What are the "exit options" or "next steps" for EM?

[remzremz]

I was wondering what the "exit" options or "next steps" after practicing EM after 10-15 years? Not quitting the field, but transitioning into an area of EM that may be less stressful and doesn't require constant night shifts. What happens when people hit their 50s and 60s? Can you do more academic work like teaching? What lower-stress sub-specialties are available? Thanks!

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[RustedFox]

Ahh, yes.

A very wise man once said to me... "As soon as you get into this field, you best be working on a plan to get out of it."

 

[slystalone]

There's always urgent care work. Academics is nice but you'll still have to do night shifts (I'm assuming)

 

[remzremz]

Ahh, yes.

A very wise man once said to me... "As soon as you get into this field, you best be working on a plan to get out of it."

That's exactly why I'm asking the question. Care to elaborate on some of the "next steps" or "exit options" that you've seen EM doctors take? Academia? Specializing somehow? Options outside of Urgent Care?

 

[Hercules]

That's exactly why I'm asking the question. Care to elaborate on some of the "next steps" or "exit options" that you've seen EM doctors take? Academia? Specializing somehow? Options outside of Urgent Care?

Yes to all of these. Plus administration, consulting, and dropping to part time.

 

[em1234]

He who fails to plan is planning to fail. -Churchill

I work full time at a very busy urban ED, between obnoxious administration, senseless patient satisfaction surveys, sniping consultants, ungrateful patients, unreasonable family members, long overnights and all the other warts of emergency medicine, I have always had an eye towards that mythical door that reads "Medicine: EXIT". For context, I'm not some disgruntled bitter burnt out pit doc. If you ask any of the 15 people in my group, they'd tell you that I'm the most content with our work environment. I always have excellent patient satisfaction scores, am well liked and respected by consultants, and generally like my job. That being said, not recognizing that our careers are physically and emotionally taxing and lend themselves to be truncated by burnout is just shortsighted and obtuse. So my tentative exit strategy includes another 10ish years of regular work and then cutting back to 1/2 or 1/4 time at my regular job. Then using my current side job/moonlighting gigs to supplement my income for another 10ish years after that as discussed below…

I'm part of a free standing ED. Free standing work is very liberating. As an owner, I and my partners are administration. Never hearing the words press-ganey are awesome. The hourly + dividend far exceeds what I make per shift at my hospital job. Who knows how long the free standing train will roll, but it's worth riding as long as it's available.

Also, I have been working at an ultra-low volume ED. Where I live, we have a bunch of "surgical hospitals" around town.
These are basically ambulatory surgery centers that want to call themselves hospitals and as such need an ED, and thus need an ED doc to sit there all day. The EDs average ~300-500 people per year. They pay is weak compared to FSED or hospital based ED work, but getting paid $90/h to do nothing for 24h isn't that bad. The only patients I have seen are post op pain, and cutting off a cast that was too tight. The surgeons call to let you know the patient is coming and usually meet them in the ED shortly after they arrive. I don't really do anything for them.

Even though I'm only 5 years out, I routinely find myself thinking about how I doubt I'll want to be doing my regular busy full time gig in 10 years. So I'm a strong proponent of aggressively saving money, paying off student loans, and learning everything you can from the White Coat Investor.

I liken a career in EM to being a professional athlete. You are going to get paid a lot of money for a short period of time, so you have to be ready to live off that money for the rest of your life, or become a successful coach/broadcaster/isotoner glove salesman. Either way will work, if you plan accordingly.

-1234

 

[NurWollen]

He who fails to plan is planning to fail. -Churchill

I work full time at a very busy urban ED, between obnoxious administration, senseless patient satisfaction surveys, sniping consultants, ungrateful patients, unreasonable family members, long overnights and all the other warts of emergency medicine, I have always had an eye towards that mythical door that reads "Medicine: EXIT". For context, I'm not some disgruntled bitter burnt out pit doc. If you ask any of the 15 people in my group, they'd tell you that I'm the most content with our work environment. I always have excellent patient satisfaction scores, am well liked and respected by consultants, and generally like my job. That being said, not recognizing that our careers are physically and emotionally taxing and lend themselves to be truncated by burnout is just shortsighted and obtuse. So my tentative exit strategy includes another 10ish years of regular work and then cutting back to 1/2 or 1/4 time at my regular job. Then using my current side job/moonlighting gigs to supplement my income for another 10ish years after that as discussed below…

I'm part of a free standing ED. Free standing work is very liberating. As an owner, I and my partners are administration. Never hearing the words press-ganey are awesome. The hourly + dividend far exceeds what I make per shift at my hospital job. Who knows how long the free standing train will roll, but it's worth riding as long as it's available.


