Urgent Care right out of residency

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enalli

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I'm finishing up second-year and have found myself increasingly interested in just going into urgent care after residency.

I have two main reasons for wanting to do this:
- The medicine: My co-residents live for the next code/decompensating septic/mystery illness and bemoan the low-acuity patients. I, on the other hand, like the low-acuity patients and although I also enjoy the occasional resuscitation, I can live without them.
- The lifestyle: I do not seem to adjust as well to evening/night shifts as well as everyone else. This schedule also makes it difficult to spend quality time with my family.

Yes, I'm aware that these two reasons may mean I probably should not have gone into EM in the first place, but what's done is done. I can live with making 120-200k a year instead of 250-350k, so the pay is not really a deal-breaker for me.

I wanted to hear any thoughts that you guys may have. Have you or anyone you know done this? Is this a really bad idea? Anything I as a naive resident am not considering? With The Upcoming Changes in Medicine™, will urgent cares still exist in 15-20 years, or will I find myself out of a job?
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Highly doubt you will be out of a job. Reimbursement may go down, but you'll be gainfully employed in some capacity.


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Feel free to do whatever you like, I would advise you to at least spend some time in a community ED before making that decision.

You're training at a tertiary center where 50% of your patients get admitted, correct?

The difference between this practice environment and a community ED with a 10% admit rate is pretty staggering. In a community ED you will have more than your fill of chronic coughs, pharyngitis, and wrist sprains. You also have the ability to sedate, reduce, and refer a displaced colles fracture, rather than just say "go to the ER" which is what the UC will encourage you to do for every interesting patient.

If the high acuity you are currently experiencing in your training environment is your primary concern, I would advise getting a lower acuity community EM job. If it is the lifestyle complaint, you could either do locums and make your own schedule or work an in an UC I guess.
 
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I opened an urgent care 2 years after finishing my EM residency. That was 5 years ago and I still own the urgent care but only work 1 shift a month in it while continuing to work full time in community EM and serving as a medical director. I would not recommend going straight into urgent care.

Take a community ED job and get boarded in EM. This will keep a lot more options open for you and you may be surprised by what you actually enjoy.

If you work in a higher paying community job you will be able to set aside cash and own an urgent care instead of being an employee of an urgent care. This makes a huge difference and owning an urgent care is very lucrative while
working in one is not.

Feel free to PM me if you have questions you don't want to ask on the forum.


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Hercules said:
I opened an urgent care 2 years after finishing my EM residency. That was 5 years ago and I still own the urgent care but only work 1 shift a month in it while continuing to work full time in community EM and serving as a medical director. I would not recommend going straight into urgent care.

Take a community ED job and get boarded in EM. This will keep a lot more options open for you and you may be surprised by what you actually enjoy.

If you work in a higher paying community job you will be able to set aside cash and own an urgent care instead of being an employee of an urgent care. This makes a huge difference and owning an urgent care is very lucrative while
working in one is not.

Feel free to PM me if you have questions you don't want to ask on the forum.


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Click to expand...

Very interesting. How are you owning an urgent care while barely working there? Most uc's are physician partnerships where everyone is putting in their share of shifts...
 
enalli said:
I'm finishing up second-year and have found myself increasingly interested in just going into urgent care after residency.

I have two main reasons for wanting to do this:
- The medicine: My co-residents live for the next code/decompensating septic/mystery illness and bemoan the low-acuity patients. I, on the other hand, like the low-acuity patients and although I also enjoy the occasional resuscitation, I can live without them.
- The lifestyle: I do not seem to adjust as well to evening/night shifts as well as everyone else. This schedule also makes it difficult to spend quality time with my family.

Yes, I'm aware that these two reasons may mean I probably should not have gone into EM in the first place, but what's done is done. I can live with making 120-200k a year instead of 250-350k, so the pay is not really a deal-breaker for me.

I wanted to hear any thoughts that you guys may have. Have you or anyone you know done this? Is this a really bad idea? Anything I as a naive resident am not considering? With The Upcoming Changes in Medicine™, will urgent cares still exist in 15-20 years, or will I find myself out of a job?
Click to expand...

I agree with the advice given to you about working at a small community hospital ER as an attending and see how you like it, before resigning yourself to an urgent care career.

