Class of 2021 job market insights

[MechEDoc]

I've done ten 12s. A little crispy at the end but the rest of the month was awesome! I'd do it nearly every month if I could ideal would be 6x12 days -> 6x12 nights -> see you in 18 days.

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[bravotwozero]

Yeah I start getting tired after 5 12's in a row. Not sure how i'd do 10.

 

[TheSingularity]

I used to be burnt to a crisp after 5 12 hour shifts. No idea how you do 10.

 

[Fox800]

I'm ready to be done at 4. 5 is pretty much the safe limit before I start to get crispy like bacon.

 

[Cinclus]

Three is my limit of shifts in a row, and I try to keep it to 2 in a row for burnout purposes (only been working 9-10 shifts per month). Staffing has been inadequate since the COVID cuts, with most of us staying several hours late recently to finish up due to poor staffing. Thinking quite hard about whether I will renew my contract new year, but I am wondering if anything else could even be found. Have been looking into super small, super rural spots.

 

[skougess]

Three is my limit of shifts in a row, and I try to keep it to 2 in a row for burnout purposes (only been working 9-10 shifts per month). Staffing has been inadequate since the COVID cuts, with most of us staying several hours late recently to finish up due to poor staffing. Thinking quite hard about whether I will renew my contract new year, but I am wondering if anything else could even be found. Have been looking into super small, super rural spots.

What I don’t understand is why put yourself through that? Why don’t you let the waiting room wait? Why are you working for free for hours after every single shift? I promise I’m not trying to be “holier than thou”. It seems like all you are doing is proving to your employer that you’re just fine working under those understaffed conditions. If I had you as an employee, I probably wouldn’t be looking to add spots either.

 

[Cinclus]

What I don’t understand is why put yourself through that? Why don’t you let the waiting room wait? Why are you working for free for hours after every single shift? I promise I’m not trying to be “holier than thou”. It seems like all you are doing is proving to your employer that you’re just fine working under those understaffed conditions.

People in the waiting room do wait. The many people they room with hypotension and hypoxia do not and cannot wait. We are being swamped with legitimately sick patients.

 

[skougess]

People in the waiting room do wait. The many people they room with hypotension and hypoxia do not and cannot wait. We are being swamped with legitimately sick patients.

Why not just pump the brakes on seeing less acute patients? Let them sit in rooms unseen? Should have no problem making up the volume with 1’s and sick 2’s if you are really needing to stay hours after every shift. I’m really not trying to be a douchenozzle, just trying to think of ways we can all do our part to hit our corporate overlords where it hurts.

 

[Fox800]

Three is my limit of shifts in a row, and I try to keep it to 2 in a row for burnout purposes (only been working 9-10 shifts per month). Staffing has been inadequate since the COVID cuts, with most of us staying several hours late recently to finish up due to poor staffing. Thinking quite hard about whether I will renew my contract new year, but I am wondering if anything else could even be found. Have been looking into super small, super rural spots.

You're giving free labor and uncompensated time to your employer who is being cheap.

 

[Cinclus]

You're giving free labor and uncompensated time to your employer who is being cheap.

Yup. And it pisses me off. I likely will not renew if this doesn't change.

 

[miacomet]

I don't get it. If you are hourly (as opposed to academic or salaried for other reasons) then they legally have to pay you if you stay late. I am salaried but paid hourly, and I bill in 15 minute increments for any time past my shift, just like my accountant does.

What happens if you just bill them for those extra hours?

 

[RustedFox]

I don't get it. If you are hourly (as opposed to academic or salaried for other reasons) then they legally have to pay you if you stay late. I am salaried but paid hourly, and I bill in 15 minute increments for any time past my shift, just like my accountant does.

What happens if you just bill them for those extra hours?

You get warned.
Then you get fired.

 

[JacobMcCandles]

I don't get it. If you are hourly (as opposed to academic or salaried for other reasons) then they legally have to pay you if you stay late. I am salaried but paid hourly, and I bill in 15 minute increments for any time past my shift, just like my accountant does.