Also, I have been working at an ultra-low volume ED. Where I live, we have a bunch of "surgical hospitals" around town.
These are basically ambulatory surgery centers that want to call themselves hospitals and as such need an ED, and thus need an ED doc to sit there all day. The EDs average ~300-500 people per year. They pay is weak compared to FSED or hospital based ED work, but getting paid $90/h to do nothing for 24h isn't that bad. The only patients I have seen are post op pain, and cutting off a cast that was too tight. The surgeons call to let you know the patient is coming and usually meet them in the ED shortly after they arrive. I don't really do anything for them.

Even though I'm only 5 years out, I routinely find myself thinking about how I doubt I'll want to be doing my regular busy full time gig in 10 years. So I'm a strong proponent of aggressively saving money, paying off student loans, and learning everything you can from the White Coat Investor.

I liken a career in EM to being a professional athlete. You are going to get paid a lot of money for a short period of time, so you have to be ready to live off that money for the rest of your life, or become a successful coach/broadcaster/isotoner glove salesman. Either way will work, if you plan accordingly.

-1234

I bet you provide a far superior experience for the patient at the FSED, since you're free of laws and policies trying to force you to provide superior patient experience. Oh, the irony.

 

[d2305]

There is this http://anesthesiology.duke.edu/?page_id=818058

 

[Arcan57]

Don't go into EM assuming you'll have a palatable exit option in 10-15 yrs. You very well may, but the 24/7 nature of EM is against the majority of us. Absent new grads being willing to work exclusively nights and weekends (which they aren't), there simply aren't enough non-weekend daytime shifts for everyone entering now to drop down to part time cushy schedules in their mid 40s. Some will transition into admin, but that's typically going to be somewhere in the 1:15 admin doc/pit doc range in terms of having a stipend big enough to allow any substantial drop in clinical shifts. The numbers are even lower for U/S, EMS, etc. You're going to find success stories (Bird, etc.) but those are going to be the minority. Docs in the states where EM pay really well will be able to work fewer of the same crappy mix of shifts we all do, but I honestly don't know how a new grad making $225k in the metro NE is going to be able to afford to take their foot off the accelerator prior to their mid/late 50s.

 

[Birdstrike]

Don't go into EM assuming you'll have a palatable exit option in 10-15 yrs...

Hmm...provocative stuff. You need to explain that in more detail, not as much what you're saying but why you feel it needs to be said. This is profound stuff, actually. Med students, pay attention to this man (or women, or trans m>f, f>m).

 

[Arcan57]

Hmm...provocative stuff. You need to explain that in more detail, not as much what you're saying but why you feel it needs to be said. This is profound stuff, actually. Med students, pay attention to this man (or women, or trans m>f, f>m).

I think we have similar ideas regarding the perception vs. reality of EM that have been spelled out in numerous threads. Extraordinarily briefly:
1) The rotation most students go through on EM has no relation to the actual job of an EP. This falsely inflates the perceived attractiveness of EM, especially in students with mod-high Step scores that end up not matching into their chosen surgical subspecialty.
2) EM pays really well in relation to the length of training and the total time in the hospital after training. This also makes it attractive to students looking for work-life balance as attendings. The major issue with this is that it encourages people who have no real taste for the actual practice of EM to overvalue it. This leads to numerous threads where people ignore the basic realities of EM while trying to contort it into something that fits their fantasies. If the med students reading this take nothing else from this post, the schedule most EPs work is a feature not a bug.
3) If you're not "feeling it", I'm not sure there is a job in which you can be competent yet still be subjected to so much negative stimuli. This causes misery.
4) Miserable docs don't invest in making their shop better, don't help out their colleagues, spread their misery to nursing and ancillary staff, and cause unnecessary confrontations with medical staff that lower the reputation of everyone.
5) People assume that S/SE pay applies to the entire country and come up with completely unrealistic calculations about their future finances. They also see the 90% percentile pay and assume they're going to be making that, which is going to be incorrect for the majority of them because math.
6) I'm worried what 2025 is going to be like when all the new grads that thought they'd be retired by then realize they still have at least 10-15 more years of working and that the FSEDs are already saturated/legislated out of existence and they have a lifestyle that can only be supported by clinical medicine.

I want people contemplating EM to go in with clear eyes/clear head because it's pretty damn rough if you don't want to be here.

 

[xaelia]

This is my exit strategy:
https://www.theabpm.org/applicationci/ci_requirements.pdf

Helped I could grandfather in last year without the 2-year fellowship.

 

[goodoldalky]

Don't go into EM assuming you'll have a palatable exit option in 10-15 yrs.

Keyword bolded above.

