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

[bravotwozero]

I got a whole heading for my rants.
Damn.

You are just that epic my friend. Don’t underestimate yourself!

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[Rekt]

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.

“Hey the specialty is such a dumpster fire terrible mess that there is way more people leaving than expected so there will be room for you!”

 

[xaelia]

I got a whole heading for my rants.
Damn.

I gotta lotta problems with you people, and now you're gonna hear about it!.mp4

 

[Fecal_Occult]

Even in this Instagram post of an EM residency congratulating their graduating class, they acknowledge how difficult the job market continues to be in certain locations (presumably large metro areas). It will only get worse each year and I would not bank on rural areas remaining in short supply of EM docs. This can easily change in 5 years. Anyone considering EM needs to stop and think. Do I love EM so much that I would be okay risking being jobless in 5 years with $200k of student loan debt? Will I be happy being shat on by patients and every other consultant in the hospital? No matter how much you try to convince yourself that you're an adrenaline junkie or how noble this profession is as seen on tv, it's just not worth it in the end.

Choose a specialty where you are in control. You need to either have a skillset that is in short supply (surgery, optho, derm, psych, anesthesia, etc.) or own your patients (FM, IM). Having leverage and being in a position to not take **** from anyone is underrated.

 

[HemorrhagicShock]

Even in this Instagram post of an EM residency congratulating their graduating class, they acknowledge how difficult the job market continues to be in certain locations (presumably large metro areas). It will only get worse each year and I would not bank on rural areas remaining in short supply of EM docs. This can easily change in 5 years. Anyone considering EM needs to stop and think. Do I love EM so much that I would be okay risking being jobless in 5 years with $200k of student loan debt? Will I be happy being shat on by patients and every other consultant in the hospital? No matter how much you try to convince yourself that you're an adrenaline junkie or how noble this profession is as seen on tv, it's just not worth it in the end.

Choose a specialty where you are in control. You need to either have a skillset that is in short supply (surgery, optho, derm, psych, anesthesia, etc.) or own your patients (FM, IM). Having leverage and being in a position to not take **** from anyone is underrated.

These look like great locations overall? What am I missing here?

 

[Fecal_Occult]

These look like great locations overall? What am I missing here?

"while the job market is improving, it remains difficult in certain locations." When residencies themselves are acknowledging that the job market is difficult, future candidates should also beware. And location isn't everything. These could be freestanding ER's or urgent cares for all you know.

 

[Apollyon]

Does Vituity sponsor this residency? Why would they name check V, as "Ambassador", and only put travel in parentheses?

 

[miacomet]

Even in this Instagram post of an EM residency congratulating their graduating class, they acknowledge how difficult the job market continues to be in certain locations (presumably large metro areas). It will only get worse each year and I would not bank on rural areas remaining in short supply of EM docs. This can easily change in 5 years. Anyone considering EM needs to stop and think. Do I love EM so much that I would be okay risking being jobless in 5 years with $200k of student loan debt? Will I be happy being shat on by patients and every other consultant in the hospital? No matter how much you try to convince yourself that you're an adrenaline junkie or how noble this profession is as seen on tv, it's just not worth it in the end.

Choose a specialty where you are in control. You need to either have a skillset that is in short supply (surgery, optho, derm, psych, anesthesia, etc.) or own your patients (FM, IM). Having leverage and being in a position to not take **** from anyone is underrated.

These look like a bunch of part-time gigs- they are working at two hospitals in two different locations. It's not so rosy....

 

[RustedFox]

I gotta lotta problems with you people, and now you're gonna hear about it!.mp4

Why do I recognize this?
What is it from?

 

[BoardingDoc]

Why do I recognize this?
What is it from?

Seinfeld. George Costanza's dad during the airing of grievances at Festivus.

 

[cyanide12345678]

These look like a bunch of part-time gigs- they are working at two hospitals in two different locations. It's not so rosy....

How can you tell these are part time gigs?

 

[miacomet]

How can you tell these are part time gigs?

Well, I suppose it's possible they are working two full-time gigs...

 

[pkwraith]

Even in this Instagram post of an EM residency congratulating their graduating class, they acknowledge how difficult the job market continues to be in certain locations (presumably large metro areas). It will only get worse each year and I would not bank on rural areas remaining in short supply of EM docs. This can easily change in 5 years. Anyone considering EM needs to stop and think. Do I love EM so much that I would be okay risking being jobless in 5 years with $200k of student loan debt? Will I be happy being shat on by patients and every other consultant in the hospital? No matter how much you try to convince yourself that you're an adrenaline junkie or how noble this profession is as seen on tv, it's just not worth it in the end.

