Need some advice on which job to choose

[confusedjobapplicant]

So I've interviewed at 3 different places, two of which are pretty similar, and one is very different from the rest. Obviously the pro's about each shop is great and they're important to me, but unfortunately no shop has all the pro's I'm looking for (and I don't think any shop will). I've been banging my head about this for the past several weeks and just cannot choose which one I want. I've talked to multiple different physicians at each job and everytime it makes me want to pick the job they're at. I was hoping I could get some more insight and advice on here. Yes I made a new account so keep my anonymity.

What I'm looking for: First most a place where I can be happy, not be dreading going to work everyday. I'm not a meat mover or workhorse, so obviously somewhere that's relatively laid back and not pressured or required to see tons of patients. I also like big hospitals (as my training is in a HUGE tertiary level 1 center) and would be nice to have all specialties on call along with a lot of young energetic staff. Money is also NOT a motivating factor for me. The less hours I can work and the less nights I can do the better, with as little non clinical duties as possible.

Job 1
Small single hospital democratic group
18 bed hospital, ~35K annual visits, ~1.5 pt/hour, EMR is Cerner
Pay: $210/hour (flat rate no RVUs) + benefits (health insurance, malpractice, 401K) (don't want to be partner, otherwise it's 2 year $5K buy in @ $170 hr/per)
Scheduling: ~120 hours for full time, all 8 hour shifts, will have single coverage at times but still have decent amount of double coverage, smaller group so will be a little harder to request a lot of time off at once, absolutely ZERO nights.
Consultants: Almost none. Will have to transfer many things out. Otherwise hospitalists seem easy enough to admit to with no pushback.
Vibe from other docs: Say it's the best place they've worked and will never want to leave. Very laid back atmosphere with low stress. The medical director was a really nice guy who seemed very genuine.
Pros: Laid back, low pressure, no nights, nice and genuine medical director
Cons: Was not impressed with the physical ED at all. Very small and kind of cramped. It's a smaller hospital, on the outskirts of a rural area, with a lot of old staff. about a 45 min drive for me (although I plan on moving after I finish residency anyways so not that big of a deal). Would like me to do non clinical duties, but I go employer route vs partner route I'm sure I could opt out of it.

Job 2
CMG (EmCare/Team health) at a relatively brand new large community hospital, ~55K visit, ~1-1.5 pt/ hour, EMR is Meditech
Pay: $215/hour + metric system bonus (can make up to $255/hr) + almost no benefits (only thing is malpractice and disability, they do not pay for health or provide 401K). Will get $32K sign on bonus. Get time and a half for any hours worked over 140 hours and for staying overtime during times of super high volume (ie staying 2 hours after an 8 hour shift you'll get 1.5x pay for those 2 hours)
Scheduling: 120 hours for full time, mix of 8's and 10's, single coverage only at night, otherwise always 3-4 docs on, will have to work about 3-5 nights
Consultants: Have most specialities, no optho or ENT, but transfers are easy and case manager takes care of that, otherwise super easy to admit to Hospitalists as they are part of and run by the same CMG corporate group as well.
Vibe from other docs: Essentially a place to work to make tons of money, given the 1.5x for more hours worked.
Pros: Make tons of money, will have residency in future and I wouldn't mind teaching, director says they could be employing full time nocturnists so possibility of no nights, new hospital, big nice ED with tons of new stuff and staff
Cons: It's a CMG. Will have pressure and metrics to deal with. EMR is horrible. The Medical director was kind of a squirrely guy and spoke like a salesman. Interestingly enough he actually used to work at Job 1, left there for this job, and was kind of bad mouthing Job 1 saying even though the people are great the hospital was not ideal to work at etc etc. Would like me to do non clinical duties, possibly incorporating residency program (which I like to teach and wouldn't mind it). About 45 min drive from me, again will be moving most likely so not a big deal

Job 3
Large democratic group, covers 4 hospitals, will be rotating at 2 of them, very similar to my residency. Don't have the combined total annual visits, but it's pretty high 100K+, ~2.2 pts/hour WITH scribes, EMR is Cerner
Pay: $180/hour +RVU based (avg is anywhere from $200-230/hour) + full benefits (health, malpractice, 401K) +$15K sign on bonus. Partner track is first 2 years just work, next 3 years hold a position (like medical director or some committee), then $200K buy in that's taken out of your dividends as a half partner.
Scheduling: 130 hours full time, mix of 8, 10, and 12's at 2 different sites, never single coverage, 4-6 nights/month.
Consultants: All specialties available. Hospitalists easy to admit once they are comfortable with you, slight pushback at times.
Vibe from other docs: They like working there, but no one seemed like it was the best thing ever, but also didn't say it was the worst place ever, more like it was just a job. Medical director very honest and straight up guy, has been around for a long time, Hospital and group has been around for a while with a ton of credibility and popularity in the area
Pros: Very popular and very credible hospital that's huge with a nice big ED, all the docs and staff are young and fun (HUGE group at ACEP and all of them partied hard), relatively close to home, multiple sites to get a variety, very similar to my training institution, SCRIBES!!
Cons: Higher pt/hour, little more hours, more nights than i'd like, partnership track is super sketchy and long (even though I don't want partner, still not a good taste in my mouth), everyone has good things to say but everyone I talked to had no passion about the job. No non clinical duties if I don't want to be a partner.

