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  • #31
    WCI-has hit a bunch of major points before I got to them. Other things include that many new grads are not working in a 1.0FTE position. Many are taking .6-.8FTE around me. I thought it was weird initially, but now I sort of get it. Some of this is family driven, for others it is lifestyle driven.

    Also, the number of visits keep increasing and the lack of access to primary care will continue to drive this for the foreseeable future.

    Telemedicine has done very little to decrease the lower acuity visits. I initially thought it would, and still can, but so far not so good.

    I could also see and do expect salaries to plateau and likely decrease. So far, this also isn’t the case from a pure numbers standpoint. I do fee that we are likely working harder/doing more work for a slightly increased salary, which likely has netted a salary drop from that standpoint.

    I’m not crazy optimistic, however I think the doom and gloomers need to slow their roll a touch. I just don’t see the EM apocalypse yet.

    Comment


    • #32







      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.
      Click to expand...


      I agree with you 100% Panscan, that's the way it SHOULD be.  But unfortunately I have seen many surgeons and physician proceduralists in the community use mid-levels for those important front end and back end tasks, even with complicated patients.  That is not as prevalent in the academic setting (where there are residents to fill that role) but it's not uncommon in the community.  Sadly, doctors are largely at fault for the way we have allowed mid levels to be overly involved in higher level decision making that really would be best done by us.  This is financially driven--it is more lucrative to just do a procedure than to explain to a patient why they don't need it and come up with alternatives.  And many patients love to think that something needs to be done to them and confuse having a procedure/operation with needing a procedure/operation, so they go along with it.

      Comment


      • #33




        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
        Click to expand...


        Just for the record, AAEM talks a good game, but it is a useless organization.  I speak from the position of someone who has spent a lot of time and money defending small, independent practice against a very anti-doctor legislature.  AAEM literally will not return phone calls or messages from (apparently) like-minded shareholders and their folks certainly do not show up in advocacy efforts, testimony, nor public commentary.  During one particularly onerous legislative session, one of the state EM doctors was on the national board of AAEM.  Seriously, at the time, this was literally the biggest threat to SDGs in a generation and an AAEM leader can't even be bothered to return a phone call from a colleague?  "Champion of the Emergency Physician?"  What a pile of horse manure.  The hypocrisy defies words.

        Anyway, interesting thread.

        Comment


        • #34




          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?
          Click to expand...


          AOC will save us all with the green new deal!!!

          Comment


          • #35







            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?
            Click to expand…


            AOC will save us all with the green new deal!!!
            Click to expand...


            LOL! The only "green new deal" is what you are smoking!

            Emergency medicine was barely a specialty when I was in med school and training. It has certainly exploded over the last 20-25 years (and generally for good reason). I have often said that it is the quickest path to the mid-tier of physician incomes, so it makes sense that it would be so popular and draw so much interest.

            The future of all medicine is certainly cloudy, and many specialties are facing their days of reckoning, for various reasons. The two specialties that seem to be the most free of imminent danger remain Derm and Ortho (and perhaps a few other surgical subspecialties), and that is why consistently recommend Derm and Ortho as the best fields for new grads.

            Comment


            • #36


              The two specialties that seem to be the most free of imminent danger remain Derm and Ortho (and perhaps a few other surgical subspecialties), and that is why consistently recommend Derm and Ortho as the best fields for new grads.
              Click to expand...


               

              There are a lot of emerging technologies in Ortho that will make it easier to do Total joints with robotic assistance, but I would agree that this is highly unlikely to cause encroachment with midlevels.  Our biggest problem in my community is podiatrists trying to expand their scope of practice trying to be able to do more and more ankle/pilon fractures.  Our admin is basically appeasing them even though the data suggests that podiatrists have worse outcomes than orthopaedic surgeons. /shrug

              Comment


              • #37
                Is Team Health still around? I used to invest in them back before Blackstone bought them out... made some decent coin but had no idea what happened to them after that. It seemed like a good model for sure.

                ...I think ER docs will be just fine. As long as you do or order or read things that make money, demand will stay high. EM does a lotta tough procedures and are basically in the same boat as ortho and ICU docs as I see it. Yeah, the young docs may have to accept lower pay and there may be more residents graduating despite negative population growth, but there will always be demand for working the hellish hours, doing ballsy procedures, and dealing with critically injured people in ERs. The ER is just not a life for most docs... from both a confidence and lifestyle standpoint. The midlevels (and most non-EM docs) I saw doing Urgent Care and FastTrack ER back when I did it as a resident were basically in over their heads on any non-basic stuff... essentially just glorified glad-handing and triage. You obviously can't replace MD/DO in the real ERs, trauma ORs, or the ICUs. People would die... a lot. Midlevels would be sued to high heck in no time.

                It is mainly FP, psych, and IM branches that don't do many procedures or order expensive tests which I'd be most worried about. This would be ID, allerg, endo, pain, PM&R, etc. Regardless of insurance changes or economics, midlevels will continue to drive the demand and pay for primary care and Urgent care services down (despite med school tuition rising), and eventually, people will just be interacting with health kiosks that will ask the right questions and triage them to specialists. Hospitals will be fine paying the MD/DOs for now since they generate a ton of lab, test, etc orders... but midlevels or future kiosks can do almost the same for much less.