I think you are going through a normal residency slump. I also trained at a level 1 trauma center and felt the same way in my 2nd year of residency, and even said the same words you did. I've since built up my confidence working in a community ER as an attending and am now planning on going back to a large academic center as a teaching attending. Moral of the story: you are in the heat of the moment, the eye of the tornado, etc.... Believe it or not, you aren't the best judge right now. It would be like my friend in college who used to do all his career planning during finals week because he was so tense about finals that each time he would downgrade his career in his mind rather than realize that everyone feels the same during finals.

If the community thing fails, then you can always quit and go to an urgent care. You will always have a job there, but it's half the salary, so don't jump to this back up right away. Just reassure yourself that it's a back-up option if you really, really need.

Also, unless your PD and program are letting you know that you're not up to snuff for EM, I wouldn't sweat this. Trust the system. Your program will train you appropriately. And they will let you know if you are not an adequate doctor for EM. If you *are* deemed adequate, then stick to ER and go to a low acuity, low stress community ER gig... It's what you deserve with your training.
 
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bravotwozero said:
Very interesting. How are you owning an urgent care while barely working there? Most uc's are physician partnerships where everyone is putting in their share of shifts...
Click to expand...

Actually with all of the mergers and buyouts, most urgent cares are now owned by corporations that employ physicians and midlevels. My urgent care is owned by myself and 4 other physicians. We purchased the land, built it, and got it up and running and then started hiring physicians to help cover it after the first year. Now we have one full time physician and two part time physicians, which leaves us covering about 2-3 shifts/month split between the 5 of us. Our employed physicians are paid an hourly rate plus a productivity bonus that brings their pay above what the larger corporation owned urgent cares are paying while still leaving us with a healthy profit.


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bravotwozero said:
Very interesting. How are you owning an urgent care while barely working there? Most uc's are physician partnerships where everyone is putting in their share of shifts...
Click to expand...
When you own a place, you set the terms. An employee can't force you to make them partner lol.
 
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bravotwozero said:
Most uc's are physician partnerships where everyone is putting in their share of shifts...
Click to expand...

Around here, most urgent cares (that are not owned by a hospital) are run by NP's. There are no independent ones run by physicians in the area that I am aware of. As an aside, you hear that "mid-levels" will take over primary care. That is not happening. Our system, and all the others I am familiar with, are hiring only FM/IM physicians for primary care. Those that had a NP for urgent same-day visits are told to phase them out. From what I see, the mid-levels are taking over urgent care ("school physicals, a few antibiotics, some tramadol, or if it is anything beyond trivial send them to the ED, and earn the same"), or working for specialists. I saw a woman yesterday who had an EGD while previously admitted (for something unrelated) and she said she never saw the GI - NP was the one who saw her before and after the procedure. She only assumes that the GI actually did the procedure.

With all that said, it is certainly possible to start out in urgent care. The question is if it is wise. The problem is that if it is all you do early on, you have basically eliminated yourself from all future ED employment. Don't shut off all of your options early on. I am also pessimistic about physicians in independent urgent care. (I will admit that I am basing it only on what I am seeing it locally.) Hospitals are willing to staff with physicians and see if as a "loss leader" to make up revenue from other activities. NP's do the trivial stuff for cheap. But between those two extremes, I don't see much of a niche for physician urgent care. But again, all medical economics are local.
 
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(1) Agree with above, don't go straight to work in a UC. Put 2 years into a community ED where you'll get paid more (get those loans gone), you'll continue to learn (you'll learn more your first year out than your last year of residency), and you can see what "real" EM is like. Get boarded. Many community EDs are 50% UC anyway...
(2) As you approach the 12mo mark in this job, take a long look at it and UC opportunities in your area. MOONLIGHT. One great benefit of EM is you can moonlight, pull a couple shifts a mo at a UC, a different ED, etc. TRY BEFORE YOU BY. Just find a nice calm community gig as your base, then take your time and try things out...

Nothing wrong with doing UC in the end if that is your true love. But if so, certainly try to be an owner-operator, don't just join up hourly for a crap chain.
 
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Vandalia said:
Around here, most urgent cares (that are not owned by a hospital) are run by NP's. There are no independent ones run by physicians in the area that I am aware of.

