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  • Future of Emergency Medicine

    Anyone else worried about the future prospects in emergency medicine?   Over the last 4 years, it looks like the ACGME has accredited 75 new EM residency programs!!!  (From counting them up on their website by year)

    This is a flood of new grads, pouring into the market soon, with more programs on the way.     That's a ton of supply.  There seem to be signs that a lot of the opportunities are drying up fast.

    These grads are highly indebted, not financially sophisticated yet, and need jobs, and will provide great cheap labor for the Contract Management Groups and their hedge fund partners (USACS, TeamHealth, Envision, etc...) who are the original side of the double-edged sword that seems to be dropping on EM.

    Overall this should drive salaries and openings down fast.  And I can already see a big change out there from what was available just a few years ago.   ?

     

     

  • #2
    Any supply stats vs demand? I’d be concerned about NPs and PAs increasing productivity and decreasing physician demand as well.

    Comment


    • #3
      I'm not a big fan of the expansion. I'm especially not a fan of the places that are getting residencies that are controlled by CMGs. With that said (and trying not to get too political or off topic), I'm more concerned about what a potential single-payer system would do in multiple ways. I'm not as concerned about PAs or NPs, either. I think they do a much better job of lobbying than physicians do but hopefully that will change.

       

      My view is probably skewed by the fact I'm with an SDG. I'm not a clock-in and clock-out kind of guy and I know I wouldn't put forth the administrative effort with a CMG that I do with an SDG so I'm not sure how I'd do if my job ever changed.

      Comment


      • #4
        some of this is in response to various data sources over the years about the looming "physician shortage"...which was first tackled by increasing the number of medical students and new medical schools. This then created the bottle neck of more graduated medical students than residency slots....so the push to open more residency positions.  How this impacts various job markets along with physician extenders "replacing physicians" rather than extending their access capabilities is TBD....as you are predicting probably not favorable, particularly with the flood of increase in a short time.

        anyone who is a current medical student this is like a pipe dream to have more slots available for matching.........

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        • #5
          Normally I'd argue that the length of EM training should be longer.  It seems absurdly short to have only 3 years to learn how to diagnose and treat all emergencies in adults, children, babies, pregnant women, and do procedures, intubations, etc...  to make matters worse is that you're in a field where you don't always get feedback on whether a diagnosis was correct or not, which I think would make the process of learning through experience a bit slower.   A retina specialist spends 6 years of residency/fellowship learning how to diagnose and treat just a tiny tissue in the back of the eye and believe me, all six of those years are necessary.

          But since NPs and PAs are allowed to do EM with even far less training.. well... clearly competence is not our nation's priority right now.  If they don't fill the spot with a physician, they'll just fill it with an NP or PA.

          Comment


          • #6
            I think that CMG jobs will be able to lower their average salaries for Emergency Medicine with lots of new grads waiting to take anything they can get. There should be less of an issue to private SDG groups that get to keep their profits themselves and decide whether to hire midlevels, or adjust other metrics for productivity.

            I think my private EM group is more likely to be affected by changes in payer mix and likely in a negative way. Some high volume EDs with poor payer mix of uninsured and Medical could actually come out ahead if everyone suddenly had insurance coverage and reimbursed a bit better like a medicare patient. We are a smaller hospital in a suburban community and do reasonably well off of low volume with a great payer mix. It's a great lifestyle job with reasonable volume and pretty good pay- but if suddenly we lost the well reimbursing private patients and all went down to Medicare rates all of a sudden we couldn't staff the ED and would like have to close or pay really poorly, leading to lots more consolidation and having fewer and fewer central receiving hospitals.

            Comment


            • #7




              Normally I’d argue that the length of EM training should be longer.  It seems absurdly short to have only 3 years to learn how to diagnose and treat all emergencies in adults, children, babies, pregnant women, and do procedures, intubations, etc…  to make matters worse is that you’re in a field where you don’t always get feedback on whether a diagnosis was correct or not, which I think would make the process of learning through experience a bit slower.   A retina specialist spends 6 years of residency/fellowship learning how to diagnose and treat just a tiny tissue in the back of the eye and believe me, all six of those years are necessary.