                The docs who order/read/perform the $$$ test/procedures like neuro, cardio, onc, GI, nephro, rad, path, etc will always have their place as long as insurance allows and pays for the advanced imaging, dialysis, chemo, etc etc testing they order or perform or read. Future fee schedules might dictate their pay ceilings, but they will always be a thing.

                The interesting ones are the highly procedure based ones that are paid by insurance: Ent, gen surg, opth, urology, podiatry, rheum, vascular, etc etc. Again, as long as insurance pays, they will do fine. Their "golden days" of highest pay have certainly passed long ago, but they still do well. If insurances lower or quits paying some of their common CPTs, then they will have to sell those services as cash and see if people will pay, just like...

                The boutique specialties like derm and plastics are always in a boom/bust spot due to economics, and that might backfire quite a bit if socialized medicine continues. Nothing changes overnight, though. The good marketers and salesmen do great in these realms, and most others do ok... or retreat to rural areas and do well due to lack of competition. Dentists are sorta in a similar position also: people aren't getting cavities much anymore but they keep surviving and thriving by coming up with new services (cosmetic, snoring devices, etc) to keep re-inventing themselves. These specialties can at least control their own price tagging for their services, a major crippling factor for most other docs who are largely at mercy of what insurances decide to allow for each CPT.

                ER will continue to thrive, though. Nothing changes overnight. Day shift might eventually pay a little less if there are that many new grads, but I think it's something that will continue to be stable and necessary. Hospitals will always need ERs as their loss-leader or break-even to get most of the $$$ makers (surgery, ICU stays, advanced imaging, etc), though. It is good to have those entities like TeamHealth looking out for group benefits, etc. If they are well run, that is a major help. Anesthesia is the only other specialty that comes to mind that really kinda "unionizes" like that for contracting with the facilities. More and more specialties should do it, especially the procedure-based ones. I wish critical care did it more, lol.

                Comment


                • #38


                  It is good to have those entities like TeamHealth looking out for group benefits, etc. If they are well run, that is a major help.
                  Click to expand...


                  What?! I don't think there's a single thing about CMGs that make it good to have them around. Their overhead (i.e. non-clinical employee compensation) is ridiculous. All their money comes from one thing: clinical work. They take hard earned physician money and give it to their administrators, recruiters, etc. They don't care about the patient, they only care about the money. From a physician stand point, none of the CMGs are well run. I was kind of going along and nodding reading your post but then I got to the above statement.

                  Comment


                  • #39
                    @Vagabond MD,
                    From postings here there was a ton of discussion regarding VC’s buying derm practices. Would that mean ortho is the most secure? Geez, that’s a really tough road to go. Regarding ortho, robotics is an assist device, enhancement. Employment models are changing, but not replaced.

                    Comment


                    • #40







                      It is good to have those entities like TeamHealth looking out for group benefits, etc. If they are well run, that is a major help.
                      Click to expand…


                      What?! I don’t think there’s a single thing about CMGs that make it good to have them around...
                      Click to expand...


                      The CMGs are definitely not ideal, but think how much our skills of starting a central line or chest tube or even doing a heart transplant or fistula or etc etc are worth. They're not worth ************************ in any other profession.

                      That high specialization severely limits our job options severely. It is the same principle you'd apply to American Airlines pilots, advanced nuclear engineers, Army tank operator, NFL player, chemical engineer in bio-pharma, search engine design programmer, police forensics lab supervisor, etc. They have basically one very narrow skill, and while lucrative and useful... it is not at all transferrable. Some of those only have a couple dozen places or companies in the world that can use their skill... and while most docs, aren't that niche oriented, it is getting more and more specialized. Therefore, those others all tend to have unions with standardized protections, benefits, pay scales, etc. I'm no general fan of unions, but for high skill, high training, and highly specialized careers... they certainly have their role.

                      If your top CPTs drop or are drastically lowered, you don't want to be on your own. Sure, if you are in an ortho group of 7 in a medium city, you probably don't need the protection since you are the only show in town. Still, the facility could always cut your pay for call... and if you debate it, they might bring in their own ortho hires. Good luck with that one. Again, while I don't love CMG or affiliate with one, I feel it is becoming a necessary evil. Docs' downfall has been and continues to be a lack of ability for docs to price tag our service in the way nearly any other white collar professional can (accountant, attorney, MBA, architect, engineer, symphony musicians, etc). The insurances set the prices. We can't. We can't just raise fees like airline ticket prices or attorney per-hour rates. We just get told what CPTs or RVUs are worth. It sucks. That is why a negotiating power working on our behalf is pretty essential for protection. JMO

                      Comment


                      • #41
                        VC is buying out ophtho as well.  I can't imaging they're not also buying ortho practices.

