Things to consider when choosing a job

[han14tra]

I have another thread on this forum seeking specific advice about my situation, but I wanted to start a discussion that could be useful to everyone. Through the interview process, it seemed like every ED could be put into 1 of the following categories:

1. Large, busy ED with consultants out the wazoo and all the designations (Level 1 or 2 trauma, chest pain center, stroke center, etc). It will have an ICU and a peds floor. You'll transfer very little. Rather people will be transferring to you. Shifts are more likely to be 8-10 hours because of the high volume, high acuity. You'll never be single coverage and will often have PAs.
2. Same as above, but it's academic with a residency program. So, you're the "supervisor" and teacher.
3. Small ED where you're it. Likely single coverage. More likely to be 12 hour shifts because of lower volume. You may even catch a few Zzz's at night when it's slow. You'll transfer anyone who is sick. May have a hospitalist, but very few consultants. You are the code team. Your sick patients are likely those who walk in or it's a "We're going to run lights and sirens to the closest ED because this person won't make it to #1 or #2 hospital alive."
4. Medium sized ED where you're not single coverage. You may be a Level 3 trauma center with some consultants on-call but rarely in house. You'll transfer quite a bit to #1 or #2 hospital. It's fairly busy there.

What are the pros and cons of each?

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[barnacle]

They are very different and ultimately you need to think about your career goals and interests. If you want to teach or do research then obviously being affiliated with a residency is your best bet. If you don't want this and want to be on your own, it's largely about coverage. A busy level 1 trauma center with good coverage can be less stressful than a single coverage shop that gets crushed. If you are em trained you may get bored at the slow single coverage low acuity setting if this is your only gig. I would prefer this as a part time gig to get a break from the chaos, but everyone is different.

 

[Sessamoid]

There are an infinite variation that you can't possible include in the list. My primary site is a moderate volume suburban ER, double covered in the day, single at night, stroke center, active cath lab, but no trauma, no peds, and soon no L&D. We transfer only very rare cases of treated aneurysm bleeds and all peds admission which are not terribly common either.

I personally like this mix. I got tired of trauma early on in my career after I learned what I needed to, as it's pretty routine from our side of the fence. Single coverage situations are just a f'ing beating unless the volume is so low that they're not paying you much anyway, and I've had jobs that fit both categories.

 

[BAM!]

Realistically, a lot of it has to due with the pay scale. That said, the academic job is probably the easiest, though it may come with other responsibilities. The small nonbusy ED likely won't pay well, you may get bored, and then it sucks when they die in front of you because you can't find an accepting hospital. The large tertiary care center can be less stressful because you should theoretically have easy access to the consultants. If the patients are being transferred to you for a consultant -- then they often already know about the patient. The medium sized hospital could be great, or awful, depending on a variety of factors.

 

[The White Coat Investor]

I have another thread on this forum seeking specific advice about my situation, but I wanted to start a discussion that could be useful to everyone. Through the interview process, it seemed like every ED could be put into 1 of the following categories:

1. Large, busy ED with consultants out the wazoo and all the designations (Level 1 or 2 trauma, chest pain center, stroke center, etc). It will have an ICU and a peds floor. You'll transfer very little. Rather people will be transferring to you. Shifts are more likely to be 8-10 hours because of the high volume, high acuity. You'll never be single coverage and will often have PAs.
2. Same as above, but it's academic with a residency program. So, you're the "supervisor" and teacher.
3. Small ED where you're it. Likely single coverage. More likely to be 12 hour shifts because of lower volume. You may even catch a few Zzz's at night when it's slow. You'll transfer anyone who is sick. May have a hospitalist, but very few consultants. You are the code team. Your sick patients are likely those who walk in or it's a "We're going to run lights and sirens to the closest ED because this person won't make it to #1 or #2 hospital alive."
4. Medium sized ED where you're not single coverage. You may be a Level 3 trauma center with some consultants on-call but rarely in house. You'll transfer quite a bit to #1 or #2 hospital. It's fairly busy there.

What are the pros and cons of each?

With all due respect, you are (like most of us did) focusing on the wrong things when selecting a long term job. Pick your job based on these factors:

1) The people you work with
2) The location
3) How much control you will have over your work environment-I'm a big fan of small democratic groups where I get to pick my shifts, workload, co-workers, policies etc.
4) Payor mix (or salary if an employee position) - It affects your salary, and over the intermediate to long run, that will matter more to you than it does now. $200K seems like gobs of money to a new grad, but in 10 years when you realize you could be paid $400K for doing the same work, you might regret it.

But I'd put ED volume, single vs double vs triple coverage, shift length, trauma center or not etc all way down the list compared to those four things. Obviously there is a big break between academic and non-academic, but that's usually not a tough decision for most. If it is, stay on at your residency for a few years to see if you like it.

