Almost one year out...

[tube_em]

Hello all,

I recently finished my emergency medicine training, and in general I actually very much enjoyed my residency and training....but now, I'm having second thoughts on whether I want to stay in EM long term. The reason is not emergency medicine itself, because I do enjoy the medicine, but other factors. I was 24 years old when I applied for residency, and since then, things have changed (gotten married, etc.). I am now almost one year post-residency, and am finding the shift work to really be a drain. For example, I worked until 4 am, and today (my "off" day) I am basically a zombie. Of course, there were more hours in residency, but the truth is the off-service rotations were usually a break from the shift work and schedule flip-flopping. I also put up with it in residency because I figured, "things will be better once I'm an attending." Things are better than in residency, but residency wasn't as long as the rest of my career. Having a week off straight, randomly every 2-3 months is great...to a point. Except I end up spending it sitting at home because the wife works, so we can't go anywhere anyway.

Additionally, the stress and worry of "missing something" are much higher than as a resident (when someone was looking over your shoulder). Thankfully, I haven't "messed up" or had a bad outcome yet, but I can see it happening...especially when the department is packed and you are running around trying to put out fires. When something does come up (so far little things) and I have to sit down and discuss it with the dept. head, it bothers me for days.

Thinking about the future, I don't think this lifestyle is sustainable for myself. The shift work and the stress at work are things that are already starting to make me question EM as a career for myself. The group I work with is excellent, as is the compensation and support/physician staffing, and I can't complain about anything about the that. In fact, I would say I am probably in one of the best hospitals/groups to practice EM in my area.

I have no interest in going to work in BFE at a small rural ER, I've moonlit at those places and found it very unfulfilling (currently work at a trauma center with >85k volume). Obviously I can eventually go part time at 50 or 55, but there's the issue of those pesky 20-25 years in between.

I've considered fellowships, including interventional pain and palliative care. Interventional pain, with its multiple procedures, would be something I could definitely see myself doing, but I know it is extremely competitive, especially for EM. Palliative care I would also be interested in (have done a rotation as a student), but interventional pain is more towards my interest. Unfortunately, I am AOBEM certified, not ABEM, so do not believe I will be eligible for any pain fellowships (required ACGME residency). I come from a strong osteopathic residency, in a trauma center with very high volume which has other (ACGME) residencies in-house, but I don't believe that'll make any difference in terms of pain fellowship.

I've even considered doing a second residency (PM&R, which I loved as a student but had it after the match in fourth year), but it's hard to imagine going back and doing another 3-4 years.

Sorry for the long post, I just wanted to see if anyone else here could give their 2 cents. I see a few of you have done fellowships and wanted to know your thoughts. I don't want this to discourage potential EM residents from pursuing the field, just go into it with your eyes open and realize every field has its pros and cons...pick the one that has the cons you can live with, and consider 20 years down the road as well (plenty of people find happiness in EM, including the vast majority of my colleagues that I work with).

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[deleted128562]

Seems like a critical care fellowship could be a good road? More hours as an attending and some switch from days to nights, but not the constant rotating shift work. Pretty cool medicine too.

 

[WilcoWorld]

I think you're at a typical and temporary low point. Quitting now would be a lot like quitting residency during the winter SICU month of your second year. I recommend you give it some more time and see if things get better - you probably don't even have a great handle on your hospital's system yet, and once you gain that your job will get much easier.

In the mean time try your best to identify what it is that's bothering you. That way, if things haven't improved once you're settled in, you can pick the solution that best addresses what's bothering you (whether that's a fellowship, a job with a different pace/schedule, or [shudder] a second residency.

 

[Birdstrike]

Hello all,

I recently finished my emergency medicine training, and in general I actually very much enjoyed my residency and training....but now, I'm having second thoughts on whether I want to stay in EM long term. The reason is not emergency medicine itself, because I do enjoy the medicine, but other factors. I was 24 years old when I applied for residency, and since then, things have changed (gotten married, etc.). I am now almost one year post-residency, and am finding the shift work to really be a drain. For example, I worked until 4 am, and today (my "off" day) I am basically a zombie. Of course, there were more hours in residency, but the truth is the off-service rotations were usually a break from the shift work and schedule flip-flopping. I also put up with it in residency because I figured, "things will be better once I'm an attending." Things are better than in residency, but residency wasn't as long as the rest of my career. Having a week off straight, randomly every 2-3 months is great...to a point. Except I end up spending it sitting at home because the wife works, so we can't go anywhere anyway.

Additionally, the stress and worry of "missing something" are much higher than as a resident (when someone was looking over your shoulder). Thankfully, I haven't "messed up" or had a bad outcome yet, but I can see it happening...especially when the department is packed and you are running around trying to put out fires. When something does come up (so far little things) and I have to sit down and discuss it with the dept. head, it bothers me for days.

Thinking about the future, I don't think this lifestyle is sustainable for myself. The shift work and the stress at work are things that are already starting to make me question EM as a career for myself. The group I work with is excellent, as is the compensation and support/physician staffing, and I can't complain about anything about the that. In fact, I would say I am probably in one of the best hospitals/groups to practice EM in my area.

I have no interest in going to work in BFE at a small rural ER, I've moonlit at those places and found it very unfulfilling (currently work at a trauma center with >85k volume). Obviously I can eventually go part time at 50 or 55, but there's the issue of those pesky 20-25 years in between.

