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Eight years ago, Rod McCaskill, an emergency physician from Raleigh, NC, left his group to join a much smaller EM practice in a less populated part of the state. Initially, McCaskill thought he made the right choice. Then three of the group’s ten physicians suddenly left. The remaining EPs were forced to cover the vacancies and McCaskill found that his workload jumped by 30 percent.

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At LA County, residents Emily Rose (bottom) and Cary Gallardo (watching the O2 sat and vitals) work to quickly secure a patient’s airway after a barbecue explosion. The airway was secured after several difficult attempts. Photo by Jeremy Orvik, MD

“I soon discovered that if you get with the wrong group, things can get very bad, very quickly,” McCaskill said. Fortunately, McCaskill was able to rejoin his original practice Wake Emergency Physicians and has had no plans of leaving again.

McCaskill is one of many EPs around the nation who have experienced the dichotomy of the emergency medicine employment market. On the one hand, studies show that EM career options are more plentiful than ever. On the other, pay raises fail to keep pace and overall job satisfaction continues to wane.

Last year in its Physician Employment and Compensation Outlook for 2007, the New England Journal of Medicine painted a rosy picture of the physician landscape. Those “heading into the job market for the first time or eyeing a career move in 2007,” the report stated, “will find plentiful opportunities and attractive compensation packages, regardless of their specialty or preferred setting.” What the report omitted was that EPs would have to work much harder to maintain what they are currently making. Working more hours, seeing more patients in busier EDs and spending more time than ever meeting regulatory requirements, all while giving up more of what’s important to them just to survive. This trend is expected to continue for several years.

While physician base pay in emergency medicine is going up competitively, compared with other specialties, EPs seem to be losing ground on annual increases, which have remained steady at about 4 percent per year since 2003. What’s more, the pay hikes are not necessarily being driven by the usual revenue generating parameters of improved reimbursement and greater productivity but by a growing series of recruiting problems affecting the profession as a whole. In other words, reimbursement may be excellent in some areas, upwardly skewing the numbers. However, are any of those areas in locations you are willing to move to?

The profession is facing an acute supply-and-demand problem, which is getting worse, says Larry Wills, vice president and director of recruiting for TeamHealth West. “Are we reaching a crisis? Absolutely,” Wills says.

An aging physician work force and growing regional differences in reimbursement, pay, and malpractice expenses are creating high demand for qualified EPs in poor, rural, and underserved areas. Yet, physician compensation isn’t necessarily reflecting the demand. In 2007, a staff physician received $213,500 in median base pay up only 4 percent from $205,000 in 2006, according to Daniel Sterns and Associates, a Pittsburgh, PA recruitment and consulting firm.

Total median compensation equaled $250,000 in 2007 compared with $240,000 the previous year. The increase barely kept abreast of inflation.

For independent contractors, both base pay and total compensation actually fell between 2006 and 2007 going from $240,000 to $227,700 in median base pay and $260,000 to $255,500 in total compensation.

The Northeast region of the country and several small, rural pockets of high poverty or heavy managed care are being hit especially hard. At the same time, the number of board-certified, residency-trained physicians entering the work force each year is falling short of taking up the slack.  Furthermore, you can turn out all of the EM graduates you want and you probably won’t impact the shortages being experienced in under-served and difficulty to recruit to areas.

“The challenge is the [physician] marketplace itself,” says Sean Crosswhite, a regional vice president with Dallas, TX-based recruiter Merritt, Hawkins. “There are literally hundreds of opportunities across the country going unfilled, and groups are scratching their heads trying to figure out where they go from here.”

Emergency physicians are in a classic buyer’s market, says Wills of TeamHealth. They “know they’re in the driver’s seat and they’ll find a job somewhere.”

The west, southwest, and southeast regions of the country are still the most desirable in terms of pay and benefits, according to consultant Daniel Stern. The least desirable region has been the northeast in places like Boston and New York for reasons that most experts can’t accurately pinpoint.

Managed care, the cost of living, harsh winters, and crushing malpractice costs are the most frequently cited. But, the high percentage of uninsured patients and an aging health care infrastructure have also contributed to lower overall physician compensation and satisfaction.

An annual review of compensation incentives compiled by Merritt, Hawkins shows that the base amounts physicians  are being offered to leave one practice for another have zig-zagged in the past five years. (The data looks at an aggregate of what physicians are being offered instead of what they actually make.)