 

[erdoc00]

I personally will never work at another single coverage ER. It gave me too much anxiety knowing at any moment one sick patient or one long procedure could destroy my day and back me up for the entire shift.

Also, many of these small single coverage shops tend to have few resources, lazy hosptalists, few specialists, and the staff might not be used to "big city" EM workups...

I had a colleauge sign a STEMI out to me one morning at shift change. Guy had been in the ER for an hour already. I was supposed to make sure his antacids were working for his epigastric pain and then discharge when feeling better.

Maybe for $1000/hr id consider doing single coverage 12s again. I wont hold my breath though.

 

[Birdstrike]

I personally will never work at another single coverage ER. It gave me too much anxiety knowing at any moment one sick patient or one long procedure could destroy my day and back me up for the entire shift.

Also, many of these small single coverage shops tend to have few resources, lazy hosptalists, few specialists, and the staff might not be used to "big city" EM workups...

I had a colleauge sign a STEMI out to me one morning at shift change. Guy had been in the ER for an hour already. I was supposed to make sure his antacids were working for his epigastric pain and then discharge when feeling better.

Maybe for $1000/hr id consider doing single coverage 12s again. I wont hold my breath though.

I laugh when people think they're better than someone else because they work at an ivory tower tertiary/quaternary referral center, because the type of place you're referring to can be very tough to work at. The place where there's a pediatric, right-heart, pulmonic-valve anterior leaflet-only specialist is not the hardest place to work. It's the easiest place to work at. I'm not casting shade, because we need people to staff those EDs, too, but many are in fact hiding from the 12-hr single coverage 30,000 patient per year ED where you may have to see up to 40-50 people in a shift with no backup and no subspecialty help. Yes, there's often a high proportion of lower acuity cases, but that's no help when you're on patient 40 of your shift with 12 rooms full, and someone in a car drops an apneic opiate OD off at your back door, or the 22 yo headache patient the nurse says is "FOS" goes unresponsive and ends up with puss coming out the spinal needle you put in their back with a spreading petechial rash.

I worked at a place just like this for 8 years, about 4 days per month, along with my main site which was a busier, level 2 trauma site which was multi-covered, with much greater subspecialty coverage (though not quite a tertiary referral center).

They both could be tough at times, for different reasons, but the single coverage slaughtering at the smaller place could get bad. Real bad. It took ambulances but had no vent, and only 2 units of blood. But there's was no limit on the amount of patients or level of foot-traffic anarchy that could pile in that place at any time. The fact that it got the rep in the community as the "smaller quicker" place (because between 1am and 6 am it was slow) caused people to pile in there at all other hours of the day like we were giving away free beer and cigarettes.

People still think their MI is heartburn, their rupturing AAA is a back strain and their septic newborn "just has a cold."

I generally agree with White Coat Investor, though, what's going to make your life good or not, has more to do with whether you are going to be given the hours you want (or always pushed to work 40 extra per month), the quality (or lack thereof) of the people you work with, and the overall attitude of the administration (are they constantly mind----ing you over irrelevant bs, or supportive).

 

[GeneralVeers]

The pay also helps. I don't mind being busy if I'm being paid $250+/hour. I would resent being busy and only making $150.

 

[Old_Mil]

There are good jobs and bad jobs in all these categories. Here's what I would consider:

1. Are you practicing in a state ranked "A or B" by the ACEP report card with regards to medical malpractice? Or is it ranked "C, D, or F"?
2. Are you practicing in a medicaid expansion state? The list of states that haven't is short: Idaho, South Dakota, Nebraska, Kansas, Oklahoma, Texas, and South Carolina. This is important to you because medicaid patients tend to overuse the ED, driving up your volumes, and have the worst demographics/psychosocial situations of all the payors.

All other things being equal, I would start my job search with the A or B malpractice states that hadn't expanded medicaid.

