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  • #46







    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.
    Click to expand...


    ED visits are actually down: https://www.usnews.com/news/health-care-news/articles/2018-09-04/study-emergency-room-visits-decrease-as-urgent-cares-become-more-popular

    Comment


    • #47







      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.



      Click to expand...



      CordMcNally wrote: "...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..."

      Ok... I will take your word for it.

      Most of the MD and CRNA guys I know in Anesth love the groups they IC with that get them contracts, group rates on malprac and other benefits, etc. It seems to be much better strength in numbers for them.

      Maybe ED is different... in my neck of the woods, ER guys are all just hospital employees, much like my specialty. I guess I wouldn't know.

      ...I had thought Team Health was doc owned back when they sold shares as a public company (TMH). That is what I liked about its model and why I invested. Like I said, my shares went up fairly big from the buyout back in 2014 or whenever and then I just sold, tough (didn't want Blackstone shares I would've gotten since they are huge and in so many investments I don't really understand it all). Maybe it got pretty dark for after that for Team Health biz dealings and the docs after that... Blackstone doesn't buy things to lose money, I guess.

      Comment


      • #48
        I wouldn't say anesthesia is a good profession to reference as they have allowed their entire profession to be overrun by CRNA. right now anesthesiologists usually supervise 4 CRNA. How long until it becomes 8?

        Comment


        • #49
          I feel like maybe you don't have a strong understanding of the current landscape of EM

          Comment


          • #50










            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.
            Click to expand…


            ED visits are actually down: https://www.usnews.com/news/health-care-news/articles/2018-09-04/study-emergency-room-visits-decrease-as-urgent-cares-become-more-popular
            Click to expand...


            That data is mixed.

            https://www.cdc.gov/nchs/data/hus/2017/074.pdf

            One or more visits per year is down from 2010 to 2016 (36.9 to 35.3% of Americans), but two or more visits per year is up (20.2 to 20.6% of Americans.) Basically I think we're seeing higher acuity patients. Same story in my practice- fewer patients but they're sicker. No surprise. I mean, how many times do you have to get an ED bill for an urgent care issue before you learn?
            Helping those who wear the white coat get a fair shake on Wall Street since 2011

            Comment


            • #51


              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.
              Click to expand...




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




              Does it take 3 years of FM training to manage diabetes? No, but that’s not where a good PCP adds value.
              Click to expand...




              If EM is what you love, it will likely provide a good living for a long time.
              Click to expand...




              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.
              Click to expand...


              What we are seeing is a vast difference in:

              - the training levels of graduating residents

              - the interests of graduating residents in: lifestyle and working location

              - the level of medicine/acuity in real ED's vs stand alone EDs and UC's.

               

              IMHO, There will always be a need for ED providers in real ED's, who can really manage true emergencies (the works). But if you look at where these CMG's and free standing ED and UC's are going - they are going to boring suburb locations. The level of acuity that these folks manage is dramatically lower than in a real ED. As such, I think there is a potential for a huge loss of skills and ability to actually be a compentant ED physician in a ER (one with a hospital upstairs).

              Is that something others have concerns about?? Do you see residents who are looking choose between the type of working environment (and thus skill level, etc) actually required?

               

              Comment


              • #52













                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.
                Click to expand…


                ED visits are actually down: https://www.usnews.com/news/health-care-news/articles/2018-09-04/study-emergency-room-visits-decrease-as-urgent-cares-become-more-popular
                Click to expand…


                That data is mixed.

                https://www.cdc.gov/nchs/data/hus/2017/074.pdf

                One or more visits per year is down from 2010 to 2016 (36.9 to 35.3% of Americans), but two or more visits per year is up (20.2 to 20.6% of Americans.) Basically I think we’re seeing higher acuity patients. Same story in my practice- fewer patients but they’re sicker. No surprise. I mean, how many times do you have to get an ED bill for an urgent care issue before you learn?
                Click to expand...


                Sorry, I thought you were referring to the number of actual ER visits, not visits per patient. It seems like total number of visits is the most important number for EM as a field, although I agree acuity is going up, which is also important for EM as a field.

                I don't think the billing issue matters as much for Medicaid/CHIP and Medicare patients, who comprise 29%  and 17% of Americans, or the uninsured, and as these numbers increase with Medicaid expansion and the aging population, maybe numbers will pop back up.

                 

                Comment


                • #53




                  Click to expand…







                  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. 
                  Click to expand…


                  What we are seeing is a vast difference in:

                  – the training levels of graduating residents

                  – the interests of graduating residents in: lifestyle and working location

                  – the level of medicine/acuity in real ED’s vs stand alone EDs and UC’s.

                   

                  IMHO, There will always be a need for ED providers in real ED’s, who can really manage true emergencies (the works). But if you look at where these CMG’s and free standing ED and UC’s are going – they are going to boring suburb locations. The level of acuity that these folks manage is dramatically lower than in a real ED. As such, I think there is a potential for a huge loss of skills and ability to actually be a compentant ED physician in a ER (one with a hospital upstairs).

                  Is that something others have concerns about?? Do you see residents who are looking choose between the type of working environment (and thus skill level, etc) actually required?

                   
                  Click to expand...


