Class of 2021 job market insights

[texER]

With the financial upheaval in EM and drop in volumes, everywhere has been very matter of fact about hiring freezes, etc. What strategies or insights should our class (largest in EM history to date) take in a market like this?

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[Rekt]

With the financial upheaval in EM and drop in volumes, everywhere has been very matter of fact about hiring freezes, etc. What strategies or insights should our class (largest in EM history to date) take in a market like this?

Hope that volumes recover quickly enough within the next few months so places know what to expect. If you haven't been, then start fighting against new residency programs opening. Not much else you can do. Oversupply is quickly coming, maybe even early as your year.

https://www.jem-journal.com/article/S0736-4679(20)30006-8/abstract

AHEAD OF PRINT: AFTER THE MATCH : Emergency Medicine News

An abstract is unavailable.

journals.lww.com

AAEM Position Statement on the Emergency Medicine Workforce | AAEM - American Academy of Emergency Medicine

AAEM was established in 1993 to promote fair and equitable practice environments necessary to allow emergency physicians to deliver the highest quality of patient care.

www.aaem.org

 

[EctopicFetus]

The oversupply is here. When I moved there was no shortage of locums jobs in and near my metro city. Now you will struggle to find a job within an hour of the city. Then pre-'Rona they discussed cutting pay, then 'Rona hit and pay and benefits got cut. No jobs..

I help residents find jobs and if you follow whats been happening SDGs and CMGs are either reneging on contracts, cutting hours, or delaying starts.

Hard to imagine this wont impact our volumes much, even a 2-3% drop in volume will be significant.

Then throw in 30M unemployed and many of those relied on insurance for them and their families.

Is the picture clearer?

So now that I have laid out what is in your path my suggestion would be a few things. 1) figure out the 2-3 places you want to be. Reach out to the groups this summer. Get on staff at 2-3 places PRN/PT etc. Those PRN/PT places can be 1-2 hours away depending on what is available. 2) you have to think both short term and long term. Take a job in the area you want to be to secure your space and keep looking for your "better" or "forever" job.

Under no circumstances do you accept money from an SDG or CMG early on. this will limit your ability to be flexible and find a job that doesnt suck.

Overall good luck.. we have screwed ourselves royally.

 

[EctopicFetus]

This is from another poster in another thread..

A lot of the answer depends on where the hospital is, and how hard it would be for them to attract new doctors. But on the whole, sadly, your friend probably doesn't have much leverage and would find himself out of a job if he told them no. EM is becoming quite saturated (as has been thoroughly discussed on this forum), and the current state of affairs has accelerated the problem/ made it worse. Most places right now are overstaffed and would have no problem getting rid of a few people. Will volumes eventually return to normal? Maybe. Or maybe a certain percentage of the population now realizes they don't need the ED for everything and will never return. In any case, a hospital can easily afford to lose a couple of ED docs right now and when/if volumes return it won't be hard to cover their shifts with a bit of OT for a while (which the remaining docs will be desperate to pick up), while easily hiring from the large EM applicant pool in the meantime.

I keep a couple of locums contacts, and right now the "best" offers they're making that I'm seeing are for jobs paying between $150-$180 an hour for horrible places with terrible support and mostly nights. One of my former residents who lost their locums gig (hospital didn't need them any more) just took a desperation job at a sleepy rural place for $90/hr because that's all she could find to offer FT hours. It's really hard out there, and this isn't the time to put your job at risk. I'd like to give you a different answer, but unless EM docs come together as a whole (which let's be real, isn't happening), then this is not the time to do anything but bend over and take it.

Full disclosure, my hospital has now taken about $50,000 away from me for this year and I've bent over and taken it. So my money (or lack thereof) is where my mouth is.

 

[Pleurodesis]

Sigh.. maybe I shouldn't have matched EM.

 

[NYEMMED]

Do a fellowship to secure a job and a bit more money...

 

[Brigade4Radiant]

I would be wary of assuming a fellowship gives your job security especially in this academic setting they are hiring freezes. If you’re being critical care then maybe.

 

[Pleurodesis]

Does anyone have any experience switching out of EM residency into another specialty? Asking for a friend..

 

[NYEMMED]

Aren't fellowships for the most part merely interests and do not lead to greater pay?

Some of them yes. You could secure a job over others especially at academic centers by having completed one (if hiring). You are buying time for a year with a somewhat paid position with benefits, during a hiring freeze that might leave you jobless otherwise.

Toxicology could "maybe" give you something to fall back on with a poison control center
EMS can give you an edge and extra pay if you become an EMS medical director for a facility that needs one
Critical care does not lead to extra pay
US does not lead to extra pay unless you are lucky to land a US director position
Wilderness, Simulation, Informatics, administration, health policy will probably be worthless unless it really interests you
Addition/Pain management/ Palliative will always likely have jobs available these days
Peds EM- Less pay

 

[TheComebacKid]

Some of them yes. You could secure a job over others especially at academic centers by having completed one (if hiring). You are buying time for a year with a somewhat paid position with benefits, during a hiring freeze that might leave you jobless otherwise.

Toxicology could "maybe" give you something to fall back on with a poison control center
EMS can give you an edge and extra pay if you become an EMS medical director for a facility that needs one
Critical care does not lead to extra pay
US does not lead to extra pay unless you are lucky to land a US director position
Wilderness, Simulation, Informatics, administration, health policy will probably be worthless unless it really interests you
Addition/Pain management/ Palliative will always likely have jobs available these days
Peds EM- Less pay

Fellowships by and large will not increase your pay substantially. A lot of jobs associated with fellowship trained individuals are at academic positions, which pay poorly to begin with.