3. PPH. 2.5 is the recommended upper limit by officialdom. 1.5-2 is probably a better number given our current medicolegal and documentation systems if you want to find something sustainable. Remember, residency lasts three years. You can tolerate anything for three years. This is the rest of your life. Remember, PPH = advertised annual volume / (total daily hours of provider coverage x 365). Also remember that advertised annual volumes aren't always accurate. Will a CEO advertise a 11,000 visit ED as a 9,000 visit department using old data if they are having trouble recruiting? Sure.
4. Mailpractice and tail. Employer / contract management paid malpractice and tail is industry standard and don't accept a job that doesn't provide it. Tail in particular, you don't want to get stuck writing a 20k-30k or more check to a malpractice company if you want to move, quit, have a family emergency, or get hit by a car and end up on medical disability.
5. Benefits: W2 is better than 1099, because you generally can't go out and buy benefits on the retail market for the hourly differential most jobs will offer for 1099 status particularly now that Obamacare has increased the cost of individual policies. If you are young, healthy, and lead a healthy lifestyle medical sharing programs are a cheaper alternative.
6. Nursing staff - who you go into battle with matters a lot. Is your ED staffed by old battle axes from clinics who are long removed from the practice of acute care medicine, or a good to work with staff who are interested in medicine and perhaps have plans to become CRNAs or flight nurses? We have absolutely *great* nurses where I work. It's probably the only thing that keeps me coming back for more at this point.
7. Consultants/Hospitalists - the amount of help/pushback that you get will vary widely from facility to facility. Current shop has a rotating schedule of locums hospitalists who aren't RVU based. Admissions are like pulling teeth. I've had to transfer critical patients that we had the ability to take care of because consultants wouldn't come in. Not a good situation.

 

[Birdstrike]

There are good jobs and bad jobs in all these categories. Here's what I would consider:

1. Are you practicing in a state ranked "A or B" by the ACEP report card with regards to medical malpractice? Or is it ranked "C, D, or F"?
2. Are you practicing in a medicaid expansion state? The list of states that haven't is short: Idaho, South Dakota, Nebraska, Kansas, Oklahoma, Texas, and South Carolina. This is important to you because medicaid patients tend to overuse the ED, driving up your volumes, and have the worst demographics/psychosocial situations of all the payors.

All other things being equal, I would start my job search with the A or B malpractice states that hadn't expanded medicaid.

3. PPH. 2.5 is the recommended upper limit by officialdom. 1.5-2 is probably a better number given our current medicolegal and documentation systems if you want to find something sustainable. Remember, residency lasts three years. You can tolerate anything for three years. This is the rest of your life. Remember, PPH = advertised annual volume / (total daily hours of provider coverage x 365). Also remember that advertised annual volumes aren't always accurate. Will a CEO advertise a 11,000 visit ED as a 9,000 visit department using old data if they are having trouble recruiting? Sure.
4. Mailpractice and tail. Employer / contract management paid malpractice and tail is industry standard and don't accept a job that doesn't provide it. Tail in particular, you don't want to get stuck writing a 20k-30k or more check to a malpractice company if you want to move, quit, have a family emergency, or get hit by a car and end up on medical disability.
5. Benefits: W2 is better than 1099, because you generally can't go out and buy benefits on the retail market for the hourly differential most jobs will offer for 1099 status particularly now that Obamacare has increased the cost of individual policies. If you are young, healthy, and lead a healthy lifestyle medical sharing programs are a cheaper alternative.
6. Nursing staff - who you go into battle with matters a lot. Is your ED staffed by old battle axes from clinics who are long removed from the practice of acute care medicine, or a good to work with staff who are interested in medicine and perhaps have plans to become CRNAs or flight nurses? We have absolutely *great* nurses where I work. It's probably the only thing that keeps me coming back for more at this point.
7. Consultants/Hospitalists - the amount of help/pushback that you get will vary widely from facility to facility. Current shop has a rotating schedule of locums hospitalists who aren't RVU based. Admissions are like pulling teeth. I've had to transfer critical patients that we had the ability to take care of because consultants wouldn't come in. Not a good situation.

Very good post. Posts like this make a forum like SDN very valuable.

 

[GeneralVeers]

I agree with Old_Mil on all his points. One big, important things missing is income tax. Moving to a state with no income tax will literally increase your take home pay by 6%-13% depending on your state. Nevada, Florida, Texas, Washington, Alaska, and South Dakota come to mind as no tax states. High tax states are New York, CA, OR, IL, MN. Is it worth working one month out of the year to pay the government just to live in ideal weather in California?

 

[Old_Mil]

I agree with Old_Mil on all his points. One big, important things missing is income tax. Moving to a state with no income tax will literally increase your take home pay by 6%-13% depending on your state. Nevada, Florida, Texas, Washington, Alaska, and South Dakota come to mind as no tax states. High tax states are New York, CA, OR, IL, MN. Is it worth working one month out of the year to pay the government just to live in ideal weather in California?

That is a good point about taxes. You expect that out of CA, OR and the northeast, but taxes in Midwestern states (except South Dakota) have become quite high. You would think that if you are paying that much in state income tax that you would get a break elsewhere like property tax but it usually doesn't work out that way. Washington has no state income tax for W2 employees but there is, I believe a "special" state tax on 1099 physicians (correct me if I am wrong) that was 3% or something of the sort. They also have F rated malpractice and the longest medal statute of limitations in the country giving lawyers five years to sue.