I am also pessimistic about physicians in independent urgent care. (I will admit that I am basing it only on what I am seeing it locally.) Hospitals are willing to staff with physicians and see if as a "loss leader" to make up revenue from other activities. NP's do the trivial stuff for cheap. But between those two extremes, I don't see much of a niche for physician urgent care. But again, all medical economics are local.
Click to expand...

Your local experience is atypical. Less than 20% of all urgent cares are hospital owned. Hospitals don't usually lose money on an UC either. Most UCs that can manage to see >25 pts/day are profitable. I am pretty bullish on the long term future for UCs. There is no facility fee (like exists with a FSED) that can be yanked out from under them to affect profitability. You make your money off basic visit E&M codes, procedures, lab work, in house X-rays, etc. The biggest impact so far has been the insurance companies setting a higher copay for seeing an UC vs PCP and even that didn't have any major effect on our financials when it occurred a few years ago.

As several of us have said to the OP so far, if you are going to do UC make sure you own it. Best way to own it (assuming you are not independently wealthy and don't have the capital on hand to start building one right away) is to get out and make some money in community ED while you're doing your research about how to go about starting an UC.
 
Take the big pay cut and do that if you want, but I would not hire you to work in my department after doing that. Your skills will deteriorate to the point of limiting your options if you change your mind later.

Basically what I am telling you is this is a terrible idea and a complete waste of your training, time, and money.
 
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I say UC right out of residency is a bad idea. Don't commit yourself and leave yourself Pegged so early on. You may be happier as an UC doc the rest of you life and still make 200K+ doing nothing but sniffles. You may enjoy it and there is nothing wrong with that.

But atleast give it a year, keep your options opened. You may end up hating UC, love EM medicince, or you might be in the middle.

If I were you, I would find a job where you do 1/2 UC, 1/2 Community EM. Give it a year, you will find out what you like better. At that point, you can make an educated decision.
 
I do work at one of those places that seems to have an admission rate close to 50%. There have been many shifts when I look at our board, then look at our attending and think "I do not want their job right now... or in x years." My experience with community EM is non-existent, and while I have thought this setting might suit me, I just assumed the difference between a 50% admit rate and a 20% admit rate wouldn't be that big in practice. There is also the thought that when things do go wrong at these places, I wouldn't have the consulting services, other residents, or other attendings to back me up.

Thanks for your replies. I hope I can figure this out soon.
 
Like a lot of posters have mentioned, don't forget that there are many different practice environments in the ER. You might be suited for a low volume, low acuity place in a rural area. You don't necessarily have to live there. A lot of groups will pay your expenses to staff these sites. Also, maybe you're looking for a low volume freestanding ER opportunity?

Keep in mind, though, taking any low volume, low acuity job will lead to a rapid deterioration of skills. It will make the occasional central line or intubation at these places very stressful.

Also, remember that urgent cares aren't necessarily a walk in the park. Sure the medicine isn't hard, but the volume tends to be high. It's not fun seeing patients, charting on patients, and discharging patients at a 3-4 per hour pace for 12-hour shifts. It's especially a hard pill to swallow when you're not being paid well for your level of training or your time.
 
txterp98 said:
Also, remember that urgent cares aren't necessarily a walk in the park. Sure the medicine isn't hard, but the volume tends to be high. It's not fun seeing patients, charting on patients, and discharging patients at a 3-4 per hour pace for 12-hour shifts. It's especially a hard pill to swallow when you're not being paid well for your level of training or your time.
Click to expand...

This is another good point. On my last urgent care shift I saw 50 patients in the first 4.5 hours. They're all low acuity but that's still not a relaxed stress free pace.




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txterp98 said:
Like a lot of posters have mentioned, don't forget that there are many different practice environments in the ER. You might be suited for a low volume, low acuity place in a rural area. You don't necessarily have to live there. A lot of groups will pay your expenses to staff these sites. Also, maybe you're looking for a low volume freestanding ER opportunity?

Keep in mind, though, taking any low volume, low acuity job will lead to a rapid deterioration of skills. It will make the occasional central line or intubation at these places very stressful.