Critical Care may not pay "more", but it pays enough to supplement your salary. In other words, you can do a 50/50 split between EM/CCM and make the same salary as if you did 100% EM. For some people, this is a good set up.

EMS largely does not pay well. There are few medical director positions that pay any meaningful salary, and most of those are held for decades on end by various medical directors. Much of EMS medical director positions are on a volunteer basis.

 

[gamerEMdoc]

With the financial upheaval in EM and drop in volumes, everywhere has been very matter of fact about hiring freezes, etc. What strategies or insights should our class (largest in EM history to date) take in a market like this?

To be fair, hiring freezes is not just an EM problem. If there are decreased volumes in hospitals across the board, many hospital-based specialties are threatened. I'd expect volumes to rebound, so I doubt hiring freezes will go on indefinitely. But if this were to drag out for 2 years, I think pretty much all fields are screwed in some way. Most of our specialties sat at home for 6 weeks and were asked to cut their pay while in the ED we never had our hours or pay cut. I wouldn't feel real secure graduating from just about anything right now.

 

[Buckeye1992]

2021 grad. signed for next year back in November. Thought at the time I pulled the trigger too soon but looks like I might have lucked out.

 

[BoardingDoc]

while in the ED we never had our hours or pay cut.

Nice for your ED. Not my experience or that of several of my colleagues at different shops.

 

[EctopicFetus]

To be fair, hiring freezes is not just an EM problem. If there are decreased volumes in hospitals across the board, many hospital-based specialties are threatened. I'd expect volumes to rebound, so I doubt hiring freezes will go on indefinitely. But if this were to drag out for 2 years, I think pretty much all fields are screwed in some way. Most of our specialties sat at home for 6 weeks and were asked to cut their pay while in the ED we never had our hours or pay cut. I wouldn't feel real secure graduating from just about anything right now.

A lot of people
Had their hours and pay cut. Not sure where you are getting your info.

 

[carbonizedeyesockets]

I think Gamer was referring to his specific job. Where I am at, despite 40-50% volume decrease, hours and pay are the same (though no mention of what will happen when we are due for a bonus). Other specialties took pay cuts, but EM, CC, and anesthesia have been kept whole for now. Those that did lose out in my department were those working PRN who were removed from the shifts so that full-timers could fill them.

 

[RustedFox]

I think Gamer was referring to his specific job. Where I am at, despite 40-50% volume decrease, hours and pay are the same (though no mention of what will happen when we are due for a bonus). Other specialties took pay cuts, but EM, CC, and anesthesia have been kept whole for now. Those that did lose out in my department were those working PRN who were removed from the shifts so that full-timers could fill them.

Today, I clicked on your icon/avatar.

For years, I thought that the text read: "Percocet Rocket".
I was wrong.

 

[EctopicFetus]

I think Gamer was referring to his specific job. Where I am at, despite 40-50% volume decrease, hours and pay are the same (though no mention of what will happen when we are due for a bonus). Other specialties took pay cuts, but EM, CC, and anesthesia have been kept whole for now. Those that did lose out in my department were those working PRN who were removed from the shifts so that full-timers could fill them.

One of the local envision anesthesia docs told me that half her group got furloughed and the other half were told they could work for 50% pay or go on furlough...

Thats a great way to cut your payroll expenses by 75%.

Most places I know cut hours and/or Pay. APP did it, Team did it and envision did it.

 

[Dr Mantis Toboggan]

One of the local envision anesthesia docs told me that half her group got furloughed and the other half were told they could work for 50% pay or go on furlough...

Thats a great way to cut your payroll expenses by 75%.

Most places I know cut hours and/or Pay. APP did it, Team did it and envision did it.

Yup the local giant HCA referral hospital has gone down to one doc/one PA at all times in their ED. Rate is the same but hours cut 40% for the docs and less midlevel coverage to boot.

 

[DocEspana]

if we are sharing horror stories, south florida checking in.

Nearly everything is teamhealth or envision. So keep that in mind that all of the other places are 2 or 3 sites while TH and Envision are representing like 10-12ish hospitals each.
Teamhealth has largely cut their staffing back about 33% with everyone relatively evenly losing about a third of their total shifts.
Envision has put nearly all of their PAs on furlough (inpatient nearly completely. in the EDs theyre doing true bare bones staffing of APPs), cut 20-25% of shifts across the board and are withholding incentives/bonuses until an unnamed later date. Those incentives make up 35-40% of your salary.
Academic center down the road cut staffing by about 33%.
SDG covering the southern half of miami went from triple coverage nearly all day to single (!!) coverage 24/7. A total cut of over 50% of total hours.
The Tenant hospitals over here had some unspecified loss of shifts - not exactly sure how much.

The only exception appears to be Schumacher. Where they have three big outposts. One had no change. One did lose about 25% of their staffing.... and my site *added* 25% more physician coverage (and no change to midlevels). But we are insanely lucky and we know it. We are the heart of COVID in south florida and our inpatient unit is such a flaming dumpster fire that the hospital agreed to pay schumacher more money to have us handle some of the inpatient codes and we translated that into an extra shift a day. It has made the already quiet volume even more easy (though obviously covering floor codes during covid times isnt lovely)

 

[gamerEMdoc]

Yeah i didnt mean EM as a specialty hasnt seen cuts, I meant personally. I realize many have seen their hours cut. Some their rate. But my point remains that so has other specialties. Saying you plan to flee EM for another specialty bc of covid causing job uncertainty seems like a rash decision when other fields face the same hiring freezes, decreased volume, pay, etc.