I've considered fellowships, including interventional pain and palliative care. Interventional pain, with its multiple procedures, would be something I could definitely see myself doing, but I know it is extremely competitive, especially for EM. Palliative care I would also be interested in (have done a rotation as a student), but interventional pain is more towards my interest. Unfortunately, I am AOBEM certified, not ABEM, so do not believe I will be eligible for any pain fellowships (required ACGME residency). I come from a strong osteopathic residency, in a trauma center with very high volume which has other (ACGME) residencies in-house, but I don't believe that'll make any difference in terms of pain fellowship.

I've even considered doing a second residency (PM&R, which I loved as a student but had it after the match in fourth year), but it's hard to imagine going back and doing another 3-4 years.

Sorry for the long post, I just wanted to see if anyone else here could give their 2 cents. I see a few of you have done fellowships and wanted to know your thoughts. I don't want this to discourage potential EM residents from pursuing the field, just go into it with your eyes open and realize every field has its pros and cons...pick the one that has the cons you can live with, and consider 20 years down the road as well (plenty of people find happiness in EM, including the vast majority of my colleagues that I work with).

I sympathize completely with your situation. The shift work got to me, too. It took a little longer for me, but after about 10 years, I was cooked from the circadian flips. I could've kept on doing it, but why? They say, "The best thing about Emergency Medicine, is that when you're off, you are off." But it's not really true, is it, when you've worked until 4 am, went to bed at 5 am and four hours later it's time to be bright-eyed, interested, involved and engaged spouse, parent or friend. Or when you've had a case so vivid, thoughts of it bleed into your "off time." Is it really that easy to flick that switch completely "off" when you walk out the door?

Whether or not this is simply a temporary rough patch or the first step to a needed career change, don't ignore or suppress that voice on your shoulder. Make the necessary changes now, whatever they are. Whether it means finding a job where there's less nights, or less shifts in general, something probably needs to change.

I think the fellowships are a good idea, all of them included. That's one way to make a change while building on your EM background, and not starting over. Laying the groundwork for a career in Administration is another, with less clinical work as a trade off. Moving into Academics may be better for some, where the focus may be more intellectual with teaching and less about grinding out max patients/max shifts beyond the point of red-lining. Partnering with someone and opening an Urgent Care is another option, with the challenge of entrepreneurship, being your own boss, with no nights and no Press Ganey. Doing another residency could be considered, but as you know it's a huge commitment. If you do that, make sure the next one is "the one."

Don't feel bad about what you are going through. It can be turned into a positive. Unfortunately, this is the Achilles heel of Emergency Medicine. The shifts, the circadian rhythm back flips, can be completely life disrupting. People will try to throw pejoratives around to try to dismiss you as "burned out" or "not meant for EM" but that's bullsh¡t. It's not easy or normal to do what Emergency Physicians expect themselves to do.

In General, the specialty has very little solution for this. The fellowships are relatively new and are a positive change, but more needs to be done. This is not a problem within you, it's a problem within the specialty (in the United States, anyways), where "physician satisfaction" and wellness, are placed far, far, below patient satisfaction, CEO satisfaction and 15-minute door to doctor times. Read this article by Gregg Henry, and "EMs Mid-Life Crisis."

http://www.epmonthly.com/departments/columns/oh-henry/ems-mid-life-crisis/

Think this all through now, rather than 10 years down the road when it's much harder to make changes. Make the best and most rational decision for you and your family. Do that, and it's likely to all work out for the best, no matter which direction you go. One thing I do know, is that life is far too short to stay trapped in a soul-crushing hospital, specialty, or profession that's not right for you. Break the chains.

 

[tube_em]

I sympathize completely with your situation. The shift work got to me, too. It took a little longer for me, but after about 10 years, I was cooked from the circadian flips. I could've kept on doing it, but why? They say, "The best thing about Emergency Medicine, is that when you're off, you are off." But it's not really true, is it, when you've worked until 4 am, went to bed at 5 am and four hours later it's time to be bright-eyed, interested, involved and engaged spouse, parent or friend. Or when you've had a case so vivid, thoughts of it bleed into your "off time." Is it really that easy to flick that switch completely "off" when you walk out the door?

Whether or not this is simply a temporary rough patch or the first step to a needed career change, don't ignore or suppress that voice on your shoulder. Make the necessary changes now, whatever they are. Whether it means finding a job where there's less nights, or less shifts in general, something probably needs to change.

I think the fellowships are a good idea, all of them included. That's one way to make a change while building on your EM background and not starting over. Laying the groundwork for a career in Administration is another, with less clinical work as a trade off. Partnering with someone and opening an Urgent Care is another. Doing another residency could be considered, but as you know it's a huge commitment. If you do that, make sure the next one is "the one."

Don't feel bad about what you are going through. It's can be turned into a positive. Unfortunately, this is the Achilles heel of Emergency Medicine. The shifts, the circadian rhythm back flips, can be completely life disrupting. People will try to pejorative around to try to dismiss you as "burned out" or "not meant for EM" but that's bullsh¡t. It's not easy or normal to do what Emergency Physicians expect themselves to do.

In General, the specialty has very little solution for this. The fellowships are relatively new and are a positive change, but more needs to be done. This is not a problem within you, it's a problem within the specialty (in the United States, anyways), where "physician satisfaction" and wellness are placed far, far, below patient satisfaction, CEO satisfaction and 15-minute door to doctor times. Read this article by Gregg Henry, and "EMs Mid-Life Crisis."

http://www.epmonthly.com/departments/columns/oh-henry/ems-mid-life-crisis/

Think this all through now, rather than 10 years down the road when it's much harder to make changes. Make the best and most rational decision for you and your family. Do that, and it's likely to all work out for the best, no matter what you do.