In 2007, for example, EPs were offered $240,000 to switch practices compared with only $239,000 in 2006. But the differences were much wider between 2004 and 2005 and again between 2006 and 2007 when pay offers climbed to $246,000 from $218,000 and $239,000 from $210,000, respectively. No reason was given for the large differences in those years.

According to a trend survey published earlier this year by Daniel Stern and Associates, EPs feel the problems affecting EM are so entrenched they are likely to remain that way for much of the next decade.

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Dr. Billy Mallon of LA County/USC summons the team together during a busy overnight shift for an improptu lecture. Photo by Jeremy Orvik, MD. More photos at www.orvik.com/jeremy

Nearly 40 percent of physicians indicated that they would consider leaving their practice. The malpractice climate was one reason cited by the survey. Overcrowding in the ED, inpatient boarding, and a lack of adequate ancillary and specialist support were also mentioned.

But surprisingly, lifestyle factors, geographical environment, and practice flexibility affect EPs the most and in a large part drive both satisfaction and individual compensation.

In the Stern survey, despite the report that nearly 80 percent reported morale between good to fair; only 15 percent said they had poor morale. 99% of survey respondents felt that the crisis in Emergency Medicine will become worse in the short term and 54% rated ED morale as fair or poor. Fortunately, with no back-up six figure incomes on the horizon, some emergency physicians are finding ways to meet their needs while riding out the storm. The one exception is the aging EP. In the next three years nearly 30 percent of all physicians will be either planning for or taking retirement, working part time, or getting out of the medical field altogether, according to Merritt, Hawkins. Dissatisfaction with the health care climate is the biggest reason.

Unlike docs in almost any other specialty, physicians in EM are more likely to leave an unsatisfying medical practice and relocate for the promise of a better life. They are also more likely to consider a reasonable cut in pay if the new practice offers them attractive amenities, says Larry Wills.

Physicians like Po Huang, MD are doing just that. Nine years ago, the 39-year-old decided to leave Pittsburgh after completing his residency and move to Boise, ID where he joined Idaho Emergency Physicians, a 24-physician practice is Boise.

Originally from Texas and a graduate of Baylor College of Medicine in Houston, Huang says he was driven by his passion for the outdoors and found Boise a near-perfect practice environment. In turn, Idaho Emergency Physicians allowed Huang to exercise his personal passions.

“The group makes a serious effort to accommodate physicians’ lifestyle,” says Thomas P. Peterson, the group’s Executive Director.

As a rule, doctors are prevented from working more than one consecutive shift without an eight-hour break in between. They’re allowed flexible time off when needed and are guaranteed an on-call physician to cover last-minute absences or leaves. An “acuity schedule” enables the staff to effectively manage their time and patient load without feeling overburdened.

“Each physician typically sees the most acute cases at the beginning of the shift,” says Peterson. As other docs arrive, they take on the more complex cases. “The system helps the docs to gradually wind down and enables them the time to complete their paperwork,” Peterson says.

The scheduling has cut the time EPs spend post-shift by an average of 1.25 hours per day, Peterson says.

But Boise has its share of big-city problems, Huang is quick to point out. There is still a worrisome amount of overcrowding, uncompensated care, and inpatient boarding, which could get worse. “I am concerned about the future,” he says.

What makes Idaho Emergency Physicians a well-run practice is in part the adequate supply of EPs, Peterson acknowledges. Any erosion in the physician supply would inevitably lead to a domino effect of eroding physician morale and effectiveness and multiplying problems in the ED, which would further aggravate the physician shortage. 
Though conditions have slowed, younger EPs seem to be as inclined as ever to relocate if it suits them. Merritt Hawkins estimates that 75 percent of young physicians will relocate in the first three years after residency.

But as the health care environment worsens and pay raises continue to narrow, physicians may find fewer and fewer places to go.

“If things don’t change,” says Peterson of Idaho Emergency Physicians, “I can see emergency medicine becoming a public utility.” To sustain their incomes, physicians will have to work harder wherever they go, Peterson says.

STAT! | by the numbers*
  • 99% of respondents believe the “crisis” in Emergency Medicine will become worse in the short term
  • 54% rated ED morale as being fair (39%) or poor (15%)
  • 72% of respondents indicated that back-up coverage is a problem in their ED
  • 61% stated that the nursing support in their departments was inadequate
  • 46% of respondents indicating that they did not have support for their Emergency Departments by Hospital Administration and Boards of Directors.

    * “2008 Trends, Predictions and Perceptions of Emergency Medicine Physicians,” a survey by Daniel Stern & Associates
 

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