Sorry for the long post. Would appreciate any help in this very important time for me!! Thanks in advance.

---

Members don't see this ad.

 

['murica]

med student here. I bolded what stood out from your post. sounds like job 1 is what you're looking for.

So I've interviewed at 3 different places, two of which are pretty similar, and one is very different from the rest. Obviously the pro's about each shop is great and they're important to me, but unfortunately no shop has all the pro's I'm looking for (and I don't think any shop will). I've been banging my head about this for the past several weeks and just cannot choose which one I want. I've talked to multiple different physicians at each job and everytime it makes me want to pick the job they're at. I was hoping I could get some more insight and advice on here. Yes I made a new account so keep my anonymity.

What I'm looking for: First most a place where I can be happy, not be dreading going to work everyday. I'm not a meat mover or workhorse, so obviously somewhere that's relatively laid back and not pressured or required to see tons of patients. I also like big hospitals (as my training is in a HUGE tertiary level 1 center) and would be nice to have all specialties on call. Money is also NOT a motivating factor for me. The less hours I can work and the less nights I can do the better, with as little non clinical duties as possible.

Job 1
Small single hospital democratic group
18 bed hospital, ~35K annual visits, ~1.5 pt/hour, EMR is Cerner
Pay: $210/hour (flat rate no RVUs) + benefits (health insurance, malpractice, 401K) (don't want to be partner, otherwise it's 2 year $5K buy in @ $170 hr/per)
Scheduling: ~120 hours for full time, all 8 hour shifts, will have single coverage at times but still have decent amount of double coverage, smaller group so will be a little harder to request a lot of time off at once, absolutely ZERO nights.
Consultants: Almost none. Will have to transfer many things out. Otherwise hospitalists seem easy enough to admit to with no pushback.
Vibe from other docs: Say it's the best place they've worked and will never want to leave. Very laid back atmosphere with low stress. The medical director was a really nice guy who seemed very genuine.
My problems: Was not impressed with the physical ED at all. Very small and kind of cramped. It's a smaller hospital, on the outskirts of a rural area, with a lot of old staff. about a 45 min drive for me (although I plan on moving after I finish residency anyways so not that big of a deal). Would like me to do non clinical duties, but I go employer route vs partner route I'm sure I could opt out of it.

Job 2
CMG (EmCare/Team health) at a relatively brand new large community hospital, ~55K visit, ~1-1.5 pt/ hour, EMR is Meditech
Pay: $215/hour + metric system bonus (can make up to $255/hr) + almost no benefits (only thing is malpractice and disability, they do not pay for health or provide 401K). Will get $32K sign on bonus. Get time and a half for any hours worked over 140 hours and for staying overtime during times of super high volume (ie staying 2 hours after an 8 hour shift you'll get 1.5x pay for those 2 hours)
Scheduling: 120 hours for full time, mix of 8's and 10's, single coverage only at night, otherwise always 3-4 docs on, will have to work about 3-5 nights
Consultants: Have most specialities, no optho or ENT, but transfers are easy and case manager takes care of that, otherwise super easy to admit to Hospitalists as they are part of and run by the same CMG corporate group as well.
Vibe from other docs: Essentially a place to work to make tons of money, given the 1.5x for more hours worked.
My problems: It's a CMG. Will have pressure and metrics to deal with. EMR is horrible. The Medical director was kind of a squirrely guy and spoke like a salesman. Interestingly enough he actually used to work at Job 1, left there for this job, and was kind of bad mouthing Job 1 saying even though the people are great the hospital was not ideal to work at etc etc. Would like me to do non clinical duties, possibly incorporating residency program (which I like to teach and wouldn't mind it). About 45 min drive from me, again will be moving most likely so not a big deal