Thank you all for your replies. As for CCM, I have an interest but not enough to make a career out of it. In terms of whether this is just a rough patch, the truth is this has been nagging me since second year of residency, but I chalked it up to "residency is tough." I have basically decided I need a change, I just am not sure where to go with it.

Birdstrike, I considered admin, and it sounds great on paper. Unfortunately it's not a guarantee, and it takes time to build up a rep to where you have enough responsibilities to cut back clinically. I would like to eventually go into admin, but not pressure myself to get there ASAP so I can cut back.

As for the circadian rhythm disruption, you hit the nail on the head. When I was single I would come back from a late shift and sleep till whenever and go back to bed whenever. Now, it doesn't work like that. My wife is understanding, and lets me sleep, etc. but she doesn't want to hang out with me at 1 am when I can't sleep. So a lot of "off time" is spent watching tv by myself at midnight....not exactly what I want now, let alone at age 50.

My group is actually very good at scheduling, and we work few true nights (there are a few nocturnalists). However, working one of the shifts that go to 3 am or 4 am, though not true overnights, can be almost as disruptive.

I'm not trying to complain, the field is definitely rewarding and exciting. I know I chose the field for the right reasons at 24, but now I realize it was short sighted. The schedule and field is great for some, and I truly wish I was one of them. Any people with fellowship experience (especially palliative or pain) or that have been in the same boat that can give their advice?

 

[RustedFox]

I think you're making a mistake by working the "until 3 or 4 am" shifts, and then trying to be up-and-at-em at 9-10 am.

Sleep 'til noon, man: You'll still have half the day, and you'll be AAOx4 for those hours, instead of awake, but not really.

I used to try and 'bend the clock' like that. Not anymore. Big mistake.

 

[TrumpetDoc]

Reading your post feels like I am seeing a post on mine! I can very much relate!

 

[goodoldalky]

Just curious… How many hours a month do you work? Just a guess.. but it sounds like you're probably working too many.

 

[tube_em]

Just curious… How many hours a month do you work? Just a guess.. but it sounds like you're probably working too many.

I don't think it's the number of hours...I work 135 a month. I can definitely do this job for a few years, but I'm thinking about 5 or 10 years from now....I know I can't do it for long.

 

[goodoldalky]

I would reconsider that.. Based on my limited experience having interviewed for a bunch of and having eventually accepted a job, 135 hours a month is very high. Attendings here may agree or disagree. IMO once you get above 120 hours a month you should be getting paid substantially more.

 

[The White Coat Investor]

Will your group let you work mostly days for lower pay?

 

[The White Coat Investor]

I don't think it's the number of hours...I work 135 a month. I can definitely do this job for a few years, but I'm thinking about 5 or 10 years from now....I know I can't do it for long.

Psssttt...it is the number of hours. Drop 3 shifts a month and see how you feel. Better I bet.

 

[Zanegray]

This is the minimum number for FT at my shop. (135 I mean) Many work more.

 

[docB]

Hello all,

I recently finished my emergency medicine training, and in general I actually very much enjoyed my residency and training....but now, I'm having second thoughts on whether I want to stay in EM long term. The reason is not emergency medicine itself, because I do enjoy the medicine, but other factors. I was 24 years old when I applied for residency, and since then, things have changed (gotten married, etc.). I am now almost one year post-residency, and am finding the shift work to really be a drain. For example, I worked until 4 am, and today (my "off" day) I am basically a zombie. Of course, there were more hours in residency, but the truth is the off-service rotations were usually a break from the shift work and schedule flip-flopping. I also put up with it in residency because I figured, "things will be better once I'm an attending." Things are better than in residency, but residency wasn't as long as the rest of my career. Having a week off straight, randomly every 2-3 months is great...to a point. Except I end up spending it sitting at home because the wife works, so we can't go anywhere anyway.

Additionally, the stress and worry of "missing something" are much higher than as a resident (when someone was looking over your shoulder). Thankfully, I haven't "messed up" or had a bad outcome yet, but I can see it happening...especially when the department is packed and you are running around trying to put out fires. When something does come up (so far little things) and I have to sit down and discuss it with the dept. head, it bothers me for days.

I could have written this exact post after my first year out. Check the archives, I probably did. In fact lots of us felt this way.

Reading your post feels like I am seeing a post on mine! I can very much relate!

I will say, and remember that I'm the de facto curmudgeonly pessimist around here, that it does get better. You get used to the shifts although they get hard again as you age. It's not so much getting used to them as learning how to actually plan for them. The "day off" on the calendar after a night shift can't be treated like a day of. It just isn't. Plan that you're asleep until at least noon or 1 and it will help. It's still hard. My kids are up at 7 no matter what so if I worked until 3 I'm up for at least a little while. But it's manageable.

I agree with Rusted here:

I think you're making a mistake by working the "until 3 or 4 am" shifts, and then trying to be up-and-at-em at 9-10 am.

Sleep 'til noon, man: You'll still have half the day, and you'll be AAOx4 for those hours, instead of awake, but not really.

I used to try and 'bend the clock' like that. Not anymore. Big mistake.

