More corporate greed: Doctors disappearing from Emergency Rooms

[Boatswain2PA]

https://khn.org/news/article/doctors-are-disappearing-from-emergency-rooms-as-hospitals-look-to-cut-costs/

 

Lots to unpack here.

Private equity operating in an environment that may be too complex to get adequate capitalistic constraints?  The NSA might be a bludgeon to change this...

 

Are EPs overtrained?  I think NPs are clearly undertrained...

What happens to hugely leveraged CMGs when they have to restructure their PE debt in a high-interest rate nvironment?  (Please please please tell me they fall apart!)

[SedRate]

[kettle]

Formal EM residencies minimum of a year should really be the standard in the future.

[Boatswain2PA]

22 minutes ago, kettle said:

Formal EM residencies minimum of a year should really be the standard in the future.

For docs?  PAs?  NPs?

[kettle]

13 minutes ago, Boatswain2PA said:

For docs?  PAs?  NPs?

PA's and NP's. I did one, 18 months, advantageous. I do feel like I provided good care and it helped me secure the best jobs out there. 

[sas5814]

I read another article about NPs and PAs in the ER though it focused almost exclusively on NPs. They had a picture of an NP, who already worked in the ER, learning to do chest tubes on a rack of ribs with the store wrapper still on it. I don't know what to say about that exactly. I don't know what the training models are these days.

I'm Army trained. We learned on goats.....

[ventana]

I am probably in the minority here but I think this needs to be addressed

 

The new grad PA and NP are not being mentored and trained, instead hospitals and for profit companies are merely treating them as interchangeable with physicians.  I even am hearing it from some docs - which seems insane in that they are in essence giving up the fight saying that you can replace doc's with NPs for pretty much everything.  

 

I can not say that PA=MD/DO in any general sense.  There are exceptions and these are more likely in the IM/PCP world and less so in the sub specialties.

I can strongly say that a New Grad NP who went through one of the hundreds of DLO programs is far far below even a new grad PA.  

 

This is going to come out in the data because companies that are only concerned with profit are going to realize they can hire these new NPs on the cheap - but they will have bad outcomes.   Unavoidable

 

 

We need to keep doing our very best to make the most competent proficient new grads - (now is not the time to water down our education) 

Then we need to mentor them (I think a 1 year mandatory fellowship in a hospital system)  to allow them to grow in the great providers we all know!!

[sas5814]

One of the problems I see nearly constantly is the attempt to classify everyone with a set of letters behind their name with the same description. That's not how anything in the medical profession works. Every MD, PA, and NP generally has core skills credentialling and then it grows from there as education and experience demonstrate.

My wife and I have a rule about arguing.... any declaration that includes absolutes (always and never) are discarded as BS and you have to start over. I think that applies pretty well to most any discussion.

[kettle]

1 hour ago, sas5814 said:

 Every MD, PA, and NP generally has core skills credentialling and then it grows from there as education and experience demonstrate.

There's a few places I work where I'm with a physician doing 12s. Depending who I work with, I have some things I'm credentialed for that they are not. These are FM trained Docs not EM trained Docs.

Ah never threw a chest tube in a goat but have intubated them and bunnies. No longer able to do that. I was fortunate to teach a procedural cadaver lab for med students in Airway management. After they left I would practice my chest tubes. Probably did 40 before my first one on a patient in the ER

[sas5814]

14 minutes ago, kettle said:

Ah never threw a chest tube in a goat but have intubated them and bunnies. No longer able to do that. I was fortunate to teach a procedural cadaver lab for med students in Airway management. After they left I would practice my chest tubes. Probably did 40 before my first one on a patient in the ER

Goats are great  because you can cric one about a dozen times.... long necks.

We passed chest tubes up and down their ribs just for the practice. This was in the days of goat lab which was a big secret back in the day. They would be anesth by a nurse anes and then shot through the back leg with a steel ball bearing then off to the OR. We would spend the day doing just about everything you might want to do to a body then they were put down after being injected with green dye. Apparently people were taking their carcasses out of the dump and eating them. Nobody will eat a green goat. It was interesting to see how fast a whole goat turned green after a green dye IV(seconds).