 

[GeneralVeers]

That is a good point about taxes. You expect that out of CA, OR and the northeast, but taxes in Midwestern states (except South Dakota) have become quite high. You would think that if you are paying that much in state income tax that you would get a break elsewhere like property tax but it usually doesn't work out that way. Washington has no state income tax for W2 employees but there is, I believe a "special" state tax on 1099 physicians (correct me if I am wrong) that was 3% or something of the sort. They also have F rated malpractice and the longest medal statute of limitations in the country giving lawyers five years to sue.

I haven't looked into WA as I never considered moving there. The surprising one is MN. With already high taxes of > 6%, they have a special "medical provider tax" of 1%. Yes you read correctly. Just because you are a physician they charge you an extra 1%. Way to go MN!

 

[deleted547339]

I haven't looked into WA as I never considered moving there. The surprising one is MN. With already high taxes of > 6%, they have a special "medical provider tax" of 1%. Yes you read correctly. Just because you are a physician they charge you an extra 1%. Way to go MN!

Holy cow, how is that even legal??

 

[GeneralVeers]

Holy cow, how is that even legal??

Here's the statute: http://www.health.state.mn.us/divs/fpc/profinfo/lic/minntax.htm

 

[Hercules]

Here's the statute: http://www.health.state.mn.us/divs/fpc/profinfo/lic/minntax.htm

This is mind blowing. Do MN lawyers pay a 1% professional tax as well? I'm going out on a limb and guessing no. Does anyone know the background for where this came from?

 

[TooMuchResearch]

This is mind blowing. Do MN lawyers pay a 1% professional tax as well? I'm going out on a limb and guessing no. Does anyone know the background for where this came from?

I would guess democrats :nothelpfulemoji:

 

[WilcoWorld]

I haven't looked into WA as I never considered moving there. The surprising one is MN. With already high taxes of > 6%, they have a special "medical provider tax" of 1%. Yes you read correctly. Just because you are a physician they charge you an extra 1%. Way to go MN!

The website makes it sound a bit different than you describe:

The tax is imposed on payments health care providers receive for providing services to patients or consumers.

If you receive payments for providing health care services - other than wages or salary from an employer - you are required to register with the Minnesota Department of Revenue for the MinnesotaCare tax.

It's more like a sales tax for medical services than it is like an extra income tax on medical providers.

So, a doc who owned an urgent care center and was also a salaried employee would have to pay 1 % extra taxes on her profits but not the salary she made working there.

That being said, I still don't like it.

 

[Hercules]

The website makes it sound a bit different than you describe:

So, a doc who owned an urgent care center and was also a salaried employee would have to pay 1 % extra taxes on her profits but not the salary she made working there.

That being said, I still don't like it.

No it's not a tax on profits-- it's an additional tax on all revenue, which is a big difference. So if you're in an SDG that has $5M in revenue that's $50k more dollars taken out of your groups paychecks simply because you are doctors. If you're employed by a hospital or CMG they're taking that extra 1% into consideration when they determine your salary/pay.

 

[Old_Mil]

That Minnesota tax sounds a lot like Washington, but I believe Washington's rate was 3%.

How this affects you even if you don't own an urgent care:

If you receive payments for providing health care services - other than wages or salary from an employer - you are required to register with the Minnesota Department of Revenue for the MinnesotaCare tax.

If you are a 1099 independent contractor you aren't getting wages or salary from an employer.

 

[WilcoWorld]

Again, I don't like or support the tax. I'm just pointing out that salaried employees don't pay that tax.

One could argue that it's a means of forcing every doctor to become an employee, and that's obviously a problem.

 

[GeneralVeers]

Again, I don't like or support the tax. I'm just pointing out that salaried employees don't pay that tax.

One could argue that it's a means of forcing every doctor to become an employee, and that's obviously a problem.

You are correct, but indirectly it will affect your salary. It adds additional cost to every employer which will get passed on to you.

 

[WilcoWorld]

You are correct, but indirectly it will affect your salary. It adds additional cost to every employer which will get passed on to you.

No disagreement there.

 

[goodoldalky]

I personally would not move to a state with a "medical provider tax". I consider it one of those situations where the states have truly been allowed to be the laboratories of democracy. And as a result states like that can find some other doctor to do their doctorin, because I'm sticking with Texas.

Now in the good old days where my group hangs up a shingle and says, here we are, and we are independent, then I'm simply passing that tax on to the patients and tacking it on the bill. However, in most cases now as an EM doc I am an employee or part of a larger entity and what happens in that scenario is I get a 2% pay cut. Surprisingly this tax looks like it has been around a long time.. so long, in fact, I'm not sure anyone even knows about it.. haha.