As for worrying about the little talks with the department head they got to me too. I would caution you to keep things in perspective. You definitely need to differentiate between issues that arise because you messed up clinically vs. things that are really just political issues. If you admitted a patient to the wrong service, pissed of a consultant because you pushed him to get out of bed and see the patient and the like you will learn those complexities as you go. Those things take several years to really master and they're really less important. Worry about the clinical stuff. Take the political stuff with a grain of salt and move on.

Whether or not this is simply a temporary rough patch or the first step to a needed career change, don't ignore or suppress that voice on your shoulder. Make the necessary changes now, whatever they are. Whether it means finding a job where there's less nights, or less shifts in general, something probably needs to change.

I agree with this but I also am more optimistic that things will improve as you get a little further along. How do you reconcile the two? Pick a date when you will reevaluate your situation. Sit down with your wife and go over your options. Select a date somewhere down the road like 6 months or a year and decide that if you get there and things still suck you'll pull the trigger and move on one of your options. I've done this in the past and it really took a load off me knowing that I had a firm date and it would go one way or the other. It let me quit worrying about the decision and let me put effort into making the existing situation and my CV for the options better.

And I wholeheartedly agree with this:

Psssttt...it is the number of hours. Drop 3 shifts a month and see how you feel. Better I bet.

Most situations in EM are helped by dialing the hours back a bit. Even just a shift a month if you can afford it without increasing your money stress.

Bottom line: Do what you need to do to be happy and keep your family sane. But know that most of us were right there with you at that point in our careers.

Good luck. I sincerely hope you sort it out and are satisfied with whatever you decide to do.

 

[dotcb]

Find a way to cut your hours to 110 for a month or two, then re-evaluate. You may need a position that allows more flexibility with the minimum number of hours to obtain benefits. 34 hours a week of clinical EM is not sustainable if your ED is at all busy or high acuity. The first year or two out are a steep learning curve. I wouldn't change fields before at least 3 years out. It sounds like you're not prioritizing or protecting your sleep, which are critical for longevity in this field.

 

[Groove]

Late to the conversation. As others have said, it's most likely your hours and possibly the work environment. I feel like you do when I work anything over 165+ and I'm bored beyond tears when I work anything approaching 120. Also, I've found that I'm immensely more happy and energized at a well run, better covered 45K lvl 2 compared to my last 90K lvl 2. Just because you work in a 90+K ED doesn't mean that anything smaller would put you working in a boring rural ED. I see very sick pt's daily at my current gig but instead of being stretched thin and having to hustle 2.5-3.0 pph with multiple dying and critical pt's every shift. I'm working 2-2.2 pph or so with excellent coverage and longer shifts and I honestly feel great when I leave every day. World of difference.

You aren't guaranteed any sig lifestyle improvement if you changed and changing specialties so early in your career would be a red flag for most people and something you might look back on and regret not at least trying to modify or tweak to your current lifestyle requirements. I would probably rate EM as one of THE most flexible and mobile specialties. Yes, the shift work sucks but you can dial it back and space things to where it honestly should not be that big of an issue.

 

[The White Coat Investor]

This is the minimum number for FT at my shop. (135 I mean) Many work more.

Sounds like a recipe for longevity.

 

[@JackShephard]

I'm curious, what's the lower # of hours some of your colleagues work? (like 25th percentile)

100 hrs a month? more or less?

 

[Hercules]

I'm curious, what's the lower # of hours some of your colleagues work? (like 25th percentile)

100 hrs a month? more or less?

The oldest guy in our group (1st EM trained guy in the state) works 80 hrs/mo in our group. We call it senior partner status. He still gets FT benefits but also pays a FT portion of the operating expenses-- so everyone wins.

 

[HLxDrummer]

How many hours are your shifts and how many shifts/month? I am just an MS2 but I have looked into EM a lot and this is one of my major concerns (really the only one). As the others have said, it seems like you need to cut back on hours. The conclusion I have come to is you can't work as many hours as you want/think you can because of the sleep problems.

Maybe something like 27 hours/week then if you add the number of hours you are sleeping when your wife is awake it will be like a normal job - probably still better than the hours a surgeon or cardiologist would work. I know the pay cut might hurt but just think how much happier you and your family may be.

Let us know what ends up happening, and good luck!

PS: The PD at my school says in this area the average EM physician does 12 shifts a month. I'm pretty sure they are 8 hour shifts. So 96 hours/month. Sounds more manageable than what you are doing.

 

[The White Coat Investor]

I'm curious, what's the lower # of hours some of your colleagues work? (like 25th percentile)

100 hrs a month? more or less?

Our minimum is 6 eights, or 48 hours. 12 hours a week. I'd guess our 25th percentile was about 10, so 80 hours.

 

[@JackShephard]

It does appear that if one was burning out, that cutting back to 80-100 hrs would be much easier than pursuing another field.

 

[tube_em]

Sorry I disappeared for a bit, worked a stretch of shifts and neglected to check back. I sincerely appreciate everyone's responses and advice.

In terms of those who mentioned cutting back hours, it's something I am definitely considering. My current contract is for 1600 hours/month. The lowest in my group that anyone works (other than admin/director, etc.) is 1500 hours/month.

The causes of the discussions with the director were partly clinical, partly political. By this I mean that in hindsight I could have done things better, but no harm was done and I did not mismanage the patient, but the admitting doc wasn't happy with my management. The director was very supportive of me, and did not throw me under the bus by any means. But it can be very disheartening (as I'm sure many of you know) to feel like you're doing things right and when you make one mistake, or piss off the wrong person, it requires a discussion with the director.