What happens if you just bill them for those extra hours?

It will specifically state in the contract something to the effect that you will only be paid for scheduled hours.

 

[miacomet]

You get warned.
Then you get fired.

Then you can sue for back wages, most likely successfully.
I had a locums offer once that wanted to pay me by the shift. No thanks.
Why are people taking jobs like this, and why are people going into EM if jobs are like this?

 

[RustedFox]

Then you can sue for back wages, most likely successfully.
I had a locums offer once that wanted to pay me by the shift. No thanks.
Why are people taking jobs like this, and why are people going into EM if jobs are like this?

Not in my state, homey.
The contract says "we can fire you at any reason, at any time."
You sign it; you agree.

 

[Groove]

I don't get it. If you are hourly (as opposed to academic or salaried for other reasons) then they legally have to pay you if you stay late. I am salaried but paid hourly, and I bill in 15 minute increments for any time past my shift, just like my accountant does.

What happens if you just bill them for those extra hours?

Most CMGs heavily frown on docs requesting to get paid for staying late. In fact, I've noticed that they will instill a culture of expectation in staying late without getting paid and spin it as "just part of the job..." as well as encourage you to pick up extra patients and save all your documentation until you get home. It's easy to brainwash new docs fresh out who are uncertain about the norms and all too eager to please authority figures. I've noticed new docs with zero charts completed, maybe 10 not even started, and staying 2 hours late all to please the director or overlord masters with a sacrifice of flesh. I've always refused to do this... I stop picking up if I don't have confidence the orders will get completed on time. I finish 100% of the charts before I leave and I never ask to get paid overtime because I'm never there past the end of my shift. I stopped chasing that CMG carrot long ago.

The extra $10-15/hr to see 3 more patients and stay 2 hours late without getting paid totals about 30 hours for me which equals ~$7500 lost versus $1950 gain in extra compensation for the month. No thanks.

 

[sloh]

Most CMGs heavily frown on docs requesting to get paid for staying late. In fact, I've noticed that they will instigate a culture of expectation in staying late without getting paid and spin it as "just part of the job..." as well as encourage you to pick up extra patients and save all your documentation until you get home. It's easy to brainwash new docs fresh out who are uncertain about the norms and all too eager to please authority figures. I've noticed new docs with zero charts completed, maybe 10 not even started, and staying 2 hours late all to please the director or overload masters with a sacrifice of flesh. I've always refused to do this... I stop picking up if I don't have confidence the orders will get completed on time. I finish 100% of the charts before I leave and I never ask to get paid overtime because I'm never there past the end of my

“All hands on deck!”

“Be a team player!”

Fu

 

[Groove]

“All hands on deck!”

“Be a team player!”

Fu

Exactly.... don't forget the emails with the Tony Robbins style inspirational quotes.

 

[bravotwozero]

yeah I don't feel guilty at all about not picking up patients in the last hour of my shift, as that's usually pointless. I will however stop the clock and shotgun some labs/orders to move things along.

 

[emergentmd]

I don't get wanting to get paid by staying late. You know when you shift ends, prepare and leave on time

Why would a slow doctor who is dumb enough to pick u a belly pain 30 min before his shift get paid more than me who is smart to not pick something that that up. If you don't want them to wait, put in some orders and pass it along.

I can tell you I almost never stay late. 2 hrs before your shift ends, start preparations to leave. If you are on RVU and want to see extract every last drop of blood then so be it. I am happy to stop seeing anything complicated 2 hrs before my shift ends.

 

[miacomet]

Not in my state, homey.
The contract says "we can fire you at any reason, at any time."
You sign it; you agree.

This isn't a state issue; it's federal. Companies still have to abide by state and federal fair wage regulations and federal civil rights laws. Unless you are salaried, my understanding (any labor lawyers chime in here) they have to pay you for hours worked. Firing someone for demanding pay for hours worked could be considered a whistleblower concern, and I think the law is on your side.

My company would love not to pay us for hours worked, but they also follow the law, and have not figured how to avoid doing so.