Choose a specialty where you are in control. You need to either have a skillset that is in short supply (surgery, optho, derm, psych, anesthesia, etc.) or own your patients (FM, IM). Having leverage and being in a position to not take **** from anyone is underrated.

Unless they're just randomly pinning places, the pins are completely off. The pin is no on Milwaukee, WI, but in random rural Wisconsin land north of Green Bay. The Seattle pin is ...not Seattle. Which is more likely? Just bad graphics or jobs in random satellite hospitals. I want to say the former but you never known anymore.

 

[solitarius]

The ED is a hellhole. I can't see why it ever got as popular as it did.

Oh yes I can. They tried so hard to make it seem cooler and more exclusive than it ever deserved to be, and for awhile, they did an f***in good job at marketing. The multiple aways, SLOEs, and video interview made it seem exclusive. The mountain-biker/snowboarder/rock-climber/traveler/global EM image made it seem cool. One classmate went into EM because "I just thought the people in EM were the biggest chillers," while another classmate was convinced that he was going to work part-time and travel or surf for half the year. And of course, the money was pretty good for awhile.

Sadly, I went to medical school with the intent of pursuing EM because of the tremendously positive experience I had there as a premed. For so many premeds, it's one of the most accessible specialties to get clinical experience, shadowing, or research. And therein lies the trap as well.

 

[miacomet]

The ED is a hellhole. I can't see why it ever got as popular as it did.

Oh yes I can. They tried so hard to make it seem cooler and more exclusive than it ever deserved to be, and for awhile, they did an f***in good job at marketing. The multiple aways, SLOEs, and video interview made it seem exclusive. The mountain-biker/snowboarder/rock-climber/traveler/global EM idealist made it seem cool. One classmate went into EM because "I just thought the people in EM were the biggest chillers," while another classmate was convinced that he was going to work part-time and travel or surf for half the year. And of course, the money was pretty good for awhile.

Sadly, I went to medical school with the intent of pursuing EM because of the tremendously positive experience I had there as a premed. For so many premeds, it's one of the most accessible specialties to get clinical experience, shadowing, or research. And therein lies the trap as well.

Exactly this. The marketing was INSANE- from all corners- TV shows, residency directors, feminem, ACEP, AAEM, where did this all come from? It was genius. And we all bought it, at our peril.

What did you end up choosing?

 

[solitarius]

Exactly this. The marketing was INSANE- from all corners- TV shows, residency directors, feminem, ACEP, AAEM, where did this all come from? It was genius. And we all bought it, at our peril.

What did you end up choosing?

The most impactful experience I had as a premed was hospice, and psychiatry really matched the quality of that experience for me. It also didn't hurt that I can practice in multiple settings including the ED, but I'll likely pass on ED psych.

 

[Frazier]

The most impactful experience I had as a premed was hospice, and psychiatry really matched the quality of that experience for me. It also didn't hurt that I can practice in multiple settings including the ED, but I'll likely pass on ED psych.

We are happy to have you in hospice & palliative medicine. I have no complaints having been practicing a few years. Of course I wish it paid more (who wouldn't?)... For reference I make about 275k. Schedule is M-R, home by 4pm. No call/weekends. I see between 0-5 patients per day depending on what's going on with consults/clinic. Visits range between 5 minutes to 70 min. Things could always change.

Patients are grateful and if they happen not appreciate/desire our involvement, that is fine. The consult ends with that encounter (vs having them follow with us longitudinally in clinic). I like having that control.

I think back about seeing upwards of 2.5 pph in the ED and am thankful. I wouldnt have my feelings hurt if they paid an extra 100k at the palliative job but do recognize that I am very much likely being paid more than the revenue being generated.

The silver lining regarding pay is I have no plans to retire -- I could do this into old age.

 

[emergentmd]

Pallative care is one sub I could do. Your schedule seems like low stress, low volume, no call.

Most of the others are not worth the extra fellowships like CC, pain, sports, Tox, etc...

 

[TrailRun]

We are happy to have you in hospice & palliative medicine. I have no complaints having been practicing a few years. Of course I wish it paid more (who wouldn't?)... For reference I make about 275k. Schedule is M-R, home by 4pm. No call/weekends. I see between 0-5 patients per day depending on what's going on with consults/clinic. Visits range between 5 minutes to 70 min. Things could always change.

Patients are grateful and if they happen not appreciate/desire our involvement, that is fine. The consult ends with that encounter (vs having them follow with us longitudinally in clinic). I like having that control.

I think back about seeing upwards of 2.5 pph in the ED and am thankful. I wouldnt have my feelings hurt if they paid an extra 100k at the palliative job but do recognize that I am very much likely being paid more than the revenue being generated.

