Why emergency medicine is a dying specialty- The thread all Med students should read

[cyanide12345678]

Ok med students - I'm going to make this easy for you guys and explain to you really the details of what you don't experience as a med student and why EM is just a terrible specialty. I'm 3.5 years out of training. I wish someone sat me down and slapped some sense into me 7-8 years ago. But here I am...slapping sense into you. So here it goes:

tldr - DO NOT DO EMERGENCY MEDICINE. Read more to understand why.

Here's the long answer of why.

Things Med students need to understand:

1) You really might not have a job. No we're not exaggerating. If you're 5-6+ years from entering the job market, you might not have a job. Like seriously - Potential unemployment with 200k+ in loans. Here's the data, make your own interpretation.

Acep report projecting a surplus of almost 8k ER doctors (1 in 5 ER docs) by 2030 (6.5 years from now). Here's the link - Read it.

DEFINE_ME

Yes yes, there are folks giving the counter argument that the report under estimated the attrition rate and hence have an optimistic view that because of a significantly higher than anticipated levels of burn out, the shortage may not be as bad. I agree, the attrition rate is MUCH more than 3% (which actually should be a red flag if you want a long career but lets ignore that fact for now). But sure, lets look at some other assumptions and analyze them as well, not just the one assumption that supports the optimistic view point. Lets look at all the assumptions.

~ Flawed assumption #1 - 3% attrition rate. Yes, I agree. That's a huge low ball.
~ Flawed assumption #2 - 2% annual growth rate assumption. Reality is tracking more along their 4% growth rate graph.

2023 positions offered - 3010 https://www.nrmp.org/wp-content/uploads/2023/03/2023-Advance-Data-Tables-FINAL.pdf
2022 positions offered - 2921 https://www.nrmp.org/wp-content/uploads/2022/11/2022-Main-Match-Results-and-Data-Final-Revised.pdf
2021 positions offered - 2840 https://www.nrmp.org/wp-content/uploads/2021/08/MRM-Results_and-Data_2021.pdf
2020 positions offered - 2665 https://www.nrmp.org/wp-content/uploads/2021/12/MM_Results_and-Data_2020-rev.pdf
2019 positions offered - 2488 https://www.nrmp.org/wp-content/uploads/2021/07/NRMP-Results-and-Data-2019_04112019_final.pdf
2018 positions offered - 2278 https://www.nrmp.org/wp-content/uploads/2021/07/Main-Match-Result-and-Data-2018.pdf
2017 positions offered - 2047 https://www.nrmp.org/wp-content/uploads/2021/07/Main-Match-Results-and-Data-2017.pdf
2016 positions offered - 1895 https://www.nrmp.org/wp-content/uploads/2021/07/Main-Match-Results-and-Data-2016.pdf
2015 positions offered - 1821 https://www.nrmp.org/wp-content/uploads/2021/07/Main-Match-Results-and-Data-2015_final.pdf

If you actually read their paper, you'll see that we're kind of following the 4% growth trend trajectory right now. 2023 basically had 3000 interns - that's 3000 graduates in 2026 (ballpark) - similar to their 4% growth rate estimate.



This match has shown that if you open the spots, someone will fill them in SOAP as 500 spots were filled this year through soap alone. Now...think about it. Giant corporations, multibillion dollar systems like HCA, envision, APP etc are actively trying to decrease costs. In business only one thing matters - profit. Opening a residency at every level 2 hospital drops costs, brings in cheap labor, allows to decrease attending staffing, and eventually increases supply for doctors to enable lower salaries. You literally have giant corporations actively working against your interest. Literally there was a leaked memo from APP (corporate ER staffing group) where they were bragging about this soon to be surplus in a presentation to investors). I don't know about you...but in the capitalistic society of the US, corporations usually get what they want. I wouldn't bet against US capitalism.

~ Flawed assumption no. 3 - 11% Increase in ER visits. The reality is, ER visits have been either stable, or on the decline - https://www.cdc.gov/nchs/data/hus/2020-2021/HCareVis.pdf . This was even happening before COVID. Now just sit down and think about it. the reality is that in the last 10-15 years we've seen a boom in urgent cares and convenience cares which have taken volume away from ERs, hence the decline in volumes recently. The next 10 years is likely going to see the boom for online virtual visits which will also take volume away from ERs. 60-70% of our volume is urgent care essentially - And that's what pays the bills and brings the money for ERs. But You have giant corporations - literally AMAZON, CVS, WALMART etc getting into convenience care medicine. I am not going to ever bet against amazon - EVER. It's partnership with Teladoc should make you re-think your career. When a few months from now you could literally say "Hey alexa, connect me to a doctor" and a teladoc doc shows up on your alexa then good luck assuming increasing ER volumes. Not to mention that the entire insurance industry is hand over fist attempting to decrease ER visits in favor of virtual visits or urgent care visits. There are just too many damn corporation juggernauts trying to take volume away from ERs to convenience care clinics and virtual visits. Even the US government is trying to decrease ER visits because medicare and medicaid is bankrupting the US. Literally...are those the people you want to bet against? Sure the baby boomers are getting old. But seriously look at the CDC data. The trend isn't in your favor. Open your eyes. The data is right there.

~ Flawed assumption no. 4 - I'm not going to even go into the assumption that 20% encounters will be seen by PAs and NPs. We all know hospitals are financially incentivized to have 1 doc supervising 2-3 PAs rather than having 2 Docs. It's been happening for a while. Money talks. Literally team health just started 100% replacing rural ERs with NPs/PAs in independent practice states for NPs/PAs as well. Yeah...that's happening already. 100% NP/PA run ERs. I'm dead serious. One of my friends lost his job as all docs were replaced by a 100% NP/PA run rural ER. I'll just leave this data here about the growth in NPs and PAs in ERs. Doctors are being replaced. It's no secret.



So - I kid you not. If you graduate in 6-7 years, you really might be unemployed as a new grad.

2) Circadian rhythym disruption - DO NOT. I repeat. DO NOT TAKE THIS LIGHTLY. It's unfair when we expect you to make this very important life decision as a mid 20 year old full of energy and likely not married and without kids. A 25 year old doesn't think this is a big deal. Life changes. You get older. And I'm not that old, but here I am needing melatonin so damn frequently now to help me switch from days to nights. The reality is - Shift work and circadian rhythym disruption leads to CAD, HTN, obesity, and early death.

This is just one of many papers out there:

Shift work, risk factors and cardiovascular disease - PubMed

The literature on shift work, morbidity and mortality from cardiovascular disease, and changes in traditional risk factors is reviewed. Seventeen studies have dealt with shift work and cardiovascular disease risk. On balance, shift workers were found to have a 40% increase in risk. Causal...

pubmed.ncbi.nlm.nih.gov

The reality is, it is so so so damn hard to do a 7 am to 7 pm shift, and then turn around the next day and do a 7 pm to 7 am shift for example. Here's what my current week looks like just to give you an idea what life could be. Yes, the remaining month isn't bad because I have a lot of days off. But I sure am hating this week:

3 days off
Day 1 - 8 am to 8 pm (hospital A)
Day 2 - 7 am to 7 pm (hospital B)
Day 3 - 8 pm to 8 am (hospital A)
Day 4 - return home at 9 am after night shift.
Day 5 - 7 am to 7 pm (hospital B)
Day 6 - 7 pm to 7 am (hospital B)
Day 7 - 7 pm to 7 am (hospital B)
4 days off.

going from AM to PM then to AM then to turn around and then back to PM....I MEAN THAT IS HARD! And that is emergency medicine unfortunately for A LOT of us.