 

[JacobMcCandles]

This isn't a state issue; it's federal. Companies still have to abide by state and federal fair wage regulations and federal civil rights laws. Unless you are salaried, my understanding (any labor lawyers chime in here) they have to pay you for hours worked. Firing someone for demanding pay for hours worked could be considered a whistleblower concern, and I think the law is on your side.

My company would love not to pay us for hours worked, but they also follow the law, and have not figured how to avoid doing so.

You'd better start the movement on the class action lawsuit because I can almost guarantee you that every CMG contract says something to the effect that you'll only be paid for hours scheduled. I don't think their lawyers are stupid enough to put this into every contract. If you're routinely staying late after every shift then that's an efficiency issue for that particular person.

 

[miacomet]

You'd better start the movement on the class action lawsuit because I can almost guarantee you that every CMG contract says something to the effect that you'll only be paid for hours scheduled. I don't think their lawyers are stupid enough to put this into every contract. If you're routinely staying late after every shift then that's an efficiency issue for that particular person.

Then their docs better be pretty open to sign outs. Not a contract I would want to sign!
It's pretty hard to leave on time in a single coverage shop, I might add.

 

[RustedFox]

Then their docs better be pretty open to sign outs. Not a contract I would want to sign!
It's pretty hard to leave on time in a single coverage shop, I might add.

Exactly this with the sign outs.
The CMG wants you to see every patient, then sign out all 8-12 of them to the next doc.

 

[miacomet]

Exactly this with the sign outs.
The CMG wants you to see every patient, then sign out all 8-12 of them to the next doc.

Mmm. Safe.

 

[Groove]

The secret to smooth sign outs is to stop putting your name on pt's waiting on the tracking board and/or starting notes on them 1-1.5 hours before you are due to leave. If I'm on a night shift with no double coverage, I'll screen 100% of these pt's, examine them, dump in orders and get the work up started. If I see that 1 or 2 are able to be discharged/admitted on time, I'll start a note on them 20 mins before I leave and complete them. Otherwise, I just leave my name off and let the new doc pick them up.

 

[Fox800]

The secret to smooth sign outs is to stop putting your name on pt's waiting on the tracking board and/or starting notes on them 1-1.5 hours before you are due to leave. If I'm on a night shift with no double coverage, I'll screen 100% of these pt's, examine them, dump in orders and get the work up started. If I see that 1 or 2 are able to be discharged/admitted on time, I'll start a note on them 20 mins before I leave and complete them. Otherwise, I just leave my name off and let the new doc pick them up.

Interesting. I don't know that my partners would let that fly... (no documentation and patient's been in the ED for 90 minutes with orders in).

I generally stop seeing folks 45-50 minutes before the end of shift (unless sick), but we have a swing-shift midlevel which helps. We are not paid on RVUs, so the expectation is that we take sign-outs without an issue.

If they are sick-ish (like a full septic work-up) but don't need critical care, I'll write a brief triage note and dump orders.

 

[Groove]

Interesting. I don't know that my partners would let that fly... (no documentation and patient's been in the ED for 90 minutes with orders in).

I generally stop seeing folks 45-50 minutes before the end of shift (unless sick), but we have a swing-shift midlevel which helps. We are not paid on RVUs, so the expectation is that we take sign-outs without an issue.

If they are sick-ish (like a full septic work-up) but don't need critical care, I'll write a brief triage note and dump orders.

Why do you need documentation? What's magical about a physician note versus a quick MSE note? What's important is that you eyeballed them and started the work up instead of leaving them on the board. If the hours are so poorly designed as to not allow any overlap so that the first physician can wind down, then that's not the leaving physician's fault. I feel very strongly about getting people out on time. More so than anyone I've met. We have a difficult job in a specialty replete with physical and emotional exhaustion and doc's burning out halfway or even a third of the way through their career. I think everyone deserves to leave on time without having to spend 2 hours documenting at home without getting paid for it. They need to get home, spend time with their families, squeeze in a quick work out, unwind, get in bed early and mentally prepare for their next shift. This whole culture indoctrinating delayed gratification, misappropriated guilt and self flagellating in the interests of our corporate overmasters needs to die. RVU shops are the absolute worst offenders. You're made to feel guilty for not picking up 100% of the pt's and starting notes 5 minutes before your shift and then brow beaten and shamed for trying to sign out your patients to the incoming doc. As if leaving on time is a sign of laziness or weakness. It's ridiculous.