I really like docB's advice about sitting down with my wife and having a set date on when to reevaluate. It will help me focus on what I can do to make things better in the meantime. I am not going to make any rash decisions, I'll definitely take my time and evaluate when the time comes.

Drummer, my shifts are a mix of 10's and 12's, approx 135 hours a month.

In terms of finding a different place to work, moving is not an option for me at this time. However, I am not planning on staying at my current job forever, and will probably be looking for a new job (unless I decide on fellowship, etc.) in the next few years. Hopefully I can find something more conducive to a long, happy career in EM.

Again, I really appreciate everyone's advice.

 

[Venko]

For different reasons, I needed a more regular schedule too and so switched to work only nights. Each place is different on whether it would also provide a shift reduction etc that may help. I would echo that I personally feel better when I sleep from 7a to 12 or 1p after the shift. Also, as far as fellowships, consider sports medicine, hyperbarics/wound cAre, toxicology, as ways to build a new skill that could result in a daytime regular job.

Good luck,
Venko

 

[pagemmapants]

80-100h? That's something that one can do and still keep benefits?
Huh.
Faculty at my training program were 14.5 shifts/mo for full time. At 8s that means 116 h/mo, for academic pay. The clinical docs at our 2nd site worked around 19 shifts/mo for years 1-3 unless they were nocturnists in which case they could cut back to 16/mo. My shop is 128 h/mo for full time and I thought that was crazy-low. I'm hypermileing myself to 156hpm because of those pesky private school loans that I want to get out from under ASAP but clearly that's not something I can sustain. However, I found I got bored at 128h/mo.

Anyway, that's pretty off topic.

My private-world burnout plan would be sports med or hyperbarics (although to do any of the fun stuff you at least have to be quasi-academic or get one of those coveted tropical jobs), but I'm keeping my foot in the door re: academics in case that becomes more feasible later on once the debt is less of a factor.

Would you consider being a nocturnist? Seems like the best way to have a "regular" schedule in the EM world and maintain your sanity. Our nocturnist found it was really conducive to kid-rasising: getting off at 6a means home at 6:30-7 just in time to get the kids up and ready for school, then bed while the kids are at school. I can imagine that would put a little strain on your relationship with your partner, depending on their schedule, but if you're not working every night that could certainly be worked around. Cosmo says it's important to schedule time for that anyway, even if you have a normal schedule!

 

[knovecc]

怒码 nice thread, how can I flag it

 

[Beth_W737]

I don't know if anyone mentioned this but the new residency merger means you can apply for allo fellowships and sit for the ACGME boards. I'm starting PGY-1 at an osteopathic EM program that will become ACGME next year (provisionally). So consider those fellowship options. Good luck!

 

[@JackShephard]

怒码 nice thread, how can I flag it

Bookmark it via your browser, or save the web address anywhere.

 

[dockiran]

Hello all,

I recently finished my emergency medicine training, and in general I actually very much enjoyed my residency and training....but now, I'm having second thoughts on whether I want to stay in EM long term. The reason is not emergency medicine itself, because I do enjoy the medicine, but other factors. I was 24 years old when I applied for residency, and since then, things have changed (gotten married, etc.). I am now almost one year post-residency, and am finding the shift work to really be a drain. For example, I worked until 4 am, and today (my "off" day) I am basically a zombie. Of course, there were more hours in residency, but the truth is the off-service rotations were usually a break from the shift work and schedule flip-flopping. I also put up with it in residency because I figured, "things will be better once I'm an attending." Things are better than in residency, but residency wasn't as long as the rest of my career. Having a week off straight, randomly every 2-3 months is great...to a point. Except I end up spending it sitting at home because the wife works, so we can't go anywhere anyway.

Additionally, the stress and worry of "missing something" are much higher than as a resident (when someone was looking over your shoulder). Thankfully, I haven't "messed up" or had a bad outcome yet, but I can see it happening...especially when the department is packed and you are running around trying to put out fires. When something does come up (so far little things) and I have to sit down and discuss it with the dept. head, it bothers me for days.

Thinking about the future, I don't think this lifestyle is sustainable for myself. The shift work and the stress at work are things that are already starting to make me question EM as a career for myself. The group I work with is excellent, as is the compensation and support/physician staffing, and I can't complain about anything about the that. In fact, I would say I am probably in one of the best hospitals/groups to practice EM in my area.

I have no interest in going to work in BFE at a small rural ER, I've moonlit at those places and found it very unfulfilling (currently work at a trauma center with >85k volume). Obviously I can eventually go part time at 50 or 55, but there's the issue of those pesky 20-25 years in between.

I've considered fellowships, including interventional pain and palliative care. Interventional pain, with its multiple procedures, would be something I could definitely see myself doing, but I know it is extremely competitive, especially for EM. Palliative care I would also be interested in (have done a rotation as a student), but interventional pain is more towards my interest. Unfortunately, I am AOBEM certified, not ABEM, so do not believe I will be eligible for any pain fellowships (required ACGME residency). I come from a strong osteopathic residency, in a trauma center with very high volume which has other (ACGME) residencies in-house, but I don't believe that'll make any difference in terms of pain fellowship.

I've even considered doing a second residency (PM&R, which I loved as a student but had it after the match in fourth year), but it's hard to imagine going back and doing another 3-4 years.

