Sad state of affairs for EM.

[chessknt]

Or they order every test known to man, costing much more than the money saved to avoid paying for that pesky physician.

In residency had a brought a young patient s/p VATS intubated, with plan for extubation in ICU. On way to CVICU pt looking like he wanted to fast track his recovery, so I told the nurse give reversal and just extubate since he met criteria anyway. Instead the ICU NP said they don't reverse patients, and instead put him on a prop drip and cardene infusion for his elevated BP and heart rate and thrashing instead of just pulling the tube. Mismanagement to the max. I have so many stories of much more mismanagement by our top of the license "colleagues"

I'm truly scared to get sick and be in any hospital, and be subject to the "care" they subject patients to

It is believable that a non-or based specialty will never have seen a reversal agent given. The scary part of that interaction was the lack of deference to your expertise.

---

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[coffeebythelake]

It is believable that a non-or based specialty will never have seen a reversal agent given. The scary part of that interaction was the lack of deference to your expertise.

These midlevel nurses are taught that they are as good... even better... than physicians. They are indoctrinated by their nursing school and the national nursing organizations.

 

[Gasworks]

They don’t give a shlt, about your quality.

This right here sums up every minute of my experience throughout multiple facilities in multiple systems over the past few years. Staffing shortages in the Covid world followed by Covid $$ drying up over the past year have accelerated this decline. I’m content to just milk this cow for another 5 years and retire in peace.

 

[DocMcCoy]

 

[Gern Blansten]

Now is the time to buy. Those who choose EMed now will likely be happy they did in a few short years. Wherever people are running away from, that is where you run to.

 

[Fpg1245]

Now is the time to buy. Those who choose EMed now will likely be happy they did in a few short years. Wherever people are running away from, that is where you run to.

The stock/ medical specialty analogy is dangerous.

If I don’t like a stock, I type it into my trading account and viola it’s done.

Trying to run from a specialty is more like filing for a divorce that’s gonna be messy

 

[chocomorsel]

Or they order every test known to man, costing much more than the money saved to avoid paying for that pesky physician.

In residency had a brought a young patient s/p VATS intubated, with plan for extubation in ICU. On way to CVICU pt looking like he wanted to fast track his recovery, so I told the nurse give reversal and just extubate since he met criteria anyway. Instead the ICU NP said they don't reverse patients, and instead put him on a prop drip and cardene infusion for his elevated BP and heart rate and thrashing instead of just pulling the tube. Mismanagement to the max. I have so many stories of much more mismanagement by our top of the license "colleagues"

I'm truly scared to get sick and be in any hospital, and be subject to the "care" they subject patients to

So why didn’t you give reversal and extubate then? No time? This is not good for the patient if you knew this was going down.

 

[2Fast2Des]

So why didn’t you give reversal and extubate then? No time? This is not good for the patient if you knew this was going down.

Because the ICU didn't have any reversal agent apparently, nor did I have it on me since extubation wasn't the plan before. They didn't want to call pharmacy and get it shipped up either

 

[chocomorsel]

Because the ICU didn't have any reversal agent apparently, nor did I have it on me since extubation wasn't the plan before. They didn't want to call pharmacy and get it shipped up either

And literally no way you could have gone back to the OR and gotten it? It was up and down some mountains, through the valley and across the river? Couldn’t have someone tube it up to you? It’s academics. Time constraints are bad in academics?
Anyway I honestly don’t know. I am pissy right now at re credentialing but this is what should have happened ideally. If you couldn’t do it you couldn’t.

 

[Southpaw]

Now is the time to buy. Those who choose EMed now will likely be happy they did in a few short years. Wherever people are running away from, that is where you run to.

I’ve thought of this and you could be right. But the odds are stacked greatly against EM right now. Midlevels, CMGs, and lack of hospital support, not even to mention the super high rates of burnout they have, all make it a very undesirable option.

 

[anbuitachi]

It'll soon to be anesthesiology. We are increasing residents way too fast. AMCs are opening new residencies and pumping out cheap labor

 

[nimbus]

Worst part of EM is that most of the patients are awake and talk.

