Announcement

Collapse
No announcement yet.

Future of Emergency Medicine

Collapse
X
 
  • Filter
  • Time
  • Show
Clear All
new posts

  • #16
    Looking at the newly approved ACGME programs it seems the vast majority are DO programs. Most of the growth in medical school graduateshave come from DO programs, so more openings in DO training programs would seem to make sense. However, I’d be interested in looking at overall total program numbers (MD + DO) and total number of grads over the last 10 years. With a combined accreditation move things may look worse than it is. But maybe not. I would use object data to support any concern.

    Looking at EM from a competition perspective it makes all the sense in the world that the future won’t be as bright. Where there’s profit and quality of life comes interest. The threat of substitutes and new entrants is high - tech, DOs, NPs, PAs. Lots of jockeying in the landscape for contracts, forcing supply at lower costs. All these things, assuming also supply is outstripping demand, suggest lower future profitability.

    Comment


    • #17
      There's a new for profit do med school popping up every week. Then they start a residency program in bfe which I'm sure is great training. /s

      Have to not allow so many new programs and schools. Leaders of all these fields and medicine are asleep at wheel. Going to end up just like law.

      Keep pumping them out

      Comment


      • #18
        Exactly the same worries in Hospital Medicine and General IM.  Make hay while the sun is shining is all I can do.  The money is really good right now (especially since I'm working as a locum in a rural location).  I don't expect it to last much longer so my goal is to save as much as possible for as long as I can.  The whole FIRE movement/idea has given me a light at the end of the tunnel.

        What worries me more than my own personal financial/employment situation, is what's going to happen to the quality of care by time I'm an old man.  I already see very sub-par medicine being practiced all over the place these days.  Once NPs/PAs and docs from sub-par schools dominating the entire IM/EM/FP landscape, I don't know where I'm going to feel comfortable going for medical care.

        Comment


        • #19
          I guess I have a slightly different perspective on this.

          The near future of EM (20 years?) is going to be more of the same. More CMG, fewer SDG, more supply all competing for the good jobs.

          I know this is a slightly unpopular opinion but as much as in any field I think EM is tiered and I find that the tiers know very little about each other. On the one hand you have the person who struggled through their med school, matched at a newish 3 year program off the beaten path, and then starts bouncing around CMGs. On the other you have elite training programs (often 4 years) that shuttle grads into high paying jobs in nice areas and put them on fast track for medical director jobs. What seems to be growing the fastest is the former.

          Who knows what the payment landscape is going to do. I find it absolutely hysterical that people talk about single payer is if it is something that is on the horizon. A democratic admin abandoned a public option in favor of subsidizing private insurance, now even that law has been gutted and dismantled. I'm curious where people think single payer is going to come from?

          Comment


          • #20
            Most MD’s at one point viewed AOA and Chief Resident as career items that might impact their career progression. Because the accreditation, credentialing and certification process is delegated to the professional organizations, DO/NP/PA have been much more active advocating for their interests. From afar, it seems very few MD’s devote any time to professional organizations or issues. Even meetings are more CME and connections. Not much effort regarding regulations or advocating. If someone doesn’t standup and say “No and here is why and a better alternative”, what is the result?

            Comment


            • #21
              Not in EM, just an outsider looking in.  But it does seem like EM it's in it's golden age.  It seems to have exploded in recent years compared to my med school days, with the attraction seemingly being shift work, "excitement" and high pay.  I imagine financially the ER can be lucrative for the hospital with the patient work ups, consultations, etc. assuming good insurance, getting free resident labor only improves the financial situation, they probably don't care about future job prospects or saturation.  Having said that I can easily see this golden age ending.  ER costs are a sore spot in healthcare and well represented in media, there could easily be more cuts/restrictions in the ER causing belt tightening, salary cuts, job losses and replacements by midlevels, which I can imagine being far easier due to ER setup, proximity to resources and other doctors, etc.  Not that this isn't happening or can't happen to any other specialty, but I feel that EM may be most vulnerable right now.

              Comment


              • #22
                @MPMD though I agree it would be shocking if single payer was adopted in 2020, I didn't foresee a Trump presidency in 2015 and am still in shock. I bet you 95% of people on here predicted higher taxes coming in 2016 or least not a tax cut for most! Our government is very unpredictable and already controls a lot of healthcare so it probably is the biggest threat to doctor paychecks.