Back to your regular programming.

[SedRate]

3 hours ago, kettle said:

There's a few places I work where I'm with a physician doing 12s. Depending who I work with, I have some things I'm credentialed for that they are not. These are FM trained Docs not EM trained Docs.

Ah never threw a chest tube in a goat but have intubated them and bunnies. No longer able to do that. I was fortunate to teach a procedural cadaver lab for med students in Airway management. After they left I would practice my chest tubes. Probably did 40 before my first one on a patient in the ER

That's awesome, man! Great idea about practicing your chest tubes. 

[SedRate]

2 hours ago, sas5814 said:

Goats are great  because you can cric one about a dozen times.... long necks.

We passed chest tubes up and down their ribs just for the practice. This was in the days of goat lab which was a big secret back in the day. They would be anesth by a nurse anes and then shot through the back leg with a steel ball bearing then off to the OR. We would spend the day doing just about everything you might want to do to a body then they were put down after being injected with green dye. Apparently people were taking their carcasses out of the dump and eating them. Nobody will eat a green goat. It was interesting to see how fast a whole goat turned green after a green dye IV(seconds).

Back to your regular programming.

Wow! I can only imagine everything else you've seen over your career. 

[CAAdmission]

4 hours ago, sas5814 said:

Nobody will eat a green goat.

I'd eat a green goat. Depends on the dye. 

[kettle]

1 hour ago, CAAdmission said:

I'd eat a green goat. Depends on the dye. 

I'd eat a green goat as well, I didn't even have to hunt last year, got a deer and moose both roadkill before November. If I eat w ditch deer,I'd definitely eat a green sheep

[ohiovolffemtp]

I've not worked for APP but I have worked for both TeamHealth and Envision.   I've not seen either one of them replace physicians with PA's or NP's.  In fact, I've seen their cost and compensation models pay physicians fully or partially on performance (RVU's) and the PA's and NP's straight hourly.  When volumes dropped, both companies cut PA/NP hours and preserved physician hours.  The thought process  seemed to be that anyone paid straight hourly was a cost to be managed down, even if they were more cost effective than physicians.  Physicians were seen as needing to be kept and preferable because their compensation was at least partially variable based on productivity.

Separately, I'm not put off by PA's and NP's going through training for advanced procedures like central lines, chest tubes, LP's, and intubation and then going through a credentialing process requiring a number of supervised procedures.  That seems to be similar to the same process the physicians went through in their residencies.

Medicine is learned by experience.  Residencies are an excellent way to get that experience and a place where physicians have a clear lead.  PA residencies go a long way to narrow that gap.  However, a smart and motivated PA can gain the competence to handle at least nearly all of EM patients by building their path to get that same experience: targeted classes, OJT - especially by consistently choosing to manage higher acuity and higher complexity patients and learning from each one.

[EMEDPA]

13 hours ago, ohiovolffemtp said:

I

Medicine is learned by experience.  Residencies are an excellent way to get that experience and a place where physicians have a clear lead.  PA residencies go a long way to narrow that gap.  However, a smart and motivated PA can gain the competence to handle at least nearly all of EM patients by building their path to get that same experience: targeted classes, OJT - especially by consistently choosing to manage higher acuity and higher complexity patients and learning from each one.

This is what you and I did and it worked, but I would be in favor of others taking a faster and higher yield path in the form of a residency. It took me 10 + years of climbing the acuity ladder up mediocre jobs before I was at a place that a new grad from an EM residency is at after 12-18 months of concentrated learning.

[ohiovolffemtp]

10 hours ago, EMEDPA said:

This is what you and I did and it worked, but I would be in favor of others taking a faster and higher yield path in the form of a residency. It took me 10 + years of climbing the acuity ladder up mediocre jobs before I was at a place that a new grad from an EM residency is at after 12-18 months of concentrated learning.