3) LOW FLEXIBILITY ONCE SCHEDULE IS MADE - You would think that if you have a crappy schedule you could switch with someone else. I'm part of a group of 100s of doctors actually. Largest hospital system in the entire state. I've tried posting shifts for exchange, very very rarely someone would take them. I literally had such severe rotator cuff tendonitis a few months ago where I couldn't lift my arm to intubate and I couldn't give up my shift despite my medical director emailing everyone. Nobody stepped up to take it last minute. Also, I have a 3 year old child who goes to day care. You know what...3 year olds get fevers, snotty noses, ear infections etc ALL THE TIME. Guess what the day care does? Calls you to take them home. What can you do as an ER doc? Almost NOTHING. You have no flexibility in life. What can my FM wife do? Her clinic literally reschedules all her patients and tells her to take the day off. The reality is...if I'm at work at my single coverage hospital, and my wife and daughter got into an accident and were on their death beds, I don't even think I could just leave work to be with them. I'd literally have to call and beg people to come in, and pray that someone comes in for me so I can be with my family. Whereas my PCP FM wife - tells the staff, patients get rescheduled - Boom. She's out the door.

4) You get sh it on by consultants - Yup. All the time. Not much to explain. You need thick skin.

5) you get sh it on by patients - Unfortunately also happens all the time. Literally 2 days ago I had a drunk patient and a psychotic patient both yelling at me. Look...my job is to help people. But some of these people are telling you to F off, calling you a terrorist (I'm Pakistani - So obvious brown skin tone), and you take it. And THAT's the people you OFTEN help. They are threatening to sue you, while you're making sure they are safe. Really...think about it, this is how sometimes your good actions are paid back - people tell you to F off and go kill yourself and that they will sue you. Some people are just terrible human beings that you have to take care of. These people WILL be kicked out immediately if they behaved like this at a specialist clinic. If someone said F off to my wife in her PCP office, 911 will be called, and that person will be escorted outside. At an ER, that person hangs out in the ER for the next 24 hours until you can get a psychiatric bed. AND GUESS WHAT!?!??! After 2-3 weeks they will be back!!! A PCP/outpatient clinic practice kicks out people so they can NEVER return. Whereas that patient that could be threatening to kill you, could be back in your ER 3 weeks later after their last psych hospitalization. I'm not exaggerating. This happens.

6) You are the dumping ground - You know what's soul crushing? When you have a full ER, you're hustling, behind on seeing patients, trying to desperately catch up, and then you get a 3 yo kid whose PCP told the mom to bring the child to the ER for the fever -_- The more years you practice, the more you realize that a lot of PCPs and specialists send patients to the ER when they just don't want to inconvenience their lives by adding one more patient to their schedule. And you know it's true because it happens so much more on Fridays -_- It's great being a PCP or a specialist with a clinic and a schedule - If your schedule is full, just send them to the ER. OUR SCHEDULE HAS NO UPPER LIMIT. People can literally just keep coming in. If 50 people showed up to my single coverage ER in 12 hours, I have to see them all! And a lot of us actually have seen 35-50 patients in a 12 hour shift during winter months. You just gotta find a way to be faster and more efficient as more and more dumping happens and more people just keep showing up.

7) You will start HATING boluses of patients - Life is much easier when you have a patient scheduled every 20-30 minutes. You know how much time you have, when you have to see the next patient etc. What happens all too frequently in the ER, you might not do anything for 30 minutes, and then 6 people check in within 15 minutes of each other. Then you start hustling and constantly feeling behind. Then you finally finish seeing those 6 people in 30 minutes, put in orders, then another 2-3 have shown up, then by the time you see them, great...another 1-2 showed up -_- You know...there are times I wish I could come out of a patient room and not see another new patient on the board. It's just incredible that even if I'm in a patient room for 2-3 minutes, somehow in that time a new patient shows up on the board. I can't imagine how nice it must be knowing what time your next patient is coming and knowing that all of your patients aren't just going to all show up at the same time. And must be really really nice knowing that a mom isn't randomly going to check in all 4 of her children, all of them with the same complaint - making you instantly behind on 4 notes.

8) Weekends and holidays - We have a good friends circle with some 8-10 other families and we're always having dinners scheduled at these friends places on the weekends. My wife goes by herself to 50% of them because I'm at work during quite a few weekends. You will miss family events, social events, and essentially things that will otherwise bring joy to your life. You will just be absent on a lot of events in life. You might have A LOT of days off during the week, but you'll still somehow miss a lot of events because you're still working more weekends and holidays than anyone else you know.

9) It gets old really fast - Have you ever seen 2-3 PPH? It's just not fun after a while and every single procedure that you liked in med school, you'll grow to hate. Suture repair? You'll be wondering how many patients you'll have to see when you walk out as the ER keeps getting busier. Same with central lines or any other procedure. They all take time, and you will always feel behind as the list of tasks you need to do accumulates.

10) Decreasing job security, and likely decreasing incomes - You know...a lot of us put up with a lot of this crap for a specialty that paid really well, and had an incredible job market. As the biggest benefit of emergency medicine has gone away, job security is declining as supply demand imbalance is slowly shifting towards increasing supply. And if there's anything you should know, supply demand principles always dictate the price. I would not be surprised when those incomes will follow supply demand metrics and drop as well.

11) It's all about the metrics - Door to doc times, door to ekg times, door to balloon times, door to antibiotic times, patient satisfaction scores, CT heads in syncope patients, CTs in patients discharged - everything is measured and your performance will be criticized.

So yes....heed the warning of those gone before you. I absolutely wish I did FM or IM instead of EM. I made a mistake and I'm owning it. I wish I could slap my 3rd year self and whisper "optho, ortho, PM&R, FM, urology, psych, radiology, anesthesiology, dermatology" in the ear of my younger self. It's not just a coincidence that EM is no. 1 for burn out. And it's not just a coincidence that the attrition rate for EM is really high.

And lastly, a request for the mods - can we sticky this thread. This is the reality that students should know.

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[Backpack234]

Not to counter anything you said here, but man I thought you used to work at a pretty rough job before landing at a unicorn you thought you’d work at forever. What happened with your job situation?

 

[BoardingDoc]

Not to counter anything you said here, but man I thought you used to work at a pretty rough job before landing at a unicorn you thought you’d work at forever. What happened with your job situation?

I'm going to assume it wasn't actually a unicorn?

Even if it were, everything he wrote is true. I'm 6 yrs out and have firmly entrenched myself in my current position. If I weren't in 90th percentile comp by MGMA, I'd be actively looking for a different career for all the reasons listed.

 

[AlmostAnMD]

What every med student considering EM needs to be like after reading this

But they probably won't get the reference

or listen, and just be like BETTER TO MATCH EM THAT NOT MATCH AT ALL, HURHURHURRrrrrrrr

in the sense that better to go to prison because it's better than being homeless

 

[Tenk]

Just so you know, Howie Mell was posting that the surplus study didn’t take into account the mass retirements we saw with Covid so it is already invalidated. I like Howie, I think he’s a pretty real guy who doesn’t have his head up his ass like some of the suits. I don’t know if his claim is true or not, but it was certainly interesting to read. Worth looking into.