The silver lining regarding pay is I have no plans to retire -- I could do this into old age.

How typical is your job? I shadowed palliative this year and while the docs seem pretty happy, they said in our state the job market wasn’t the best and I might need to move out of state. They also seem to make less and work a lot more than you’re describing, and the NP issue seemed present there as well. I make the same as you for full-time EM (Northeast). If I could get a job with a four day work week for 275 iI’d apply in a heartbeat. I ended up applying to pain.

 

[GonnaBeADoc2222]

Was told I'd be a great psychiatrist in med school.

Loved my rotation.

Got Honors.

Chose EM anyway.

Dumb.

 

[bravotwozero]

From WCIs blog post, published today:

The 2023 number [of residency slots] is 3,011. In three decades, we've 6Xed the number of residency spots. We've more than doubled the number of spots since I graduated in 2006. The number of spots since 2015 has increased by 65%. That was the year that this year's EM residency graduates were applying to medical school. Sixty-five percent. That's a massive increase. Yes, the entire Match has gotten bigger in that time period. PGY1 positions for all specialties increased from 27,293 to 36,277 (a 33% increase). But the increase in EM was double that.

 

[Frazier]

How typical is your job? I shadowed palliative this year and while the docs seem pretty happy, they said in our state the job market wasn’t the best and I might need to move out of state. They also seem to make less and work a lot more than you’re describing, and the NP issue seemed present there as well. I make the same as you for full-time EM (Northeast). If I could get a job with a four day work week for 275 iI’d apply in a heartbeat. I ended up applying to pain.

I am not certain how common it is, but I think it is lower volume than average... out of the handful of places I've worked/interviewed it would be slightly above average comp and below average workload.

Some places pay more, but the volume is heavier... such as kaiser where salary would be in the 300's, but it is a packed schedule in clinic from what I heard.

I dont have any home program residents/fellows however, which I do miss from my prior position. My wife wanted this geographical region in the west so I kept my eye on the market for over a year to see what popped up. I got lucky that this particular job opened in the region we were hoping for.

You are correct that the job market has tightened to some degree with NP/PA. We do not have any on our team at present, just 2 docs and the IDT.

Pain is great, congrats!

 

[Kryptocoin]

Palliative is ripe for NP takeover. Low risk specialty, low stress, decent pay....I'd be surprised if more facilities don't start using NP for half the pay.

My ER can't seem to keep midlevels. We have high turnover. Lots of high acuity patients and they only make $75/h. They are quitting and going to clinic work or other low stress gigs.

 

[Frazier]

Palliative is ripe for NP takeover. Low risk specialty, low stress, decent pay....I'd be surprised if more facilities don't start using NP for half the pay.

My ER can't seem to keep midlevels. We have high turnover. Lots of high acuity patients and they only make $75/h. They are quitting and going to clinic work or other low stress gigs.

I suppose it would depend on what you mean by takeover... it is not the type of specialty where you will find hordes of NP tiktokers posting about their palliative job. It is very hard to hang a shingle given the nature of our patient population and how referrals come about.

If you mean that when volume ramps, admin would look to hire an NP over an MD -- that can be true to a degree in the sense of cost cutting however MD leadership is generally required if they wish to have any sort of certified cancer center, hospice, fellowship, etc, etc.

At my prior position we had 5 docs and 2 NP's and 1 PA. They were excellent and sought help/second opinion for the high level stuff. Generally the docs, NP/PA, nurses, social workers, etc that seek out and maintain a footing in hospice/palliative are not militant personalities trying to take over anything. But I do agree that if NP/PA did not exist, the prior position would have likely been 6 or 7 docs. My current position our staff is only composed of docs. I wrote at length in HPM threads about your sentiment, which overall I agree [with the additional qualifiers].

I authored this thread 2 years ago, so your wording is convenient coincidence:

NP's & PA's : Will Palliative Medicine be taken over by midlevels, APP's, extenders, XYZ? Click to find out!

Hopefully, the title catches search results for those looking for answers. This is a hot topic clearly on many individual minds. I see the sentiment about other specialties on different social media platforms. I see it in other subforums. I personally get asked this question on SDN about once...

forums.studentdoctor.net

 

[cyanide12345678]

I suppose it would depend on what you mean by takeover... it is not the type of specialty where you will find hordes of NP tiktokers posting about their palliative job. It is very hard to hang a shingle given the nature of our patient population and how referrals come about.

If you mean that when volume ramps, admin would look to hire an NP over an MD -- that can be true to a degree in the sense of cost cutting however MD leadership is generally required if they wish to have any sort of certified cancer center, hospice, fellowship, etc, etc.