Job 3
Large democratic group, covers 4 hospitals, will be rotating at 2 of them, very similar to my residency. Don't have the combined total annual visits, but it's pretty high 100K+, ~2.2 pts/hour WITH scribes, EMR is Cerner
Pay: $180/hour +RVU based (avg is anywhere from $200-230/hour) + full benefits (health, malpractice, 401K) +$15K sign on bonus. Partner track is first 2 years just work, next 3 years hold a position (like medical director or some committee), then $200K buy in that's taken out of your dividends as a half partner.
Scheduling: 130 hours full time, mix of 8, 10, and 12's at 2 different sites, never single coverage, 4-6 nights/month.
Consultants: All specialties available. Hospitalists easy to admit once they are comfortable with you, slight pushback at times.
Vibe from other docs: They like working there, but no one seemed like it was the best thing ever, but also didn't say it was the worst place ever, more like it was just a job. Medical director very honest and straight up guy, has been around for a long time, Hospital and group has been around for a while with a ton of credibility and popularity in the area
My problems: Higher pt/hour, little more hours, more nights than i'd like, partnership track is super sketchy and long (even though I don't want partner, still not a good taste in my mouth), everyone has good things to say but everyone I talked to had no passion about the job. No non clinical duties if I don't want to be a partner.

Sorry for the long post. Would appreciate any help in this very important time for me!! Thanks in advance.

 

[da8s0859q]

Job 1. The way you write about them suggests that it's your preference as well. Can you overlook or at least be okay with the physical side (cramped ED, etc)?

Just my opinion. PGY2 starting to look around with a couple similar priorities to yours.

 

[CliveStaples]

My unprofessional opinion also says that Job 1 seems to be the job that you favor most (and for valid reasons, don't get me wrong). I am curious about more details about that partnership track and why you aren't interested, however. I understand that the pay is lower for a couple years, but generally that will be made up very quickly.

Do you anticipate that you won't stay at the job long, and thus you want to maximize what you make? Will you have to start working nights on the partner track? I'm not saying it's unwise to think you won't be there forever (all the evidence says that it's very unlikely you stay with your first job out of residency), but I would still be interested in checking out that partner track a little bit more if I were you.

 

[confusedjobapplicant]

Thanks for the responses guys. I guess I should make it more known that I felt very uncomfortable with the physical ED of Job 1. It was cramped, no private rooms. I guess you could say I'd much rather have the appeal of a bigger ED with nice facilities and new equipment. Also I'd like to be at a place where there are a lot of young people and young staff, Job 1 seemed more the type where older docs and older nurses would go to take it easy (which is exactly what I want, but in a super nice big ED, which I realize are pretty much mutually exclusive haha).

CliveStaples - the reason I'm not interested in partnership track is because a) I don't know what my future holds - I'm single, always wanted to move to a different state, so I don't know where I'll be in 2 years from now. So yes I do want to maximize my money during the time I'm there. and B) with becoming partner also comes holding positions in committees and more non clinical work which I'm not interested in. I may be interested in it later, and can always switch to partnership track, but it does not appeal to me at this point in my life.

Bottom line: Job is a job, I work to live, I have a lot of other interests in life, and do not wish to put most of my hours in my job. But when I am at work I want to be happy and enjoy where I'm working, not hate it.

 

[The White Coat Investor]

Would like me to do non clinical duties, but I go employer route vs partner route I'm sure I could opt out of it........(even though I don't want partner, still not a good taste in my mouth),

Well, this is actually really easy. You don't want a partnership job. Two of these are partership jobs. One isn't. Go there. Why are you complaining about working for a CMG when you don't want to be a partner?

 

[Arcan57]

I give the bonus points for dinging for lack of passion when the OP says they're not good at their job (ie moving patients), they don't want to work often, and they don't want to do anything to make their shop better.

 

[confusedjobapplicant]

Well, this is actually really easy. You don't want a partnership job. Two of these are partership jobs. One isn't. Go there. Why are you complaining about working for a CMG when you don't want to be a partner?

Just because it's not partnership doesn't exclude the fact that I still have to deal with CMG metric systems. And both the partnership tracks at the two jobs havejust employee tracks as well.

I give the bonus points for dinging for lack of passion when the OP says they're not good at their job (ie moving patients), they don't want to work often, and they don't want to do anything to make their shop better.

I'm not following? If you're implying that I have a lack of passion for EM, then as I already stated above EM is just a job and I have other interests I have much more passion for I would rather spend my time on.

 

[Arcan57]

I'm not following? If you're implying that I have a lack of passion for EM, then as I already stated above EM is just a job and I have other interests I have much more passion for I would rather spend my time on.

I'm disheartened by your honesty and fear that the future of EM is bleaker because of the prevalence of that attitude among graduating residents. I also have a built in prejudice against people that are content to be mediocre at their job (while it may be a job to you, it's going to be life or death to some of your patients).

 

[Birdstrike]

I'm disheartened by your honesty ....

Honesty, is good, no?