I think one of the points Arcan is referring to is the fact that it is not as easy as saying "Yep, I'm a board certified ED doc, I've been doing this 15 years, now it's time for my part time - part cushy 9-5 weekday work gig."

In order to have a palatable exit option in 10-15 years, you have to plan to build a palatable exit option. One will not magically appear. It is also not as easy as "make a ton of money for x years, buy a bunch of stock, have it grow into a ginormous pile of money, then chill." Most BCEM docs are still working as pit docs when they are 50+.

Bird did a fellowship that he knew would create a palatable exit option. That wasn't an accident, though. He didn't assume it. Some folks take ownership of FSED businesses. Others get their MBA to ensure they are qualified for the inside track on admin or consulting. Other docs invest in real estate, car dealerships, transmission shops, or other non-healthcare related businesses. You get the idea. Some docs, do nothing. And they typically continue to work in the ED until they retire, which may be great or it may be barely tolerable, depending on who you are.

 

[Birdstrike]

I agree with you guys. Some very good posts above

I always go back to Greg Henry's article on EM's mid life crisis:

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

There is no natural progression in EM to make the fit of the specialty adjust to you, like other careers where one goes from doing "young man's work" to work more suited for and palatable to someone with 10, 20 or 30 in the game. You generally do the same work and shifts day one as you do your final day before retiring, but you aren't the same person on those two days or those in between.

Therefore those "mid career shifts" best be given some thought in advance rather than put off until too late or done as the plane goes down in flames. Also, don't plan on retiring at 40. It's a great goal, but often life gets in the way. If it does happen, congrats, and expect to fully enjoy coming back and posting on the, "I'm retiring at 40, I'm rich beeyotch!" thread (another SDN classic). Emergency Medicine is one of the hardest working medical specialties, and anyone buying the false "lifestyle specialty" and "cushy schedule" misunderstanding-propaganda-lies, is setting themselves up for a rude awakening.

Also, see the this thread for a similar discussion:

http://www.forums.studentdoctor.net/index.php?threads/Medical-students-ambivalent-about-EM.1104226/

 

[BKN]

EM is a tough job. The nights get difficult as one gets older. Some groups have an opt-out policy for a specified age. Most groups have to pay a night differential to get the younger guys to do the shifts. BTW if you are young and, don't have family attachments that require you to be up during the day- you can do nothing but nights. The money is good if you are the prince of darkness or the queen of the night.

 

[RuralEDDoc]

If you have the stomach and mind for it, get started in admin early if you think that can be your exit path. Doesn't have to mean becoming assistant medical director. It can mean becoming the expert in HCAPHS and patient satisfaction, core measures and PQRS at your shop to help teach your others how to help jump through the hoops. As crappy as all that stuff is, you can provide service to your group on these issues; they aren't going away, in fact they are increasing in importance. Even being the "sepsis champion" or something silly like that helps you develop a taste and mind for admin. Start looking into MBA's or MHAs, many are part time and can be done in 2-3 years.
With all that said, if you have no interest in admin, find another "way out", such as broadening clinical skills outside of EM (eg fellowships).

 

[Old_Mil]

Also keep in mind that residency grads of a few decades ago had the benefit of the best bull market in history supporting their retirement plans. That, as well as social security and medicare.

If you are getting out of residency now, you will likely have none of these things and will need to work till you are dead.

 

[Birdstrike]

Also keep in mind that residency grads of a few decades ago had the benefit of the best bull market in history supporting their retirement plans. That, as well as social security and medicare.

If you are getting out of residency now, you will likely have none of these things and will need to work till you are dead.

That's okay, because in EM you're usually dead by 50 or so. It's not that long. Clean kill.

 

[turtledog]

That's okay, because in EM you're usually dead by 50 or so. It's not that long. Clean kill.

It can't possibly be that bad, otherwise the surgeons would have all committed suicide by age 40.

There are some inherent things about EM that protects it from some other abuses of in medicine: capped work hours and the ability to switch jobs relatively easily after settling for a few years. This makes EM almost unique among the higher paying medical specialties. Its downsides like working nights and weekends are also slightly offset by not having to take call.

 

[Birdstrike]

It can't possibly be that bad, otherwise the surgeons would have all committed suicide by age 40.

There are some inherent things about EM that protects it from some other abuses of in medicine: capped work hours and the ability to switch jobs relatively easily after settling for a few years. This makes EM almost unique among the higher paying medical specialties. Its downsides like working nights and weekends are also slightly offset by not having to take call.

