Practicing physician wanting to cross over to Emergency Medicine

[JustPlainBill]

So it didn't take long....thought I'd be happy doing outpatient FM with a nice,sane schedule....yeah right....It's more social issues management, keeping hospital admits happy and trying to get people to care enough about themselves to put down the fork and do table pushaways.....

Helped with a code last week and forgot just how exhilarating it could be....

So--any suggestions would be helpful--- do I stay in FM, somehow get some real experience managing airways and just start gaining experience working small ER in the boonies

Or...do I go back into the residency application cycle and get ready to move PRN?

BTW, I'm 51 with 2 high schoolers....This is career 2 for me...any attendings/PDs have words of wisdom?

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[RustedFox]

Hey, I'm only one fellah - but here's what I would do if I were you:

1.) It sounds to me from your first sentence, your "joined date" and your post count that you're "new" to the FM gig, and are *likely?* a new grad at age 51 into the FM world.

2.) At age 51, with 2 kids ready to hit college... I would not subject myself to 3 more years of indentured servitude. No way.

3.) Limited idea what PDs would say, but I would not count on your experience as an FM attending having a lot of weight with PDs.

Best wishes, and good luck.

 

[DeadCactus]

Unless you're wealthy from your previous career, I would go the rural ED route. There is still lots of need and plenty of opportunity. EM residency is the ideal and gold standard, but subjecting yourself to 2.5 to 3 years of residency at 51 when there are plenty of places that would be lucky to have a motivated physician over a mid-level is not the best approach to me.

 

[Birdstrike]

So it didn't take long....thought I'd be happy doing outpatient FM with a nice,sane schedule....yeah right....It's more social issues management, keeping hospital admits happy and trying to get people to care enough about themselves to put down the fork and do table pushaways.....

Helped with a code last week and forgot just how exhilarating it could be....

So--any suggestions would be helpful--- do I stay in FM, somehow get some real experience managing airways and just start gaining experience working small ER in the boonies

Or...do I go back into the residency application cycle and get ready to move PRN?

BTW, I'm 51 with 2 high schoolers....This is career 2 for me...any attendings/PDs have words of wisdom?

How long have you been doing FM?

 

[JustPlainBill]

Hey, I'm only one fellah - but here's what I would do if I were you:

1.) It sounds to me from your first sentence, your "joined date" and your post count that you're "new" to the FM gig, and are *likely?* a new grad at age 51 into the FM world.

2.) At age 51, with 2 kids ready to hit college... I would not subject myself to 3 more years of indentured servitude. No way.

3.) Limited idea what PDs would say, but I would not count on your experience as an FM attending having a lot of weight with PDs.

Best wishes, and good luck.

In short --

1) Yes, I'm a new FM grad -- had thought about doing EM but really didn't want to uproot the family (kids were in Jr. High/High school then in a good school system with lots of friends/family/grandparents nearby) plus at the place where I did my EM rotation, it seemed that all the fun stuff (trauma/cardiac) was done by the trauma/cards people and the rest was FM at 0300. I was a different person then, dropped some pounds which improved my outlook on life (nothing like being a fat troll to make you not want to get off your butt and work). Been doing FM as an attending for about 3 months in a town where there's literally no support for jack -- the EMS routes any trauma, cardiac, GI to the next higher facility -- we tend to get COPD exac, CHF exac, AMS which tend to be transferred in the AM -- really it's just a support short stay facility for the 9 million nursing homes in the area....but they do take FM docs to work it so that's a plus....but it requires hospitalist work which I do not really care for ---

2) I hear you on the indentured servitude -- making money beats not making money any day of the week -- but it's the experience with the big stuff that I think I need -- while I may never work trauma, I believe that Murphy of Murphy's law fame was a freakin' optimist -- it's better to have a skill like intubation, chest tubes, etc. and not need it, than need it and not have it.

Appreciate the insight....