 

[confusedjobapplicant]

I'm disheartened by your honesty and fear that the future of EM is bleaker because of the prevalence of that attitude among graduating residents. I also have a built in prejudice against people that are content to be mediocre at their job (while it may be a job to you, it's going to be life or death to some of your patients).

We all see multiple threads here everyday how one person is burnt out or another person hates what they're doing. I'm merely preventing that situation from happening in the first place and then really being a threat to my patients at that point. It doesn't mean I will be bad doctor which is what you're implying.

I would be happy to discuss this further with you over PM or in another thread if you wanted to start one, otherwise I'd appreciate anymore insight into which job I should choose.

 

[bonedrone14]

Just an ms3 here, but I don't think the idea of "medicine is just a job" necessitates that you'll give lackadaisical effort. I think it just means you want to have time to do other things besides work all the time.

 

[Birdstrike]

So I've interviewed at 3 different places, two of which are pretty similar, and one is very different from the rest. Obviously the pro's about each shop is great and they're important to me, but unfortunately no shop has all the pro's I'm looking for (and I don't think any shop will). I've been banging my head about this for the past several weeks and just cannot choose which one I want. I've talked to multiple different physicians at each job and everytime it makes me want to pick the job they're at. I was hoping I could get some more insight and advice on here. Yes I made a new account so keep my anonymity.

What I'm looking for: First most a place where I can be happy, not be dreading going to work everyday. I'm not a meat mover or workhorse, so obviously somewhere that's relatively laid back and not pressured or required to see tons of patients. I also like big hospitals (as my training is in a HUGE tertiary level 1 center) and would be nice to have all specialties on call along with a lot of young energetic staff. Money is also NOT a motivating factor for me. The less hours I can work and the less nights I can do the better, with as little non clinical duties as possible.

Job 1
Small single hospital democratic group
18 bed hospital, ~35K annual visits, ~1.5 pt/hour, EMR is Cerner
Pay: $210/hour (flat rate no RVUs) + benefits (health insurance, malpractice, 401K) (don't want to be partner, otherwise it's 2 year $5K buy in @ $170 hr/per)
Scheduling: ~120 hours for full time, all 8 hour shifts, will have single coverage at times but still have decent amount of double coverage, smaller group so will be a little harder to request a lot of time off at once, absolutely ZERO nights.
Consultants: Almost none. Will have to transfer many things out. Otherwise hospitalists seem easy enough to admit to with no pushback.
Vibe from other docs: Say it's the best place they've worked and will never want to leave. Very laid back atmosphere with low stress. The medical director was a really nice guy who seemed very genuine.
Pros: Laid back, low pressure, no nights, nice and genuine medical director
Cons: Was not impressed with the physical ED at all. Very small and kind of cramped. It's a smaller hospital, on the outskirts of a rural area, with a lot of old staff. about a 45 min drive for me (although I plan on moving after I finish residency anyways so not that big of a deal). Would like me to do non clinical duties, but I go employer route vs partner route I'm sure I could opt out of it.

Job 2
CMG (EmCare/Team health) at a relatively brand new large community hospital, ~55K visit, ~1-1.5 pt/ hour, EMR is Meditech
Pay: $215/hour + metric system bonus (can make up to $255/hr) + almost no benefits (only thing is malpractice and disability, they do not pay for health or provide 401K). Will get $32K sign on bonus. Get time and a half for any hours worked over 140 hours and for staying overtime during times of super high volume (ie staying 2 hours after an 8 hour shift you'll get 1.5x pay for those 2 hours)
Scheduling: 120 hours for full time, mix of 8's and 10's, single coverage only at night, otherwise always 3-4 docs on, will have to work about 3-5 nights
Consultants: Have most specialities, no optho or ENT, but transfers are easy and case manager takes care of that, otherwise super easy to admit to Hospitalists as they are part of and run by the same CMG corporate group as well.
Vibe from other docs: Essentially a place to work to make tons of money, given the 1.5x for more hours worked.
Pros: Make tons of money, will have residency in future and I wouldn't mind teaching, director says they could be employing full time nocturnists so possibility of no nights, new hospital, big nice ED with tons of new stuff and staff
Cons: It's a CMG. Will have pressure and metrics to deal with. EMR is horrible. The Medical director was kind of a squirrely guy and spoke like a salesman. Interestingly enough he actually used to work at Job 1, left there for this job, and was kind of bad mouthing Job 1 saying even though the people are great the hospital was not ideal to work at etc etc. Would like me to do non clinical duties, possibly incorporating residency program (which I like to teach and wouldn't mind it). About 45 min drive from me, again will be moving most likely so not a big deal