 

[bravotwozero]

Just so you know, Howie Mell was posting that the surplus study didn’t take into account the mass retirements we saw with Covid so it is already invalidated. I like Howie, I think he’s a pretty real guy who doesn’t have his head up his ass like some of the suits. I don’t know if his claim is true or not, but it was certainly interesting to read. Worth looking into.

Tried to google that, didn't find much, if you have a link to this, would appreciate it if you could post it.

 

[JacobMcCandles]

At some point it’s gotta get old typing out the same doom and gloom. Like with many things in life, the truth likely lies somewhere in the middle. For those who spend a majority of their time griping about their job, I would recommend using that time to do other things in life you enjoy.

 

[JacobMcCandles]

Reading a bit more into the original post, I think it's clear that your group/hospital system is awful. There are ZERO reasons why there should be 24-hour turnarounds scheduled unless you switched into that. Pissy consultants can happen everywhere but, again, there is ZERO reason why it should happen 'all the time'. It sounds like the foundation for your group wasn't set solid and/or there are some subpar docs in your group who call consultants about everything so their frustration spills over into every call.

 

[cyanide12345678]

Not to counter anything you said here, but man I thought you used to work at a pretty rough job before landing at a unicorn you thought you’d work at forever. What happened with your job situation?

Unicorn ER job? Forever? Lol.

My current job is amenable to having a longer career, let’s say my current job probably added 5-7 years to my career. While i only average 1.2 pph, mostly because of night shifts where you see 8-10 a shift usually. Like every ER doctor i experience the challenges - as a rural ER, my hospitals barely admits anything, then i play the game of finding a bed, often involving multiple phone calls, followed by playing the game of wait for the ambulance which often will take another 7-8 hours.

I am still afraid of what the job market will be like if my state became an independent NP/PA practice state - will my employer literally just get rid of all of us and replace with NPs after that especially in the 8000 annual volume ER setting that i practice now?

I still see a lot of crap that happens in the ER even in rural medicine, probably not as frequently as urban ERs, but yes, my ‘unicorn’ job of getting paid $200/hr for seeing 1.2 pph did add a few years to my career. But id rather still have a normal circadian rhythm, good sleep hygiene, make it to all family events, and have the ability to just kick some people out of the ER without thinking of emtala etc. and you’d be surprised, even a rural shop can get pretty busy at times where every time you walk out, someone seems to be checking in.

Again…. It’s not a coincidence that the attrition rate is really high in this specialty. It just took me time to understand why.

 

[Tenk]

Tried to google that, didn't find much, if you have a link to this, would appreciate it if you could post it.

I do not. He just mentioned it on EMDOCS on some random thread during all the moaning and groaning about the match rates recently. If you actually look at this paper though a lot of the data it uses is definitely precovid or right around when Covid was ramping up. I think it just got published in 2021. Hopefully they do an update study.

 

[RocuROMANium]

Thanks @cyanide12345678. I worked in the ED for 5 years prior to med school and witnessed most of that firsthand. I pretty much got used to patients acting crazy but what would really piss me off is how other departments and consults would act towards ED personnel. It’s like this weird rivalry would develop between us and the hospital or us and the OR. Saw a lot of entertaining arguments though ha.

Point 7 is so true! At our ED it seemed like all of these random patients got together on a bus to have a field trip to the ED. A steady stream of patients is fine because it keeps you busy and it’s manageable but boluses could be soul crushing for the staff.

Anyways, going in to med school I knew that I didn’t want to go into EM for the reasons mentioned above and others too and instead wanted to pursue surgery. However, as med school kicked off I found myself becoming more interested in EM because it would be easier to attain than surgery until my wife called me out and said don’t be lazy and settle for something that you were never interested in. This thread is the final nail in the coffin and now you can at least say you persuaded one med student off of the cliff! Thank you!

 

[GonnaBeADoc2222]

Thanks @cyanide12345678. I worked in the ED for 5 years prior to med school and witnessed most of that firsthand. I pretty much got used to patients acting crazy but what would really piss me off is how other departments and consults would act towards ED personnel. It’s like this weird rivalry would develop between us and the hospital or us and the OR. Saw a lot of entertaining arguments though ha.

Point 7 is so true! At our ED it seemed like all of these random patients got together on a bus to have a field trip to the ED. A steady stream of patients is fine because it keeps you busy and it’s manageable but boluses could be soul crushing for the staff.

Anyways, going in to med school I knew that I didn’t want to go into EM for the reasons mentioned above and others too and instead wanted to pursue surgery. However, as med school kicked off I found myself becoming more interested in EM because it would be easier to attain than surgery until my wife called me out and said don’t be lazy and settle for something that you were never interested in. This thread is the final nail in the coffin and now you can at least say you persuaded one med student off of the cliff! Thank you!

Finally. One listens.

 

[AwakeCric]

I'm an Attending 4 years out. I agree with everything said above. Take it serious. I'm already looking for a way out. I'll explain what happened to me. I guess I'll just add to the narrative. I'm sorry if it is a bit long.

I was one of those students who "who couldn't see myself doing anything else." I volunteered in an emergency department in high school. Then I worked as a tech for 6 years before medical school.

I graduated residency in 2019. I had a pick of 2-3 good jobs close to home. I ended up signing to a hospital employee model. I had a 100K student loan repayment bonus. I never signed any NP charts for patients I never saw. I was teaching faculty for the family practice residency. I was on the trauma committee. I was number two in the department for patients per hour and had middle of the pack patient satisfaction scores.

Then in 2020 the pandemic came. I sat in a meeting where the director of Infectious Disease said the mortality from COVID would be 1 in 10. Obviously, things did not shake out like that, but at least for a few months that is what we thought. Every doctor in the ED signed up voluntarily for call shifts where we would be called in for patient surges. We were told to see COVID patients in a tent provided by FEMA. We didn't have enough PPE to go around so we were reusing N95 masks over multiple shifts we would put in paper bags and hang on the wall and cover them up with bandanas to keep then cleaner for longer. One of the guys had a newborn at home and would sleep in his car because he was scared of giving his one month old COVID. However, the volumes were elevated for maybe a month or two then people just stopped coming to the emergency room. People coming into the ED dropped about 20% and when people were admitted they would board in the ER because the rest of the hospital was just full.

Because the volumes dropped they cut the hours to the emergency physicians. We were fully staffed before the pandemic, but now as the volumes dropped by 20% we were overstaffed by 20%. So, the decision was made by the medical director that the new doctors would be fired the old ones would stay. I remember being at a family party with my newly pregnant wife and getting the phone call that I was one of the 6 doctors let go. Now, this 100K student loan bonus I signed for I had to pay back. I had 3 months to find a new job. I couldn't believe after MCAT, Medical school acceptance, USMLE, and 500K in student loans I didn't have a job. I have no red flags, never been sued (so far), and am a pretty efficient physician. I was so willing to work in a tent with a reused mask, but once the volumes dropped I was out.

I scrambled to sign a new job. However, because almost every emergency department had the same issue as above I had no negotiating power. One job I interviewed for and was offered a job had an insane non-compete. I was not able to work at any other hospital. I was unable to quit for two years and I had to give 6 months notice if I did leave after two years. Ultimately, I picked up a CMG gig. Yesterday, my inbox had 40 charts for patients I never saw I had to sign. Last month, I got an email that my pay was decreasing. No discussion. Just a Docusign for a new contract for a lower pay.