Sorry for the long post, I just wanted to see if anyone else here could give their 2 cents. I see a few of you have done fellowships and wanted to know your thoughts. I don't want this to discourage potential EM residents from pursuing the field, just go into it with your eyes open and realize every field has its pros and cons...pick the one that has the cons you can live with, and consider 20 years down the road as well (plenty of people find happiness in EM, including the vast majority of my colleagues that I work with).

I know this was last year, but I was wondering how your situation is now?

 

[docdragon]

Wow, thanks for the post. At just about a year out, working 140-160hrs/month, I just saw this. My spouse is antsy about night shifts, though doesn't mind them as much when I can stick with 8-hrs instead of 12's for coverage. I have a really supportive ED and love the docs & nurses, but this business is definitely tougher with more stress, a spouse, neighbors who crank up the radio at 7:30am most weekends, worsening malpractice environment, increasingly complex hospital admission procedures, and the typical patient surges. I have a strong leaning toward a fellowship anyway, sports med or peds, and am watching for the right time (which will never come, and is currently scheduled around June) to volunteer to lower my total hours.

What stages have other people experienced? I had pinned the life cycle as:
yr 1 -- glad to be out, intellectually & emotionally exhausting
yr 2-5 -- continue to learn, settle in
yr 5-10 -- not particularly more stressful, but still proving self if in academics, publishing, etc
yr 10 -- next age change hits around here, v high risk of tedium

 

[womp]

How is this any different than traditional q4-7 call that other physicians do? The nights are often just as disruptive, except they often still have to go to work the next day. Is it really the Circadian rhythm disruptions? Or do some ED docs just schedule their life to have more free days (over-extend their days off doing other activities when they should really be sleeping)?

 

[Tecmo Bowl]

How is this any different than traditional q4-7 call that other physicians do? The nights are often just as disruptive, except they often still have to go to work the next day. Is it really the Circadian rhythm disruptions? Or do some ED docs just schedule their life to have more free days (over-extend their days off doing other activities when they should really be sleeping)?

It's different from what other physicians do because working q4-7 doesn't necessarily mean working every 4th through 7th night. Sure, if you are a neurosurgeon/vascular surgeon/etc. at an academic referral center your schedule is going to suck, but 90% of medicine doesn't occur at these centers and unfortunately we get a skewed perception on how the medical system works by only seeing the robust academic mills that have every specialist known to man during medical school and residency. Your community orthopod isn't getting called in at 2am for that Colle's Fracture. If there is a bad femur fracture, chances are that they need a level 1 trauma center (your level 1 trauma center attendings lifestyle sucks).

Most internists are using hospitalist services now. Most community surgeons use NPs/PAs for all of their scut work and generally can sleep during the night and operate in the AM if bread and butter surgery comes in (GBs, appys, etc.).

Unfortunately, the jobs in medicine with rough lifestyles are ones that require you to see emergencies at any time of the day and any time of the year: CT surgery, trauma surgeons, interventional cards, IR, etc. Unfortunately, Emergency Medicine falls into this realm. We are at the forefront of seeing emergencies. True, 80% of what we see is bull****, and we have started use NPS and PAs for our scutwork (urgent care), but the truth is, there needs to be somebody staffing the ER who can manage that gsw to the chest that roles in, or the 6 year old coding asthmatic patient, or the 24 year old female in active labor with a shoulder dystocia presentation, or the septic pulmonary htn patient. A good NP and PA can do 80% of our job, but that 20% is what separates us and is why an attending EM doctor should be in every ED at all times.

There are lots of specialties with worse lifestyles, but most specialties in medicine have better lifestyles as an attending (even if they had worse lifestyles as residents). It is not a ROAD specialty. Switching from nights to days and back to nights does play a toll. Working holidays does play a toll. The irregularity does play a toll. You choose EM because you like the variety, can put up with seeing 80% of patients who could have went to an internist or FM doc, enjoy seeing the 18% of patients who are sick and need admission, and thrive on the 2% of patients who are having actual emergencies and without your procedural/diagnostic/clinical skills likely would have died even if you never get credit for saving that patient.

 

[shopsteward]

The starting point for anyone concerned about work patterns/stress is to put themselves into a position of financial independence. Pay off debts, don't let your lifestyle inflate, buy a modest house (and only after you are well settled geographically and family-wise and in a location with more than one satisfactory job option). Stash your savings in low-cost index funds (Vanguard). On a doctor's earnings, in a very few years you can be modestly set for life. You then have complete freedom to say "I won't work a job that needs night shifts/more than 80 hours a week/isn't properly resourced/whatever, and to negotiate on the basis that you can walk away if you don't get what you want.

If enough docs do this, the pay differential for working nights will then be worth while to those who don't have their finances in order - who will be the newly qualified, the ones with huge student loans, and the longer-qualified who have bought expensive cars/houses/boats/planes and who have married/divorced expensive men/women.

 

[Got Em]

Say that someone is willing to work at least 12 x 12 hr shifts per month, and willing to work days, nights (until 1am or so), weekends, but ZERO overnights. If you're willing to take a huge paycut ($350k to $250k, etc), how likely is it that the scheduler/group will agree to such an arrangement?

I've heard from people that cutting back shifts isn't an option at some places and changing shifts isn't either. However, it would make sense to me if you're paying a 50% or so differential for overnight shifts, there will be more people willing to work those.