 

[dotcb]

I would not do an EM residency if I were you. See what you can find in Family Medicine, there are lots of FM job descriptions out there.

 

[JustPlainBill]

How long have you been doing FM?

Post residency -- about 3 months at a small hospital with virtually no support and call Q4 weekends and call for unassigned Q4 days -- the call is really a support pager for the 9 million nursing homes -- and yes, I did get a page to continue centrum silver, dulcolax, vitamin D and fish oil at 0035 ----

 

[JustPlainBill]

I would not do an EM residency if I were you. See what you can find in Family Medicine, there are lots of FM job descriptions out there.

I assume you mean lots of FM job descriptions with some fast track ED/urgent care work.....

 

[USCDiver]

You are going to have a real hard time finding an EM residency spot for a number of reasons, not least of which is your spot won't get funding. There are EM fellowships for FM grads. You may consider looking into those if you are concerned your lack of EM experience will be dangerous.

 

[gman33]

I wouldn't do EM without further training even if you can find a job.
There is a lot of overlap, but not so much in the really high acuity parts. ie trauma, airway, etc.
Give the FM route a couple of years minimum. Find another job if the current gig sucks.
Going back for another residency is most likely not worth it at this point.
Earliest entry would be more than a year away.
4 more years until you start EM at 55 is not ideal.

 

[JustPlainBill]

You are going to have a real hard time finding an EM residency spot for a number of reasons, not least of which is your spot won't get funding. There are EM fellowships for FM grads. You may consider looking into those if you are concerned your lack of EM experience will be dangerous.

Appreciate the feedback -- but I do have a question -- I thought funding was only an issue if you were switching within fields -- i.e. if a PGY2 FM wanted to switch to another FM program, funding was an issue. I know of 2 cases at Parkland where former FM docs were accepted and funded into the EM program -- luck of the draw in that 2 EM residents transferred for personal reasons and these two guys filled the slots....I didn't know about SAEM then....

Would Freida be the source for EM fellowships for FM grads? Would that allow me to sit for ABEM boards? I'd kinda feel like a goober but I'm planning on hitting the conferences, joining ACEP and just trying to absorb all I can and get experience where I can for now.....

 

[JustPlainBill]

I wouldn't do EM without further training even if you can find a job.
There is a lot of overlap, but not so much in the really high acuity parts. ie trauma, airway, etc.
Give the FM route a couple of years minimum. Find another job if the current gig sucks.
Going back for another residency is most likely not worth it at this point.
Earliest entry would be more than a year away.
4 more years until you start EM at 55 is not ideal.

I hear you on the "starting at 55" point -- I may try to find some "fast track" ER work or do a fellowship as another poster suggested.....The EM guys at Parkland have been really nice and helpful -- just a great crew that actually taught when I did my month there during residency ---

 

[Birdstrike]

Post residency -- about 3 months at a small hospital with virtually no support and call Q4 weekends and call for unassigned Q4 days -- the call is really a support pager for the 9 million nursing homes -- and yes, I did get a page to continue centrum silver, dulcolax, vitamin D and fish oil at 0035 ----

That's sounds truly gad-awful, but there's no reason to be in that situation for much longer. Go work somewhere you are associated with a hospital that has hospitalists and work an entirely outpatient job. I personally know several FPs that make over the national average salary for FM and they see about 25 patients per day, 8-5, Mon-Fri with a 12-1pm lunch every day. Zero hospital call and all their patients are admitted to hospitalists. Zero hospital rounding and about 1 after hours call per week, rarely if ever after midnight. If so, it's, "I'll work you in first thing Monday," or if it can't wait, "Go to the ER." They work no nights, no weekends, no holidays. Ever. No 2 am dulcolax-Tylenol-need-a-foley-needs-to-fart call from any nurses. Go find that job, or make that job.

On the flip side. EM residency at the age of 50+? I won't tell another grown man what to do with his life, but...

"Whatchoo talkin' about, Willis?!"