Job 3
Large democratic group, covers 4 hospitals, will be rotating at 2 of them, very similar to my residency. Don't have the combined total annual visits, but it's pretty high 100K+, ~2.2 pts/hour WITH scribes, EMR is Cerner
Pay: $180/hour +RVU based (avg is anywhere from $200-230/hour) + full benefits (health, malpractice, 401K) +$15K sign on bonus. Partner track is first 2 years just work, next 3 years hold a position (like medical director or some committee), then $200K buy in that's taken out of your dividends as a half partner.
Scheduling: 130 hours full time, mix of 8, 10, and 12's at 2 different sites, never single coverage, 4-6 nights/month.
Consultants: All specialties available. Hospitalists easy to admit once they are comfortable with you, slight pushback at times.
Vibe from other docs: They like working there, but no one seemed like it was the best thing ever, but also didn't say it was the worst place ever, more like it was just a job. Medical director very honest and straight up guy, has been around for a long time, Hospital and group has been around for a while with a ton of credibility and popularity in the area
Pros: Very popular and very credible hospital that's huge with a nice big ED, all the docs and staff are young and fun (HUGE group at ACEP and all of them partied hard), relatively close to home, multiple sites to get a variety, very similar to my training institution, SCRIBES!!
Cons: Higher pt/hour, little more hours, more nights than i'd like, partnership track is super sketchy and long (even though I don't want partner, still not a good taste in my mouth), everyone has good things to say but everyone I talked to had no passion about the job. No non clinical duties if I don't want to be a partner.

Sorry for the long post. Would appreciate any help in this very important time for me!! Thanks in advance.

1-Pick where you want to live and go work there.

2-Rent, do not buy, during the first year. If you are offered the choice of A) renting for one year at any EM job, versus, B) not renting the first year at a new and "perfect" EM job plus guaranteed eternal-consciousness on your deathbed, always choose A. Don't think. Just pick A. Trust me.

3- It doesn't really matter what job you pick, as long as you follow rule 2. Secret- ITS ALL THE SAME SH¡T.

Yep. Cow 1, Cow 2, Cow 3. Same sh¡t. Pick one. Doesn't matter. All are fat. All will getcha milk.

They're gonna dress one up like a cheetah, the other like a thoroughbred horse and the other like a show dog, but, nope.


Same sh¡t.

Don't sweat it.

Rent it.



Plus, jobs CHANGE. "Perfect Job" could get steam roller by two CMGs and transition through 2 EMR systems between your sign on date and start date. Either way, you'll get paid.

 

[Arcan57]

We all see multiple threads here everyday how one person is burnt out or another person hates what they're doing. I'm merely preventing that situation from happening in the first place and then really being a threat to my patients at that point. It doesn't mean I will be bad doctor which is what you're implying.

I would be happy to discuss this further with you over PM or in another thread if you wanted to start one, otherwise I'd appreciate anymore insight into which job I should choose.

Never putting the effort in in the first place doesn't prevent burnout, FWIW. From a choosing job standpoint, it sounds like you want to be somewhere else. If you bust your hump you're probably be able to get a license graduation in the state in which you actually want to live. While your first job is unlikely to last long (Birdstrike's post oversimplifies but is generally true), it's usually easier to transition within a job market you're already a presence in then to break in cold. Since factors external to work are your main motivation, why aren't you trying to maximize your situation vis-a-vis them? Don't let convenience create myopia, unless there's some elephant in the room regarding your current situation that you haven't posted.

Just an ms3 here, but I don't think the idea of "medicine is just a job" necessitates that you'll give lackadaisical effort. I think it just means you want to have time to do other things besides work all the time.

Disagree. At some point you have to put in a period of enough effort and intensity into getting good at medicine to be able settle down into the groove of it "just being a job". While it would be super sweet if that period coincided with the end residency, that's not the case.

 

[confusedjobapplicant]

1-Pick where you want to live and go work there.

2-Rent, do not buy, during the first year. If you are offered the choice of A) renting for one year at any EM job, versus, B) not renting the first year at a new and "perfect" EM job plus guaranteed eternal-consciousness on your deathbed, always choose A. Don't think. Just pick A. Trust me.

3- It doesn't really matter what job you pick, as long as you follow rule 2. Secret- ITS ALL THE SAME SH¡T.

Yep. Cow 1, Cow 2, Cow 3. Same sh¡t. Pick one. Doesn't matter. All are fat. All will getcha milk.

They're gonna dress one up like a cheetah, the other like a thoroughbred horse and the other like a show dog, but, nope.


Same sh¡t.

Don't sweat it.

Rent it.



Plus, jobs CHANGE. "Perfect Job" could get steam roller by two CMGs and transition through 2 EMR systems between your sign on date and start date. Either way, you'll get paid.