Here is my advice: If you are a current medical student just avoid emergency medicine all together. If you are a current resident work really hard to get a fellowship that gives you options CCM, pain, sports, administration/MBA, addiction, palliative. If you are a new attending pay off your student loans as fast as possible and work on diversifying your skills. No one is coming to save emergency medicine. I don't know what those skills are. I'm trying to figure that out for myself.

 

[kumatie]

I'm an Attending 4 years out. I agree with everything said above. Take it serious. I'm already looking for a way out. I'll explain what happened to me. I guess I'll just add to the narrative. I'm sorry if it is a bit long.

I was one of those students who "who couldn't see myself doing anything else." I volunteered in an emergency department in high school. Then I worked as a tech for 6 years before medical school.

I graduated residency in 2019. I had a pick of 2-3 good jobs close to home. I ended up signing to a hospital employee model. I had a 100K student loan repayment bonus. I never signed any NP charts for patients I never saw. I was teaching faculty for the family practice residency. I was on the trauma committee. I was number two in the department for patients per hour and had middle of the pack patient satisfaction scores.

Then in 2020 the pandemic came. I sat in a meeting where the director of Infectious Disease said the mortality from COVID would be 1 in 10. Obviously, things did not shake out like that, but at least for a few months that is what we thought. Every doctor in the ED signed up voluntarily for call shifts where we would be called in for patient surges. We were told to see COVID patients in a tent provided by FEMA. We didn't have enough PPE to go around so we were reusing N95 masks over multiple shifts we would put in paper bags and hang on the wall and cover them up with bandanas to keep then cleaner for longer. One of the guys had a newborn at home and would sleep in his car because he was scared of giving his one month old COVID. However, the volumes were elevated for maybe a month or two then people just stopped coming to the emergency room. People coming into the ED dropped about 20% and when people were admitted they would board in the ER because the rest of the hospital was just full.

Because the volumes dropped they cut the hours to the emergency physicians. We were fully staffed before the pandemic, but now as the volumes dropped by 20% we were overstaffed by 20%. So, the decision was made by the medical director that the new doctors would be fired the old ones would stay. I remember being at a family party with my newly pregnant wife and getting the phone call that I was one of the 6 doctors let go. Now, this 100K student loan bonus I signed for I had to pay back. I had 3 months to find a new job. I couldn't believe after MCAT, Medical school acceptance, USMLE, and 500K in student loans I didn't have a job. I have no red flags, never been sued (so far), and am a pretty efficient physician. I was so willing to work in a tent with a reused mask, but once the volumes dropped I was out.

I scrambled to sign a new job. However, because almost every emergency department had the same issue as above I had no negotiating power. One job I interviewed for and was offered a job had an insane non-compete. I was not able to work at any other hospital. I was unable to quit for two years and I had to give 6 months notice if I did leave after two years. Ultimately, I picked up a CMG gig. Yesterday, my inbox had 40 charts for patients I never saw I had to sign. Last month, I got an email that my pay was decreasing. No discussion. Just a Docusign for a new contract for a lower pay.

Here is my advice: If you are a current medical student just avoid emergency medicine all together. If you are a current resident work really hard to get a fellowship that gives you options CCM, pain, sports, administration/MBA, addiction, palliative. If you are a new attending pay off your student loans as fast as possible and work on diversifying your skills. No one is coming to save emergency medicine. I don't know what those skills are. I'm trying to figure that out for myself.

Is your cmg teamhealth? I heard massive pay cuts are coming from them.

 

[GonnaBeADoc2222]

This is a courageous post.

Most people this happens to are not coming in here to tell this story.

Nor is anyone making <$200/hr.

This forum self selects for people making 200-300/hr.

My friend in CMG land had similar thing happen. Massive hours/pay cut during COVID to be followed by massive increase in required hours once volume surged back.

"Healthcare Heroes" was the gaslight of the century.

This is the Rape of Emergency Medicine, pt II

 

[AwakeCric]

Is your cmg teamhealth? I heard massive pay cuts are coming from them.

No. But I have heard that about about pretty much all of them.

If they are not cutting hourly they are doing things like if the 8a-8p doctor is doing OK then they will call the 12p-12a guy at 10am and tell them to come in at 1pm rather than 12pm cutting an hour from the shift. It's how they get around not sending you a new contract with paying you less.

 

[cyanide12345678]

No. But I have heard that about about pretty much all of them.

If they are not cutting hourly they are doing things like if the 8a-8p doctor is doing OK then they will call the 12p-12a guy at 10am and tell them to come in at 1pm rather than 12pm cutting an hour from the shift. It's how they get around not sending you a new contract with paying you less.

Yes that happened a lot at my previous teamhealth site too. Staffing was made flexible. Shifts that used to be guaranteed became flexible, could be canceled last minute if lower volume day.

 

[FlaminHotER]

Mods please please pin/sticky this thread

Great write up cyanide

 

[kumatie]

No. But I have heard that about about pretty much all of them.

If they are not cutting hourly they are doing things like if the 8a-8p doctor is doing OK then they will call the 12p-12a guy at 10am and tell them to come in at 1pm rather than 12pm cutting an hour from the shift. It's how they get around not sending you a new contract with paying you less.

How is that not a break if your contract?

 

[bravotwozero]

How is that not a break if your contract?

they'll just change the contract and then make you docusign it. Or you can find a new job. EM contracts are meaningless, except when it comes to them enforcing non competes.

 

[cyanide12345678]

How is that not a break if your contract?

They send you a new contract. You sign it otherwise you risk losing your job.

Today i can find another job, they are still out there.

5 years from now, i probably won’t be able to find many other jobs within my local market, and will be forced to sign whatever new contract. The jobs available will be far and few, likely several hours away, and as a man with a kid in school, a home, a working spouse, it will be very hard to uproot my life for a middle of no where job. If I’m not FI by then, I’m at the mercy of my employer and whatever terms they set.

 

[miacomet]

Honestly, I would tell new grads to do a fellowship or a second residency, even in IM or FP unless they are hardcore academic and don't mind working somewhere underpaid, or have talents of the administrative type (mediocre and smiley with a cheap suit). Even employed gigs are miserable these days.

 

[GonnaBeADoc2222]

Second residency is extreme. That's a 1M+ opportunity cost.

 

[miacomet]

Second residency is extreme. That's a 1M+ opportunity cost.

How so if you end up practicing 10 more years, happily, than you would have in EM?

 

[Brigade4Radiant]

EM doc contracts are just one way. Also if you are in a hospital system GI or ENT can simply refuse to talk to you and you have to transfer the patient to another system.

EM doctors have the most power in academic strings with consultants since you are dealing with residents. The hospitalist who is an employee can straight up deny your WEAK elderly admit and now you have to deal with it

 

[FlaminHotER]

Probably too little too late

Major thing to save our speciality is to close many of these crappy programs that should NEVER have opened to begin with

 

[thegenius]

I wonder if there is a forum, anywhere, about anything, where all the posts are about how people love their jobs. Where 100% of the posts about job satisfaction are positive.

That space doesn't exist.