Seriously? I did EM for 10 years, full-time grinding out shift work, and I'm moving in the opposite direction (away from shift work) as I get older. Maybe it's easy to say since I've had the codes, the chaos, the circus, the anarchy and the stories to tell. And there's things I loved about it, but ohh..... the nights. Oh my God, the nights, back to days, back to nights, not knowing when it's night or day, or Monday or Saturday, wondering why I'm wide awake at 3 am when I should be asleep and falling asleep at 2 pm when I need to be waking up.

The nights. As you get older, they're brutal. Don't let people tell you you can do EM and find a job where you can avoid this. These are people that think 6pm - 4am is not a "night" shift. There's nothing that offsets the circadian rhythm disruption. Nothing. You have to deal with it.

The cost of doing another residency. You'll never earn that back at the age of 51. Also, by switching to EM, you shorten your career span. FM- you can do it till your 80. Why?

No nights.

The codes, the traumas, the adrenaline? It fades. Tachyphylaxis my friend. Then when that fades and the codes are routine, what are you doing? Mostly family medicine now (except for the occasional code) only in the ED, but now at 3 am, or Saturday night, or on Christmas, or Fourth of July, or Super Bowl Sunday.

Find a cushy outpatient FM gig with hospitalists to cover the off hours. Get into triathlons or 5k/10k/marathons if you want adrenaline highs. But residency #2 after an already late in life residency just having finished?

Do you have a significant other? What do they think? It's a pretty big sacrifice to support someone going through a residency and they need a payoff, too, such as being able to see their loved one. I don't know how many sig others are willing to sign up for unlimited #'s of residencies? A 1 yr fellowship to advance the career and increase salary? Maybe. But trash residency #1 to do another with more adrenaline? That's a lot to ask.

That being said, I won't tell a grown man what to do with his life. Do what's best for you and your family. But, starting EM at 50+....?


Ooh....the nights, the nights, the nights.

 

[USCDiver]

Medicare funding for your residency starts with your intern year and extends through whatever the number of years your first program is. All subsequent years of training are funded at 50% So if you initially matched into FM (3 years) and you've already used up all 3 of those any further training will have to be at least 50% funded by the hospital itself. Now some programs are willing to take partially unfunded residents and pay for them out of the departmental budget but they have to have a good reason for doing so. Lots of good information here. https://members.aamc.org/eweb/upload/Medicare Payments for Graduate Medical Education 2013.pdf

I don't know much about the EM/FM fellowships except that you definitely will NOT be allowed to sit for ABEM.

 

[Groove]

I had a massive essay and before clicking send, saw that bird had covered it all much more eloquently.

In short, don't do a residency at 51 just a few months into your first FM job. You'll regret it. Pick up a few rural ED shifts for your monthly adrenal fix if that's what you need right now. It gets old.

Good luck.

 

[Birdstrike]

I had a massive essay and before clicking send, saw that bird had covered it all much more eloquently.

In short, don't do a residency at 51 just a few months into your first FM job. You'll regret it. Pick up a few rural ED shifts for your monthly adrenal fix if that's what you need right now. It gets old.

Good luck.

Dude....

I want the massive essay. Post it. Help a fellow SDN-brother out. Don't leave me hangin' with the only massive essay on the thread. There can never be too many inappropriately massive essays on a thread. Even if three words get the point across completely effectively....massive essay comin'.

Lol. JK. Thanks, man.


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[@JackShephard]

That's sounds truly gad-awful, but there's no reason to be in that situation for much longer. Go work somewhere you are associated with a hospital that has hospitalists and work an entirely outpatient job. I personally know several FPs that make over the national average salary for FM and they see about 25 patients per day, 8-5, Mon-Fri with a 12-1pm lunch every day. Zero hospital call and all their patients are admitted to hospitalists. Zero hospital rounding and about 1 after hours call per week, rarely if ever after midnight. If so, it's, "I'll work you in first thing Monday," or if it can't wait, "Go to the ER." They work no nights, no weekends, no holidays. Ever. No 2 am dulcolax-Tylenol-need-a-foley-needs-to-fart call from any nurses. Go find that job, or make that job.

