Is Emergency Medicine Dying

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Matthew S. -

I feel like this somewhat misses the point of why EM is under threat. From the residency perspective, the idea of offering these non-emergency services simply because we're available isn't foreign or novel. That's what we're being trained in and what we're used to, so being an availabeist (availabist?) is not discordant with why we chose EM.

What REALLY makes EM as a career feel like it's dying to those of us still in residency is the rapid decline in jobs available to us thanks to an over supply of new residency programs and APPs, as well as the CMG takeover. It's easy to adapt to new and changing expectations on us as physicians, but you have to have a job to be able to do that. THAT is the real threat to the field.

John V. -

Between CMGs, hospital admins, and uncle Sam I’m not even sure docs have a seat at the real table to self determine our specialties future. CMG’s spending millions in Washington, running residency programs, and establishing national department doc:APP ratio norms that are way out of balance .......good business plan for their ends. They are literally draining the lifeblood and credibility of our specialty. I agree EM is on the downswing but disagree it has anything to do with turkey sandwiches or willingness to perform a 5am ear wash. Especially after the heroism we demonstrated over the past year, despite pay and or hours cuts, I give all EM docs a pass on the blame. We are still the singular best part of the equation.

tom f. -

hi guys!

excellent pod. I love it.
few thoughts. agree completely with the thoughts expressed here.
our EM specialty, if I recall, was begun with the dedication of such folk as the orthopedic doc (if I remember correctly), whose son was in a major MVA, and went the local community hospital. here he recognized (it was early 70's I think) that the ER's were terribly deficient (did he start the ATLS system?)

we, as ER docs, are expected to be the jacks of all trades, and masters of all trades. we must master the simple and the complex, the sore throats and the threatened airways, the nauseous woman who unexpectedly is found to be pregnant , and the peri-mortem hysterotomy.

had a case last week. blind in her right eye for three days . didn't have the resources to come to the ER sooner. stat ocular US showed a badly detached retina. that was the easy part. the next was a little harder. we have no ophtho servicing our ER. I called the next closest place (45 minutes north in Modesto. spoke to my friend the ER doc there, who had me call the ophtho on-call, who had me call the retinal specialist (this is all at 8pm) , who was super gracious and would see the patient the next day, and take her to the OR if needed, despite the fact that she was homeless and without insurance. her truck was far from he hospital, it was raining. we had her sleep in the ED, and our charge nurse got her to her ophtho appt that next day.

my point is: you are right. our specialty has morphed into something perhaps different (altho I'm not completely sure about that, we should ask Rick Bukata and Jerry Hoffman and Greg Henry), but just as beautiful I think, if not more so, and perhaps a little more complex, and sometimes requiring St. MacGyver, to get our results.
Jack of all trades,masters of all. and education, as doc Pescatori says here, through platforms like your team's Swami that maker it possible.

thanks guys.
tom fiero , merced, ca.

tom f. -

please correct my misspell.. its doc Pescatore!

John C. -

Loved this, we are the light in the dark. Sometimes our light is an airway and sometimes a turkey sandwich.
What an amazing job we have.

Keith H. -

Don't underestimate the lowly turkey sandwich. For many of our homeless folks, I have nothing at 3 am to help their addiction, their mental health issues, or their being lost in an increasingly complex health care system they can't navigate. (How do you sign up for MediCal when you don't have a phone and administration won't pay for Social Service at night.) The only comfort I can give is that turkey sandwich.

Geoffrey M. -

I would love to hear Rick and Jerry on this. I think emergency medicine is failing its patients -the essence of emergency medicine is dying. It is not advocating for our patients who are triaged as chest pain pathway or stroke pathway or sepsis pathway -- given a triage number not based on clinical judgement. It biases patient management thereafter. It is medicine by numbers and not by clinical judgement. When a patient comes with a sore throat - that is what it is to him- that is what he knows. If it is a viral pharyngitis our management is largely reassurance but if it is quinsy we manage that. If it is chest pain pathway with normal ecg and troponins we are expected to NOT reassure but do some demented dance to suggest there is a 0.01% chance you may have a mace- god forbid unstable angina.
Get a barrage of tests and which mostly find nothing. Not uncommonly this patient will return with the same symptoms, like a viral pharyngitis - only no reassurance offered here. Just back on the pathway to despair. The fortunate patient is now the one with a myocardial infarction. I fear the wave of stroke pathway it seems to be building. No more funny turns just a stroke pathway.

Mel H. -

My biggest concern is the explosion of residencies. I know lots of ER docs worry about APP's but this is not the issue. We appear to be making a new residency every 5 minutes and this will be a huge issue if they are not tied to rural and remote care. Australia opened residencies and medical schools in remote areas to address the issue of the cities making too many docs for the local area but most of them not wanting to go live and practice in areas of greatest need.

Mel H. -

See this article:

Brown R., Jr -

Mathew S and Mel hit the nail on the head. As much as I enjoyed the podcast, it totally missed the glaringly obvious subject matter about the real threat to the specialty. It's actually NOT in dealing with the subacute or non emergent pathology. Let's face it, if all of those cases dried up, the majority of us working in the community wouldn't have a job anymore because we have an oversupply of emergency docs. The real issue is the massive proliferation of residency programs and dumping of residents into the work force with a huge supply that overwhelms the actual needs. I think most academic physicians, which unfortunately also tend to be involved in our national organizations, are completely blind to the issue because they are relatively cocooned. The rest of us feel the cramped space all too much. Just talk to your residents and ask them how many of them are having problems finding jobs. An issue that was almost unheard of 10 years ago. We've hired some new docs who went months without jobs and were in a state of panic because they couldn't find anything. This was pre-COVID. CMGs are sponsoring more and more residency programs in a concerted effort to increase supply of EM residents and saturate the market which drives down salaries for EM docs and provides a constant steady state of available bodies for the department. Now, I've heard some people say this will be good for the specialty because it will facilitate standardization in credentialing among emergency physicians. It's a valid argument but I think it fails on several fronts and is a subject for a different conversation. Regardless, it's extremely concerning to me that all of us out in the community recognize this problem and hear the woes of newly graduated residents all too frequently yet I hear nobody talking about it. ACEP seems oblivious but then again...they have always been in bed with the CMGs. APPs infringing on our turf....good grief...I WISH that was our biggest problem right now and I never thought I would say that.

Daniel S. -

It's time to unionize

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EM:RAP 2021 March SNACK: Is Emergency Medicine Dying? Full episode audio for MD edition 12:47 min - 14 MB - M4A