At my prior position we had 5 docs and 2 NP's and 1 PA. They were excellent and sought help/second opinion for the high level stuff. Generally the docs, NP/PA, nurses, social workers, etc that seek out and maintain a footing in hospice/palliative are not militant personalities trying to take over anything. But I do agree that if NP/PA did not exist, the prior position would have likely been 6 or 7 docs. My current position our staff is only composed of docs. I wrote at length in HPM threads about your sentiment, which overall I agree [with the additional qualifiers].

I authored this thread 2 years ago, so your wording is convenient coincidence:

NP's & PA's : Will Palliative Medicine be taken over by midlevels, APP's, extenders, XYZ? Click to find out!

Hopefully, the title catches search results for those looking for answers. This is a hot topic clearly on many individual minds. I see the sentiment about other specialties on different social media platforms. I see it in other subforums. I personally get asked this question on SDN about once...

forums.studentdoctor.net

In theory i think i would love palliative care. I’ve seriously thought about it.

The 1 year opportunity cost seems a really high number that i can’t mentally get over.

A part of me wonders if it makes financial sense - or if I’m just better off working 8 days a month in EM and making the same as a palliative doc. Why work 20 days a month making 250k when i can make 250k working 8-9 days a month?

 

[Frazier]

In theory i think i would love palliative care. I’ve seriously thought about it.

The 1 year opportunity cost seems a really high number that i can’t mentally get over.

A part of me wonders if it makes financial sense - or if I’m just better off working 8 days a month in EM and making the same as a palliative doc. Why work 20 days a month making 250k when i can make 250k working 8-9 days a month?

It's a great question. If the aim of the work is to maximize money with as few hours at work as possible (totally makes sense), then EM def wins out.

I too want to maximize money (so again not knocking it), but I also really enjoy the work itself and have no urge to retire from it. So doing what I enjoy at a comfortable pace for 16-20 days/month if fine... I can't say the same for my time in the ED (opposite rather), so in my case HPM wins out everytime [opportunity cost of the fellowship or not].

Everyone will be different, I agree, so no "right" or "wrong" -- but rather what is best choice for the individual doc. Many docs would hate HPM so it isnt a universal great option for all.

 

[FlaminHotER]

Pretty good article from WCI today

Emergency Medicine's Popularity Plummets | White Coat Investor

More than 550 emergency medicine residency spots went unmatched this year. How did that happen, and what should be done about it?

www.whitecoatinvestor.com

Basically reiterates what we all have been discussing the past week

Now comes the time for action and putting pressure on ACEP, AAEM, and the RRC-EM to shut down crappy programs and not approve any new ones

 

[Trousseau]

Our hospital’s Palliative Team is about 70% NP lol. It’s an option for retiring doctors I guess, but not something that should be your primary career plan.

 

[Pudortu]

In theory i think i would love palliative care. I’ve seriously thought about it.

The 1 year opportunity cost seems a really high number that i can’t mentally get over.

A part of me wonders if it makes financial sense - or if I’m just better off working 8 days a month in EM and making the same as a palliative doc. Why work 20 days a month making 250k when i can make 250k working 8-9 days a month?

Brother this is exactly what I thought about.
I do enjoy sitting with people towards the end of life and making them comfortable. But the opportunity cost and issue with midlevels is a hurdle I just can’t get over. Back to the grind in the pit.

 

[TooMuchResearch]

"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.

You want to help them? Make sure they barely pass the EM rotation. Oh wait, 9th tier residencies would still match them.

 

[Splenda88]

In theory i think i would love palliative care. I’ve seriously thought about it.

The 1 year opportunity cost seems a really high number that i can’t mentally get over.

A part of me wonders if it makes financial sense - or if I’m just better off working 8 days a month in EM and making the same as a palliative doc. Why work 20 days a month making 250k when i can make 250k working 8-9 days a month?

You are smart, my man. Lol

 

[Entadus]

In theory i think i would love palliative care. I’ve seriously thought about it.

The 1 year opportunity cost seems a really high number that i can’t mentally get over.

A part of me wonders if it makes financial sense - or if I’m just better off working 8 days a month in EM and making the same as a palliative doc. Why work 20 days a month making 250k when i can make 250k working 8-9 days a month?

easy. No nights. No call. No weekends. No holidays at work. NO ED.

I make slightly >275 right now with a 5 day work week (4.5 days clinical).
But I get 7 weeks PTO, a week of CME, 13 paid holidays.
Trust me it feels good to make >$130/hr while on vacation. Even if it's "only" $130/hr. It raises the $ per actual hour of work significantly.

To summarize, and in agreement with Frazier, the pace is sustainable.

 

[Franzd'Epinay]

In theory i think i would love palliative care. I’ve seriously thought about it.