                  Interesting thoughts. If anything I think newer grads tend to over-prioritize sexy things like high acuity and trauma. I think many people want a nice job but recognize that too nice of an area can actually be kind of boring.

                  Once you hit a critical mass (I would say 4-5 years out of residency in a decently sick shop) I think skill atrophy is a greatly overestimated area of concern. Yeah after 2-3 years without a bunch of difficult airways you might not be a the peak of your skill but I don't think the world of EM is full of docs working in nice shops who feel like they just can't take care of the sick people any more. The other thing you have to remember is that in general as your shop gets nicer and nicer your backup tends to be more present and collegial.

                  EM is funny in that you are such a care coordinator that as long as your are in the lanes of your shop I think you're ok. You might be in a place where the culture is that the specialists don't come in, as long as they aren't Monday morning quarterbacking you in QI committee that's fine. Or you might be in a place where the expectation is that plastics comes in for complex lacs, anesthesia comes down for tricky airways etc. In the latter as long as you are playing nice in the sandbox and getting along with everyone life is good. Some problems can arise if you are the one guy swimming against the current in either direction. The last time I was faced with a predicted difficult airway I just called anesthesia. They came down, took one look at what was going on, said "************************ dude, thanks for calling us early," helped me take care of it, and then left with handshakes and backslaps all around. I later found out the anesthesia attending was tickled pink to have the chance to help out with a complex case.

                  We have this ideal in EM that we need to be about to operate alone which is important but also exists kind of outside of the reality that we are increasingly never alone.

                  Comment


                  • #54
                    @IntensiveCareBear,
                    “I’m no general fan of unions, but for high skill, high training, and highly specialized careers… they certainly have their role.”

                    ???? Why would you not prefer a group or actually “hire someone “ to negotiate rates as you wish? Or do you want to be paid by the hour and seniority? Collective bargaining doesn’t require a union. Would you think a strike would be appropriate? I would think you would run a cost benefit on your union dues as well. Be careful what you wish for.

                    Comment


                    • #55
                      Well, that didn’t take long….. (sorry to rehash an old thread) It’s now front page news in the EM press that there is going to be a massive surplus 10,000 or so ED physicians > ED positions within 9 years. The national organizations can’t really hide from this now? This year has been a rough one for graduating residents struggling to find jobs, some having to take fellowships and locums because they can’t find places to work. Can’t say you couldn’t see this coming.

                      https://journals.lww.com/em-news/Ful...EPs,_EM.1.aspx
                      Last edited by Jaqen Haghar MD; 06-17-2021, 06:35 AM.

                      Comment


                      • #56
                        In addition to the CMG 3D printers churning out new EM grads, I am also interested in seeing how the "physician associates" exacerbate the situation.

                        Whatever, they can have my 0.4 FTE spot sooner than later.

                        Comment


                        • #57
                          Originally posted by Jaqen Haghar MD View Post
                          The national organizations can’t really hide from this now?
                          They're still doing a pretty good job of it.

                          Comment


                          • #58
                            Originally posted by Jaqen Haghar MD View Post
                            Well, that didn’t take long….. (sorry to rehash an old thread) It’s now front page news in the EM press that there is going to be a massive surplus 10,000 or so ED physicians > ED positions within 9 years. The national organizations can’t really hide from this now? This year has been a rough one for graduating residents struggling to find jobs, some having to take fellowships and locums because they can find places to work. Can’t say you couldn’t see this coming.

                            https://journals.lww.com/em-news/Ful...EPs,_EM.1.aspx
                            That’s nuts. This is what happens when national organizations don’t examine workforce needs on an ongoing basis and when the ACGME doesn’t assess these issues before approving of more residency slots.

                            Comment


                            • #59
                              Originally posted by Jaqen Haghar MD View Post
                              Well, that didn’t take long….. (sorry to rehash an old thread) It’s now front page news in the EM press that there is going to be a massive surplus 10,000 or so ED physicians > ED positions within 9 years. The national organizations can’t really hide from this now? This year has been a rough one for graduating residents struggling to find jobs, some having to take fellowships and locums because they can find places to work. Can’t say you couldn’t see this coming.

                              https://journals.lww.com/em-news/Ful...EPs,_EM.1.aspx
                              Regarding the ACGME numbers you initially cited, are you sure some of these weren't DO programs not recognized by the ACGME but were recognized in the last 3-4 years? I recall seeing where DO programs were going to be brought under ACGME oversight in the last few years. Not sure if that artificially boosted numbers of late when in fact they already existed but weren't counted in the ACGME accredited programs.

                              Comment


                              • #60
                                Originally posted by ENT Doc View Post

                                Regarding the ACGME numbers you initially cited, are you sure some of these weren't DO programs not recognized by the ACGME but were recognized in the last 3-4 years? I recall seeing where DO programs were going to be brought under ACGME oversight in the last few years. Not sure if that artificially boosted numbers of late when in fact they already existed but weren't counted in the ACGME accredited programs.
                                I’m not sure how many, since it was a couple years ago, but some were. Some of these were new osteopathic programs too. It looks like 30-something of the current existing 247 programs were once osteopathic. It’s crazy though, how many new programs were started from scratch just locally. They are opening another one this year…. 5 miles away! That makes #7 within 30 minutes of here…. All new the past few years. It’s insanity.

                                Comment

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