or nothing at all.

 

[xaelia]

Yeah, kinda sounds like you either need to have the first tee time of the day or nothing at all.

A lotta golf on an average muni is better than no golf on pristine grounds.

Annoyingly, where I live has a lot of courses and not a lot of practice facilities ... I do prefer to be sharp enough to get the value out of my rounds, and that's why I don't play much these days.