Gallows humor. Exaggeration for effect. Yadda yadda

 

[turtledog]

My bigger question is how saturated are the major cities already becoming? From rumors I'm hearing in my area around Boston, starting salaries are not anywhere close to the lofty numbers posted on SDN, tend to be low to mid 200ks, and that's for the ones who found a job. Boston might be unique since it has a lot of academic hospitals and healthcare system monopoly. How are other cities faring?

 

[bashwell]

Here's another option for some who are willing to live and work overseas, where attending (consultant) level emergency physicians don't have to work past midnight or often not even nights:

http://offthescript.com.au/2012/06/...-in-the-world-to-practice-emergency-medicine/

 

[goodoldalky]

My bigger question is how saturated are the major cities already becoming? From rumors I'm hearing in my area around Boston, starting salaries are not anywhere close to the lofty numbers posted on SDN, tend to be low to mid 200ks, and that's for the ones who found a job. Boston might be unique since it has a lot of academic hospitals and healthcare system monopoly. How are other cities faring?

The answer to your question is not how saturated major cities are becoming, it is how saturated they are with lower-paying CMGs. Some CMGs are better than others. Some on the east coast are notorious for paying what I believe to be a ridiculously low hourly rate, however certain large markets in the area have had all of their contracts bought out by these groups so that tends to be what you get. Academic jobs also tend to pay less.

You may be finding that a lot of these hospitals are contracted with CMGs. I would encourage you to look into different facilities, if there are any, not staffed by contract management groups, and see what the difference is. Ask around your residency program and see if you can get some other leads. I'm not saying all independent or democratic groups are a better deal, some are actually not a good deal at all, but you have to have a basis for comparison.

 

[docdragon]

Ironically, some of the CMGs pay better in low reimbursement climates because they can spread the wealth from other locations to support staffing. Talk about regression to the mean... MA is tough, especially near Boston, because of market saturation. And a lot of the contracts in MA are currently held by one group. There have been a couple of jobs advertised in/nearer western Mass over the last year, mix of independent, community/academic linked, and hospital based groups.

Cities are often lower than the surrounding country, but there isn't a perfect correlation. Supply and demand are huge factors, but so is reimbursement rate. And concentrations of academic centers in cities. And malpractice risk.

 

[pkwraith]

I don't know about at 10-15 years, but there's some specialty changes possible as well. Where I attended medical school, half the Pain/Palliative medicine were ex-EM physicians. They bit the bullet for the 1-year fellowship, and exchanged a salary drop for the cush life style.

A lot tougher to get into academics

 

[EctopicFetus]

All good stuff and kudos to the OP for taking a look at their career path beyond the 3-5 year horizon. I have been out for 6+ years and still enjoy it. I hope that continues but now that I have saved a little I have started looking at non clinical ways to make extra money. This will allow me to cut back hours when I want and if I choose not to cut my clinical hours will at worst put me in a spot where I can achieve my financial freedom number even sooner.

 

[emergentmd]

I was wondering what the "exit" options or "next steps" after practicing EM after 10-15 years? Not quitting the field, but transitioning into an area of EM that may be less stressful and doesn't require constant night shifts. What happens when people hit their 50s and 60s? Can you do more academic work like teaching? What lower-stress sub-specialties are available? Thanks!

Don't let anyone tell you otherwise. EM is VERY easy to transition into something easier/no nights. I am at my 15 yr and currently working on my "exit" plan and hopefully in 5 yrs (or less) I will be there. I wish someone told me when I was in my 5-10 yr about working on an exit plan.

I am going to preface this by saying that I still love my job, love the 15 dys/130 hr a wk job I have, love the medicine involved, Work very little nights where I am up all night (maybe 2-3 days a month now). I will also say that working a hard night is tough. Dealing with alot of the crap does get tiring (drunks, complaints, etc) but it really doesn't bother me much.

But to answer you question, my exit plan is as follows. I just started to work on it about 6 months ago.

1. Bought 7 investment properties since last year and all 13 units rented. I hope to bring in Free cash flow of 50K a yr and as I raise rent, hope to get to 70K in 2 yrs. I also plan on buying another 5-10 properties in the next 5 yrs. It will be nice to get passive income. If I can get 100-150K in passive income, I am 1/3 of the way towards my current income. I plan on not stopping this. Goal is to get 25 investment property.

2. Investing in a FSED. Hope to join one in the next 3-6 months. If it works out, hopefully I can pull in another 200K working 15 hrs a week. that gets me to about 80% of my income

3. Work Locums. Maybe 2 dys a month (5hrs/wk). That gets me another 100k a year. Gotta keep my skills up.

So if everything works out in 5 yrs, I will have my current income working working 15 easy hrs a wk and 5 tough hrs a week. I am a person who will not sit around not working. I need to keep my mind sharp and physically doing EM medicine is good physical work.