                        With re: to the future of healthcare as a whole:  It's a zero sum game with a limited amount of money for healthcare. Physician groups have got to push to lower healthcare costs by convincing politicians and the public to cut the costs of pharmaceuticals, administrative costs etc. or the gov't will just continue cutting reimbursements to physicians. Single payer does not have to be horrible for physicians -- Canadian physicians get paid very well (Canadian ophtho makes way more than in the US). I'm assuming their healthcare costs less through savings from other sources, like lower drug costs.

                        Pushing for laws eliminating physician non-competes (like the laws in Massachusetts and California) will also, at the very least, give employed physicians more negotiating power against VC groups and hospitals and increase physician autonomy and independence.

                         

                        Comment


                        • #42




                          The CMGs are definitely not ideal, but think how much our skills of starting a central line or chest tube or even doing a heart transplant or fistula or etc etc are worth. They’re not worth ************************ in any other profession.
                          Click to expand...


                          Because other professions are a completely different...profession? Of course if I tried to get a job in a completely different profession then my skills wouldn't transfer. I think that's true for any professional profession. That statement doesn't make any sense.




                          If your top CPTs drop or are drastically lowered, you don’t want to be on your own.
                          Click to expand...


                          Yes, I do. If you work for a CMG, the administrators aren't going to take a pay cut so the physician is going to take an even bigger pay cut. Besides, with a CMG, I have absolutely no say in how the business is ran. Zero.

                           




                          Again, while I don’t love CMG or affiliate with one, I feel it is becoming a necessary evil.
                          Click to expand...


                          You still haven't pointed out how they're necessary. Is giving physicians 50% of what the CMG bills and collects off of them necessary? No. Evil? Yes. CMGs add nothing to our profession. Sure, they're better at schmoozing administrators and making promises to get contracts but that's about it.

                          Comment


                          • #43



                            CordMcNally wrote:
                            Click to expand…




                            ...




                            Again, while I don’t love CMG or affiliate with one, I feel it is becoming a necessary evil.
                            Click to expand…


                            You still haven’t pointed out how they’re necessary. Is giving physicians 50% of what the CMG bills and collects off of them necessary? No. Evil? Yes. CMGs add nothing to our profession. Sure, they’re better at schmoozing administrators and making promises to get contracts but that’s about it.
                            Click to expand...


                            In addition to the contracting, group benefits discounts, coordinated HR, legal services savings, etc that they can do, CMG or similar "union" type entity would actually have the ability to coordinate labor strikes or make exclusive contracts and pay scales. The days when the doctors ran hospitals are long gone, and we are now skilled professionals in need of representation and protection just like the pilots or military officers or specialized engineers I mentioned. This ability to strike or make demands is absolutely necessary in those other professional industries, whether actually using the abilities or just the implied threat of it. Doctors have gone on strike in Europe many times in the past due to unfair hours or pay, etc... with varying success. As it stands, it would be very hard to coordinate and execute such an effort in USA with most hospitals having MDs just scattered among private practices and maybe a few hospital employees (depending on specialty).

                            I realize you had bad experience with CMG or facility employment or similar entity, but that does not mean that all operate the same or that the idea is lunacy. We are unfortunately in a career field where everyone wants the million dollar workup, but nobody wants to pay for it (or can pay). We have almost no control of setting price rates for our services. It will probably get worse before it gets better... if it does get better. Strength in numbers usually beats underbidding one another in a dog-eat-dog mentality. We shall see, I guess. Nothing changes overnight. I'm on the same team as you

                            Comment


                            • #44


                              In addition to the contracting, group benefits discounts, coordinated HR, legal services savings, etc that they can do, CMG or similar “union” type entity would actually have the ability to coordinate labor strikes or make exclusive contracts and pay scales.
                              Click to expand...


                              Most CMGs hire independent contractors so the IC is largely responsible for their own benefits. What kind of legal service savings? That's why you purchase malpractice insurance and most all EM jobs have malpractice provided so that's a none starter. The part you don't understand is that CMGs and physicians aren't on the same team. They don't want the same things. A labor strike is the last thing a CMG would want.


                              I realize you had bad experience with CMG or facility employment or similar entity, but that does not mean that all operate the same or that the idea is lunacy.
                              Click to expand...


                              My first and only job out of residency has been with an SDG. I did moonlight with some CMGs in residency but I deleted every email that wasn't a pay stub and showed up to my shifts, worked them, then went home with a little jingle in my pocket that I could put in my solo 401k.

                              Comment


                              • #45




                                Is Team Health still around? I used to invest in them back before Blackstone bought them out… made some decent coin but had no idea what happened to them after that. It seemed like a good model for sure.

                                It is good to have those entities like TeamHealth looking out for group benefits, etc. If they are well run, that is a major help.
                                Click to expand...


                                Huh???   This sounds like the sales pitch they give to the residents who don't have a clue.

                                When a CMG moves in you find out quick that You are the cost savings they are talking about. They cut physician pay, increase work load, maybe cost-save or cut some benefits.  But you don't see a dime of it.  And the dimes you used to see are fewer and further between.  The profits from the ED get shipped up to the hedge fund and corporate suits.  And there are plenty of profits.

                                It's not a major help to the physicians, that's for sure.  But it is a major help to the corporate owners.

                                Comment

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