The 1 year opportunity cost seems a really high number that i can’t mentally get over.

A part of me wonders if it makes financial sense - or if I’m just better off working 8 days a month in EM and making the same as a palliative doc. Why work 20 days a month making 250k when i can make 250k working 8-9 days a month?

It makes sense if you hate every hour of those 8 shifts and it bleeds into anxiety the other 22 days you're not working. Also, having 2 of those shifts be overnights, 4 evenings, and some of the day shifts fall on the weekend would certainly not help.

 

[WilcoWorld]

If you need to be talked into practicing Palliative Medicine, I'd recommend that you not practice Palliative Medicine.

 

[Mount Asclepius]

If you need to be talked into practicing Palliative Medicine, I'd recommend that you not practice Palliative Medicine.

I think that’s why I like it. Maybe someday. I loved critical care early on, but as I’ve grown disenfranchised with fixing really sick people I’ve become more interested in helping them better in the end. Not for me now, but maybe someday. I think I’ll know if it’s the right time/fit and want it to be organic. I don’t see it as an out though. Just a possible transition to something else…

 

[DOswag]

I lurked on SDN for years back when I was premed. I worked in an ER as a tech back during that time and was dead set on EM when I got into med school. I figured I liked working in the ER as a tech and I fell for some of the marketing that had been done. "only work 3 days per week!" "no call!", "lots of time off!" "never gets boring" "see everything". When I started doing rotations in EM and being on the other side so to speak of seeing patients, pretty quickly I started feeling some of the things mentioned by the OP. I hated switching shifts from days to nights and back. I started resenting patients who came to the ER for their back pain of "years" trying to get pain meds. At the time I chalked it up to just being a burned out med student. I really enjoyed my psychiatry rotation as a 3rd year student but still felt I was definitely going to do EM. I applied to EM and didn't match (military match) and was deferred for a civilian intern year. During that year I really questioned if I wanted to do EM anymore and if I should pay attention more to some of those concerns I had at that time. I spent some more time on psychiatry during my intern year which was a traditional rotating internship. Absolutely fell in love with psychiatry then, applied psych in the next cycle and matched. I am extremely happy that I made that decision as I am certain I would've been miserable in EM. Now I'm almost done with my payback for military as I'm separating this summer. I've signed with an outpatient clinic where I'll have regular hours, no nights, no call, and the job has serious income potential on par with some other specialties.

 

[RustedFox]

I lurked on SDN for years back when I was premed. I worked in an ER as a tech back during that time and was dead set on EM when I got into med school. I figured I liked working in the ER as a tech and I fell for some of the marketing that had been done. "only work 3 days per week!" "no call!", "lots of time off!" "never gets boring" "see everything". When I started doing rotations in EM and being on the other side so to speak of seeing patients, pretty quickly I started feeling some of the things mentioned by the OP. I hated switching shifts from days to nights and back. I started resenting patients who came to the ER for their back pain of "years" trying to get pain meds. At the time I chalked it up to just being a burned out med student. I really enjoyed my psychiatry rotation as a 3rd year student but still felt I was definitely going to do EM. I applied to EM and didn't match (military match) and was deferred for a civilian intern year. During that year I really questioned if I wanted to do EM anymore and if I should pay attention more to some of those concerns I had at that time. I spent some more time on psychiatry during my intern year which was a traditional rotating internship. Absolutely fell in love with psychiatry then, applied psych in the next cycle and matched. I am extremely happy that I made that decision as I am certain I would've been miserable in EM. Now I'm almost done with my payback for military as I'm separating this summer. I've signed with an outpatient clinic where I'll have regular hours, no nights, no call, and the job has serious income potential on par with some other specialties.

I remember you.

 

[collegestud2013]

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 is notoriously underpaid and would not recommend it for anyone who is financially conscious or is the primary breadwinner for their household. Given that kids overall are generally healthy as a whole, the overall trend of decreasing birth rates, and the large shift to to an aging population, the forces of supply and demand won't be in favor of peds and if anything will favor geriatrics. Financially speaking, it's not not the most practical to limit your practice to only those under the age of 18.

Cash concierge peds is a possibility for some and has the potential to make a lot more typical employed peds taking insurance, but it's still a small niche.

For those who don't have the stats in med school to enter something competitive like derm, ophtho, radiology, or a surgical subspecialty, IM probably offers the most flexibility to switch around down the line in case the job market in one area goes down the drain. You can do hospitalist, primary care, urgent care, telemedicine, (which FM can too) but as well as all the plethora of subspecialty fellowships like cards, GI heme/onc, CC, rheum, allergy, etc...