 

[bashwell]

1. Bought 7 investment properties since last year and all 13 units rented. I hope to bring in Free cash flow of 50K a yr and as I raise rent, hope to get to 70K in 2 yrs. I also plan on buying another 5-10 properties in the next 5 yrs. It will be nice to get passive income. If I can get 100-150K in passive income, I am 1/3 of the way towards my current income. I plan on not stopping this. Goal is to get 25 investment property.

25 investment properties! Actually even 7 seems a lot to me. But I know next to nothing about real estate, and maybe like many in med I tend to be risk averse. But maybe this is something worth looking into. Is it difficult managing all of these, or do you hire property managers?

2. Investing in a FSED. Hope to join one in the next 3-6 months. If it works out, hopefully I can pull in another 200K working 15 hrs a week. that gets me to about 80% of my income

Can any physician invest in FSED, or only EPs?

Thanks.

 

[emergentmd]

25 investment properties! Actually even 7 seems a lot to me. But I know next to nothing about real estate, and maybe like many in med I tend to be risk averse. But maybe this is something worth looking into. Is it difficult managing all of these, or do you hire property managers?

Can any physician invest in FSED, or only EPs?

Thanks.

7 is a good amount but 25 would be a great amount. The cost and time to manage these places are not worth it so I have a prop manager. It costs me some $$ but well worth never talking to a tenant. Once you get a few properties, the ball starts to snowball.

My 7 properties will get me about 50K this year and I plan on putting money down on another property. Once I get to 12 properties, I should get 100k in FCF (free cash flow) and then I would buy 2 more. I hope to hit the 20-25 mark in 10 yrs. If I get to 20 properties, I should free cash flow 200k/yr.

I would think any Doc can invest in FSEDs but if you are partner, you have to work some shifts. Hard to do that unless your boarded in ED.

I tell my friends that this is the golden age for EM. Options are plentiful, money is great, there is a great shortage so I can name my price. I have no clue what it would look like in 5 yrs but my plan is to suck as much out of this golden goose as I can before this whole medicine pyramid implodes.

 

[goodoldalky]

Just a word of caution though on emergent's real estate income, he probably got into things right as the market was down ~7-8 yrs ago, and the time to buy was then. It is easier to make money with that timing, than if you were to go into it now, when the markets have rebounded in many locations, increasing your risk substantially. You can lose a lot of money if you don't know what you are doing especially now with prices climbing. Maybe emergent can coach you up.

 

[emergentmd]

Just a word of caution though on emergent's real estate income, he probably got into things right as the market was down ~7-8 yrs ago, and the time to buy was then. It is easier to make money with that timing, than if you were to go into it now, when the markets have rebounded in many locations, increasing your risk substantially. You can lose a lot of money if you don't know what you are doing especially now with prices climbing. Maybe emergent can coach you up.

Disclaimer - I do not pretend to be an expert in anything esp real estate. I think people in general try to keep information that could benefit others. I try to treat people the way I wish to be treated. Thus I will always be happy to educate people on what I wish I was told 10 yrs ago.


I completely disagree with this statement or maybe just from your ignorance. I actually bought them all in the last year. If I timed it right, I would have bought 7 yrs ago and would have paid 50% less for the same properties.

Unless you start looking into real estate and study the numbers, you will never find good investment properties. I have learned alot in the past year and I wish someone would have explained me all of this 10 yrs ago. You have to do due diligence but you have to start somewhere. I am in no way some expert in real estate, some guru, or have all of the connections. But I do read and understand the numbers.

Of course there is risks and real estate is the same.

There are alot of upside to investors at this time. The biggest is the interest rate. Plus Fannie backed loans are of great benefit thus you can get up to 10 loans with rates very close to a person buying a homestead (ie, no need for a commercial loan).

People get stuck on a bunch of different numbers and formulas that makes it way too complicated. I focus on Return on investment. Its simple. How much of a return am I getting on the cash I am laying out. If you have 150k to invest and a duplex costs 150k with rent at 2k a month.

You could buy it outright and you would generate 24k yearly in rent. Take away vacancies (2k), prop tax (3k), insurance(1K), prop manager(2K), repairs(4K) then you are left with 12k a year. So your Return on investment is about 8%. Not great in an area where value is not going up, pretty good in an area where value is going up.

No say, you leveraged the 150k and bought 3 duplexes putting 33% down.

Your yearly rent would be 72K. Take away vacancies (6K), Prop tax (9k), insurace (3k), Prop manager (6k), repair (12k), Principle/interest ($1500/mo or 18k). So your ROI is 72k-54K. or 18K a year. Your ROI is now 12% which is much better plus you get 3x the appreciation of the property.