This is a healthcare problem, not an EM only problem.

 

[sylvanthus]

I would honestly recommend a fellowship to upcoming new grads in this climate. In the past, it didn't make financial sense, but things are changing. There could come a time where due to the market being flooded and hospitals taking on more midlevels in the ED, that EM pay actually becomes lower than many ICU gigs. Also, it is nice having the option and flexibility to do multiple jobs/specialties. I'm likely biased, but my ICU pay has not changed, my EM pay has dropped. I think having more options at this point is worth the extra time in residency.

 

[EctopicFetus]

Good thing I don't graduate until 2022

I think you are looking at it all wrong young padawan.

 

[EctopicFetus]

I would honestly recommend a fellowship to upcoming new grads in this climate. In the past, it didn't make financial sense, but things are changing. There could come a time where due to the market being flooded and hospitals taking on more midlevels in the ED, that EM pay actually becomes lower than many ICU gigs. Also, it is nice having the option and flexibility to do multiple jobs/specialties. I'm likely biased, but my ICU pay has not changed, my EM pay has dropped. I think having more options at this point is worth the extra time in residency.

I think this depends on your work environment. in this time the SDGs will fare much better than our CMG colleagues. Hopefully with blood spilled the CMGs can fall off an create an environment where good and decent SDGs can take over.

 

[Bill Brasky]

Good thing I don't graduate until 2022

When we graduate, the oversupply will be worse, whatever slashed rates they're offering now "because volume is low" will become the new normal, and we will be competing both with our own class and the 2021 grads who will have thus far struggled to get a steady gig because of what's happening now. Things aren't going to go back to what used to be normal.

 

[The Knife & Gun Club]

if we are sharing horror stories, south florida checking in.

Nearly everything is teamhealth or envision. So keep that in mind that all of the other places are 2 or 3 sites while TH and Envision are representing like 10-12ish hospitals each.
Teamhealth has largely cut their staffing back about 33% with everyone relatively evenly losing about a third of their total shifts.
Envision has put nearly all of their PAs on furlough (inpatient nearly completely. in the EDs theyre doing true bare bones staffing of APPs), cut 20-25% of shifts across the board and are withholding incentives/bonuses until an unnamed later date. Those incentives make up 35-40% of your salary.
Academic center down the road cut staffing by about 33%.
SDG covering the southern half of miami went from triple coverage nearly all day to single (!!) coverage 24/7. A total cut of over 50% of total hours.
The Tenant hospitals over here had some unspecified loss of shifts - not exactly sure how much.

The only exception appears to be Schumacher. Where they have three big outposts. One had no change. One did lose about 25% of their staffing.... and my site *added* 25% more physician coverage (and no change to midlevels). But we are insanely lucky and we know it. We are the heart of COVID in south florida and our inpatient unit is such a flaming dumpster fire that the hospital agreed to pay schumacher more money to have us handle some of the inpatient codes and we translated that into an extra shift a day. It has made the already quiet volume even more easy (though obviously covering floor codes during covid times isnt lovely)

What is this magical SDG covering south Miami? I thought the whole state was basically one giant team health pyramid scheme?

 

[Rekt]

What is this magical SDG covering south Miami? I thought the whole state was basically one giant team health pyramid scheme?

You don't hear about SDGs because they don't have any need whatsoever to recruit. They fill via word of mouth only. There's actually a few SDGs left in FL but they're extremely competitive and you just have to be lucky. Essentially like every other real SDG throughout the country. Some SDGs do have residencies as well, but you'll likely be competing against a good amount of other residents for what little spots are open if any.

 

[Torsion]

When we graduate, the oversupply will be worse, whatever slashed rates they're offering now "because volume is low" will become the new normal, and we will be competing both with our own class and the 2021 grads who will have thus far struggled to get a steady gig because of what's happening now. Things aren't going to go back to what used to be normal.

As a 2023 graduate, I genuinely hope that members of our profession wouldn't stand for such an arbitrary pay cut if the only justification is to divert more money to the pockets of private equity partners. If volumes return to normal, EDs will be busy and open and must be staffed. We might not be the rare, prized pediatric congenital heart surgeons, but we sure as hell aren't cashiers or parking valets either. We should have some leverage if we choose to have it.

 

[DocEspana]

What is this magical SDG covering south Miami? I thought the whole state was basically one giant team health pyramid scheme?

Don't go there. the pay is *horrendous* and they argue that they are a lifestyle group, so you'll just accept it. Except I know people who work at my CMG shop and there and they are desperate to leave there because it still sucks as much as anywhere else but it sucks in its own novel way AND you're not paid well for it.

 

[HemorrhagicShock]

I registered this account (been on this website for over a decade with a different account, and cannot use it due to massive doxx potential) purely to contribute to this thread. EM attending now for a few years. Miss PandaBear's rants and Long Dong's dermatology trolling.

Make no mistake that everything @EctopicFetus has posted above is 100% true as it stands for community emergency medicine. I think @gamerEMdoc has a skewed view of EM's future prospects, partly due to his/her position in a residency program that's relatively protected, and (not trying to call out or anything) but also benefits from a steady stream of "fresh blood."