                I think the ACA was a temporary boom for EM with a decrease in non payers (though converted to partial payers due to large deductibles), especially since IM/FM were ill prepared for an influx of new patients so many came with their shiny new insurance cards to the ER. But now the dismantling without replacement will lead to limited high deductible plans or people just dropping insurance all together.

                As for CMGs, I don't see how they can be stopped at this point (other than government regulation). As for those in SDGs, I don't think they are ever safe from CMG takeovers. I'm with a CMG and was starting to regret not working with a not too far away SDG but then I learned they were bought out prior to when I would have made partner.

                Another factor that I didn't foresee before this year is hospital failure/consolidation. A hospital closed nearby so now more EM docs around so higher competition while dumping tons of patients on us without much RVU incentive via my CMG. In other words, more miserable job with less alternatives/pay around town. Many hospitals are folding up shop and mega hospital groups (like HCA) continue to expand.

                All this to say I cannot predict the doctor market just like I can't predict the stock market. So I am preparing for the worst by saving tons, while hoping for the best.

                Comment


                • #23
                  The only fields that are relatively insulated from midlevel invasion and oversupply are the surgical sub-specialties, and if you look at how the optometrists are attempting to encroach on the ophthalmologists' turf in some states, that is a concerning sign for the future.  If we're honest with ourselves, we also realize that it probably doesn't take 4 yrs medical school, 5 years of orthopedic surgery residency, and 1 year fellowship to produce a hip surgeon.  I actually legitimately wonder if you take a halfway decent midlevel with good dexterity, put them in and OR for 2 yrs where all they are doing is hip arthroplasty, will you produce a halfway competent surgeon?  I dunno.

                  Bottom line is, we (physicians) are an expensive resource.  Americans want highly specialized services for free and they want it now.  They have no problem spending $1,000 on an iPhone X and then expressing righteous indignation at an ED bill because "nothing was done for me."  "Quality" in healthcare is a very difficult thing to study so instead of putting some effort into actually defining it, we are left with government shortcuts like MIPS that penalize me for ordering a head CT in blunt head trauma unless it meets extremely specific criteria, but offers me absolutely no medmal protection if I follow those criteria, but miss a diagnosis.

                  Pay off debt, save a lot, live reasonably, hopefully escape before it crashes down.

                  Comment


                  • #24


                    I’m curious where people think single payer is going to come from?
                    Click to expand...


                    First, the ACA is far from gutted and dismantled.  The only thing that's happened is that the individual mandate has been repealed.  Otherwise, everything else is still in place - alternative payment systems, Medicaid expansion, pre-existing condition protection, mandatory insurance for 50 employees, etc.

                    Second, Obama got what he could given the votes he could get - the public option wasn't supported by several Democrats at the time, and given all the concessions that were needed to bring everyone on board he knew this was a non-starter.  Insurers and everyone else in the medical establishment applying pressure helped stop this as well.  The ACA was a bit of a shock to many and wasn't recommended as a thing to tackle by the CEA or even his VP.  But it shouldn't have come as a shock; he ran on doing exactly what was instituted in the ACA - incremental expansion of government towards more of a single payer.

                    So where will it come from?  It will come from the people who are proposing it and others too unwilling to recognize that single payer does not mean better health.  All Democrat 2020 candidates are currently in support of single payer in one form or another.  So pardon me if I take people at their word.  I think it's sad - not hilarious - that people would expect something different from an administration proposing single payer and with the support of a party where apparently no moderates apparently exist to throw their hat in the ring.  When Obama proposed the ACA you might have been able to count on one hand how many Democrats wanted single payer.  Not the case anymore.  Whether in one sweeping bill or as another incremental change single payer is a looming threat.  And yes, it is a threat.

                    Comment


                    • #25




                      Pay off debt, save a lot, live reasonably, hopefully escape before it crashes down.
                      Click to expand...


                      .....
                      Erstwhile Dance Theatre of Dayton performer cum bellhop. Carried (many) bags for a lovely and gracious 59 yo Cyd Charisse. (RIP) Hosted epic company parties after Friday night rehearsals.