 

[namethatsmell]

Ok med students - I'm going to make this easy for you guys and explain to you really the details of what you don't experience as a med student and why EM is just a terrible specialty. I'm 3.5 years out of training. I wish someone sat me down and slapped some sense into me 7-8 years ago. But here I am...slapping sense into you. So here it goes:

tldr - DO NOT DO EMERGENCY MEDICINE. Read more to understand why.

Here's the long answer of why.

Things Med students need to understand:

1) You really might not have a job. No we're not exaggerating. If you're 5-6+ years from entering the job market, you might not have a job. Like seriously - Potential unemployment with 200k+ in loans. Here's the data, make your own interpretation.

Acep report projecting a surplus of almost 8k ER doctors (1 in 5 ER docs) by 2030 (6.5 years from now). Here's the link - Read it.

DEFINE_ME

Yes yes, there are folks giving the counter argument that the report under estimated the attrition rate and hence have an optimistic view that because of a significantly higher than anticipated levels of burn out, the shortage may not be as bad. I agree, the attrition rate is MUCH more than 3% (which actually should be a red flag if you want a long career but lets ignore that fact for now). But sure, lets look at some other assumptions and analyze them as well, not just the one assumption that supports the optimistic view point. Lets look at all the assumptions.

~ Flawed assumption #1 - 3% attrition rate. Yes, I agree. That's a huge low ball.
~ Flawed assumption #2 - 2% annual growth rate assumption. Reality is tracking more along their 4% growth rate graph.

2023 positions offered - 3010 https://www.nrmp.org/wp-content/uploads/2023/03/2023-Advance-Data-Tables-FINAL.pdf
2022 positions offered - 2921 https://www.nrmp.org/wp-content/uploads/2022/11/2022-Main-Match-Results-and-Data-Final-Revised.pdf
2021 positions offered - 2840 https://www.nrmp.org/wp-content/uploads/2021/08/MRM-Results_and-Data_2021.pdf
2020 positions offered - 2665 https://www.nrmp.org/wp-content/uploads/2021/12/MM_Results_and-Data_2020-rev.pdf
2019 positions offered - 2488 https://www.nrmp.org/wp-content/uploads/2021/07/NRMP-Results-and-Data-2019_04112019_final.pdf
2018 positions offered - 2278 https://www.nrmp.org/wp-content/uploads/2021/07/Main-Match-Result-and-Data-2018.pdf
2017 positions offered - 2047 https://www.nrmp.org/wp-content/uploads/2021/07/Main-Match-Results-and-Data-2017.pdf
2016 positions offered - 1895 https://www.nrmp.org/wp-content/uploads/2021/07/Main-Match-Results-and-Data-2016.pdf
2015 positions offered - 1821 https://www.nrmp.org/wp-content/uploads/2021/07/Main-Match-Results-and-Data-2015_final.pdf

If you actually read their paper, you'll see that we're kind of following the 4% growth trend trajectory right now. 2023 basically had 3000 interns - that's 3000 graduates in 2026 (ballpark) - similar to their 4% growth rate estimate.

View attachment 367998

This match has shown that if you open the spots, someone will fill them in SOAP as 500 spots were filled this year through soap alone. Now...think about it. Giant corporations, multibillion dollar systems like HCA, envision, APP etc are actively trying to decrease costs. In business only one thing matters - profit. Opening a residency at every level 2 hospital drops costs, brings in cheap labor, allows to decrease attending staffing, and eventually increases supply for doctors to enable lower salaries. You literally have giant corporations actively working against your interest. Literally there was a leaked memo from APP (corporate ER staffing group) where they were bragging about this soon to be surplus in a presentation to investors). I don't know about you...but in the capitalistic society of the US, corporations usually get what they want. I wouldn't bet against US capitalism.

~ Flawed assumption no. 3 - 11% Increase in ER visits. The reality is, ER visits have been either stable, or on the decline - https://www.cdc.gov/nchs/data/hus/2020-2021/HCareVis.pdf . This was even happening before COVID. Now just sit down and think about it. the reality is that in the last 10-15 years we've seen a boom in urgent cares and convenience cares which have taken volume away from ERs, hence the decline in volumes recently. The next 10 years is likely going to see the boom for online virtual visits which will also take volume away from ERs. 60-70% of our volume is urgent care essentially - And that's what pays the bills and brings the money for ERs. But You have giant corporations - literally AMAZON, CVS, WALMART etc getting into convenience care medicine. I am not going to ever bet against amazon - EVER. It's partnership with Teladoc should make you re-think your career. When a few months from now you could literally say "Hey alexa, connect me to a doctor" and a teladoc doc shows up on your alexa then good luck assuming increasing ER volumes. Not to mention that the entire insurance industry is hand over fist attempting to decrease ER visits in favor of virtual visits or urgent care visits. There are just too many damn corporation juggernauts trying to take volume away from ERs to convenience care clinics and virtual visits. Even the US government is trying to decrease ER visits because medicare and medicaid is bankrupting the US. Literally...are those the people you want to bet against? Sure the baby boomers are getting old. But seriously look at the CDC data. The trend isn't in your favor. Open your eyes. The data is right there.

~ Flawed assumption no. 4 - I'm not going to even go into the assumption that 20% encounters will be seen by PAs and NPs. We all know hospitals are financially incentivized to have 1 doc supervising 2-3 PAs rather than having 2 Docs. It's been happening for a while. Money talks. Literally team health just started 100% replacing rural ERs with NPs/PAs in independent practice states for NPs/PAs as well. Yeah...that's happening already. 100% NP/PA run ERs. I'm dead serious. One of my friends lost his job as all docs were replaced by a 100% NP/PA run rural ER. I'll just leave this data here about the growth in NPs and PAs in ERs. Doctors are being replaced. It's no secret.

View attachment 367999

So - I kid you not. If you graduate in 6-7 years, you really might be unemployed as a new grad.

2) Circadian rhythym disruption - DO NOT. I repeat. DO NOT TAKE THIS LIGHTLY. It's unfair when we expect you to make this very important life decision as a mid 20 year old full of energy and likely not married and without kids. A 25 year old doesn't think this is a big deal. Life changes. You get older. And I'm not that old, but here I am needing melatonin so damn frequently now to help me switch from days to nights. The reality is - Shift work and circadian rhythym disruption leads to CAD, HTN, obesity, and early death.

This is just one of many papers out there:

Shift work, risk factors and cardiovascular disease - PubMed

The literature on shift work, morbidity and mortality from cardiovascular disease, and changes in traditional risk factors is reviewed. Seventeen studies have dealt with shift work and cardiovascular disease risk. On balance, shift workers were found to have a 40% increase in risk. Causal...

pubmed.ncbi.nlm.nih.gov

The reality is, it is so so so damn hard to do a 7 am to 7 pm shift, and then turn around the next day and do a 7 pm to 7 am shift for example. Here's what my current week looks like just to give you an idea what life could be. Yes, the remaining month isn't bad because I have a lot of days off. But I sure am hating this week:

3 days off
Day 1 - 8 am to 8 pm (hospital A)
Day 2 - 7 am to 7 pm (hospital B)
Day 3 - 8 pm to 8 am (hospital A)
Day 4 - return home at 9 am after night shift.
Day 5 - 7 am to 7 pm (hospital B)
Day 6 - 7 pm to 7 am (hospital B)
Day 7 - 7 pm to 7 am (hospital B)
4 days off.

going from AM to PM then to AM then to turn around and then back to PM....I MEAN THAT IS HARD! And that is emergency medicine unfortunately for A LOT of us.