Despite all the doom and gloom on here, EM does have other options for all those who are already in residency or attending and getting burned out working in the ER. Urgent care and telemedicine are options just like IM or FM, and there are some fellowships like critical care of pain management but not as many options as IM.

 

[collegestud2013]

Our hospital’s Palliative Team is about 70% NP lol. It’s an option for retiring doctors I guess, but not something that should be your primary career plan.

Agreed. Palliative Care work may be slower paced the EM and even slower than hospitalist, and involve no nights or weekends, which makes it more sustainable, but on paper it can look like a money loser for the hospital and a service that is non-essential and can easily be cut if the hospital decides to tighten its finances (of course since palliative care physicians are IM or FM trained they could just go back to PCP or hospitalist if that happened).

GOC conversations with families naturally tend to be time-consuming, and thus palliative care probably thus generates less billable RVUs than hospitalist or EM just from the low volume, and their pay has to be significantly subsidized by the hospital. Their financial value mainly comes from being able to convince families to make their dying patients DNR/DNI and comfort care so they don't use up more super expensive resources in the ICU that most of the time are futile.

 

[Frazier]

Agreed. Palliative Care work may be slower paced the EM and even slower than hospitalist, and involve no nights or weekends, which makes it more sustainable, but on paper it can look like a money loser for the hospital and a service that is non-essential and can easily be cut if the hospital decides to tighten its finances (of course since palliative care physicians are IM or FM trained they could just go back to PCP or hospitalist if that happened).

GOC conversations with families naturally tend to be time-consuming, and thus palliative care probably thus generates less billable RVUs than hospitalist or EM just from the low volume, and their pay has to be significantly subsidized by the hospital. Their financial value mainly comes from being able to convince families to make their dying patients DNR/DNI and comfort care so they don't use up more super expensive resources in the ICU that most of the time are futile.

First, this will be a long post, not to convince you. I do not mind so much what you think one way or another. However search engines link to SDN threads and SDN's search function might return this as a result when someone interested searches for "palliative care"... so this is more for "them" (the future) than for you at present.

You are correct in that a C-Suite Suit might look at the numbers and decide to discontinue their palliative medicine program, fire all docs, etc... however, they would also be sinking their hospital to some degree if it was any sort of institution beyond being a critical access hospital. There are multiple facets of a robust, comprehensive health system which have grown to require palliative physician representation essentially. The joint commission requires palliative physician being on board to achieve and maintain inpatient palliative certification. Centers that would desire heart failure certification require palliative medicine. LVAD center? Requires palliative medicine. Want that cash cow Cancer Center certification? Requires palliative medicine involvement. In fact as of 2018, 95% of NCI Cancer Centers/etc have integrated palliative programs. Hospice certification for your GIP unit? Yep, requires palliative physician.

The aforementioned Suit could release the entire palliative program and have all the oncologists manage their patient's symptoms, GOC talks, etc... Heme/Onc tend to be pretty busy docs already, so I would guess that the majority would not be happy about multiplying their workload and the pushback from that realm with heavy sway would also throw a bit of a wrench in the plan.

To your point, sure, there is support that aligning a patient's future care with their actual goals and preferences can save a healthcare system money ("cost saving") on avoiding providing care and interventions discordant to the patient's wishes.

You conveniently ignore we also see people in the clinic and help to keep them out of the emergency department, bounceback, or direct admit for wide range of physical symptoms psychological/social issues. Where do you think the severe cancer-related pain crisis is going to go if they can't get ahold of anyone to manage their pain? The ED. How about the guy that keeps vomiting after discharge by hospitalist with "zofran 4mg Qdaily PRN n/v"? Bounceback. Maybe the patient might even call their on-call oncologist -- and be told to go to the ED. What is a common disposition in the ED for folks that present in a recalcitrant pain crisis? Or the fun scenario of vomiting up all their PO pain meds at home? "Admit for pain control." How about the patient with dementia which was previously cared for by spouse at home, but spouse broke their own hip and needs surgery? Who is going to get up that respite? Neurologist on-call from home? Nope, to the ED for social admit they go. Well, the palliative IDT could have done it all outpatient. In other words, goals of care are a significant portion of palliative's "cost savings" but the reach spans outside the acute ICU consult ("make them DNR/DNI plz pretty plz") and into the community day in and day out.

Additionally, when it comes to billing, it is typically all top-level coding given the nature of our patients and the underlying complexity (i.e. RVU's are higher than the typical outpatient FM/IM visit coding). Critical care time for billing also has been established. So while we might not bill at the frequency of our IM/FM colleagues, we are right to consistently bill at a higher level given the nature of our work.