 

[EM_Rebuilder]

25 investment properties! Actually even 7 seems a lot to me. But I know next to nothing about real estate, and maybe like many in med I tend to be risk averse. But maybe this is something worth looking into. Is it difficult managing all of these, or do you hire property managers?

Can any physician invest in FSED, or only EPs?

Thanks.

Anyone can invest into a FSED, you do not have to be a physician. In fact, many people (even some physicians) argue that one of the 'problems' with FSED is physician ownership and that physicians should not be allowed to own a facility.. or at least own a facility they also work in.

 

[bashwell]

Disclaimer - I do not pretend to be an expert in anything esp real estate. I think people in general try to keep information that could benefit others. I try to treat people the way I wish to be treated. Thus I will always be happy to educate people on what I wish I was told 10 yrs ago.


I completely disagree with this statement or maybe just from your ignorance. I actually bought them all in the last year. If I timed it right, I would have bought 7 yrs ago and would have paid 50% less for the same properties.

Unless you start looking into real estate and study the numbers, you will never find good investment properties. I have learned alot in the past year and I wish someone would have explained me all of this 10 yrs ago. You have to do due diligence but you have to start somewhere. I am in no way some expert in real estate, some guru, or have all of the connections. But I do read and understand the numbers.

Of course there is risks and real estate is the same.

There are alot of upside to investors at this time. The biggest is the interest rate. Plus Fannie backed loans are of great benefit thus you can get up to 10 loans with rates very close to a person buying a homestead (ie, no need for a commercial loan).

People get stuck on a bunch of different numbers and formulas that makes it way too complicated. I focus on Return on investment. Its simple. How much of a return am I getting on the cash I am laying out. If you have 150k to invest and a duplex costs 150k with rent at 2k a month.

You could buy it outright and you would generate 24k yearly in rent. Take away vacancies (2k), prop tax (3k), insurance(1K), prop manager(2K), repairs(4K) then you are left with 12k a year. So your Return on investment is about 8%. Not great in an area where value is not going up, pretty good in an area where value is going up.

No say, you leveraged the 150k and bought 3 duplexes putting 33% down.

Your yearly rent would be 72K. Take away vacancies (6K), Prop tax (9k), insurace (3k), Prop manager (6k), repair (12k), Principle/interest ($1500/mo or 18k). So your ROI is 72k-54K. or 18K a year. Your ROI is now 12% which is much better plus you get 3x the appreciation of the property.

Thanks emergenmd! Really appreciate you educating those who want to learn more. Apart from what you've written, are there other resources (e.g. websites, books) you'd recommend to help learn a bit more about investing in real estate, etc.? Thanks again.

 

[Birdstrike]

Anyone can invest into a FSED, you do not have to be a physician. In fact, many people (even some physicians) argue that one of the 'problems' with FSED is physician ownership and that physicians should not be allowed to own a facility.. or at least own a facility they also work in.

Physician ownership is everything that is right about FSEDs.

 

[Birdstrike]

Don't let anyone tell you otherwise. EM is VERY easy to transition into something easier/no nights. I am at my 15 yr and currently working on my "exit" plan and hopefully in 5 yrs (or less) I will be there. I wish someone told me when I was in my 5-10 yr about working on an exit plan.

I am going to preface this by saying that I still love my job, love the 15 dys/130 hr a wk job I have, love the medicine involved, Work very little nights where I am up all night (maybe 2-3 days a month now). I will also say that working a hard night is tough. Dealing with alot of the crap does get tiring (drunks, complaints, etc) but it really doesn't bother me much.

But to answer you question, my exit plan is as follows. I just started to work on it about 6 months ago.

1. Bought 7 investment properties since last year and all 13 units rented. I hope to bring in Free cash flow of 50K a yr and as I raise rent, hope to get to 70K in 2 yrs. I also plan on buying another 5-10 properties in the next 5 yrs. It will be nice to get passive income. If I can get 100-150K in passive income, I am 1/3 of the way towards my current income. I plan on not stopping this. Goal is to get 25 investment property.

2. Investing in a FSED. Hope to join one in the next 3-6 months. If it works out, hopefully I can pull in another 200K working 15 hrs a week. that gets me to about 80% of my income

3. Work Locums. Maybe 2 dys a month (5hrs/wk). That gets me another 100k a year. Gotta keep my skills up.

So if everything works out in 5 yrs, I will have my current income working working 15 easy hrs a wk and 5 tough hrs a week. I am a person who will not sit around not working. I need to keep my mind sharp and physically doing EM medicine is good physical work.