 

[WilcoWorld]

Say that someone is willing to work at least 12 x 12 hr shifts per month, and willing to work days, nights (until 1am or so), weekends, but ZERO overnights. If you're willing to take a huge paycut ($350k to $250k, etc), how likely is it that the scheduler/group will agree to such an arrangement?

I've heard from people that cutting back shifts isn't an option at some places and changing shifts isn't either. However, it would make sense to me if you're paying a 50% or so differential for night shifts, there will be more people willing to work those.

It's very unlikely that your scheduler will promise you zero overnights (the recruiters are a different story).

If you have partners who need money, you can pay them in one form or another to work your overnights. Many (but not most) EM docs do this. However, if the ED is ever short-staffed (and they all are sometime) you're going to be asked to help out. So an honest scheduler will not promise that you'll never work overnight.

 

[goodoldalky]

Say that someone is willing to work at least 12 x 12 hr shifts per month, and willing to work days, nights (until 1am or so), weekends, but ZERO overnights. If you're willing to take a huge paycut ($350k to $250k, etc), how likely is it that the scheduler/group will agree to such an arrangement?

I've heard from people that cutting back shifts isn't an option at some places and changing shifts isn't either. However, it would make sense to me if you're paying a 50% or so differential for overnight shifts, there will be more people willing to work those.

There are groups with nocturnists that limit the number of nights the rest of the crew work, but it is generally not zero. Taking a large pay cut (i.e.: halving your salary) to work all days is possible, but involves working at an urgent care, not an ED.

Emergency medicine will require you to work nights basically. Plan on that.

 

[Mad Jack]

Say that someone is willing to work at least 12 x 12 hr shifts per month, and willing to work days, nights (until 1am or so), weekends, but ZERO overnights. If you're willing to take a huge paycut ($350k to $250k, etc), how likely is it that the scheduler/group will agree to such an arrangement?

I've heard from people that cutting back shifts isn't an option at some places and changing shifts isn't either. However, it would make sense to me if you're paying a 50% or so differential for overnight shifts, there will be more people willing to work those.

My roommate is interested in EM, and asked an EM doc that'd been practicing for quite some time a very similar question. She laughed in his face, and said if something like that were possible, she'd have been doing it a decade ago.

 

[Got Em]

My roommate is interested in EM, and asked an EM doc that'd been practicing for quite some time a very similar question. She laughed in his face, and said if something like that were possible, she'd have been doing it a decade ago.

There are groups with nocturnists that limit the number of nights the rest of the crew work, but it is generally not zero. Taking a large pay cut (i.e.: halving your salary) to work all days is possible, but involves working at an urgent care, not an ED.

Emergency medicine will require you to work nights basically. Plan on that.

I'm almost set on EM and I'm definitely okay with doing nights. I'm just still very naive about scheduling and why it "has to be done" like it is currently.

It seems to me that many people are willing to take MUCH LESS salary to not work overnights. From researching on SDN, it seems like the overnight differential is 10-30% (WCI's groups is 40%), but this is very low IMO. Can someone explain why we are not paying nocturnists more? If we paid a 50% differential, wouldn't we have a much easier time with filling these nocturnal shifts?

For example, if a shop has a schedule of 6 x 12s (days, nights, weekends) and 6 x 12s (overnights) per 28s for a salary of $351k. Here are 3 options:
1) Same schedule = $351k
2) 12 x 12s of only days, nights, weekends at 150/hr = $280,800
3) 12 x 12s of only overnights at 225/hr = $421,200

The average salary in Southcentral/Southeast states are about $350k. I believe there are many that are willing to work at option 2 for even less than $280k and even be okay with a higher overnight differential. I believe this can alleviate the problem with flip-flopping as we get older and the nocturnal route would be ideal for younger physicians to pay off loans faster. Why isn't this done more? I'm really sorry if this is a stupid question...I just never really understood the reasons why this isn't done.

 

[dav86]

It doesn't HAVE to be done like it "currently" is, it is likely done this way because that is what the schedulers have to work with.

First, I don't think that many people want to do nights. And to preserve the field, the nocturnists typically would be new grads and again I am assuming many groups can't find enough new grads willing to work all nights. Also most groups aren't paying a 50% night shift differential. Likely because most new grads are stupid and will sign with CMGs and hospital employed groups for either no differential or something between 10-20 bucks an hour so they can live in the "desirable" locations (i.e. San Diego, Seattle, Chicago, New York City, etc.).

Also, to change the system you will have to get the older guys to buy into making a 100k less a year. If they are working tw0-three nights a month and making 350-400k and your new system says they can dump their nights to make 280 a year, I don't know how many are willing to do that.

I think the scheduling dilemma is a little more complicated than just throwing a 100k a year more at nocturnists. Again, CMGs won't pay you that and SDG will need a majority of the partnership to buy into that change.

I am starting a SDG in Aug and obviously have little experience with actual practice, but this is what I have gathered throughout the interview process.

 

[Arcan57]

I'm almost set on EM and I'm definitely okay with doing nights. I'm just still very naive about scheduling and why it "has to be done" like it is currently.

It seems to me that many people are willing to take MUCH LESS salary to not work overnights. From researching on SDN, it seems like the overnight differential is 10-30% (WCI's groups is 40%), but this is very low IMO. Can someone explain why we are not paying nocturnists more? If we paid a 50% differential, wouldn't we have a much easier time with filling these nocturnal shifts?