I've been reading your posts for a very long time, even as a medical student before wanting to do EM, so I really value your opinion. This really puts things into perspective. In the end, it's essentially all the same. I think I'm over obsessing about this too much.

Never putting the effort in in the first place doesn't prevent burnout, FWIW. From a choosing job standpoint, it sounds like you want to be somewhere else. If you bust your hump you're probably be able to get a license graduation in the state in which you actually want to live. While your first job is unlikely to last long (Birdstrike's post oversimplifies but is generally true), it's usually easier to transition within a job market you're already a presence in then to break in cold. Since factors external to work are your main motivation, why aren't you trying to maximize your situation vis-a-vis them? Don't let convenience create myopia, unless there's some elephant in the room regarding your current situation that you haven't posted.



Disagree. At some point you have to put in a period of enough effort and intensity into getting good at medicine to be able settle down into the groove of it "just being a job". While it would be super sweet if that period coincided with the end residency, that's not the case.

I agree, I haven't been as pro active as I should have. My initial plan was to stick around where I'm at for a couple years, get a feel for how the real world is, get an idea of what I'm really looking for, then when I decide I'm ready to move (mentally and physically) I'll have an idea what to look for. Moving somewhere else is all very premature...it's just an idea and I have a feeling I won't be staying in the city I'm at for a long time.

And to address your other point - again just because I have no interest in non clinical duties or want to work less hours does not mean I will give up learning about EM - I still study, I will still read journals, I just don't wish to put as much time in the hospital as others. Does not make me a bad or poor doctor.

 

[Arcan57]

I've been reading your posts for a very long time, even as a medical student before wanting to do EM, so I really value your opinion. This really puts things into perspective. In the end, it's essentially all the same. I think I'm over obsessing about this too much.



I agree, I haven't been as pro active as I should have. My initial plan was to stick around where I'm at for a couple years, get a feel for how the real world is, get an idea of what I'm really looking for, then when I decide I'm ready to move (mentally and physically) I'll have an idea what to look for. Moving somewhere else is all very premature...it's just an idea and I have a feeling I won't be staying in the city I'm at for a long time.

And to address your other point - again just because I have no interest in non clinical duties or want to work less hours does not mean I will give up learning about EM - I still study, I will still read journals, I just don't wish to put as much time in the hospital as others. Does not make me a bad or poor doctor.

I'm sensing a general laissez-faire attitude but you may benefit from taking an evening or weekend and figuring out what you'd like the next year and next 5 years of your life to look like. The questions you'll have to answer are likely to be much more significant than what job you decide to take (my read would be to take job #2 since you sound really uncomfortable the actual day to day (poor physical plant, decreased social opportunities) with job 1 and it sounds like you'd wash out quickly in job 3). If there's someplace you'd rather be, it's easier to move there after residency since (I'm presuming based on typical graduating resident demographics) your odds of getting into a relationship that may be geographically restrictive are reasonably high.

 

[confusedjobapplicant]

I'm sensing a general laissez-faire attitude but you may benefit from taking an evening or weekend and figuring out what you'd like the next year and next 5 years of your life to look like. The questions you'll have to answer are likely to be much more significant than what job you decide to take (my read would be to take job #2 since you sound really uncomfortable the actual day to day (poor physical plant, decreased social opportunities) with job 1 and it sounds like you'd wash out quickly in job 3). If there's someplace you'd rather be, it's easier to move there after residency since (I'm presuming based on typical graduating resident demographics) your odds of getting into a relationship that may be geographically restrictive are reasonably high.

Very valid points. I do have a very "let things happens" attitude as you stated, good pickup. On that note, as you stated as well, there is someplace I'd rather be...I just haven't found it yet. I know I'm not meant to stay here forever - just a gut feeling as I've always wanted to move to another state.

What made you say I'd wash out of job 3? Is it because of the higher pt/hr?

 

[Arcan57]

Very valid points. I do have a very "let things happens" attitude as you stated, good pickup. On that note, as you stated as well, there is someplace I'd rather be...I just haven't found it yet. I know I'm not meant to stay here forever - just a gut feeling as I've always wanted to move to another state.

What made you say I'd wash out of job 3? Is it because of the higher pt/hr?

Yes. Don't mistake metrics as being the province of CMGs. Anyone that has any hope of keeping their contract is keenly interested in metrics and there's not a lot of sympathy for a new doc that can't keep up with the pace. If it's a high acuity shop, 2.2 is very busy. If it's a 5% admit rate, you might be ok.

 

[Birdstrike]

Don't mistake metrics as being the province of CMGs.

It's part of the DNA of Emergency Medicine. Metrics will never go away. It's like the turnstiles at Disney. It's just the only way the bean counters are able to translate what you do into a language that makes sense to them.