On the flip side. EM residency at the age of 50+? I won't tell another grown man what to do with his life, but...

"Whatchoo talkin' about, Willis?!"

Seriously? I did EM for 10 years, full-time grinding out shift work, and I'm moving in the opposite direction (away from shift work) as I get older. Maybe it's easy to say since I've had the codes, the chaos, the circus, the anarchy and the stories to tell. And there's things I loved about it, but ohh..... the nights. Oh my God, the nights, back to days, back to nights, not knowing when it's night or day, or Monday or Saturday, wondering why I'm wide awake at 3 am when I should be asleep and falling asleep at 2 pm when I need to be waking up.

The nights. As you get older, they're brutal. Don't let people tell you you can do EM and find a job where you can avoid this. These are people that think 6pm - 4am is not a "night" shift. There's nothing that offsets the circadian rhythm disruption. Nothing. You have to deal with it.

The cost of doing another residency. You'll never earn that back at the age of 51. Also, by switching to EM, you shorten your career span. FM- you can do it till your 80. Why?

No nights.

The codes, the traumas, the adrenaline? It fades. Tachyphylaxis my friend. Then when that fades and the codes are routine, what are you doing? Mostly family medicine now (except for the occasional code) only in the ED, but now at 3 am, or Saturday night, or on Christmas, or Fourth of July, or Super Bowl Sunday.

Find a cushy outpatient FM gig with hospitalists to cover the off hours. Get into triathlons or 5k/10k/marathons if you want adrenaline highs. But residency #2 after an already late in life residency just having finished?

Do you have a significant other? What do they think? It's a pretty big sacrifice to support someone going through a residency and they need a payoff, too, such as being able to see their loved one. I don't know how many sig others are willing to sign up for unlimited #'s of residencies? A 1 yr fellowship to advance the career and increase salary? Maybe. But trash residency #1 to do another with more adrenaline? That's a lot to ask.

That being said, I won't tell a grown man what to do with his life. Do what's best for you and your family. But, starting EM at 50+....?


Ooh....the nights, the nights, the nights.

Do you still practice EM?

You always make it sound very rough!

 

[Birdstrike]

Do you still practice EM?

You always make it sound very rough!

I don't work in an ER in the traditional sense right at this moment. I no longer grind it out in the pit daily, no. However, I haven't gone anywhere, I still see patients (not in an ER per se) and I'm doing somethings that in a sense expand the specialty, and I like to think make it stronger. I still am keeping my ABEM boards, and don't rule out going back to ER shift work at some point. I've built on my ER background, not thrown it away.


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[BoardingDoc]

I don't work in an ER in the traditional sense right at this moment. I no longer grind it out in the pit daily, no. However, I haven't gone anywhere, I still see patients (not in an ER per se) and I'm doing somethings that in a sense expand the specialty, and I like to think make it stronger. I still am keeping my ABEM boards, and don't rule out going back to ER shift work at some point. I've built on my ER background, not thrown it away.


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What exactly do you do Birdstrike? If getting into specifics isn't an option for you, can you broad stroke it for me? Your comment above was interesting, but pretty vague. Right now I'm sort of picturing you working in/running an urgent care.

 

[JustPlainBill]

Ok, so I've decided: Screw EM, going into Trauma surgery and starting down that road this application cycle.....Just kidding -- no way I'm that much of a masochist.....

On a serious note -- I've got multiple people -- including some close friends in Emergency Medicine that I trust -- telling me that doing a residency is really not a good idea at my current age/stage of life -- some did say a one year fellowship may be an option.....most have said to get some airway management experience but try to work fast track ER or urgent care and get an outpatient job that you can work at on the side....