The silver lining of COVID19 is that it has brought the critical problems of EM that would have peaked in the next 5-10 years to the forefront. Due process, private equity, workforce issues (too many new residencies), medmal considerations, and others. They're all reaching an apex now, so it's an extremely scary time to be graduating or even considering emergency medicine as a career if you are a medical student. EM doctors are being FIRED. The reward for your hard work is going to shareholders who share no liability. You are now competing with far more graduates for jobs, whose debts all but require them to work residency hours as attendings for the first few years if they have any hope to pay off their debts soon. And we all know the lawyers and patients get hungrier and hungrier by the day.

I do not think that even with return of volumes will we see any return to normalcy. Midlevels reign supreme, and systems have been clear about this for the last decade. They do NOT value MD/DO expertise in the ED beyond access to the license for billing and displacing risk onto that physician's license.

Also while I agree with @gamerEMdoc regarding everybody being affected, not just EM, I think that perspective is short-sighted. Many other specialties have options for different practice environments that aren't tied to a hospital. Radiologists can own imaging centers and do outpatient stuff. They have IR, and DR. Various sub-specialty surgeons can have pure outpatient practices with surgery centers. Even FM has a plethora of options that we don't necessarily have access to unless you're one of these intrepid ER docs that's breaking off and starting DPC practices. IM and Peds both have tons of fellowships that result in a variety of outpatient practice options and significantly higher pay. EM is fairly stifling even when considering the fellowship options. And what EM doctor wants to do urgent care full time? Hourly rates aren't enough to pay back significant debt burdens, and urgent care owners don't want physicians that will practice real medicine, they want midlevels who will acquiesce to patient requests for zpacks, xrays, and steroids.

The only "hope" here is that the pendulum swing has been accelerated to now, and perhaps in 10 years we'll have a swing back, just in time for me to pay off all my loans... *dies inside*

 

[workhardoverall]

As a 2023 graduate, I genuinely hope that members of our profession wouldn't stand for such an arbitrary pay cut if the only justification is to divert more money to the pockets of private equity partners. If volumes return to normal, EDs will be busy and open and must be staffed. We might not be the rare, prized pediatric congenital heart surgeons, but we sure as hell aren't cashiers or parking valets either. We should have some leverage if we choose to have it.

They are standing for it and it’s only further being perpetuated by the spineless sell outs powering the CMG machine. Taking a salary bump and the promise of less clinical work and burden in return for training and retaining the next wave of low paid docs. If salary cuts genuinely concern you this much, then you clearly went into EM for the wrong reasons. Salaries are only going to go down from here on out no matter where you work and it’s anyone’s guess how low.

We’re already seeing it in FL. HCA trained residents can’t get a gig at their own saturated shops, then look elsewhere in the state to no avail and end up moving all over the country to work for pennies on the dollar. This further driving down salaries and setting new, low norms around the country.

In 2020-2021, Texas will have opened up three new residencies - Lubbock, HCA Houston, and Baylor DFW - and possibly a fourth in HCA El Paso if they can find another sell out.

Best advice I can dole out, don’t go into EM if money is even a small fraction of an interest to you.

 

[HemorrhagicShock]

As a 2023 graduate, I genuinely hope that members of our profession wouldn't stand for such an arbitrary pay cut if the only justification is to divert more money to the pockets of private equity partners. If volumes return to normal, EDs will be busy and open and must be staffed. We might not be the rare, prized pediatric congenital heart surgeons, but we sure as hell aren't cashiers or parking valets either. We should have some leverage if we choose to have it.

They've already spoken loud and clear. There are plenty within your chosen specialty that have no problem selling out the young, and even a global pandemic has not resulted in any kind of collective action or voice. You may have seen these facebook groups that have popped up over the last two months trying to rally physicians and the amount of in-fighting I see within these groups is all the evidence I need that any physician union or collective bargaining outfit or whatever you want to call it is not going to happen (not trying to start a discussion on whether a union is bad or good, that's been rehashed many times here).

You are exactly right - we AREN'T the prized pediatric congenital heart surgeons. That's all you need to know. An NP/PA can do 90% of what you can do, and the system is clear about nobody caring much regarding that extra 10% because there are specialists on call. They'll have to deal with a lot more terrible consults, and over-admissions, but that's money in the bank for systems. More tests, more consults, more admissions = more collections for the hospitals. Your expertise is NOT VALUED in the current system. Make sure you do a fellowship!

 

[kaygeebee]

Best advice I can dole out, don’t go into EM if money is even a small fraction of an interest to you.

Any recommendations as far as alternative fields? I have significant student loan debt..

 

[hundreddaysoff]

2 years out of residency here. The strategy that has worked well for me is to gun for a niche: full-time nocturnist position in a small single-coverage CMG shop in a medium-sized city that for cultural and climate reasons many graduating residents and even midlevels find revolting. The more brain drain there is in your target city, the better this strategy should work.

If you're single-coverage in a shop with only like 5 regular credentialed docs, it's real hard for anyone to cut your hours in the short term, no matter how low your census goes.

Agree with always having 1-2 backup gigs in your pocket to diversify risk of contract/CMG/hospital failure, even if the pay isn't so great.

I'm in the minority opinion here about CMG stipends. I took one at the end of intern year and I've eaten a lot of corporate BS for it over the past 2 years that my contract has lasted. But ultimately I think it was helpful because (1) I "locked in" a sweet vintage-2016 hourly rate and (2) it gives my medical director a reason/narrative to keep my shift$ steady every month (needed 14 shifts/mo on average for 2y as payback condition).

