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

[miacomet]

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).

I don't know how to explain this to you, but hospitals make more money when NPs order more tests and admit more patients, as multiple other posters have explained in painstaking detail

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[sloh]

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

This is such a good read even if you don't care about palliative medicine. Long but well worth it.

 

[Bill Brasky]

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.

This is what does it for me. I totaled my car in a snow storm this winter right before a night shift. Drifted across an intersection, rolled off an embankment straight into a tree. Everything hurt. I still showed up to work, and was lauded for only being 30 minutes late.

This "specialty" is completely dehumanizing. I'm less than a year out of residency and already interviewing for nonclinical jobs.

 

[RustedFox]

This is what does it for me. I totaled my car in a snow storm this winter right before a night shift. Drifted across an intersection, rolled off an embankment straight into a tree. Everything hurt. I still showed up to work, and was lauded for only being 30 minutes late.

This "specialty" is completely dehumanizing. I'm less than a year out of residency and already interviewing for nonclinical jobs.

That last line.
Yep. That's it.

 

[TrailRun]

This is what does it for me. I totaled my car in a snow storm this winter right before a night shift. Drifted across an intersection, rolled off an embankment straight into a tree. Everything hurt. I still showed up to work, and was lauded for only being 30 minutes late.

This "specialty" is completely dehumanizing. I'm less than a year out of residency and already interviewing for nonclinical jobs.

Same - Wife and my infant were in a relatively minor crash. Single coverage, would have loved to leave. But instead stayed to take care of the viral URI, ankle pains, ETOH, etc. If the majority were actually sick wouldn’t mind but…. so it goes. In this last week I literally saw someone who came to the ER for a pimple, and another for a foot callus. Best of luck!

 

[Dr Mantis Toboggan]

Same - Wife and my infant were in a relatively minor crash. Single coverage, would have loved to leave. But instead stayed to take care of the viral URI, ankle pains, ETOH, etc. If the majority were actually sick wouldn’t mind but…. so it goes. In this last week I literally saw someone who came to the ER for a pimple, and another for a foot callus. Best of luck!

In my state all you have to do to close the ER is call the state and EMS to tell them you are closed and put a sign on the door directing walk ins to the closest facility.

Doesn’t mean it wouldn’t end your career but that’s all you are legally required to do.

 

[cyanide12345678]

This is what does it for me. I totaled my car in a snow storm this winter right before a night shift. Drifted across an intersection, rolled off an embankment straight into a tree. Everything hurt. I still showed up to work, and was lauded for only being 30 minutes late.

This "specialty" is completely dehumanizing. I'm less than a year out of residency and already interviewing for nonclinical jobs.

What sort of non clinical jobs were you able to find looking to take ER docs - would you at least break 200k with such a non clinical job?

 

[xaelia]

In my state all you have to do to close the ER is call the state and EMS to tell them you are closed and put a sign on the door directing walk ins to the closest facility.

Doesn’t mean it wouldn’t end your career but that’s all you are legally required to do.

Closing the ED doors is the easy part; transferring care of patients already in the ED is the harder bit.

 

[cyanide12345678]

Closing the ED doors is the easy part; transferring care of patients already in the ED is the harder bit.

Closing doors is easy???? I mean come on. You’re going to jeopardize being immediately fired and potentially reported for patient abandonment.

 

[xaelia]

Closing doors is easy???? I mean come on. You’re going to jeopardize being immediately fired and potentially reported for patient abandonment.

That's the "relatively easy" part – you can close the doors to new entrants, as cited above, but you can't abandon patients in the department.

 

[Dr Mantis Toboggan]

That's the "relatively easy" part – you can close the doors to new entrants, as cited above, but you can't abandon patients in the department.

If you transfer care of admitted folks to the hospitalist once you’ve admitted everyone you could peace out no? Obviously this is a purely theoretical exercise. I’ve never thought about this, not once, ever.

 

[Brigade4Radiant]

What sort of non clinical jobs were you able to find looking to take ER docs - would you at least break 200k with such a non clinical job?

That’s the thing about non-clinical jobs. Yeah, the hours are good, but you get non-clinical pay.

Realistically, I plan to do ER for the next 10 years even part time because to me yeah, I do some telehealth on the side.