My general plan is to get more comfortable with airways and do some locums at low speed ER/fast track ER/urgent care and build my own outpatient practice -- i.e. get the hell out of hospital work. Most of the locums I've seen is out in the boonies and the real trauma gets routed elsewhere but since crises by definition can't be predicted, I feel like I need to at least be able to establish an airway and stabilize a patient to ship them out either by ground or air. In the meantime, nothing says I can't be a straphanger and go to the EM conferences and learn about something that interests me -- I've always been a 'I'd rather know it and not need it than need it and not know it' type of person....


Thanks for all the comments/advice ---

 

[EM_Rebuilder]

Ok, so I've decided: Screw EM, going into Trauma surgery and starting down that road this application cycle.....Just kidding -- no way I'm that much of a masochist.....

On a serious note -- I've got multiple people -- including some close friends in Emergency Medicine that I trust -- telling me that doing a residency is really not a good idea at my current age/stage of life -- some did say a one year fellowship may be an option.....most have said to get some airway management experience but try to work fast track ER or urgent care and get an outpatient job that you can work at on the side....

My general plan is to get more comfortable with airways and do some locums at low speed ER/fast track ER/urgent care and build my own outpatient practice -- i.e. get the hell out of hospital work. Most of the locums I've seen is out in the boonies and the real trauma gets routed elsewhere but since crises by definition can't be predicted, I feel like I need to at least be able to establish an airway and stabilize a patient to ship them out either by ground or air. In the meantime, nothing says I can't be a straphanger and go to the EM conferences and learn about something that interests me -- I've always been a 'I'd rather know it and not need it than need it and not know it' type of person....


Thanks for all the comments/advice ---

Not to cause fear, but I disagree with that statement. I have worked at two Level 1 Trauma Systems, and upwards of 15 or so rural/small EDs. I have had MUCH more clusters/super sick/just me patients in those cases. I have dropped an airway, and two chest tubes, while having the nurses page a helicopter. At my Level 1 center, there is umpteen residents and other people swarming the patient.

Just dont want you to think that you will 'never get someone sick or bad trauma' in a rural ER. Tractors roll over, cars roll/hit trees in rural america, etc.

I think small ERs within/near a city with a more major center is a more ideal bet of low acuity but depending on where you are in our country, you might be limited on where you can work...

Good luck, and I agree with others. 1.)3 months is too short of a time to know you hate it 2.)another residency at 51 is crazy 3.) try to fill in some ER shifts on occasion and then consider a swap to the small places if able.

 

[Birdstrike]

Just dont want you to think that you will 'never get someone sick or bad trauma' in a rural ER. Tractors roll over, cars roll/hit trees in rural america, etc.

Absolutely. A level 1 is the easiest place to work, where consulto-mania is rampant. The more Podunk the place, the more your skills are tested. You'll get the heroin-OD drop off by panicked friends, not breathing at the back door, and you have no vent, no ICU, no anesthesia, and no nothin'. All you got is shaky-knees numero uno. If ambulance traffic is accepted at all, this all applies.

You'll get the 4-yr-old, no vitals, grape in the trachea, EMS wants you to get an airway, before transferring to tertiary Level 1.

Yep. EM_Rebuilder esta correcto.

 

[deleted6669]

as noted above, rural depts are where the real action is. At a big trauma ctr there are specialty teams who swoop in and have all the fun and get all the cool procedures.
I work at both urban inner city trauma centers with em docs and rural critical access hospitals with FM docs. The guys at the rural facilities are using their high end procedural skills on a daily basis while many of my em doc friends at the trauma ctr have to schedule OR and ICU time in order to get intubations and central lines.
The EM fellowships for FM physicians are an excellent way to get into the action fast. the alternative is gradually working your way up the em ladder from urgent care to fast track to places with intermediate level acuity to working in main depts. That process took me over ten years before I could land jobs working in main. It would probably take less time as a physician, but probably not much less. All the FM attendings I work with at the rural sites either did a fellowship or spent 5+ years getting good at em.
best of luck whatever you decide.