 

[coffeebythelake]

Of course its always a matter of supply and demand.
EM is already oversaturated and there isn't much demand going forward the next decade or more,
Anesthesia demand continues to go up with NORA, aging population, etc

 

[nimbus]

It'll soon to be anesthesiology. We are increasing residents way too fast. AMCs are opening new residencies and pumping out cheap labor

View attachment 367768

This is a curve of the number of applicants, not number of spots.

Also the difference in an ED/rad onc training program that is acgme compliant vs an anesthesi residency that is acgme compliant is pretty vast.

We need like 5000 more doctors in this field as it is, and it will take more than a decade to even get that

We will all have plenty of work. But getting paid for working is a different thing.

 

[coffeebythelake]

Worst part of EM is that most of the patients are awake and talk.

Worst part of EM is that 90% of the patients are not actually emergencies.
Their name is a misnomer.

 

[Southpaw]

It'll soon to be anesthesiology. We are increasing residents way too fast. AMCs are opening new residencies and pumping out cheap labor

The problems of anesthesiology aren't really changing. Or at least they havent changed over the last decade really IMO. One could make the argument the field is in an even better place than it was a decade ago. The number of applicants reflect that at least. The problems with anesthesiology remain the AANA and the fact that if you want top level income in this field you're going to be working nights and weekends in the hospital. Honestly that's probably true of any field of hospital based medicine these days.

Radiology seems in a much better position these days. When I applied EM was more popular than radiology as everyone was concerned with AI in rads. It's clear now that radiology as a field needs radiologists to do the work. Midlevels seem to have made little to no inroads there. Family medicine also seems appealing simply because of their crazy in demand job market and the fact that a lot of people want a physician as their primary care provider.

 

[coffeebythelake]

We will all have plenty of work. But getting paid for working is a different thing.

All a matter of supply and demand.
I don't have a magic 8 ball to predict how things will look like 30 years from now, and both sides of the equation can change, but right now demand >> supply of anesthesia professionals
As physicians we suck at lobbying and assigning a fair monetary value for our work.
We know CRNAs collectively have a strong lobbying power and that might serve as a backstop to how low the wages can go.
What we also know is that surgical operations is a HUGE money maker for hospitals in terms of facility fees and ancillary charges,
Locums are getting paid $400+/hour, even in **** areas with poor payer mix, and way more than they collect in anesthesia billing.
If push comes to shove, the bean-counters will pay whatever is necessary to keep the show going, even if it means big stipends in the face of reduced anesthesia payments per unit.

 

[GravelRider]

All a matter of supply and demand.
I don't have a magic 8 ball to predict how things will look like 30 years from now, and both sides of the equation can change, but right now demand >> supply of anesthesia professionals
As physicians we suck at lobbying and assigning a fair monetary value for our work.
We know CRNAs collectively have a strong lobbying power and that might serve as a backstop to how low the wages can go.
What we also know is that surgical operations is a HUGE money maker for hospitals in terms of facility fees and ancillary charges,
Locums getting paid $400+/hour. If push comes to shove, the bean-counters will pay whatever is necessary to keep the show going, even if it means big stipends in the face of reduced anesthesia payments per unit.

In some ways the CRNAs helped drive up our pay over the past few years. The CRNAs were demanding and receiving very high hourly pay. In many cases, CRNAs were not the cheaper option. In my first job out of residency, I made significantly less on an hourly basis than the per diem CRNAs I worked with. CRNAs pricing themselves so high in many markets have only helped us. In many instances, paying a few more bucks an hour for a more versatile anesthesiologist is the better option for a hospital.

 

[GravelRider]

I’ve thought of this and you could be right. But the odds are stacked greatly against EM right now. Midlevels, CMGs, and lack of hospital support, not even to mention the super high rates of burnout they have, all make it a very undesirable option.

I think we also underestimate the toll covid had on EM. Many of the students currently matching were rotating during the peak of the covid waves. EM really was the front line of many of those covid spikes. Add the above mentioned factors to a staff that is burnt out and exhausted and the field really loses its attractiveness. Mentorship plays an extremely important role in students choosing a field and when your potential mentors are beaten down and cynical, it’s no wonder that students are steering clear of the specialty.