Long story short, it sounds like you are speaking as someone that is neither an EM doc or an HPM doc. I happen to be both. Why not fire all the ED docs and have the ED run exclusively by NP/PA with off-site "physician supervision"? ED docs "can easily be cut if the hospital decides to tighten its finances". Psych docs? Fire them and tighten up finances. Rheum docs "can easily be cut if the hospital decides to tighten its finances". Allergy docs "can easily be cut if the hospital decides to tighten its finances". Hospitalists "can easily be cut if the hospital decides to tighten its finances"....It isn't that simple.

I think you likely don't know what you are talking about -- and perhaps have a limited view and understanding to whatever hospital you practice in conjunction with practicing as a hospitalist? Was your experience a couple weeks or a month rotation in residency? Or maybe I am wrong and you are a natural expert and truly know the specialty better than the trained specialist themselves?

EDIT: To clarify, we are certainly not a big revenue stream like ortho, etc. However, to pretend that HPM as a field would universally be on the chopping block for the reasons originally quoted ("let's tighten finances") is misguided... Let's ignore the inpatient RVU's, outpatient RVU's, "cost savings", the loss of all the little badges of honor (certified XYZ) that health systems love to tout so much -- or just dropping capabilities/status period (such as for LVADs), and of course the opportunity cost of having the other specialists try to make up our workload on top of their own workloads. We aren't paid that much.

 

[GatorCHOMPions]

Additionally, when it comes to billing, it is typically all top-level coding given the nature of our patients and the underlying complexity (i.e. RVU's are higher than the typical outpatient FM/IM visit coding). Critical care time for billing also has been established. So while we might not bill at the frequency of our IM/FM colleagues, we are right to consistently bill at a higher level given the nature of our work.

Pain shares call and inpatient responsibilities with Palliative at my current job, and we see each others RVU production. The Palliative guy generates about 10k wRVUs per year! Granted he gets all the RVUs from the midlevel he supervises. And a good part of his job is managing and directing the inpatient Pain service. He has to be making like 500k, though, for M-F 9-5 work with occasional weekend call.

 

[TrailRun]

Admittedly I don't know much about the business of medicine, but from a financial perspective, how does making a patient CMO/ DNR etc save the hospital money? I recognize they would get less aggressive treatment (central lines, pressors, intubation, prolonged ICU stay); but aren't these the things that the hospital makes the most on? And to your point about keeping people out of the ER, doesn't the hospital make money for the more people come to the ER (isn't that why they advertise wait times on billboard to encourage low acuity visits)? I can see how palliative can be cost saving (more so for the patients), and of course unquestionably better for patient care. Just trying to understand the economics of how the hospital would even care about 'saving costs' when it seems the more testing/procedures/visits/admits benefits them financially.

 

[emergentmd]

Pall-med seems like a great field for someone wanting a low stress bankers hour job. I applaud you for getting in early but I fear now that EM docs/med students find out it, this will be flooded too. I remember Rad Onc being the ROAD type job. No one knew about it, the ones who got in were banking 750K bankers hours low stress. Well guess what? Insurance figured it out and targeted it. Med students figured it out and was difficult to match into. So you go the classic supply going up, demand going down as insurance cut reimbursement.

Almost all medical fields will see this fate in some form. History has taught us this many times over with Optho, Interventional Card, GI, etc. They all still do well, but ask the forefathers what they were making.

Bottom line to all med students is pick what you like to do, make as much as you can early on x 10 yrs, then you can coast when you hit 40.

 

[miacomet]

Pall-med seems like a great field for someone wanting a low stress bankers hour job. I applaud you for getting in early but I fear now that EM docs/med students find out it, this will be flooded too. I remember Rad Onc being the ROAD type job. No one knew about it, the ones who got in were banking 750K bankers hours low stress. Well guess what? Insurance figured it out and targeted it. Med students figured it out and was difficult to match into. So you go the classic supply going up, demand going down as insurance cut reimbursement.

Almost all medical fields will see this fate in some form. History has taught us this many times over with Optho, Interventional Card, GI, etc. They all still do well, but ask the forefathers what they were making.

Bottom line to all med students is pick what you like to do, make as much as you can early on x 10 yrs, then you can coast when you hit 40.

Assuming one picks a field where there are jobs for the next decade or so, unlike rad onc or perhaps EM

 

[emergentmd]

Assuming one picks a field where there are jobs for the next decade or so, unlike rad onc or perhaps EM

Yeah, pick something where you can bank alot b/c any field can change for the worse in 10 yrs. EM you still can bank for atleast 5.