3) LOW FLEXIBILITY ONCE SCHEDULE IS MADE - You would think that if you have a crappy schedule you could switch with someone else. I'm part of a group of 100s of doctors actually. Largest hospital system in the entire state. I've tried posting shifts for exchange, very very rarely someone would take them. I literally had such severe rotator cuff tendonitis a few months ago where I couldn't lift my arm to intubate and I couldn't give up my shift despite my medical director emailing everyone. Nobody stepped up to take it last minute. Also, I have a 3 year old child who goes to day care. You know what...3 year olds get fevers, snotty noses, ear infections etc ALL THE TIME. Guess what the day care does? Calls you to take them home. What can you do as an ER doc? Almost NOTHING. You have no flexibility in life. What can my FM wife do? Her clinic literally reschedules all her patients and tells her to take the day off. The reality is...if I'm at work at my single coverage hospital, and my wife and daughter got into an accident and were on their death beds, I don't even think I could just leave work to be with them. I'd literally have to call and beg people to come in, and pray that someone comes in for me so I can be with my family. Whereas my PCP FM wife - tells the staff, patients get rescheduled - Boom. She's out the door.

4) You get sh it on by consultants - Yup. All the time. Not much to explain. You need thick skin.

5) you get sh it on by patients - Unfortunately also happens all the time. Literally 2 days ago I had a drunk patient and a psychotic patient both yelling at me. Look...my job is to help people. But some of these people are telling you to F off, calling you a terrorist (I'm Pakistani - So obvious brown skin tone), and you take it. And THAT's the people you OFTEN help. They are threatening to sue you, while you're making sure they are safe. Really...think about it, this is how sometimes your good actions are paid back - people tell you to F off and go kill yourself and that they will sue you. Some people are just terrible human beings that you have to take care of. These people WILL be kicked out immediately if they behaved like this at a specialist clinic. If someone said F off to my wife in her PCP office, 911 will be called, and that person will be escorted outside. At an ER, that person hangs out in the ER for the next 24 hours until you can get a psychiatric bed. AND GUESS WHAT!?!??! After 2-3 weeks they will be back!!! A PCP/outpatient clinic practice kicks out people so they can NEVER return. Whereas that patient that could be threatening to kill you, could be back in your ER 3 weeks later after their last psych hospitalization. I'm not exaggerating. This happens.

6) You are the dumping ground - You know what's soul crushing? When you have a full ER, you're hustling, behind on seeing patients, trying to desperately catch up, and then you get a 3 yo kid whose PCP told the mom to bring the child to the ER for the fever -_- The more years you practice, the more you realize that a lot of PCPs and specialists send patients to the ER when they just don't want to inconvenience their lives by adding one more patient to their schedule. And you know it's true because it happens so much more on Fridays -_- It's great being a PCP or a specialist with a clinic and a schedule - If your schedule is full, just send them to the ER. OUR SCHEDULE HAS NO UPPER LIMIT. People can literally just keep coming in. If 50 people showed up to my single coverage ER in 12 hours, I have to see them all! And a lot of us actually have seen 35-50 patients in a 12 hour shift during winter months. You just gotta find a way to be faster and more efficient as more and more dumping happens and more people just keep showing up.

7) You will start HATING boluses of patients - Life is much easier when you have a patient scheduled every 20-30 minutes. You know how much time you have, when you have to see the next patient etc. What happens all too frequently in the ER, you might not do anything for 30 minutes, and then 6 people check in within 15 minutes of each other. Then you start hustling and constantly feeling behind. Then you finally finish seeing those 6 people in 30 minutes, put in orders, then another 2-3 have shown up, then by the time you see them, great...another 1-2 showed up -_- You know...there are times I wish I could come out of a patient room and not see another new patient on the board. It's just incredible that even if I'm in a patient room for 2-3 minutes, somehow in that time a new patient shows up on the board. I can't imagine how nice it must be knowing what time your next patient is coming and knowing that all of your patients aren't just going to all show up at the same time. And must be really really nice knowing that a mom isn't randomly going to check in all 4 of her children, all of them with the same complaint - making you instantly behind on 4 notes.

8) Weekends and holidays - We have a good friends circle with some 8-10 other families and we're always having dinners scheduled at these friends places on the weekends. My wife goes by herself to 50% of them because I'm at work during quite a few weekends. You will miss family events, social events, and essentially things that will otherwise bring joy to your life. You will just be absent on a lot of events in life. You might have A LOT of days off during the week, but you'll still somehow miss a lot of events because you're still working more weekends and holidays than anyone else you know.

9) It gets old really fast - Have you ever seen 2-3 PPH? It's just not fun after a while and every single procedure that you liked in med school, you'll grow to hate. Suture repair? You'll be wondering how many patients you'll have to see when you walk out as the ER keeps getting busier. Same with central lines or any other procedure. They all take time, and you will always feel behind as the list of tasks you need to do accumulates.

10) Decreasing job security, and likely decreasing incomes - You know...a lot of us put up with a lot of this crap for a specialty that paid really well, and had an incredible job market. As the biggest benefit of emergency medicine has gone away, job security is declining as supply demand imbalance is slowly shifting towards increasing supply. And if there's anything you should know, supply demand principles always dictate the price. I would not be surprised when those incomes will follow supply demand metrics and drop as well.

11) It's all about the metrics - Door to doc times, door to ekg times, door to balloon times, door to antibiotic times, patient satisfaction scores, CT heads in syncope patients, CTs in patients discharged - everything is measured and your performance will be criticized.

So yes....heed the warning of those gone before you. I absolutely wish I did FM or IM instead of EM. I made a mistake and I'm owning it. I wish I could slap my 3rd year self and whisper "optho, ortho, PM&R, FM, urology, psych, radiology, anesthesiology, dermatology" in the ear of my younger self. It's not just a coincidence that EM is no. 1 for burn out. And it's not just a coincidence that the attrition rate for EM is really high.

And lastly, a request for the mods - can we sticky this thread. This is the reality that students should know.

"Nah, you don't get it...I'll be happy being an EM doc making 85k--it's really so much $, more than I'll ever need... you just don't get it! And seeing 4 pt/hr is a service to society to cut costs. And blindly signing 100 NP charts is what it means to be a team-player! And all those patients threatening to kill you are just having a bad day and need to take it out on somebody, have some empathy. You're just another tone-deaf boomer with a lame attitude and nothing will make you happy." ~ voice inside the head of far too many med students

One med student I mentor was gung-ho on EM. I wasn't able to convince him to do psych--the best positioned specialty for the foreseeable future--but thankfully was able to help him see EM would be a terrible choice. He just matched to peds and so happy for him...and the outlook for his future career satisfaction/longevity--and even possibly earnings--looks a couple million lumen brighter than EM. Yes, peds.

 

[namethatsmell]

Just so you know, Howie Mell was posting that the surplus study didn’t take into account the mass retirements we saw with Covid so it is already invalidated. I like Howie, I think he’s a pretty real guy who doesn’t have his head up his ass like some of the suits. I don’t know if his claim is true or not, but it was certainly interesting to read. Worth looking into.

Doesn't take into account that a healthy proportion of those FTEs will be replaced with midlevels, not docs.