TL;DR: Not enough “heroes work here” signs.

 

[coffeebythelake]

TL;DR: Not enough “heroes work here” signs.

"Heroes work here"
Honestly that's the only thing hospital admins have been doing.
Putting up cheap placards outside the hospital proclaiming this.
No pay raise, no resources to help deal with burnout.
Lots of lip service to EM physicians during the pandemic, but also secretly plotting to stab them in the back and hire midlevels to save money.

 

[anbuitachi]

This is a curve of the number of applicants, not number of spots.

Also the difference in an ED/rad onc training program that is acgme compliant vs an anesthesi residency that is acgme compliant is pretty vast.

We need like 5000 more doctors in this field as it is, and it will take more than a decade to even get that

I thought it is applicant who matched? I did not compare actual numbers from official website but I remember anesthesiology spots increases like crazy

 

[coffeebythelake]

I thought it is applicant who matched? I did not compare actual numbers from official website but I remember anesthesiology spots increases like crazy

well there were 3600 anesthesia matched and basically no unmatched spots.
if we are to extrapolate this maybe there were 200 new spots created compared to 2022

 

[vector2]

 

[Dr. Rude]

View attachment 367785

Translation:

Q: Who coulda knowed?

———————————————

A: everybody you sanctimonious phony pieces of stool.

 

[coffeebythelake]

Translation:

Q: Who coulda knowed?

———————————————

A: everybody you sanctimonious phony pieces of stool.

EM societies: It looks really bad so lets post a lengthy statement that says absolutely nothing!

 

[abolt18]

EM societies: It looks really bad so lets post a lengthy statement that says absolutely nothing!

I don't get why it looks bad, honestly. I'd love it if anesthesia programs were running unfilled. It means less competition for me in the future and potentially better compensation due to supply/demand. With all I've heard about the terrible EM market the last few years, shouldn't these guys be celebrating the slowdown? (Except of course the attendings who may actually have to see patients and write notes now... Sad for them)

 

[coffeebythelake]

I don't get why it looks bad, honestly. I'd love it if anesthesia programs were running unfilled. It means less competition for me in the future and potentially better compensation due to supply/demand. With all I've heard about the terrible EM market the last few years, shouldn't these guys be celebrating the slowdown? (Except of course the attendings who may actually have to see patients and write notes now... Sad for them)

it looks bad because a good number of those scramble spots will end up being filled, just not the candidates the programs were hoping for. in other words, candidates that are less qualified and less competitive. and what happens when a program has a lot of unfilled spots even after this? well the work is the same but you have fewer people to do it.

top programs in the country probably won't ever worry about this problem. they will still have their pick of the best candidates.
but the middle and lower tier programs will be screwed big time.

 

[abolt18]

it looks bad because a good number of those scramble spots will end up being filled, just not the candidates the programs were hoping for. in other words, candidates that are less qualified and less competitive. and what happens when a program has a lot of unfilled spots even after this? well the work is the same but you have fewer people to do it.

top programs in the country probably won't ever worry about this problem. they will still have their pick of the best candidates.
but the middle and lower tier programs will be screwed big time.

Touché. Didn't think about that.

 

[pgg]

it looks bad because a good number of those scramble spots will end up being filled, just not the candidates the programs were hoping for. in other words, candidates that are less qualified and less competitive. and what happens when a program has a lot of unfilled spots even after this? well the work is the same but you have fewer people to do it.

top programs in the country probably won't ever worry about this problem. they will still have their pick of the best candidates.
but the middle and lower tier programs will be screwed big time.

Like mid 1990s anesthesiology ... which led to a couple years where our board pass rate was approximately 50%.

I wonder how many of the unfilled EM programs will simply choose to remain unfilled, rather than accept applicants they don't really want.

 

[Southpaw]

I wonder how many of the unfilled EM programs will simply choose to remain unfilled, rather than accept applicants they don't really want.

This is my question. And my guess is approximately 0 which will underline, put in italics, and greatly bold the underlying problem with EM and all of medicine. I hope to be proven wrong.