              But since NPs and PAs are allowed to do it with even far less training.. well… clearly competence is not our nation’s priority right now.  If there are jobs that need to be filled in emergency medicine, I’d rather be treated by a physician.
              Click to expand...


              3 years is very adequate time for EM training.  I say this as a 4 year grad of a high volume high acuity program.  Our job is to stabilize and disposition, not to always get the "right" diagnosis.  Retina requires an extremely fine tuned exam and highly meticulous surgical skills.  EM is macro - sick vs not sick, get tube in hole, get needle in vessel, etc.

               




              I think that CMG jobs will be able to lower their average salaries for Emergency Medicine with lots of new grads waiting to take anything they can get. There should be less of an issue to private SDG groups that get to keep their profits themselves and decide whether to hire midlevels, or adjust other metrics for productivity.

              I think my private EM group is more likely to be affected by changes in payer mix and likely in a negative way. Some high volume EDs with poor payer mix of uninsured and Medical could actually come out ahead if everyone suddenly had insurance coverage and reimbursed a bit better like a medicare patient. We are a smaller hospital in a suburban community and do reasonably well off of low volume with a great payer mix. It’s a great lifestyle job with reasonable volume and pretty good pay- but if suddenly we lost the well reimbursing private patients and all went down to Medicare rates all of a sudden we couldn’t staff the ED and would like have to close or pay really poorly, leading to lots more consolidation and having fewer and fewer central receiving hospitals.
              Click to expand...


              Yeah until the CMG takes your contract.  We are all probably screwed in EM, but then again, so is most of medicine.

               

              Comment


              • #8




                Normally I’d argue that the length of EM training should be longer.  It seems absurdly short to have only 3 years to learn how to diagnose and treat all emergencies in adults, children, babies, pregnant women, and do procedures, intubations, etc…  to make matters worse is that you’re in a field where you don’t always get feedback on whether a diagnosis was correct or not, which I think would make the process of learning through experience a bit slower.   A retina specialist spends 6 years of residency/fellowship learning how to diagnose and treat just a tiny tissue in the back of the eye and believe me, all six of those years are necessary.

                But since NPs and PAs are allowed to do EM with even far less training.. well… clearly competence is not our nation’s priority right now.  If they don’t fill the spot with a physician, they’ll just fill it with an NP or PA.
                Click to expand...


                In residency, we would always use the "Retinal Specialist" example as the exact polar opposite specialty to Emergency Medicine.  When being an expert on the eye isn't enough.... they specialize on just one part of the eye.  It's such a small area of medicine that you can know everything there is to know about it.  6 years of training to master 1,000mm.  It would take an EM residency of 100 years to master the rest.

                But not to upset any specialists out there...  I love all you guys.  It's just as Dilaudums said.  The jobs are very different.

                 

                 

                 

                 

                Comment


                • #9


                  We are all probably screwed in EM, but then again, so is most of medicine.
                  Click to expand...


                  Bingo.


                  ACGME has accredited 75 new EM residency programs
                  Click to expand...


                  I had no idea!  There are still jobs in my area.  And I seem to get weekly phone calls and daily emails for jobs that somehow get through my spam/junk/block filters.


                  you don’t always get feedback
                  Click to expand...


                  Not disagreeing that it takes awhile to learn stuff, but that part of the comment made me chuckle...I guarantee you that if I miss something, feedback comes out of the woodwork from the Monday morning quarterbacks.

                  Anyway, back to Jaqen: I think EM is more hosed by the explosion of CMGs, hyperbolic growth of the medical bureaucracy, "value" proposition of midlevels, and general lack of ownership mentality from folks coming out of school/residency...but again, that is doctoring in general, right?