(Scare quotes as yes, I know these things are only gentleman's agreements and there is no real legal protection here and I am totally expendable to my CMG's C-suite. But my medical director and other docs are who I deal with on a daily basis, not admin, and gentleman's agreements still seem to mean something to them. Or maybe I just got lucky over the past 2 years, who knows.)

Not saying CMG stipends for everyone, but if you're planning to take a CMG job anyway and know what you're signing up for, I do think there are some soft benefits as well as a bit of ~guaranteed cash for a nice downpayment on your house or whatever.

 

[HemorrhagicShock]

Any recommendations as far as alternative fields? I have significant student loan debt..

Radiology money is still good and the field is still accessible by middle-tier and above candidates. Imaging demand will always be there and the AI threat is not real at least for the next two decades.

Psychiatry I think is short-sighted. Easy for any ancillary mental health provider (clinical psychologist, mental health FNPs, maybe even MFTs and various pharmacists) to vie for prescribing rights. I think it's a hot field now, but in 5 years or so it'll be just like us. There's no specific fee-for-service physical skill required and thus systems, payors, and legislators will likely race to the bottom to cover the volume of patients.

Of course the classics: dermatology, plastic surgery, ENT, neurosurgery, urology, ortho etc. type fields will continue to reimburse well or at least above that of the average physician. Good luck matching if you're the average tier medical student.

I hear a lot of doom and gloom from radiation oncology colleagues where I work, but they then turn around and talk about their million dollar cars and houses, so I think they're still a lucrative enterprise. I suspect this will continue to be the case as they control their supply.

I think FM is not an unreasonable choice if you are a hustler and business-minded person who can create a DPC practice or some other cash-paying niche, but this is no guarantee and more of a risk for most medical students. Preventative care and primary care is dead as a MD/DO driven field.

PMR is done (see recent CMS allowance of midlevels to reimburse for inpatient rehabilitation services). Too many other specialties can do the lucrative outpatient injections, pain, and similar stuff. Systems unlikely to value the costly and complex rehabilitation and functional expertise.

Not sure about pathology and neurology going forward, I don't know much about their practice environments and current market forces at play.

Anesthesia, now that they are "post-CRNA" (achieved a steady-state with their midlevel encroachment) may be a safe bet too. Friends from medical school talk about fairly nice salaries in the 400 range, with a wide variety of practice environments and subspecialty/fellowship options. I see a lot of anesthesiologists in administration as well.

 

[TheComebacKid]

They've already spoken loud and clear. There are plenty within your chosen specialty that have no problem selling out the young, and even a global pandemic has not resulted in any kind of collective action or voice. You may have seen these facebook groups that have popped up over the last two months trying to rally physicians and the amount of in-fighting I see within these groups is all the evidence I need that any physician union or collective bargaining outfit or whatever you want to call it is not going to happen (not trying to start a discussion on whether a union is bad or good, that's been rehashed many times here).

I've said many times over the past several years, EM physicians are 100% to blame for this. Not NPs. Not hospital corporations, or the CMGs or the shareholders. WE chose to get all giddy over 400/hr hourly wages at the expense of being slaves for a corporation, putting our own medical licenses on the line so an NP could get away with some online training program, and watched while these groups ate away at SDGs in highly desirable cities (think Denver for instance). We took the money, KNOWING full well that we were raping and pillaging our specialty, but we didn't care. We are now reaping what we sowed. Shame on a large proportion of the current EM physician workforce, many of whom post in this forum for selling us out like this.

You are exactly right - we AREN'T the prized pediatric congenital heart surgeons. That's all you need to know. An NP/PA can do 90% of what you can do, and the system is clear about nobody caring much regarding that extra 10% because there are specialists on call. They'll have to deal with a lot more terrible consults, and over-admissions, but that's money in the bank for systems. More tests, more consults, more admissions = more collections for the hospitals. Your expertise is NOT VALUED in the current system. Make sure you do a fellowship!

I disagree. I don't think an NP can do 10% of what I can. They simply do not have the training to take care of any amount of acuity whatsoever, and have zero resuscitation skills. Of course that will change somewhat, given the ICUs are training NPs/PAs to do their own lines, even intubations, WITHOUT supervision, but at least for now, we are better than they are at that.

They cannot see the same volume as us. They get bogged down on ordering cardiac enzymes on teenagers who had chest pain after a fight with their parents. They order CT scans on patients who had a CT scan the day before. They consult specialists for a distal radius fracture that I can manage in a few minutes. I know these things "bill" for the system, but I can see three times as many patients as they can on any given shift. I believe hospital systems value that.

Many of them do not want to work nights. They don't want to work weekends. They don't want to work holidays. This is why we get paid anything at all in EM, because we are willing to do those things.

If you get rid of CMGs, you get rid of NP/PA dominance. With the way medicare reimbursement is going, the system is going to stop rewarding people for ordering a CT scan when they received one THAT SAME MORNING.

I don't think fellowships protect you from midlevel creep. Tox programs in the country are having NPs see consults during daytime hours. EMS is already talking about having NPs/PAs perform medical direction and manage stuff in the field. And critical care is overrun by NPs/PAs in the ICUs who are billing for their own procedures and critical care time. Meanwhile, physicians are TRAINING them to perform in these arenas, and constantly talking about how great they are. It's a complete joke.