                      Comment


                      • #26
                        “ I actually legitimately wonder if you take a halfway decent midlevel with good dexterity, put them in and OR for 2 yrs where all they are doing is hip arthroplasty, will you produce a halfway competent surgeon? “

                        What does the midlevel do when no hips on the schedule and oncall for the holiday weekend?

                        “I do hips, I don’t do windows or trauma or knees or backs!”

                        Comment


                        • #27




                          The only fields that are relatively insulated from midlevel invasion and oversupply are the surgical sub-specialties, and if you look at how the optometrists are attempting to encroach on the ophthalmologists’ turf in some states, that is a concerning sign for the future.  If we’re honest with ourselves, we also realize that it probably doesn’t take 4 yrs medical school, 5 years of orthopedic surgery residency, and 1 year fellowship to produce a hip surgeon.  I actually legitimately wonder if you take a halfway decent midlevel with good dexterity, put them in and OR for 2 yrs where all they are doing is hip arthroplasty, will you produce a halfway competent surgeon?  I dunno.

                          Bottom line is, we (physicians) are an expensive resource.  Americans want highly specialized services for free and they want it now.  They have no problem spending $1,000 on an iPhone X and then expressing righteous indignation at an ED bill because “nothing was done for me.”  “Quality” in healthcare is a very difficult thing to study so instead of putting some effort into actually defining it, we are left with government shortcuts like MIPS that penalize me for ordering a head CT in blunt head trauma unless it meets extremely specific criteria, but offers me absolutely no medmal protection if I follow those criteria, but miss a diagnosis.

                          Pay off debt, save a lot, live reasonably, hopefully escape before it crashes down.
                          Click to expand...


                          This kind of technician like thinking is wrong and dangerous for medicine as a whole. Sure you could train someone to do a hip replacement in 2 years, that's not what an orthopedic surgeon is. They're a brain that makes decisions about who gets the hip replacement, who needs scoped, the post-operative therapy regimen, complications from the surgery and etc. Performing the surgery is one mere facet of what they do, even for that single patient.

                          This kind of marginalizing of physicians and what they contribute is extremely foolish. There are a ton of PGY2 surgery residents who could crank out lap appys and be fine 95% of the time(and probably be better than a non-zero portion of attendings). But that's not what physicians are. We are not technicians cranking out a procedure. IR figured this out where they aren't just monkeys doing what they're told. Ie you can't just order a nephrostomy and expect the IR person to do it without question. The IR team has to evaluate the patient, figure out if its indicated, etc. That step is extremely important.

                          A technician just sees " patients needs x, I do x" A physician goes, " the person has this complaint, let's think about that and what we're going to do about it" HUGE difference.

                           

                          Does it take 3 years of FM training to manage diabetes? No, but that's not where a good PCP adds value. If you reduce everything down to it's most simple task then everybody looks overqualified. Until stuff hits the fan and the midlevel has no idea what they're doing(if they even did to start with) and retreats to the defense of their attending who cleans up the mess.

                          Comment


                          • #28
                            This was copied from the SDN forums...
                            I highlighted the important parts

                            American Academy of Emergency Medicine

                            Updated Position Statement on Advanced Practice Providers
                            The American Academy of Emergency Medicine (AAEM) believes that emergency department patients should have timely and unencumbered access to the most appropriate care led by a board certified emergency physician (ABEM, AOBEM). We do not support the independent practice of Advanced Practice Providers (APPs)* and other non-physician clinicians.

                            Properly trained APPs may provide emergency medical care as members of an emergency department team and must be supervised by a physician who is board certified in emergency medicine.

                            As a member of the emergency department team an APP should not replace an emergency physician, but rather should engage in patient care in a supervised role in order to improve patient care efficiency without compromising safety.

                            The role of the APPs within the department must be defined by their clinical supervising physicians, who must know the training of each APP and be involved in the hiring and continued employment evaluations of each APP as part of the emergency department team, with the intent to insure that APPs are not put into patient care situations beyond their clinical training and experience.

                            Collaborating physicians must be permitted adequate time to be directly involved in supervision of care. They must not be required to supervise more APPs than is appropriate to provide safe patient care. Furthermore, supervision must not be in name only. Physicians are expected, and must be permitted, to be involved in meaningful and ongoing assessment of the APPs’ work.