 

[Fox800]

Sign outs are dangerous. They lead to worse care. They also lead to prolonged ED courses with changing workups. I get these transfers sometimes where the patient has been in the ED all day and been take care of by 2-3 different EPs signing out the patient telephone game style. I ask the patient what brought them in originally and it has nothing to do with why they were transferred. You need to be comfortable in EM evaluating a patient and dispoing them within 2 hours. I like the partial > total RVU model the best, with both preferable over not RVU based. If you are paid to see a patient then staying a little later isn’t the end of the world. You’re right, if just paid for the shift then what’s the incentive to work. There needs to be incentive to see patients or people slack. No one likes picking up a complicated patient an hour before the end of shift. Sometimes it’s better for patients to just wait. However, leaving multiple patients waiting more than a hour for the next physician to see is somewhat poor form. I agree that you shouldn’t pick up more complicated patients like weak and dizzy elderly, altered patients or chest/abdominal pain patients within under an hour to go. It’s better to let the oncoming EP see the patient than do a quick, half-hearted work up signing them out, or staying hours after your shift ends. Critical patients can’t wait, and low acuity patients can be dispo’d quickly. Those middle acuity patients are the hardest at the end of a shift.

So what's your approach to patients with chest pain, abdominal pain, AMS, etc in the last hour of your shift? These people by definition probably shouldn't linger without orders. Do you just eyeball and place basic orders, but leave for the oncoming doc as a new patient?

 

[Fox800]

w

Why do you need documentation? What's magical about a physician note versus a quick MSE note? What's important is that you eyeballed them and started the work up instead of leaving them on the board.

That's generally what I do. Brief note about complaint and orders entered, and will sign out to oncoming physician. No exam documented unless pertinent (ex a neuro complaint).

 

[Groove]

So what's your approach to patients with chest pain, abdominal pain, AMS, etc in the last hour of your shift? These people by definition probably shouldn't linger without orders. Do you just eyeball and place basic orders, but leave for the oncoming doc as a new patient?

Totally agree and I don't think we're differing that much in our approach. I'll eyeball all high risk complaints, examine them and start orders. I may or may not write an MSE note. Honestly, I usually don't though it's probably a good idea from a medicolegal standpoint. I'll even eyeball the sprains and lacs, etc.. I've learned that if you just get in the habit of getting up and eyeballing everyone near the end of your shift, dropping in orders for the incoming doc, you'll many times become surprised at the ones ready for disposition before you leave. For those, I'll start the note real quick and wrap them up myself. All the rest...I let the incoming doc start the note. If I'm double coverage, I'm not as inclined to screen everyone unless the other doc is overwhelmed and they have a high risk complaint. In an RVU shop, it's often humorous to see the second doc suddenly put his name all over the board 10 mins before the new doc arrives in an effort to deny him/her any patients which does nothing but delay LOS I might add.

 

[Brigade4Radiant]

Just have the nurse put in put protocol orders I don’t see patients in the last two or three hours of my shift. When I go to work I go to the waiting room and I see more than what’s expected that in the beginning half of my shift. And then the last two or three hours is documenting stuff Just like it’s not acceptable being lied to your shop it is not acceptable for me to stay over no way no how

 

[Old_Mil]

This would be an excellent time to look at overseas opportunities in Canada, Australia, or New Zealand. The future of generalist physician pay in the US is going to be low.

 

[Old_Mil]

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.

General medicine has no future in the US outside of concierge medicine. C-suites have seen to that, hiring PAs and NPs is much cheaper.