I do think things will equilibrate from a COVID standpoint. I think volume will return. I think we will have jobs. I think our hourly rates will continue to go down. I agree, if you value making as much money as possible and being protected from mid level creep and corporate erosion, EM is not the field to go into. If you enjoy the specialty and like the work, in spite of everything else, then it's still a good career choice for some students.

 

[HemorrhagicShock]

I disagree. I don't think an NP can do 10% of what I can. They simply do not have the training to take care of any amount of acuity whatsoever, and have zero resuscitation skills. Of course that will change somewhat, given the ICUs are training NPs/PAs to do their own lines, even intubations, WITHOUT supervision, but at least for now, we are better than they are at that.

There are tons of PA/NP EM "fellowships" which after 1 year give them the training they need to be autonomous in the ED. You often find these side-by-side within residency programs as well. As you suggest they're already well versed with procedures, including intubations.

They cannot see the same volume as us. They get bogged down on ordering cardiac enzymes on teenagers who had chest pain after a fight with their parents. They order CT scans on patients who had a CT scan the day before. They consult specialists for a distal radius fracture that I can manage in a few minutes. I know these things "bill" for the system, but I can see three times as many patients as they can on any given shift. I believe hospital systems value that.

Many of them do not want to work nights. They don't want to work weekends. They don't want to work holidays. This is why we get paid anything at all in EM, because we are willing to do those things.

They may not see the same volume as us, but you can get 3 of them for 1 of us. There's your fix. And you're proving my point regarding overutilization as a means to profit for the system.

If you get rid of CMGs, you get rid of NP/PA dominance. With the way medicare reimbursement is going, the system is going to stop rewarding people for ordering a CT scan when they received one THAT SAME MORNING.

Not following this one. CMGs aren't going away anytime soon, in fact via COVID19 the ones that have survived are picking up steam and grabbing up contracts from the ashes. And there's no better minion to follow metric based medicine than a midlevel, so the CT example is moot too.

I don't think fellowships protect you from midlevel creep. Tox programs in the country are having NPs see consults during daytime hours. EMS is already talking about having NPs/PAs perform medical direction and manage stuff in the field. And critical care is overrun by NPs/PAs in the ICUs who are billing for their own procedures and critical care time. Meanwhile, physicians are TRAINING them to perform in these arenas, and constantly talking about how great they are. It's a complete joke.

I do think things will equilibrate from a COVID standpoint. I think volume will return. I think we will have jobs. I think our hourly rates will continue to go down. I agree, if you value making as much money as possible and being protected from mid level creep and corporate erosion, EM is not the field to go into. If you enjoy the specialty and like the work, in spite of everything else, then it's still a good career choice for some students.

I do agree with much of this. At the end of the day you can only choose EM if you'll be okay making a likely $150-200k/year salary working full time (this is geared towards those medical students who matched this year, and will match next year). And that's in an undesirable location as well. God forbid you try to get a job in a nice city...

 

[Torsion]

Best advice I can dole out, don’t go into EM if money is even a small fraction of an interest to you.

I do agree with much of this. At the end of the day you can only choose EM if you'll be okay making a likely $150-200k/year salary working full time (this is geared towards those medical students who matched this year, and will match next year). And that's in an undesirable location as well. God forbid you try to get a job in a nice city...

I think most people enter medicine because they are service-oriented and like science, but I'd also posit that money is certainly at least a "fraction of an interest" to almost all of us. Money should be a consideration for any career path or job choice.

I chose to match into EM because I enjoy the scope and variety of the medical work and the close knit team environments that I've observed in many EDs. The competitive pay is certainly appealing as I'm sure it was for anyone who is currently in the field. The speculated salary quoted above would represent a 50% plummet to current compensation, putting EM the lowest of low in terms of physician pay by as much as 50-60k based on salary averages, bordering on what I know some first year ED PAs are making in my current state. I think I have a right to be concerned if this were to be a true possibility.

 

[GatorCHOMPions]

I do agree with much of this. At the end of the day you can only choose EM if you'll be okay making a likely $150-200k/year salary working full time (this is geared towards those medical students who matched this year, and will match next year). And that's in an undesirable location as well. God forbid you try to get a job in a nice city...

I usually feel fairly doom and gloom about the outlook of EM (mostly from lack of appreciation and lifestyle standpoint) but I cannot see pay dropping THAT much. How did you even come up with that figure? The most saturated, CMG monopolized markets (select few cities) today pay $150/hour and at 1440 hours that’s still 216k. Even NYC pays like $180/hour and how much more saturated can you get? I know of jobs within 1-2 hours of an international airport paying over $250/hour even in these COVID times.

I think a more realistic figure is $200/hour norms for most areas within a few years. Don’t get me wrong this is still a big pay cut from a few years ago, but you’ll still pull 300k working reasonable hours.

 

[Rekt]

I usually feel fairly doom and gloom about the outlook of EM (mostly from lack of appreciation and lifestyle standpoint) but I cannot see pay dropping THAT much. How did you even come up with that figure? The most saturated, CMG monopolized markets (select few cities) today pay $150/hour and at 1440 hours that’s still 216k. Even NYC pays like $180/hour and how much more saturated can you get? I know of jobs within 1-2 hours of an international airport paying over $250/hour even in these COVID times.