                            Billing should reflect the involvement of the physician in the emergency visit. If the physician's name is used for billing purposes, the physician's involvement must add value to the patient visit.

                            A physician should not be required to cosign the chart, nor should his/her name be invoked with regard to any patient unless he/she has been actively involved in that patient’s care.

                            APPs should not supervise emergency medicine residents, nor should they interfere in the education or clinical opportunities for emergency medicine residents.

                            Every practitioner in an ED has a duty to clearly inform the patient of his/her training and qualifications to provide emergency care. In the interest of transparency, APPs and other non-physician clinicians should not be called ‘doctor’ in the clinical setting.

                            *This designation includes, but is not limited to the following practitioners:

                            Acute Care Nurse Practitioner (ACNP)
                            Adult Nurse Practitioner (ANP)
                            Advanced Nurse Practitioner (APN)
                            Advanced Practice Registered Nurse (APRN)
                            Advanced Registered Nurse Practitioner (ARNP)
                            Certified Nurse Practitioner (CNP)
                            Clinical Nurse Specialist (CNS)
                            Certified Registered Nurse Practitioner (CRNP)
                            Doctor of Nursing Practice (DNP)
                            Doctor of Nursing Science (DNS, DNSc)
                            Doctor of Science (DSC)
                            Doctor of Science in Nursing (DSN)
                            Doctor of Pharmacy (PharmD)
                            Emergency Nurse Practitioner (ENP)
                            Family Nurse Practitioner (FNP)
                            Nurse Practitioner (NP)
                            Nurse Practitioner Certified (NPC)
                            Pediatric Clinical Nurse Specialist OR Psychiatric Clinical Nurse Specialist (PCNS)
                            Pediatric Nurse Practitioner (PNP)
                            Pediatric Nurse Practitioner - Acute Care (PNP-AC)
                            Women’s Health Nurse Practitioner (WHNP)
                            Advanced Physician Assistant (APA)
                            Advanced Physician Assistant Certified (APA-C)
                            Doctor of Medical Science (DMSc)
                            Physician Assistant (PA)
                            Physician Assistant Certified (PA-C)
                            Registered Physician Assistant (RPA)
                            Registered Physician Assistant Certified (RPA-C)
                            Approved 1/29/2019

                            Amazing slogan too. 'Champion of the Emergency Physician"

                            I had some experience with the PACs and administration and wondered why they cant have similar position statements. They could literally copy and paste this and just list CRNAs in the above list.

                            There are multiple parallels that exist between the mid level incursion in anaesthesia and ED.

                            In less than 2 pages, they have accomplished what our advocacy groups have supposedly championed for years though not bothered to put on paper a formal and clear position statement, distribute to their members and the public at large

                            Comment


                            • #29




                              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...


                              Ehhhhh....I wouldn't worry too much about it. I think many of those new programs were previously DO programs- i.e. not really new. Also, people are going to the ED more each year. Finally, there are still many non emergency physicians working in emergency departments.

                              If EM is what you love, it will likely provide a good living for a long time. Will we look back on now as the golden age of EM salaries? Perhaps. Wouldn't surprise me. But it's always going to provide a good living especially if people keep doing it part-time and retiring early from it due to burnout.
                              Helping those who wear the white coat get a fair shake on Wall Street since 2011

                              Comment


                              • #30




                                “ I actually legitimately wonder if you take a halfway decent midlevel with good dexterity, put them in and OR for 2 yrs where all they are doing is hip arthroplasty, will you produce a halfway competent surgeon? “

                                What does the midlevel do when no hips on the schedule and oncall for the holiday weekend?

                                “I do hips, I don’t do windows or trauma or knees or backs!”
                                Click to expand...


                                Same thing that happens now in the non-surgical realm.  The midlevel doesn't take call, the doctor does.  The doctor takes the difficult/time-consuming/guaranteed poor outcome cases for many more years of training and slightly more pay than the midlevel, while the midlevel "helps out" the doc by taking all the easy/guaranteed good outcome cases off their hands.  And then publishes studies about how they have better outcomes.

                                Comment

                                Working...
                                X