The moral of the story here is if you are currently a medical student, don't match EM.

If you're a premed, get out while the getting is good.

Remember that in the golden age of medicine in the US, PAs and NPs didn't even exist. That day isn't coming back.

 

[miacomet]

All I can say folks is, multiple streams of income.

 

[EctopicFetus]

All I can say folks is, multiple streams of income.

truer words were never spoken on this forum

 

[Bea5T]

All I can say folks is, multiple streams of income.

Passiveincomemd.com

 

[Mr Bitterness]

You get warned.
Then you get fired.

USACS was clear on this time and time again. Told the directors that it was non negotiable to refuse overtime except for very specific conditions. They switched to a scheduling company that required director approval if you made changes. If you did not document that the doc saw and dispo’d 2 patients or more for each hour they charged, the overtime would be denied. Didn’t matter if you were helping out, doing procedures, EMS calls, documenting, etc. Didn’t get fired, just a lot of docs who got refused overtime even though they were helping out, seeing patients, etc.

 

[EctopicFetus]

USACS was clear on this time and time again. Told the directors that it was non negotiable to refuse overtime except for very specific conditions. They switched to a scheduling company that required director approval if you made changes. If you did not document that the doc saw and dispo’d 2 patients or more for each hour they charged, the overtime would be denied. Didn’t matter if you were helping out, doing procedures, EMS calls, documenting, etc. Didn’t get fired, just a lot of docs who got refused overtime even though they were helping out, seeing patients, etc.

Time to change behavior or file a complaint with the feds.

 

[Alvarez13]

USACS was clear on this time and time again. Told the directors that it was non negotiable to refuse overtime except for very specific conditions. They switched to a scheduling company that required director approval if you made changes. If you did not document that the doc saw and dispo’d 2 patients or more for each hour they charged, the overtime would be denied. Didn’t matter if you were helping out, doing procedures, EMS calls, documenting, etc. Didn’t get fired, just a lot of docs who got refused overtime even though they were helping out, seeing patients, etc.

This is where every doc, let me say again EVERY DOC, comes together and says no picking up pts 2 hrs out.

We need to realize we're the reason the patient is there. That's it. Stand up, stand together and stop being fu***** pushovers.

Also get your act together ACEP.

 

[BoardingDoc]

This is where every doc, let me say again EVERY DOC, comes together and says no picking up pts 2 hrs out.

We need to realize we're the reason the patient is there. That's it. Stand up, stand together and stop being fu***** pushovers.

Also get your act together ACEP.

Yeah, this part at least I don't get. I have no idea who in their right mind is seeing any patients after their shift ends unless they work in a productivity based model or if you're otherwise getting paid to stay late.

At my last side gig, I was paid hourly and was told I wouldn't get paid for staying late. I stopped seeing any new patients 1.5 hrs before the end of my shift so that I could clean up and was out the door within 5 min of my scheduled shift end time.

 

[RustedFox]

Yeah, this part at least I don't get. I have no idea who in their right mind is seeing any patients after their shift ends unless they work in a productivity based model or if you're otherwise getting paid to stay late.

At my last side gig, I was paid hourly and was told I wouldn't get paid for staying late. I stopped seeing any new patients 1.5 hrs before the end of my shift so that I could clean up and was out the door within 5 min of my scheduled shift end time.

This should be (if it's not already, and in all my jobs to date, hasn't been) spelled out clear as day in the contract.
Envision would always "move the goalposts" on us.

First, it was "you won't be paid if you don't pick a patient/hour".
Then, it was "you won't be paid unless you're doing a procedure".
Next, it was "you wont be paid unless you're doing a procedure, or pick up 2 patients/hour"

And of course, somewhere along the line, it was: "you need to pick up every patient within ten minutes of their arrival, and we don't care if 5 patients arrive in your last :30 minutes".

 

[partypantss]

Damn, well, as a MS4 going into EM that was feeling excited about all of the interview invitations I've been getting so early in the cycle, reading through this whole thread definitely killed my good mood.