Also, remember that urgent cares aren't necessarily a walk in the park. Sure the medicine isn't hard, but the volume tends to be high. It's not fun seeing patients, charting on patients, and discharging patients at a 3-4 per hour pace for 12-hour shifts. It's especially a hard pill to swallow when you're not being paid well for your level of training or your time.
Click to expand...

Great post.

Although I would say that one year as an attending in a lower acuity place--not TOO low acuity but less than the level 1 trauma center university hospital--is a good way to build up confidence. It was for me.

Now, I want to head back to the mother ship... Ironically, there is where my skills will deteriorate the most, due to residents doing the procedures.
 
txterp98 said:
Like a lot of posters have mentioned, don't forget that there are many different practice environments in the ER. You might be suited for a low volume, low acuity place in a rural area. You don't necessarily have to live there. A lot of groups will pay your expenses to staff these sites. Also, maybe you're looking for a low volume freestanding ER opportunity?

Keep in mind, though, taking any low volume, low acuity job will lead to a rapid deterioration of skills. It will make the occasional central line or intubation at these places very stressful.

Also, remember that urgent cares aren't necessarily a walk in the park. Sure the medicine isn't hard, but the volume tends to be high. It's not fun seeing patients, charting on patients, and discharging patients at a 3-4 per hour pace for 12-hour shifts. It's especially a hard pill to swallow when you're not being paid well for your level of training or your time.
Click to expand...


I've thought about this lately. There are a few UrgentCare sites opening or "blocks" from my home; and I've toyed with the idea of walking up and saying: "Hey, I'm a BC EM doc. If you need help, I'll pick up some shifts." I want to see what its like.

My first thoughts were: "I know this is where medicine goes to die; but let me punch the timeclock and have an easy day making easy money."
My second thoughts were: "Ugh. 4 patients an hour? Don't freaking rush/hassle me. Let me work."

I'm sure there's a balance to be struck. I get the sense that the key is going to be a solid EMR with dictation capabilities. DragonSpeak has really set the standard.
 
RustedFox said:
I've thought about this lately. There are a few UrgentCare sites opening or "blocks" from my home; and I've toyed with the idea of walking up and saying: "Hey, I'm a BC EM doc. If you need help, I'll pick up some shifts." I want to see what its like.

My first thoughts were: "I know this is where medicine goes to die; but let me punch the timeclock and have an easy day making easy money."
My second thoughts were: "Ugh. 4 patients an hour? Don't freaking rush/hassle me. Let me work."

I'm sure there's a balance to be struck. I get the sense that the key is going to be a solid EMR with dictation capabilities. DragonSpeak has really set the standard.
Click to expand...
If you decide to do that (and I know lots of EM folks that do) for God's sake make sure you're paid on productivity. I thought I had a good UC deal that paid roughly $140/hour until I realized that those 4-6 patients/hour that I was seeing would have grossed me minimum $160/hour (as much as $300/hour during flu season) if we'd used standard FM wRVUs rates.
 
RustedFox said:
I'm sure there's a balance to be struck. I get the sense that the key is going to be a solid EMR with dictation capabilities. DragonSpeak has really set the standard.
Click to expand...

The key is a good EMR that was built for urgent care (usually either Docutap or practice velocity) with good scribes. Seriously. During peak season we have days where we see 8-10 pts/hr for a 10 hr shift and walk out on time with charts complete. When we first started we thought we would need midlevels or an extra physician once we got over 5 pts/hr but we learned to make the process much more efficient. The vast majority of urgent care patients aren't very complicated and the majority can be seen and treated very quickly.



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Hercules said:
The key is a good EMR that was built for urgent care (usually either Docutap or practice velocity) with good scribes. Seriously. During peak season we have days where we see 8-10 pts/hr for a 10 hr shift and walk out on time with charts complete. When we first started we thought we would need midlevels or an extra physician once we got over 5 pts/hr but we learned to make the process much more efficient. The vast majority of urgent care patients aren't very complicated and the majority can be seen and treated very quickly.



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Click to expand...
Your Docutap must be different from the one I used, because that thing sucked.

Cerner with good URI/UTI/Flu templates, can usually start to finish charting a patient in under 60 seconds.
 
VA Hopeful Dr said:
Your Docutap must be different from the one I used, because that thing sucked.

Cerner with good URI/UTI/Flu templates, can usually start to finish charting a patient in under 60 seconds.
Click to expand...