I think a more realistic figure is $200/hour norms for most areas within a few years. Don’t get me wrong this is still a big pay cut from a few years ago, but you’ll still pull 300k working reasonable hours.

Physicians have never really had a problem with saturation in the past. Rads had a slight blip but that resolved. EM is once again going to be the first at doing something/going through something. Saturation is going to hit hard. Practicing docs don't care now because they think they're untouchable. Most of you guys know CMGs don't give a damn about any of you. Why do you think they wouldn't take me for 150/hr and axe your ass at 2XX? I HAVE to have a job. If I have to cold call crap factories saying I'll work for less then whatever you're paying the docs now, so be it. Obviously a hopeful hyperbole, but it could easily be the future.

 

[Brigade4Radiant]

Physicians have never really had a problem with saturation in the past. Rads had a slight blip but that resolved. EM is once again going to be the first at doing something/going through something. Saturation is going to hit hard. Practicing docs don't care now because they think they're untouchable. Most of you guys know CMGs don't give a damn about any of you. Why do you think they wouldn't take me for 150/hr and axe your ass at 2XX? I HAVE to have a job. If I have to cold call crap factories saying I'll work for less then whatever you're paying the docs now, so be it. Obviously a hopeful hyperbole, but it could easily be the future.

Are you a PA? Also CMG are changing also EM pay wouldn’t be that low if it is then all other specialties will be affected.

 

[workhardoverall]

Money should be a consideration for any career path or job choice.

you answered the question so let the record show that when it happens, you picked the wrong specialty.

 

[docB]

Does anyone have any experience switching out of EM residency into another specialty? Asking for a friend..

I don't think that any of these issues are isolated to EM.

 

[HemorrhagicShock]

I usually feel fairly doom and gloom about the outlook of EM (mostly from lack of appreciation and lifestyle standpoint) but I cannot see pay dropping THAT much. How did you even come up with that figure? The most saturated, CMG monopolized markets (select few cities) today pay $150/hour and at 1440 hours that’s still 216k. Even NYC pays like $180/hour and how much more saturated can you get? I know of jobs within 1-2 hours of an international airport paying over $250/hour even in these COVID times.

I think a more realistic figure is $200/hour norms for most areas within a few years. Don’t get me wrong this is still a big pay cut from a few years ago, but you’ll still pull 300k working reasonable hours.

Physicians have never really had a problem with saturation in the past. Rads had a slight blip but that resolved. EM is once again going to be the first at doing something/going through something. Saturation is going to hit hard. Practicing docs don't care now because they think they're untouchable. Most of you guys know CMGs don't give a damn about any of you. Why do you think they wouldn't take me for 150/hr and axe your ass at 2XX? I HAVE to have a job. If I have to cold call crap factories saying I'll work for less then whatever you're paying the docs now, so be it. Obviously a hopeful hyperbole, but it could easily be the future.

@GatorCHOMPions - @Rekt has the right idea. There are MULTIPLE market forces here that you're neglecting. With a ton of EM physicians, many of whom have debts and must work to they off will be happy to accept lower and lower rates to undercut more expensive "top-heavy" practicing clinicians. Any of us who have been in the field for a while too know that the "young guns" coming out of residency will see more patients than the (even slightly) older physician. Add in decreasing reimbursements as pro-insurance pro-payor suprise billing legislation gets passed along with a far more cost-conscious patient, and suddenly this becomes clearer. EMTALA remains an unfunded mandate and there's zero political will to change this, even in a global pandemic. You should look into how much of the CARES act went to CMG administrators instead of into the pockets of actual providers.

Your assessment of rates being in the $150/hr being only in "CMG monopolized markets (select few cities)" is completely incorrect. I practice in the PNW and there are many rural or suburban shops (CMG and not) that because of payor mix and volumes cannot afford to pay more than rates close to that. As a result they can hardly "afford" BCEM physicians and have a ton of rotating FMs and other non-boarded docs willing to cover. Keep in mind your competition is not just newly graduating EM physicians, but FMs, IMs, gen surg, PA/NPs, and others who routinely cover EDs in scenarios like this.

It's great that you know of places that still pay $250/hr because I can tell you right now that I definitely don't have access to anything that pays near that in my three state area where I hold licenses. And I get all the recruiter texts, emails, and calls too. Nobody is offering that much, and good luck getting into a locked-in SDG where sweat equity isn't a guarantee to make partner (much more likely to be paid terribly for 3-5 years after which the partners sell off the practice to a conglomerated system or CMG).

Yes, I want to continue hope that hourly rates will stay reasonable such that one can maintain even 250k/year full-time, but there is no indicator that this is a reality, and at the end of the day one has to prepare in the event that rates DO drop that low. Keep a modest lifestyle, aggressively eliminate your high interest student loan debt, invest/save heavily, marry rich, and diversify your income stream.

Your MD/DO and license can be leveraged in many ways!

 

[Torsion]

@GatorCHOMPions - @Rekt
Your assessment of rates being in the $150/hr being only in "CMG monopolized markets (select few cities)" is completely incorrect. I practice in the PNW and there are many rural or suburban shops (CMG and not) that because of payor mix and volumes cannot afford to pay more than rates close to that. As a result they can hardly "afford" BCEM physicians and have a ton of rotating FMs and other non-boarded docs willing to cover. Keep in mind your competition is not just newly graduating EM physicians, but FMs, IMs, gen surg, PA/NPs, and others who routinely cover EDs in scenarios like this.