 

[AlmostAnMD]

Damn, well, as a MS4 going into EM that was feeling excited about all of the interview invitations I've been getting so early in the cycle, reading through this whole thread definitely killed my good mood.

This is why my new hobby is collecting bourbon.

My Old Fitzgerald 16 year bottled-in-bond just arrived today.

Currently project is finding a way to make a perfect spherical ice cube. Sure, you can use a mold, but where the mold meets there is a nubbin that has to be shaved off somehow.

Just drink a lot, it'll all work out somehow

 

[partypantss]

This is why my new hobby is collecting bourbon.

My Old Fitzgerald 16 year bottled-in-bond just arrived today.

Currently project is finding a way to make a perfect spherical ice cube. Sure, you can use a mold, but where the mold meets there is a nubbin that has to be shaved off somehow.

Just drink a lot, it'll all work out somehow

I couldn't make it through more than half of the thread without some liquid courage.

 

[Mr Bitterness]

This is where every doc, let me say again EVERY DOC, comes together and says no picking up pts 2 hrs out.

We need to realize we're the reason the patient is there. That's it. Stand up, stand together and stop being fu***** pushovers.

Also get your act together ACEP.

Easy to say. When the change was made to require approval by directors, I told the docs that worked for me that I would NEVER turn down their overtime requests in shift admin, and to please put in every minute they worked. At other sites it was very different. We all know plenty of docs who stay hours late to document, and won’t bill for it. They either bought into the BS about “you’re the owner of a business”, or they were terrible docs that wanted to keep their jobs, or they were young and are afraid to bill extra. Either way a big percentage of the docs at the sites would never bill for staying late. Incredible abuse of the time and worth of the docs, (and this didn’t start til Dominic sold out to private equity.)

And to those who say to sue. . . . Good luck. You’re going to quit your job, and sue a massive PE backed company/ your employer for denying you a few hours of pay?

 

[RustedFox]

Easy to say. When the change was made to require approval by directors, I told the docs that worked for me that I would NEVER turn down their overtime requests in shift admin, and to please put in every minute they worked. At other sites it was very different. We all know plenty of docs who stay hours late to document, and won’t bill for it. They either bought into the BS about “you’re the owner of a business”, or they were terrible docs that wanted to keep their jobs, or they were young and are afraid to bill extra. Either way a big percentage of the docs at the sites would never bill for staying late. Incredible abuse of the time and worth of the docs, (and this didn’t start til Dominic sold out to private equity.)

And to those who say to sue. . . . Good luck. You’re going to quit your job, and sue a massive PE backed company/ your employer for denying you a few hours of pay?

At my one site; they straight took it out of the director's hands.
Nope. No overtime for you. Or you. Or anyone.

 

[GeneralVeers]

This is why my new hobby is collecting bourbon.

My Old Fitzgerald 16 year bottled-in-bond just arrived today.

Currently project is finding a way to make a perfect spherical ice cube. Sure, you can use a mold, but where the mold meets there is a nubbin that has to be shaved off somehow.

Just drink a lot, it'll all work out somehow

I rather like the nubbin. On mine if I underfill the mold they come out concave, and the sphere looks like a cool Death Star.

 

[GeneralVeers]

At my one site; they straight took it out of the director's hands.
Nope. No overtime for you. Or you. Or anyone.

They like to prey on physician altruism. Right now I don't mind staying and helping out because I'm on RVU and will get paid for anything I see after my shift. If I'm hourly, forget it. I stop picking up anything more than a simple med refill 2 hours before the end of shift, and I'm out the door right when the clock strikes 12, regardless of how busy the department is.

 

[CliveStaples]

This is why my new hobby is collecting bourbon.

My Old Fitzgerald 16 year bottled-in-bond just arrived today.

Currently project is finding a way to make a perfect spherical ice cube. Sure, you can use a mold, but where the mold meets there is a nubbin that has to be shaved off somehow.

Just drink a lot, it'll all work out somehow

I picked one up from the Heaven Hill gift shop this year. Let me know how you like it.