With Docutap, templates, and a scribe I can start to finish charting a patient with scripts and discharge instructions in less than 5 sec :)

I'll quit digressing on EMRs though. Hopefully the OP has heard all of the good advice to push forward with EM and try a different environment after residency before throwing in the towel and doing nothing but UC.


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If that is what you want to do, great. Do what makes you happy.

Just be aware that your pay will be much lower because you will be competing directly with NPs and PAs in the labor force and no urgent care manager is going to pay you extra for your degree.

Also this is probably a one way street because after some period of time you will have lost the skill set to ramp back up to a higher acuity practice.
 
Umm I don't see that quoted statement anywhere in the following:

Physician - Urgent Care - 300K + Opportunity
Job Locations US-NJ-Wayne
ID 2017-1485 Category Medical Staff
Overview

CityMD is a network of urgent care centers dedicated to setting an unprecedented standard of care for our patients and an edifying, intuitive work environment for our employees. We are looking for board-certified Emergency and Family Practice trained physicians who thrive in an environment surrounded by highly trained and motivated individuals and operate on one of the most advanced administrative systems in healthcare today. Your responsibilities will include the diagnosis and treatment of patients of all ages, and interpreting and archiving medical information.

Highlights:
Scribes on staff. This allows you to focus your time on direct patient care.
Advanced imaging available on a routine and STAT basis, including CT, US and MRI.
Specialist consultation allows for 48 hour turn around and same day results for urgent cases.
State-of-the-art facilities, digital X-Ray, laboratory services with modern, clean and aesthetically designed work environments.
Dedicated physician led Aftercare team following up on all aspects of patient care.
Integrated Electronic Medical Records across all CityMD locations.
Our commitment to our patients and employees, along with our state-of-the-art personalized healthcare delivery system, has taken CityMD from one location on the Upper East Side to over 50 in the New York area including Manhattan, Brooklyn, Queens, Long Island, Rockland and Westchester County. As a proud “People First” company, we are centered on the values of integrity, excellence, professionalism and quality.
Highlights:

Our Compensation package is broken down as follows:
1. Competitive hourly rate plus incentive bonus up to 80K!
2. 160 hours Paid time off
3. $3000 annually in CME
4. 401k will match up to 4% of your contributions
5. Full medical, dental and vision benefits
6. Occurrence based malpractice policy
** In addition, our premium pay is an additional $45 per hour
Responsibilities

We are hiring board-certified physicians who are Emergency Medicine or Family Medicine trained to work in our state-of-the-art urgent care centers. Our facilities are staffed with highly trained and motivated individuals who operate one of the most advanced administrative systems in healthcare today.


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AOAmed said:
"Minimum compensation 300,000 with competitive hourly rate plus incentive bonus up to 80K!"
Click to expand...
Doesn't say how many shifts/month. Is 300k worth 20 12-hour shifts per month?

It says they have scribes, that suggests very high volume. Is 300k worth seeing 100 patients in 12 hours?
 
Apollyon said:
Something is weird about this AOAmed person. It seems as if they've deleted anything they've ever written before this thread (with a grand total of 21 posts in 3 years that this person has put up).
Click to expand...

Birdstrike Jr?
 
Why would anyone want to work at an urgent care for $300,000? There was an ad stapled to a telephone pole near my house that said they had "work at home jobs" that required only 20 hours a week and paid $50K+ a month!

That is over twice as much for probably one-third of the work. Plus you can work at home.
 
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AOAmed said:
AFC Doctors Express Urgent Care -- Average Salary $300,000.
AFC Doctors Express Urgent Care Urgent Care Physician Salaries in the United States | Indeed.com
Click to expand...
This link does not state a 300K minimum either. It is also using self reported salaries as well as job postings which are scraped by an algorithm which likely doesn't have the wherewithal to realize that job postings like your first one shouldn't be taken at face value. Now that I've written that out, I think I understand why you thought this link would bolster your argument.
 
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Work in a community ED that forces docs to work a few shifts a month in their in-house UC/fast track.

Notice if, when in fast track, you are happy or wishing to be in the real ED.

Get EM money and both EM and UC experience for a year or so. Then re-visit this thread. Then decide.

HH
 
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