But working in an office with a boss for low six figures no way

 

[WorkNoteEmergency]

I did a small amount of consulting work for very small cap pharmaceutical company in my home town. I was oh so close to it turning into a long term deal but it fell through when the upper management turned over. Anyway I looked hard into more work in the industry and so far came up empty. There are a few Pharma companies that offer fellowships to learn the ropes of the business; seem to be aimed more at newly graduated residents though. Pharma is awash in money and it is an industry where one of us could make comparable income with potential for much greater with preferred stock and/or advancement to executive levels.

If I was fresh out of residency I would lay groundwork for this industry. Another route to this would be to stay in academics and get involved in research projects with neurology, cardiology and (I know, long shot) oncology.

 

[LabMonster]

OP - Well said. 10 years out and looking for a way out. I don't want to give it up entirely, I criced an angioedema lady a few weeks ago at a rural hospital and I know 75% of the locums scabs (IM/FP out of residency) who DON'T do any procedures and weren't EM trained would have watched her die. I'm seeing a lot of underqualified docs in the ERs in the rural parts of the west. As mentioned, the FP/PAs are increasing, and maybe 20% are actually trained in EM. The rest order EVERY test then ask me how to interpret the results.

I strongly considered trauma surgery, but now I'm kicking myself I didn't go FP/EM - I would likely go concierge PP. Going to keep moving meat until the majority of my kids are out of HS and/or my wife's business takes off and we don't need the income.

I agree with the OP, consider other options beside EM. If you're not even in medical school yet, DO SOMETHING ELSE. We are NOT that well paid for the training, debt, stress, etc that we endure.

I guess one could say, "Well, what did you expect?" I expected: respect, autonomy, teams willing to solve problems creatively, job satisfaction, joy in my work and to save lives. Every once in a while there is joy and it's usually because I'm still saving lives. The rest is a pipe dream. Capitalism and good old aggressive American business gusto has trashed this profession.

 

[LabMonster]

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.

Did you do fellowship? I'm still thinking about PC/hospice...

 

[ShockIndex]

Closing doors is easy???? I mean come on. You’re going to jeopardize being immediately fired and potentially reported for patient abandonment.

There is already a thread in this forum about how reasonable it is to simply put up a sign and shut down your ED if your relief no-shows.

No relief

You are probably pretty safe doing that unless a patient presents in extremis after 0700 while you are still in the ED. Then, I’d say that all bets are off - your license and ass are on the line if you do not render aid. On the other hand, telling your charge nurse to shut down triage an hour...

forums.studentdoctor.net

I seem to recall that the main proponent of this idea (now a deleted account) was a site moderator and “verified” expert at the time of this conversation. Plenty of other forum members chimed in with their internet credentials and likes to support the group think that shuttering an ED was doable by an EP without first getting approval from hospital admin or their employer. Just cover up a sign and you will be scott free…

I post this as a reminder of the hazards to following the advice of anonymous internet experts over your own common sense.

 

[Frazier]

Did you do fellowship? I'm still thinking about PC/hospice...

Yes, i did. It is much harder getting a palliative job without fellowship, not to mention that EM residency doesn't make a palliative med specialist (so that should be a focus too).

You could prob land a hospice gig, but times have changed from years past and most will want someone BE/BC in HPM or have the hospice medical director certification.

It was a different story 20, 10, even 5 years ago.

Browse the HPM subforum on here if you haven't yet.

I thoroughly enjoy the content of my job, the patient population, and the work life balance. I was able to rearrange my schedule and now work 3.5 days per week: 2 days of clinic and 1.5 days of inpatient consults.

Granted at 275k, I make less than the average EM doc.

It is nice consistently enjoying one's field.

 

[Birdstrike]

We did a month of Hospice and Palliative during my Pain fellowship. I liked it and think I would have been happy doing it. The reason I chose Pain over Palliative was, the opportunity cost of doing the fellowship year, pushed me towards the field with the greater income potential of those two, which at the time was Pain.

But I think Hospice and Palliative would have worked out well if I had chosen it. In fact, I'm guessing I could probably do H&P care right now, if I wanted to, with my EM + Pain certifications, but I have no need to pursue that avenue.