 

[Southpaw]

View attachment 367785

Ah yes, a task force. SDN EM has predicted this for years now and been saying that the house is burning while the societies have been whistling Dixie. But sure, get your task force going. Let’s let the academicians and CMG shills sit around and try to figure this one out.

 

[GravelRider]

Ah yes, a task force. SDN EM has predicted this for years now and been saying that the house is burning while the societies have been whistling Dixie. But sure, get your task force going. Let’s let the academicians and CMG shills sit around and try to figure this one out.

But a task force sounds so dang cool. Would you rather be a member of a task force or a think tank?

 

[Southpaw]

But a task force sounds so dang cool. Would you rather be a member of a task force or a think tank?

If either have anything to do with hospital based medicine, more meetings, and/or hospital administration, the answer is no.

 

[dannyboy1]

it looks bad because a good number of those scramble spots will end up being filled, just not the candidates the programs were hoping for. in other words, candidates that are less qualified and less competitive. and what happens when a program has a lot of unfilled spots even after this? well the work is the same but you have fewer people to do it.

top programs in the country probably won't ever worry about this problem. they will still have their pick of the best candidates.
but the middle and lower tier programs will be screwed big time.

Lol. Are you smoking something. The THOUSANDS of unmatched Caribbean and FMGs will be thrilled to take these spots.

 

[coffeebythelake]

What If I Do Not Match? Scrambling for a Spot and Going Outside the Match

Matching into emergency medicine (EM) is getting progressively more competitive. Applicants must therefore prepare for the possibility of not matching…

www.sciencedirect.com

The Journal of Emergency Medicine, published Feb 2020, did not age well

 

[anbuitachi]

its more meaningful to look at final unfilled spots IMO.

 

[anbuitachi]

This was from ASA president last year
His response to anesthesiology matching well is to expand anesthesiology positions

 

[Southpaw]

This was from ASA president last year
His response to anesthesiology matching well is to expand anesthesiology positions
View attachment 367851

I would not expect any academician in any field to have a clue what is happening in the community.

 

[Dr. Rude]

I would not expect any academician in any field to have a clue what is happening in the community.

They have more than a clue. They just don’t care.

 

[coffeebythelake]

Yes.. completely out of touch w reality. Remember, these are the same people at ASA that decided to go barehanded in a polticial knife fight with the AANA.

 

[cowbydoc]

This was from ASA president last year
His response to anesthesiology matching well is to expand anesthesiology positions
View attachment 367851

This is so short sighted. At our place this was admin’s first thought as well to counter the rise in salaries. “More residents! They’re cheap and will dilute the labor pool!”
Food for thought: I was an ER attending physician from 2008-2011. Moonlighting during my anesthesia residency from 2011-2014. The market was fantastic. Jobs everywhere. Money flying around like a rap video. Now, the market is crap in large part due to huge proliferation of residencies and encroachment from mid levels. Sound familiar?
There may be a need for more anesthesiologists but I would much rather take our cues from derm and OMFS than ER. Contact the ASA if needed but our salaries are increasing based on demand>>supply. We can’t oversupply and expect to maintain fair market value.

 

[2Fast2Des]

This was from ASA president last year
His response to anesthesiology matching well is to expand anesthesiology positions
View attachment 367851

Dead God does anyone in the ASA actually have a brain or care? I mean what exactly do they do...? Other than collect my dues and write dumb articles like this

 

[coffeebythelake]

Dead God does anyone in the ASA actually have a brain or care? I mean what exactly do they do... Other than collect my dues

And what exactly do they do with our membership dues because it seems like nothing is done to bolster our profession. Does Randall and his gang spend it on booze and hookers?

 

[Dr. Rude]

This is so short sighted. At our place this was admin’s first thought as well to counter the rise in salaries. “More residents! They’re cheap and will dilute the labor pool!”
Food for thought: I was an ER attending physician from 2008-2011. Moonlighting during my anesthesia residency from 2011-2014. The market was fantastic. Jobs everywhere. Money flying around like a rap video. Now, the market is crap in large part due to huge proliferation of residencies and encroachment from mid levels. Sound familiar?
There may be a need for more anesthesiologists but I would much rather take our cues from derm and OMFS than ER. Contact the ASA if needed but our salaries are increasing based on demand>>supply. We can’t oversupply and expect to maintain fair market value.