Bean Counter the Great- "2.2 beans per hour, Igor. 2.2 beans per hour, YOU FOOL!"

Igor Assistant-Bean Counter- "Ah ha! I was lost, Master, but I get it now! I GET IT! And there you have, the unified theory, of Emergency Department, Economics! Beans per hour, can be converted, to a dollar amount per hour! Hoohoohwaahwahhwaahaha!"

(Ahhhhhh....and the clouds open, Angels sing, organ music roars, and lightening strikes Igor and his Master yet again, so they can be empowered to live yet another day.)

 

[Birdstrike]

I've been reading your posts for a very long time, even as a medical student before wanting to do EM...

Eh....most of 'em are pretty crazy, overly dour, or written in double-agent spy font. I usually delete 'em anyways. Thanks, though.

 

[tkim]

no nights. pick 1

 

[Birdstrike]

Bottom line: Job is a job, I work to live, I have a lot of other interests in life, and do not wish to put most of my hours in my job. But when I am at work I want to be happy and enjoy where I'm working, not hate it.

There's nothing wrong with this. In fact, it might be a more evolved stage than a lot of people are at. Just be careful how it comes across, because as a newbie attending it can be misconstrued as a slacker or prematurely burned out attitude. I personally don't think this is necessarily the case. But just be aware the "It's just a job" talk, no matter how evolved or correct could be seen as "overly cynical" for a newbie. Not true, in my opinion, just FYI: ridiculously jaded docs do not like interviewing newbies that seem as much or more jaded than them. Some view the cynicism and jadedness as a badge of honor earned only after time in the trenches, precisely the amount of time they've spent in said trenches, minus the amount of time you've spent in the trenches. To some, cynicism is brewed, bottled, fermented and aged and can only be truly appreciated by a select few aficionados with the appropriate palette.

Example:

http://mobile.journals.lww.com/em-n....aspx?year=2014&issue=03000&article=00006#ath

 

[WilcoWorld]

It's part of the DNA of Emergency Medicine. Metrics will never go away. It's like the turnstiles at Disney. It's just the only way the bean counters are able to translate what you do into a language that makes sense to them.

Bean Counter the Great- "2.2 beans per hour, Igor. 2.2 beans per hour, YOU FOOL!"

Igor Assistant-Bean Counter- "Ah ha! I was lost, Master, but I get it now! I GET IT! And there you have, the unified theory, of Emergency Department, Economics! Beans per hour, can be converted, to a dollar amount per hour! Hoohoohwaahwahhwaahaha!"

(Ahhhhhh....and the clouds open, Angels sing, organ music roars, and lightening strikes Igor and his Master yet again, so they can be empowered to live yet another day.)

You jumped ahead. The angels didn't start singing until Bean Counter the Great realized that he could set the Beans/hr-to-dollar conversion at whatever number he wanted.

 

[confusedjobapplicant]

Yes. Don't mistake metrics as being the province of CMGs. Anyone that has any hope of keeping their contract is keenly interested in metrics and there's not a lot of sympathy for a new doc that can't keep up with the pace. If it's a high acuity shop, 2.2 is very busy. If it's a 5% admit rate, you might be ok.

What if I said the 2.2 pt/hr is with NPs/PAs and with scribes...does that make a difference at all?

For some reason I cannot explain I feel Job 3 calling me. I don't now why, but my gut is telling me to choose it. I can't make any logical sense out of it...more nights, more hours, more work...why do I feel a pull to Job 3? ugh

 

[Arcan57]

What if I said the 2.2 pt/hr is with NPs/PAs and with scribes...does that make a difference at all?

For some reason I cannot explain I feel Job 3 calling me. I don't now why, but my gut is telling me to choose it. I can't make any logical sense out of it...more nights, more hours, more work...why do I feel a pull to Job 3? ugh

Probably because it reminds you of residency and you are looking to hold onto the familiar. Who you go to battle with does make a difference, and if you clicked with the nursing/ancillary staff that's not something to be discounted. If it's because you felt kinship with the docs, realize they don't contribute nearly as much to attending life as when you were a resident and had multiple docs leaving shift at the same time.

 

[Hercules]

What if I said the 2.2 pt/hr is with NPs/PAs and with scribes...does that make a difference at all?

Yes the difference between 2.2 with scribes and midlevels vs 2.2 by yourself is huge. That said you may be getting quoted 2.2 as the number you will be seeing by yourself plus the midlevels. 2.2 is still not ridiculously fast, but if the midlevels are seeing all the low acuity and you're seeing 2.2 high acuity pts/hr you're probably going to feel rushed based on what you have posted so far.