Agreed.  However, there just aren't enough PA EM residency slots available to meet the need.  Also, I wonder that the motivations for a shorter training pathway and quicker return to the workforce that lead folks to pick PA school vs medical school would also motivate them to go straight to work vs spending another 12-18 months in a training setting.  For me, I needed to return to family, home, and paycheck, even though a few EM PA residencies were available when I graduated.  I even was told by my PA program faculty that I didn't need to do an EM residency because of my years in fire/EMS - which was completely wrong.

[CAAdmission]

To an extent, some of this comes down to the type of facility you work at. I worked at a large academic medical center that had a physician residency program. Even though there was no formal PA residency program, the culture of the institution was oriented toward teaching. The attending physicians were genuinely interested in the professional development of all of the providers in the department, PAs included. This was back in the days before many PA residencies were around, but it almost served as a quasi-residency.

I have also worked at community hospitals where you were basically thrown to the wolves and had no support. Not a good place to try to start a career. 

 

Edited February 18, 2023 by CAAdmission

[TeddyRucpin]

8 hours ago, ohiovolffemtp said:

Agreed.  However, there just aren't enough PA EM residency slots available to meet the need.  Also, I wonder that the motivations for a shorter training pathway and quicker return to the workforce that lead folks to pick PA school vs medical school would also motivate them to go straight to work vs spending another 12-18 months in a training setting.  For me, I needed to return to family, home, and paycheck, even though a few EM PA residencies were available when I graduated.  I even was told by my PA program faculty that I didn't need to do an EM residency because of my years in fire/EMS - which was completely wrong.

The last sentence hits close to home. Coming from a similar background and then doing a rotation in EM, you realize how the difference in knowledge can still be night and day. It's hard to fathom getting a month in EM then expecting to get a job where you'll be trained to the top of your license. I know it's happened before but probably takes years and involves jumping from place to place. A residency, particularly in fields like EM or CC, has its role. 

[kettle]

8 hours ago, TeddyRucpin said:

The last sentence hits close to home. Coming from a similar background and then doing a rotation in EM, you realize how the difference in knowledge can still be night and day. It's hard to fathom getting a month in EM then expecting to get a job where you'll be trained to the top of your license. I know it's happened before but probably takes years and involves jumping from place to place. A residency, particularly in fields like EM or CC, has its role. 

I was told the same thing, was told that I shouldn't do a residency since I'd make less. In 18 months I learned a ton. I also learned what I didn't know and that was more valuable. I work about 75% of my time solo coverage. I have zero issues reaching out to others, specialists and ED docs at other facilities.

Residency for a specialty is fantastic. So many new grads get thrown into the fire and it sets them up for failure 

[ventana]

The hardest specialty is old fashion PCP medicine

yet NCCPA will not do a CAQ????

[rev ronin]

1 hour ago, ventana said:

The hardest specialty is old fashion PCP medicine

yet NCCPA will not do a CAQ????

1) Covering what?

2) How much profit will they make from it?

[ventana]

21 hours ago, rev ronin said:

1) Covering what?

2) How much profit will they make from it?

1) Internal Medicine

2)  A lot - I would pay a for a CAQ for a IM cert and then politic for independence

[iconic]

3 hours ago, ventana said:

1) Internal Medicine

2)  A lot - I would pay a for a CAQ for a IM cert and then politic for independence

We don’t need CAQ to politic for independence when NPs are getting it with 500 shadowing hours and online nursing modules 

Edited February 22, 2023 by iconic

[CAAdmission]

While we are talking about corporate greed, let's not forget physician greed. Many of the docs I have worked with have been some of the most avaricious people I have ever met, and I know a lot of lawyers and investment banker type people. 

It was the docs who were running the healthcare system into the ground. The regulatory mess we deal with is in at least small part due to docs gaming Medicare and Medicaid. When docs thought selling out to corporate med could make them richer, they quickly did so. In most groups I worked for, the docs drove vehicles that cost more than my annual salary. I'd have a new baby at home and my holiday bonus would be a poinsettia plant. 

Don't be too mad at the corporate folks - they are simply doing what their MBA programs trained them to do. Be mad at the docs that let these people take over the system. And it was all out of greed.