 

[Birdstrike]

The mid-level experiment is not new. It's become clear that there's a mix and ratio of physicians and mid-levels working together, that seems to work best in each practice setting. There are very few specialties going forward that are going to be 100% physician, or 100% mid-levels. I suppose I could be wrong, but I honestly think the fear of mid-level encroachment at this point in time, far outweighs the reality mainly because they're immersed in nearly all settings in medicine already. I'm not sure how much more unoccupied territory there is left for them to encroach upon.

 

[dozitgetchahi]

This is what does it for me. I totaled my car in a snow storm this winter right before a night shift. Drifted across an intersection, rolled off an embankment straight into a tree. Everything hurt. I still showed up to work, and was lauded for only being 30 minutes late.

This "specialty" is completely dehumanizing. I'm less than a year out of residency and already interviewing for nonclinical jobs.

When I was rounding in the ER, an ER resident told me a couple stories that were sad and frankly disgraceful. First, one of her co residents was riding his bike to work, fell off and dislocated a shoulder. He reportedly popped it back in and finished the shift.

After that, all the residents felt they couldn’t take off for anything whatsoever because someone else had been so “hardcore”…so later that year she was on a shift with food poisoning and had massive diarrhea. Couldn’t hold it at one point and straight up **** her pants during a code. There was no time to clean up for the rest of the shift, so she finished the shift with **** in her pants.

 

[GassYous]

When I was rounding in the ER, an ER resident told me a couple stories that were sad and frankly disgraceful. First, one of her co residents was riding his bike to work, fell off and dislocated a shoulder. He reportedly popped it back in and finished the shift.

After that, all the residents felt they couldn’t take off for anything whatsoever because someone else had been so “hardcore”…so later that year she was on a shift with food poisoning and had massive diarrhea. Couldn’t hold it at one point and straight up **** her pants during a code. There was no time to clean up for the rest of the shift, so she finished the shift with **** in her pants.

Yeah someone coming in with diarrhea and not washing their hands properly in Intern year led to 1/3 of the im residents out all at the same time

 

[BoardingDoc]

When I was rounding in the ER, an ER resident told me a couple stories that were sad and frankly disgraceful. First, one of her co residents was riding his bike to work, fell off and dislocated a shoulder. He reportedly popped it back in and finished the shift.

After that, all the residents felt they couldn’t take off for anything whatsoever because someone else had been so “hardcore”…so later that year she was on a shift with food poisoning and had massive diarrhea. Couldn’t hold it at one point and straight up **** her pants during a code. There was no time to clean up for the rest of the shift, so she finished the shift with **** in her pants.

I have called out of work a handful of times. It has almost exclusively been due to gastrointestinal distress. Working a shift while you're glued to the toilet just isn't viable.

That said, yeah, ER sick call culture is pretty Spartan, and I don't mean that in a "badass" way.

 

[dozitgetchahi]

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

It’s absurd. I can remember as a premed and med student, there was this prevailing idea that all doctors had to be this sort of utterly self sacrificing, Ghandi level saint of a person who was supposed to selflessly do this high level doctor work basically for free.

(No word on how that was supposed to work with $500k in student loans.) Surprise surprise, real world docs don’t act or think like this at all.

 

[Socrates25]

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.

True. I'm private practice peds. I see approx 20 patients per day. And I made 310k last year. I could bump up to 40 and get probably 450-500k probably but I value quality of life more than $$$ which is why I chose peds in the first place and not neurosurgery.

When you run your own office you make a lot more money than being employed by someone else.

 

[cyanide12345678]

True. I'm private practice peds. I see approx 20 patients per day. And I made 310k last year. I could bump up to 40 and get probably 450-500k probably but I value quality of life more than $$$ which is why I chose peds in the first place and not neurosurgery.

When you run your own office you make a lot more money than being employed by someone else.

You’re making some very decent money even right now compared to your pediatrics peers. Good for you

 

[Socrates25]

You’re making some very decent money even right now compared to your pediatrics peers. Good for you

It's because my peers don't know their own worth and are getting massively shortchanged by working as an employee for a large group or hospital chain.

 

[Bulliedinschool2doc]

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.

I think thats where I am at. Will probably end up doing the fellowship route, still plan on going into the field