 

[WilcoWorld]

Palliative Medicine is a wonderful job for docs who want to marry their communication skills with their knowledge of medicine to improve the lives of patients and families. For those docs - assuming they aren't afraid to face death and suffering squarely in the face - Palliative Medicine will improve their lives as well. But I think it's not a good way to "escape" the ED. If you're fed up with the frustrations of working within the healthcare system or dealing with emotional patients or high maintenance consultants, I would not recommend going into a field where you have to become fluent in hospice admission (and recertification) criteria and insurance preauthorization for prescriptions so that you can take care of sad/angry/confused patients (and their families!) while trying to reconcile the disparate recommendations of several subspecialists.

 

[Frazier]

Admittedly I don't know much about the business of medicine, but from a financial perspective, how does making a patient CMO/ DNR etc save the hospital money? I recognize they would get less aggressive treatment (central lines, pressors, intubation, prolonged ICU stay); but aren't these the things that the hospital makes the most on? And to your point about keeping people out of the ER, doesn't the hospital make money for the more people come to the ER (isn't that why they advertise wait times on billboard to encourage low acuity visits)? I can see how palliative can be cost saving (more so for the patients), and of course unquestionably better for patient care. Just trying to understand the economics of how the hospital would even care about 'saving costs' when it seems the more testing/procedures/visits/admits benefits them financially.

Great question!

Short version for the underlying "cost" concepts involving the relationship between hospital (as a provider) and reimbursing entities (as a payer): global budgets, utilization-based budgets, capitation, managed care, DFFS, NpD, HMOs, and integrated health systems.

Here is the long version (>40 pages) that is much more eloquent than I for a more comprehensive answer. I draw your attention to start on page 6 if pressed for time and want to jump right to your answers...

Palliative Care in California: The Business Case for Hospital-Based Programs https://www.chcf.org/wp-content/uploads/2017/12/PDF-PalliativeCareBusinessCase.pdf

 

[DeadCactus]

Great question!

Short version for the underlying "cost" concepts involving the relationship between hospital (as a provider) and reimbursing entities (as a payer): global budgets, utilization-based budgets, capitation, managed care, DFFS, NpD, HMOs, and integrated health systems.

Here is the long version (>40 pages) that is much more eloquent than I for a more comprehensive answer. I draw your attention to start on page 6 if pressed for time and want to jump right to your answers...

https://www.chcf.org/wp-content/uploads/2017/12/PDF-PalliativeCareBusinessCase.pdf&ved=2ahUKEwj_5ejR_Pn9AhUPPkQIHQ28BkoQFnoECD0QAQ&usg=AOvVaw0lbk4i5yfdTfY7O3G3D2kK

Maybe just a problem on my end, but the link doesn't seem to be working. It looks like this is the article it's meant to go to?

The Business Case for Palliative Care: Translating Research Into Program Development in the U.S.

Specialist palliative care (PC) often embraces a “less is more” philosophy that runs counter to the revenue-centric nature of most health care financing in the U.S. A special business case is needed in which the financial benefits for organizations such as hospitals and payers are aligned with...

www.jpsmjournal.com

 

[Frazier]

Maybe just a problem on my end, but the link doesn't seem to be working. It looks like this is the article it's meant to go to?

The Business Case for Palliative Care: Translating Research Into Program Development in the U.S.

Specialist palliative care (PC) often embraces a “less is more” philosophy that runs counter to the revenue-centric nature of most health care financing in the U.S. A special business case is needed in which the financial benefits for organizations such as hospitals and payers are aligned with...

www.jpsmjournal.com

I fixed the link (hopefully). Thanks for heads-up!

Palliative Care in California: The Business Case for Hospital-Based Programs https://www.chcf.org/wp-content/uploads/2017/12/PDF-PalliativeCareBusinessCase.pdf

 

[collegestud2013]

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.

Sounds like something the hospital would not end up being happy about, and would jeopardize Teamhealth losing its contract with the hospital down the line. If Teamhealth is cutting staffing or by replacing physicians with NPs (in states that allow independent practice), the short term cost savings will only benefit TeamHealth and its investors, and not the hospital. The hospital, on the other hand, will get hit the downstream issues of poor staffing like NPs ordering more tests (which has been shown in studies to be the case by independent NPs vs physicians in the ED), the costs which the hospital will be eating. Also more patient safety issues and errors will come up with NPs, which will increase the number of lawsuits the hospital gets named in. Though as far has I know, the latter hasn't been well proven in a study yet, and maybe that's why hospitals still aren't as hesitant to replace physicians with independent NPs yet until the lawsuits start coming in several years later.

For many hospitals, probably better for them just to hire physicians directly instead of contracting with a CMG. The CMG is essentially another middleman and their only incentives are to turn a profit in the middle and do the minimum to keep their contract with the hospital. And when malpractice lawsuits come up, they seem to be less often named in them (usually the named parties are the physicians involved and the hospital).