For example, if a shop has a schedule of 6 x 12s (days, nights, weekends) and 6 x 12s (overnights) per 28s for a salary of $351k. Here are 3 options:
1) Same schedule = $351k
2) 12 x 12s of only days, nights, weekends at 150/hr = $280,800
3) 12 x 12s of only overnights at 225/hr = $421,200

The average salary in Southcentral/Southeast states are about $350k. I believe there are many that are willing to work at option 2 for even less than $280k and even be okay with a higher overnight differential. I believe this can alleviate the problem with flip-flopping as we get older and the nocturnal route would be ideal for younger physicians to pay off loans faster. Why isn't this done more? I'm really sorry if this is a stupid question...I just never really understood the reasons why this isn't done.

A couple of points:

1) Basing assumptions off the highest paying region and then generalizing to the entire country will lead to inaccurate final numbers.
2) Running the number briefly, most shops will have 30-60 overnight shifts/month. That's 2.5 to 5 nocturnists per shop to keep everyone else off nights. Regardless of pay, that's going to be hard to find.
3) Most nocturnists aren't willing to work weekends which still leaves 8 overnight shifts per month, at least.
3) Everyone wants to maximize their money and most docs are willing to take 3-5 overnights/mo rather than lose $100k.
4) CMGs would happily pay nocturnists $100k more if the rest of the docs were happy having that $100k taken out of their pay. They'd advertise the sh%& out of that to pull in docs that want to work days. It would require a push by the non-nocturnists which doesn't typically happen for the reasons above.
5) Young docs are better able to tolerate night shifts but they also are more possessive of their night life, especially single or married w/o kids couple.

 

[goodoldalky]

There is also the problem of filling the schedule. As a medical director, your chief concern with regard to the schedule is that it is full. This is a challenge in EM because physicians tend to change jobs more frequently than in other fields. It is much easier to compensate for these unexpected changes when you have a large group of doctors, none of which are promised anything in terms of whether they are working nights or not. Now, when you encounter the inevitable scenario where you lose a nocturnist or two, all of the sudden you are in a position where you are scrambling to get these people who were promised no nights to now work nights, and overall it creates a messy situation. That is, unless, you carry a surplus of nocturnists to ensure you always have night coverage - but what are you going to do, pay them the nightly rate to work the same day shift the other doc is doing for less while the nights are overstaffed?

To me one of the main reasons these scenarios are a little uncommon and often don't last long is the issue of schedule stability in EM.

 

[Got Em]

A couple of points:

1) Basing assumptions off the highest paying region and then generalizing to the entire country will lead to inaccurate final numbers.
2) Running the number briefly, most shops will have 30-60 overnight shifts/month. That's 2.5 to 5 nocturnists per shop to keep everyone else off nights. Regardless of pay, that's going to be hard to find.
3) Most nocturnists aren't willing to work weekends which still leaves 8 overnight shifts per month, at least.
3) Everyone wants to maximize their money and most docs are willing to take 3-5 overnights/mo rather than lose $100k.
4) CMGs would happily pay nocturnists $100k more if the rest of the docs were happy having that $100k taken out of their pay. They'd advertise the sh%& out of that to pull in docs that want to work days. It would require a push by the non-nocturnists which doesn't typically happen for the reasons above.
5) Young docs are better able to tolerate night shifts but they also are more possessive of their night life, especially single or married w/o kids couple.

Thank you for giving your input.

I'm in the south region and most likely will stay here, so that's why I used it for my calculations. I came across a couple of websites where WCI spoke about how his shop gives a 40-50% pay differential for overnights and those same shifts that couldn't fill before "magically" filled. His point was that when you give enough of a differential (there has to be a point in every group), it's often easier to fill these undesirable shifts. He then pointed out how he doesn't know why other places don't do this, so I was just trying to continue the convo. Anyway, I feel like I have a better idea of why it's not done. Thanks!

 

[UnderwaterDoc]

To the OP

Nocturnist is the way to go. Ask you director for more pay or less hours and they will very likely agree given that everybody hates nights. Then schedule your shifts in blocks. I do 4-5 shifts in a row with a 7-8 days off in between. Makes my time off much more enjoyable. Usually takes me a whole day to flip back to day schedule.

On a related note, I love the people stating that 135 hours is "too much". At my shop the average hours for our group is 160, many work more. I gotta find myself one of these cushy jobs one of these days , and before you ask, we do not have a high turnover of docs, not even close.

 

[goodoldalky]

On a related note, I love the people stating that 135 hours is "too much". At my shop the average hours for our group is 160, many work more. I gotta find myself one of these cushy jobs one of these days , and before you ask, we do not have a high turnover of docs, not even close.

In general I would say that 160 hours is way too many. However, every hospital is different. Every provider is different. Kudos to you Underwater as you must have herculean grit and stamina.
There are 2 guys in my group who max out around 170 a month, and I have no idea how they do it. Average is 110. The higher patients per hour you see and the higher the acuity in general the more difficult it is to work a higher number of hours. If you are at a place where you do 24s and see 1 pph and discharge them, you may be able to work a lot more. I see around 3.0 pph and admit 30% and there's no way I could pull 160. Everyone will probably have a slightly different "redline" so to speak.

 

[turtledog]

Here in Boston metro area, average income for EM docs is only about $260k (and lower for academics and starting salaries). Hard to imagine someone willing to make significantly less than that to avoid nights, especially given the high cost of living here. These huge salaries you see posted are not reflective of the reality of desirable metro areas along the coast.