 

[miacomet]

"Nah, you don't get it...I'll be happy being an EM doc making 85k--it's really so much $, more than I'll ever need... you just don't get it! And seeing 4 pt/hr is a service to society to cut costs. And blindly signing 100 NP charts is what it means to be a team-player! And all those patients threatening to kill you are just having a bad day and need to take it out on somebody, have some empathy. You're just another tone-deaf boomer with a lame attitude and nothing will make you happy." ~ voice inside the head of far too many med students

One med student I mentor was gung-ho on EM. I wasn't able to convince him to do psych--the best positioned specialty for the foreseeable future--but thankfully was able to help him see EM would be a terrible choice. He just matched to peds and so happy for him...and the outlook for his future career satisfaction/longevity--and even possibly earnings--looks a couple million lumen brighter than EM. Yes, peds.

Preach. Some of us can't get fellowships, or second residencies, and oh boy what's coming the pike will be hard to bear.

 

[miacomet]

Also, gotta add, that these academic residencies think they have WAY more influence than they do out in the community. Was told by one resident that Dr. Bigwig, residency director, would always get them a fabulous job ANYWHERE they wanted.

Aske my then director, he asked "Who the f*** is Dr. Bigwig?" So kids, don't believe what the permanently employed, bubbled academicians say when they try and entice you to EM.

 

[GonnaBeADoc2222]

"Nah, you don't get it...I'll be happy being an EM doc making 85k--it's really so much $, more than I'll ever need... you just don't get it! And seeing 4 pt/hr is a service to society to cut costs. And blindly signing 100 NP charts is what it means to be a team-player! And all those patients threatening to kill you are just having a bad day and need to take it out on somebody, have some empathy. You're just another tone-deaf boomer with a lame attitude and nothing will make you happy." ~ voice inside the head of far too many med students

One med student I mentor was gung-ho on EM. I wasn't able to convince him to do psych--the best positioned specialty for the foreseeable future--but thankfully was able to help him see EM would be a terrible choice. He just matched to peds and so happy for him...and the outlook for his future career satisfaction/longevity--and even possibly earnings--looks a couple million lumen brighter than EM. Yes, peds.

C'mon lol.

I'm full of the doom and gloom too, but the only way Peds is MAYBE making more than EM is private practice NICU.

There are pediatric hemeoncs making 100k

 

[miacomet]

C'mon lol.

I'm full of the doom and gloom too, but the only way Peds is MAYBE making more than EM is private practice NICU.

There are pediatric hemeoncs making 100k

Yeah, but you can do it FOREVER. No quitting at 40. Can run your own gig.
Lots of cash pay peds practices on the coasts that do well, very well.
Peds cards and NICU pay decently and not so many nights.

 

[finalpsychyear]

"Nah, you don't get it...I'll be happy being an EM doc making 85k--it's really so much $, more than I'll ever need... you just don't get it! And seeing 4 pt/hr is a service to society to cut costs. And blindly signing 100 NP charts is what it means to be a team-player! And all those patients threatening to kill you are just having a bad day and need to take it out on somebody, have some empathy. You're just another tone-deaf boomer with a lame attitude and nothing will make you happy." ~ voice inside the head of far too many med students

One med student I mentor was gung-ho on EM. I wasn't able to convince him to do psych--the best positioned specialty for the foreseeable future--but thankfully was able to help him see EM would be a terrible choice. He just matched to peds and so happy for him...and the outlook for his future career satisfaction/longevity--and even possibly earnings--looks a couple million lumen brighter than EM. Yes, peds.

Most people aren't going to just jump into psych and rarely understand all the politics of the other specialties by the end of 3rd year in medical school.

Psych's run been around the same time EM started its run. IMO we are next on the chopping block. The only advantage is we can hang a shingle or work remotely. It'll be a 200k gig w/i the next 5 years for employed models. 1 psych doc supervising 5 mid levels is being pushed in a lot of employed models.

Psych Np's are the true winners most likely for the next decade.

 

[GonnaBeADoc2222]

Yeah, but you can do it FOREVER. No quitting at 40. Can run your own gig.
Lots of cash pay peds practices on the coasts that do well, very well.
Peds cards and NICU pay decently and not so many nights.

Peds cards market is very poor and academic.

Cash peds is gonna be rare for all comers.

 

[miacomet]

Most people aren't going to just jump into psych and rarely understand all the politics of the other specialties by the end of 3rd year in medical school.

Psych's run been around the same time EM started its run. IMO we are next on the chopping block. The only advantage is we can hang a shingle or work remotely. It'll be a 200k gig w/i the next 5 years for employed models. 1 psych doc supervising 5 mid levels is being pushed in a lot of employed models.

Psych Np's are the true winners most likely for the next decade.

Ability to hang a shingle with low overhead is much of the battle....

 

[Celexa]

Most people aren't going to just jump into psych and rarely understand all the politics of the other specialties by the end of 3rd year in medical school.

Psych's run been around the same time EM started its run. IMO we are next on the chopping block. The only advantage is we can hang a shingle or work remotely. It'll be a 200k gig w/i the next 5 years for employed models. 1 psych doc supervising 5 mid levels is being pushed in a lot of employed models.

Psych Np's are the true winners most likely for the next decade.

People can come over to the psych forum if they want to watch our specialty have this debate, but two seconds there shows that we have many happy and content posters from a wide variety of jobs AND w wide variety of career stages, unlike here in the EM forums.

The ability to hang a shingle isnt 'the only advantage', it's one of two differences that matter. The other being choice.

I worry for the field that the ****ty level of care provided makes people think that there isn't good mental health care out there and give up looking. But once people interact with a good psychiatrist? They're loyal for life. They CHOOSE to see us when we differentiate ourselves from the crowd.

Any psychiatrist with a modicrum of hustle and the modest administrative skills needed to run a solo practice is in a great position and will continue to be. Modern medicine may be falling apart but we will be the last to go.

 

[xaelia]

Aske my then director, he asked "Who the f*** is Dr. Bigwig?" So kids, don't believe what the permanently employed, bubbled academicians say when they try and entice you to EM.

If your goal is to come out the other side of residency as an academic, then the academic connections from your training institution may (or may not) matter.

Geographic location of training probably matters most with respect to being able to pick the best jobs to continue practicing in that area.

 

[namethatsmell]

C'mon lol.

I'm full of the doom and gloom too, but the only way Peds is MAYBE making more than EM is private practice NICU.

There are pediatric hemeoncs making 100k

You're right, peds specialties generally pay poorly. NICU and PICU do fairly well though. But I've met more than a few pp gen peds docs who do no nights/weekends/holidays (and less phone call than I would have expected, and buffered by an RN line). Many make 250-400k. How? By actually having ownership of their practice. I don't mean to imply that tons of peds docs are making fortunes. Many aren't, but many do better than I would have expected.

And when balanced with much better lifestyle, job security, job diversity/options...yeah I'd say their future is brighter than EM.

 

[namethatsmell]

Most people aren't going to just jump into psych and rarely understand all the politics of the other specialties by the end of 3rd year in medical school.

Psych's run been around the same time EM started its run. IMO we are next on the chopping block. The only advantage is we can hang a shingle or work remotely. It'll be a 200k gig w/i the next 5 years for employed models. 1 psych doc supervising 5 mid levels is being pushed in a lot of employed models.

Psych Np's are the true winners most likely for the next decade.