                  Comment


                  • #10




                    Any supply stats vs demand? I’d be concerned about NPs and PAs increasing productivity and decreasing physician demand as well.
                    Click to expand...


                    No stats.  But some anecdotes from the residents this year aren't great, and the places I used to peruse for job info look hideous now.  The PA/NP situation looks the same to me now, as it did 13 years ago from a supervisory standpoint.  But I do see tons of NPs keeping their bedside nursing jobs now.  I think they oversupplied themselves too.

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                    • #11
                      medicine in general is heading towards oversupply for tons of fields.

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                      • #12
                        I just got a raise at my CMG

                        Comment


                        • #13




                          Anyone else worried about the future prospects in emergency medicine?   Over the last 4 years, it looks like the ACGME has accredited 75 new EM residency programs!!!  (From counting them up on their website by year)

                          This is a flood of new grads, pouring into the market soon, with more programs on the way.     That’s a ton of supply.  There seem to be signs that a lot of the opportunities are drying up fast.

                          These grads are highly indebted, not financially sophisticated yet, and need jobs, and will provide great cheap labor for the Contract Management Groups and their hedge fund partners (USACS, TeamHealth, Envision, etc…) who are the original side of the double-edged sword that seems to be dropping on EM.

                          Overall this should drive salaries and openings down fast.  And I can already see a big change out there from what was available just a few years ago.
                          Click to expand...


                          Maybe this isn't as bad as it seems. I believe some prior AOA programs are moving to ACGME accreditation. Here's a brief article on the single accreditation system. All of this was new to me until I started looking into your post, but I don't think it is quite the volume you are concerned about.

                          I think demand for EM will continue but like most specialties it will eventually even out (maybe on oversupply). There have been places like Raleigh/Durham and Denver that have been very tough markets for years. When I moved to Dallas 5 years ago it was not too hard to get a job. Now it is starting to fill up a bit.

                          I'm definitely looking to get to a democratic group and away from mega-corp while I still can. My mega-corp treats me well but I don't like the end boss being a stock holder if I can help it.

                          Comment


                          • #14


                             






                            but I don’t think it is quite the volume you are concerned about.

                            I think demand for EM will continue but like most specialties it will eventually even out (maybe on oversupply). There have been places like Raleigh/Durham and Denver that have been very tough markets for years. When I moved to Dallas 5 years ago it was not too hard to get a job. Now it is starting to fill up a bit.

                            I’m definitely looking to get to a democratic group and away from mega-corp while I still can. My mega-corp treats me well but I don’t like the end boss being a stock holder if I can help it.
                            Click to expand...


                            I see what you are saying here.  But I can't easily tell by looking.  I can tell you for sure that 5 new emergency medicine residencies (with 2 more on the way?) have started within about a 40 minute drive from where I am, in the last 3-4 years.

                            Now that seems to have fixed the problem of open jobs around here.

                            Comment


                            • #15
                              I think EM has always been oversold as a good gig, and that the last few years have been unusually kind to the field, with big salary bumps despite the encroachment of CMGs.

                              Yes, I think we are heading towards oversupply, much like anesthesia. Yes, I think it will be harder to find the dwindling number of decent jobs, and yes the new grads with tons of debt (how is this worth it to anybody?) are going to swamp the field and take anything they can get, lowering all our salaries. That having been said, perhaps EM will lose popularity as anesthesia did, the career tends to be very short, and there are an increasing number of exit strategies (addiction, pain, neuro crit, cc, admin, telehealth, palli, UC) that new grads appear interested in jumping to right out of residency, so perhaps there is hope.

                              Any job where you are essentially a widget, even a highly trained widget, is inherently unstable. I would recommend any and all medical students look at fields where they can have their own book of business and work in a non-CMS environment, and that current EM docs find a marketable niche and look for an employed gig.

                              It might be time for me to jump ship from EM in a year or two, so that may be one less doc to compete with

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