 

[Old_Mil]

Cerner is so bad, I would consider rejecting job 1 and job 3 on that basis alone despite my skepticism of CMGs.

Otherwise, job 1. No nights is a big deal.

Are all three jobs in the same state? You don't mention the two biggest destroyers of EM quality of life: malpractice and medicaid expansion and if any one of the three better from that perspective.

 

[confusedjobapplicant]

Cerner is so bad, I would consider rejecting job 1 and job 3 on that basis alone despite my skepticism of CMGs.

Otherwise, job 1. No nights is a big deal.

Are all three jobs in the same state? You don't mention the two biggest destroyers of EM quality of life: malpractice and medicaid expansion and if any one of the three better from that perspective.

Well my training institution uses EPIC, which is the only hospital in the area that uses it, next best is cerner around here.
All three are in the same state.

Unfortunately I'm not well versed with medicaid expansion and what to look out for?

 

[confusedjobapplicant]

So for any of you who were wondering for an update and which one I went with - it was Job 3.

It was not an easy choice at all, but relieved nonetheless the decision is made. If I don't like it then I know what definitely not to look for in my next job!

 

[emergentmd]

I think it was a good choice. I would have taken #3 too. Take the money, benefits. Work and decide to move if needed. No reason a new grad (I assume new) should work at a place seeing 1.5/hr

 

[Birdstrike]

I think if you go with your gut feeling as to what's the best, you should have no regrets, regardless of how things turn out. You know you made the best decision possible, at the time.

 

[tkim]

So for any of you who were wondering for an update and which one I went with - it was Job 3.

It was not an easy choice at all, but relieved nonetheless the decision is made. If I don't like it then I know what definitely not to look for in my next job!

You chose wrong. Should have taken the job with no overnights. Serious.

 

[Old_Mil]

All three are in the same state.

Unfortunately I'm not well versed with medicaid expansion and what to look out for?

In conjunction with Obamacare, some states have expanded Medicaid, others have not.

This webpage:

http://familiesusa.org/product/50-state-look-medicaid-expansion

Has about the best map I have seen which shows which states have and which states haven't. Medcaid expansion.generally takes people who used to have cheaper individual policies or were uninsured and made up to 30k a year and.puts them on Medicaid. Stated another way it takes a large number of people who once had skin in the game so to speak and turns them into people who have no skin in the game.

As an emergency physician you are in a unique position. Any other physician can simply not accept assignment or close their practice to new patients. Even our local "community health center" has closed its doors to new patients including medicare/medicaid.

Guess where people with no skin in the game show up when they can't get or don't want to be bothered with getting an outpatient appointment? That's right...your ER. We are probably seeing as many medicaid kids in a day as we used to see in a week. Now that our 2014 numbers are out we have had a 19.35% increase in visits. I expect that to continue to.rise.

...and when people are moved off self pay or private insurance onto medcaid collections drop off.

Since an EP can neither close the doors nor change staffing when volumes get out of hand you should really think twice before working in a state that has expanded Medicaid.

 

[The White Coat Investor]

...and when people are moved off self pay or private insurance onto medcaid collections drop off.

Since an EP can neither close the doors nor change staffing when volumes get out of hand you should really think twice before working in a state that has expanded Medicaid.

I'm not sure it's entirely clear whether the positive effect of fewer "no-pay" patients (trading self-pays to Medicaid) + more total patients is less than or greater than the negative effect of moving previously insured patients onto lower paying Medicaid. I suspect it is greater than overall, but I haven't seen any data on the subject.

 

[Old_Mil]

This CNBC article seems to reflect some of what I have said above.

"And so, 2015 is already turning out to be the year when Americans are going to learn the hard way that single-payer systems can only function via rationing. And with Medicaid enrollees, that rationing will especially be cruel because we're talking about millions of poor people who won't even get in the door to see a doctor in the first place. And that also means breaking the promise that emergency rooms will get some kind of traffic relief thanks to Obamacare. Those rejected Medicaid patients are going to have to go somewhere, and the ER will remain the only places that can't turn them away.

Not that some people aren't trying to change that. Newly-elected Virginia Delegate Kathleen Murphy has publicly called for a new state law forcing doctors to accept Medicaid and Medicare patients no matter what. As if the number of career physicians quitting the profession weren't bad enough, politicians like Murphy seem to be Hell-bent on pushing even more out the door whether they realize it or not."

http://www.cnbc.com/id/102330644?__source=xfinity|mod&par=xfinity

My personal feeling is that it will only be a matter of time before rather than trying to enforce accepting Medicaid patients through state law it will be done on a national level using the DEA as the soup nazi approved blunt instrument of choice. No CMS? No DEA! I guess I should have listened better in OMM.