I don't think the average EP, most of whom have little if any business or real estate experience, would find a five year plan to build a real estate property ownership and management business an "easy" exit option. Easy, yet incredibly unrealistic, is walking in to your directors office and saying, "I'm burned out. I want to earn my same salary yet work half the shifts and no nights until I retire." That option would be incredibly easy, yet it generally doesn't exist except in Fairy Land. Your plan is certainly much more realistic, yet I personally would not consider it remotely "easy."

That bring us full circle to the 800 lb gorilla in the room: EM has few "easy" exit or wind down options that don't dramatically cut one's pay (like urgent care or going part time). This contrasts with other industries where generally as one goes higher up the food chain, work quality improves as does salary. For example, as one moves up to CEO in the corporate world, neither are they expected to do the heavy lifting of an entry level employee, nor are they expected to accept a declining salary. The CEO get an increasing salary, the hours of his/her choosing and calls the shots. In EM, there is no such natural progression outside of possibly being a director or moving up in academics, or if one gets creative with a non-traditional fellowship or outside investments. We can agree the options are there. I would just disagree that they're generally "easy." Significant planning and hard work is required. It won't happen as a natural progression.

 

[emergentmd]

I don't think the average EP, most of whom have little if any business or real estate experience, would find a five year plan to build a real estate property ownership and management business an "easy" exit option. Easy, yet incredibly unrealistic, is walking in to your directors office and saying, "I'm burned out. I want to earn my same salary yet work half the shifts and no nights until I retire." That option would be incredibly easy, yet it generally doesn't exist except in Fairy Land. Your plan is certainly much more realistic, yet I personally would not consider it remotely "easy."

That bring us full circle to the 800 lb gorilla in the room: EM has few "easy" exit or wind down options that don't dramatically cut one's pay (like urgent care or going part time). This contrasts with other industries where generally as one goes higher up the food chain, work quality improves as does salary. For example, as one moves up to CEO in the corporate world, neither are they expected to do the heavy lifting of an entry level employee, nor are they expected to accept a declining salary. The CEO get an increasing salary, the hours of his/her choosing and calls the shots. In EM, there is no such natural progression outside of possibly being a director or moving up in academics, or if one gets creative with a non-traditional fellowship or outside investments. We can agree the options are there. I would just disagree that they're generally "easy." Significant planning and hard work is required. It won't happen as a natural progression.

My statement of easy transition pertains to getting out of the ER, working less nights, working in a less stressful environment. Its easy for any ED doc to go from working full time in the ED to working part time, doing UC, doing FSEDs. Anyone can do this in 3 months easily. Sure you have to take a cut in pay but every field that works less will make less Money. Your statement of becoming a CEO is much more unrealistic. How many people ever get close to the "O" Suite?

Everyone should work towards passive income b/c when your are 60, no one wants to be a full time ED doctor. There are many ways to get passive income and making alot of $$$ as an ED doc allows you to obtain passive income. Everyone has to put in their years to build up "ammunition" to get towards passive income.

I am in my 15th yr and finally feel like I have enough ammunition to crank up on passive income investments. There is no way I could have done this in year one or even five. But I should have started to do this in year 5 rather than 15.

You can invest in real estate. You can invest in a business like a FSED. You can save and put the money into investments that generate dividends. ALL passive income when you are too old to work in the Pit.

I have over 7 figures in investments and now I am working on the other two avenues. I have a 7 figure portfolio in real estate excluding my home and hope to hit my 25 property goal. I hope to invest in a FSED soon.

The key is to diverse and not put all of your eggs in 1 basket. If all 3 of these works out, I will be in easy street in 5 yrs. If the FSED and real estate do not work out, I will still have my investments which will give me a decent retirement.

My bet is atleast 2 of the 3 will work out to some degree.

 

[EctopicFetus]

I too love love love real estate. Ever since high school I found this to be a field where with patience you can make money. My first real estate investment was an accident (sort of). None the less I generate a "profit" FCF plus paying down principal on loan of about 18-22K (depending on repairs) on an investment of 33k.

This doesnt even include appreciation which I estimate to be 8-10k per yr.

My hope is to hit the real estate even harder in the next 12-18 months and generate some FCF and then use that to buy more. I too would like to be a mini real estate mogul. With rates at the bottom like they are now it is a great time to invest.

 

[emergentmd]

I too love love love real estate. Ever since high school I found this to be a field where with patience you can make money. My first real estate investment was an accident (sort of). None the less I generate a "profit" FCF plus paying down principal on loan of about 18-22K (depending on repairs) on an investment of 33k.

This doesnt even include appreciation which I estimate to be 8-10k per yr.

My hope is to hit the real estate even harder in the next 12-18 months and generate some FCF and then use that to buy more. I too would like to be a mini real estate mogul. With rates at the bottom like they are now it is a great time to invest.