The market can turn on a dime. Ask anybody practicing in the 90s how bad it got how quickly and then again when it got good in the early 00s

 

[Southpaw]

They have more than a clue. They just don’t care.

When I was a resident not a single attending could tell me anything about private practice. No one educated me on CRNA issues or value/lack thereof with regard to fellowship. In the entire 4 years I was there, and I really truly loved residency by the way, we had 3 1-hr blocks dedicated to guys actually in private practice coming to talk to us as a group. My academic chair was a great guy and an excellent academician, but absolutely clueless as to what mattered to a community anesthesiologist or how a private group achieved income or derived value in their work.

Out of my entire group of attendings in residency maybe 3-4 donated to ASAPAC. And one could make a solid argument that contributing to the PAC and even the ASA is absolutely worthless, but I'm just making the point that they didn't care.

I'm guessing maybe less than 5% of academic attendings (just a shot in the dark number, admittedly) understand base and time units for our field. Nor do they understand contract negotiations with insurance companies and hospitals. These things matter GREATLY to anesthesiologists in the community.

It's not a stretch at all in my opinion to say that if decisions around expansion of residency spots, or decisions made about the desperate state of EM (which is largely based on what has occurred in community practices as opposed to large tertiary centers), are left to academicians or CMG shills as opposed to guys actually showing up day in/day out to see patients and do the work, then the world of medicine will not get to a better place.

 

[vector2]

I'm guessing maybe less than 5% of academic attendings (just a shot in the dark number, admittedly) understand base and time units

Ha, indeed, 5% is probably generous. My academic colleagues are absolutely clueless about anesthesia billing, although it's a bit hard to blame them since 1. we're salaried, 2. google doesn't yield very many (if any) detailed, comprehensive, easy to understand, + free guides on how anesthesia billing works.

 

[kidthor]

Ha, indeed, 5% is probably generous. My academic colleagues are absolutely clueless about anesthesia billing, although it's a bit hard to blame them since 1. we're salaried, 2. google doesn't yield very many (if any) detailed, comprehensive, easy to understand, + free guides on how anesthesia billing works.

The disconnection from billing is a major problem in my opinion, especially since we have other people billing "for us" using our personal names and then collecting the money. I can't think of too many industries where your name is used to bill for you without you really knowing anything. At least in law and consulting and so forth people are intimately aware of their billing and rates and such.

A former employer of mine outright refused to show me any of my own billing. They claimed it was proprietary and too complicated.

The essence of corporate America screwing over doctors is rooted in removing us from any and all business functions within medicine. The government is a knowing corporate-captive accomplice, too.

 

[Anesthesia_Guy]

Dead God does anyone in the ASA actually have a brain or care? I mean what exactly do they do...? Other than collect my dues and write dumb articles like this

Well....you CAN do something about them taking your money.

 

[dannyboy1]

The disconnection from billing is a major problem in my opinion, especially since we have other people billing in our name on behalf us and then collecting the money. I can't think of too many industries where your name is used to bill for you without you really knowing anything. At least in law and consulting and so forth people are intimately aware of their billing and rates and such.

The essence of corporate America screwing over doctors is linked to removing us from any and all business functions within medicine. The government is a knowing corporate-captive accomplice, too.

Maybe. It certainly is nice to be paid a flat rate/hour though. I hear the stories from the old timers about all the schemes to maximize individual units (at the expense of the younger guys ). It’s definitely a lot easier just to show up….

 

[dieABRdie]

I can't think of too many industries where your name is used to bill for you without you really knowing anything. At least in law and consulting and so forth people are intimately aware of their billing and rates and such.

This.

What other profession sacrifices most of their young adult life in school/training, works 80 hour weeks for several years, then at the end of it... just hands over their professional license to some MBA to do whatever the hell they want with it.

I hate it.

I decided not to. I wish more would do the same.