Why on earth would a psychiatrist take an employed job (especially like you describe) when they can have their own pp with virtually no overhead (and cash-only if they desire)? This is your specialty's single biggest bargaining chip...along with the fact it's also a very nuanced/cerebral field that somebody with less training can't pretend to do very well, and can't be easily replaced with algorithms and "AI."

I'm in an outpatient specialty that can also have a fair amount of nuance and detective work. Have many patients tell me they don't wish to see a midlevel...and these are not just high SES "educated" patients. I'd guesstimate that probably >75% of patients would chose to see a doc vs a midlevel and pay more to do so. Major exception is if the midlevel will happily prescribe opioids and/or help patients file paperwork for frivolous disability claims. I imagine the same is true for pysch--except the psych NPs that certain patient prefer to see dole out benzo's like pez.

Every field has challenges, including psych. But none has as much control over their current practice and future destiny as psych.

 

[namethatsmell]

Preach. Some of us can't get fellowships, or second residencies, and oh boy what's coming the pike will be hard to bear.

I know I've said this before...and I don't want to be a broken record...but...

the only person trapping any EM doc "in the ED" is that doc.

 

[finalpsychyear]

Why on earth would a psychiatrist take an employed job (especially like you describe) when they can have their own pp with virtually no overhead (and cash-only if they desire)? This is your specialty's single biggest bargaining chip...along with the fact it's also a very nuanced/cerebral field that somebody with less training can't pretend to do very well, and can't be easily replaced with algorithms and "AI."

I'm in an outpatient specialty that can also have a fair amount of nuance and detective work. Have many patients tell me they don't wish to see a midlevel...and these are not just high SES "educated" patients. I'd guesstimate that probably >75% of patients would chose to see a doc vs a midlevel and pay more to do so. Major exception is if the midlevel will happily prescribe opioids and/or help patients file paperwork for frivolous disability claims. I imagine the same is true for pysch--except the psych NPs that certain patient prefer to see dole out benzo's like pez.

Every field has challenges, including psych. But none has as much control over their current practice and future destiny as psych.

Yeah but the vast majority aren't doing PP that's the issue. I was 1/7 in my class and maybe a handful have gone from my program in last 5 years.


Takes time to build as well in general. Those out of the gate offers can be temping and often have non competes

 

[RocuROMANium]

"Nah, you don't get it...I'll be happy being an EM doc making 85k--it's really so much $, more than I'll ever need... you just don't get it! And seeing 4 pt/hr is a service to society to cut costs. And blindly signing 100 NP charts is what it means to be a team-player! And all those patients threatening to kill you are just having a bad day and need to take it out on somebody, have some empathy. You're just another tone-deaf boomer with a lame attitude and nothing will make you happy." ~ voice inside the head of far too many med students

One med student I mentor was gung-ho on EM. I wasn't able to convince him to do psych--the best positioned specialty for the foreseeable future--but thankfully was able to help him see EM would be a terrible choice. He just matched to peds and so happy for him...and the outlook for his future career satisfaction/longevity--and even possibly earnings--looks a couple million lumen brighter than EM. Yes, peds.

Dude that is scary how verbatim those words are with our interprofesional education and medical humanities classes. It’s the emasculation of physicians in general imo. Never does a session go by without several med students complaining of how ignorant and terrible docs before them are. It’s some of the cringiest most naïve and ungrateful crap I’ve ever heard. But society and giant health systems are trying to breed this mindset when we’re young I guess

 

[miacomet]

I know I've said this before...and I don't want to be a broken record...but...

the only person trapping any EM doc "in the ED" is that doc.

Depends on your age, financial situation, no?

 

[namethatsmell]

Depends on your age, financial situation, no?

I'm not implying it's easy or immediate--of course you're right, will depend on the person's life situation. But there's nothing stopping most of us, today, from making plans to move towards another path. And the longer one waits to start, the older they'll be.

 

[namethatsmell]

Dude that is scary how verbatim those words are with our interprofesional education and medical humanities classes. It’s the emasculation of physicians in general imo. Never does a session go by without several med students complaining of how ignorant and terrible docs before them are. It’s some of the cringiest most naïve and ungrateful crap I’ve ever heard. But society and giant health systems are trying to breed this mindset when we’re young I guess

The irony is that one of the med students who blathered on about old/"out of touch" docs "ruining" so much...was older than me.

 

[WorkNoteEmergency]

Holy **** AwakeCric, that is horrible and sadly, completely unsurprising. In the first summer of the pandemic, when all hell was breaking loose in Italy, NYC and we were apprehensively waiting for the storm to hit us, we had our pay cut, minimum hours increased, performance metric bonus made more stringent and payment moved from monthly to lump sum at end of contract year. When it became apparent that the hospital had bought a large lot of counterfeit N95’s , we were told to continue using them as there was “no data to show they’re worse than the real ones”. At the same time they cut staff out of the group, choosing the 3 non EM boarded docs in my rural hospital (out of 5 full time docs) with > 50 years experience working in ERs between them. When they did this, those of us left had to pull extra night shifts because the new ABEM eligible docs “weren’t ready” to work solo nights. Meanwhile, I have a decon room set up in my basement and I make sure to tell my wife if I end up on a vent to make sure I end up in our hometown academic hospital rather than the system I work in. When a vaccine became available, there was no priority given to hospital workers and when I drove an hour to the mothership hospital (not rolled out at my rural hospital until 3 weeks later) I was in line behind one of our physician executives. The executives did do their part though, as to help make fiscal ends meet during those trying times they were forced to take an extra 3 days off unpaid at Christmas and Thanksgiving.

The point of this rant is that, dear student, your executive leadership and administrators won’t give a **** about you and just want someone , anyone in the pit to generate RVU’s and keep the lights on. I am hospital employed and for a while, it was good. I recognized at the time that it was only good while our bosses allowed it to be so. At the time I was well paid and generally respected by leadership. I did not realize how quickly that could change and it only took about a year and a half of revolving door CEO’s and generation of a culture of “stepping stone to better corporate job” mentality to completely turn that around.

I will differ from the OP on a couple of points. I think it’s hard to predict for sure, but over the past year, volumes in my rural ED have increased about 10% over pre pandemic levels. Our previously sparse specialist coverage has diminished further and primary care/urgent care referrals seem to have increased. My hospital system is beginning a telehealth initiative with one of the goals being “decrease in ED visits“ but my experience is better access to primary and urgent care = more ED referrals as these are all staffed by inexperienced and overworked mid levels. Ideally one would think it meant demand for well trained and skilled physicians in the ED would increase but who knows with the crop of knuckleheads running the show.

 

[HemorrhagicShock]

For real mods... can we have some formal vote or some discussion on getting the OP stickied. It's well-written, informed, and codifies the entire situation.

 

[VA Hopeful Dr]

@BoardingDoc has put together a thread with links to popular threads. Look at the top of the forum.

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[RustedFox]

@BoardingDoc has put together a thread with links to popular threads. Look at the top of the forum.

Popular threads

Popular EM Forum Threads Training Residency Program Reviews Pain Medicine is an Official Subspecialty of Emergency Medicine Sleep Medicine Impressive Lab Results ER Hall of Fame Cautionary Tales Why EM is a dying specialty Stories Birdstrike Compendium You Can Tie, You Can Lose, But...

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I got a whole heading for my rants.
Damn.