It's great that you know of places that still pay $250/hr because I can tell you right now that I definitely don't have access to anything that pays near that in my three state area where I hold licenses. And I get all the recruiter texts, emails, and calls too. Nobody is offering that much, and good luck getting into a locked-in SDG where sweat equity isn't a guarantee to make partner (much more likely to be paid terribly for 3-5 years after which the partners sell off the practice to a conglomerated system or CMG).

The 2019-2020 ACEP survey had Oregon and Washington hourly avg at $215 and $219, respectively. It would seem that some people somewhere in the PNW are earning a lot more than these offers. The survey numbers correlate reasonably well in my home region for the offers I've been quoted by attendings and residents in person so it doesn't seem like the survey is missing the mark by 30-40% at least here.

 

[GatorCHOMPions]

@GatorCHOMPions - @Rekt has the right idea. There are MULTIPLE market forces here that you're neglecting. With a ton of EM physicians, many of whom have debts and must work to they off will be happy to accept lower and lower rates to undercut more expensive "top-heavy" practicing clinicians. Any of us who have been in the field for a while too know that the "young guns" coming out of residency will see more patients than the (even slightly) older physician. Add in decreasing reimbursements as pro-insurance pro-payor suprise billing legislation gets passed along with a far more cost-conscious patient, and suddenly this becomes clearer. EMTALA remains an unfunded mandate and there's zero political will to change this, even in a global pandemic. You should look into how much of the CARES act went to CMG administrators instead of into the pockets of actual providers.

Your assessment of rates being in the $150/hr being only in "CMG monopolized markets (select few cities)" is completely incorrect. I practice in the PNW and there are many rural or suburban shops (CMG and not) that because of payor mix and volumes cannot afford to pay more than rates close to that. As a result they can hardly "afford" BCEM physicians and have a ton of rotating FMs and other non-boarded docs willing to cover. Keep in mind your competition is not just newly graduating EM physicians, but FMs, IMs, gen surg, PA/NPs, and others who routinely cover EDs in scenarios like this.

It's great that you know of places that still pay $250/hr because I can tell you right now that I definitely don't have access to anything that pays near that in my three state area where I hold licenses. And I get all the recruiter texts, emails, and calls too. Nobody is offering that much, and good luck getting into a locked-in SDG where sweat equity isn't a guarantee to make partner (much more likely to be paid terribly for 3-5 years after which the partners sell off the practice to a conglomerated system or CMG).

Yes, I want to continue hope that hourly rates will stay reasonable such that one can maintain even 250k/year full-time, but there is no indicator that this is a reality, and at the end of the day one has to prepare in the event that rates DO drop that low. Keep a modest lifestyle, aggressively eliminate your high interest student loan debt, invest/save heavily, marry rich, and diversify your income stream.

Your MD/DO and license can be leveraged in many ways!

We will have to agree to disagree on the numbers. I work in a (historically) low paying region in the country and can just tell you my experiences and those of my former co-residents and colleagues. I also have a pulse on current resident trends in my region which support what I wrote above. I know nothing about the PNW, but perhaps it was hot a few years ago and like Texas there’s reversion to the mean and they are overshooting it the wrong way. Again, I agree pay will go down but we disagree on the extent.

Back to the original intent of the thread, agree with others who say to have more than 1 job to diversify yourself. Also agree with finding a niche in whatever setting you choose whether it’s academics via fellowship and teaching/education or community via admin or being a nocturnist.

 

[EctopicFetus]

I personally think we drop to under 200/hr As a normal rate. I think something closer to 180 will be the new norm whereas I think our current norm is 220.
I might be wrong but I see a glut of docs. eds closing and CMG financial stress. Throw in OON billing, insurance consolidation, the push for telemedicine and mid levels.

 

[Dr Mantis Toboggan]

My first job in 2003 in academics paid around $100 an hour. I believe pay is a bell curve and we are past the peak and headed back down to about that level, adjusted for inflation.

I personally think we drop to under 200/hr As a normal rate. I think something closer to 180 will be the new norm whereas I think our current norm is 220.
I might be wrong but I see a glut of docs. eds closing and CMG financial stress. Throw in OON billing, insurance consolidation, the push for telemedicine and mid levels.

 

[Hercules]

My first job in 2003 in academics paid around $100 an hour. I believe pay is a bell curve and we are past the peak and headed back down to about that level, adjusted for inflation.

Adjusting for inflation that would be ~$130/hr. There’s no way I would even consider doing EM for $130/hr. There’s too many easier ways to make that kind of money. Even urgent care is going to pay close to or better than that without having to do the nights and holidays.

 

[ERDude]

Adjusting for inflation that would be ~$130/hr. There’s no way I would even consider doing EM for $130/hr. There’s too many easier ways to make that kind of money. Even urgent care is going to pay close to or better than that without having to do the nights and holidays.

Agreed. My absolute floor I think would be 200/hr and I wouldn't be willing to see more than 1.5pph at that rate. If rates in my area ever get that low it probably means either my SDG folded or volumes never bounced back.

 

[Yellow345]

Agreed. My absolute floor I think would be 200/hr and I wouldn't be willing to see more than 1.5pph at that rate. If rates in my area ever get that low it probably means either my SDG folded or volumes never bounced back.

What would be the alternative for you (or other EM physicians) if the pay went lower? Just quit? Fellowship? Administration? I'm just curious how EM physicians could have any other choice than to work for the lower pay unless they had enough savings to retire especially with a mortgage/family expenses.