I feel that if interest rates goes up, it may be more difficult to buy Cash flowing homes. But on the flip side, it would make sense that if rates goes up then cost of investing will go up. Thus rent has to follow.

 

[EctopicFetus]

I feel that if interest rates goes up, it may be more difficult to buy Cash flowing homes. But on the flip side, it would make sense that if rates goes up then cost of investing will go up. Thus rent has to follow.

I think in a lot of ways rent is independent but you may be right. As interest rates go up fewer people can afford to buy homes, hence needing to rent therefore driving prices up. I just dont think that market is as elastic as we think unless you are talking about the cheapest of properties.

I hope to get very low rates and lock them in hence protecting my investment.

 

[emergentmd]

I think in a lot of ways rent is independent but you may be right. As interest rates go up fewer people can afford to buy homes, hence needing to rent therefore driving prices up. I just dont think that market is as elastic as we think unless you are talking about the cheapest of properties.

I hope to get very low rates and lock them in hence protecting my investment.

I agree. I am trying to pick as much as I can in the next 2 yrs. If Rates ever go above 6%, it starts to not make as much sense.

 

[deuist]

I'm part of a free standing ED. Free standing work is very liberating. As an owner, I and my partners are administration.

If you don't mind my asking, how did you get into that field? I imagine the investment costs upfront would keep many physicians away from setting up freestanding emergency department. Also, who determined the build location as well as what services to offer? How is inventory and purchasing handled?

 

[deleted206819]

If you don't mind my asking, how did you get into that field? I imagine the investment costs upfront would keep many physicians away from setting up freestanding emergency department. Also, who determined the build location as well as what services to offer? How is inventory and purchasing handled?

My POV is very similar to em1234's in that while I enjoy EM and my current group we are constantly under pressure to do more with less while bowing at the altar of "customer" satisfaction, ever increasing administrative demands to perform, and dealing with a less than friendly clientèle of which only 1 in 5 actually pay us anything. I'm one year out of residency to boot.

My group and I are opening our first FSED this fall and we are all looking forward to get that business up and running ASAP as it could mean the difference between burning out / unhappy to being happy and content. It also means better pay and setting you own rules for what makes sense and what doesn't. We are all partners and administrators in this venture.

As to your questions:
How did you get into that field? I imagine the investment costs upfront would keep many physicians away from setting up freestanding emergency department.
I'm one year out but saved up money by working a week after residency and for the next 6-9 months at >160 hours to save up a chunk of cash to put down. Upfront costs are/were > $50k but also on the hook liability wise if the venture goes down in flames (>$250k). The a single buildup of an FSED from soup to nuts is $2 million +.

Also, who determined the build location as well as what services to offer? How is inventory and purchasing handled?
We hired commercial real estate agents to look into the areas that would be potentially profitable given household income, median income, traffic patterns, population density, and projected growth over the next 1-5 years. It's not easy picking a site because you are dueling with other major players in the marketplace including other FSEDs and non-medical businesses. It's complicated to explain in a single post or several for that matter. We've been looking for 12 months + before landing on our current site.

 

[emergentmd]

My POV is very similar to em1234's in that while I enjoy EM and my current group we are constantly under pressure to do more with less while bowing at the altar of "customer" satisfaction, ever increasing administrative demands to perform, and dealing with a less than friendly clientèle of which only 1 in 5 actually pay us anything. I'm one year out of residency to boot.

My group and I are opening our first FSED this fall and we are all looking forward to get that business up and running ASAP as it could mean the difference between burning out / unhappy to being happy and content. It also means better pay and setting you own rules for what makes sense and what doesn't. We are all partners and administrators in this venture.

As to your questions:
How did you get into that field? I imagine the investment costs upfront would keep many physicians away from setting up freestanding emergency department.
I'm one year out but saved up money by working a week after residency and for the next 6-9 months at >160 hours to save up a chunk of cash to put down. Upfront costs are/were > $50k but also on the hook liability wise if the venture goes down in flames (>$250k). The a single buildup of an FSED from soup to nuts is $2 million +.

Also, who determined the build location as well as what services to offer? How is inventory and purchasing handled?
We hired commercial real estate agents to look into the areas that would be potentially profitable given household income, median income, traffic patterns, population density, and projected growth over the next 1-5 years. It's not easy picking a site because you are dueling with other major players in the marketplace including other FSEDs and non-medical businesses. It's complicated to explain in a single post or several for that matter. We've been looking for 12 months + before landing on our current site.

Being an owner of a FSED is not toooo cash intensive. I would say 50-100 k depending on how mcuh you want to own. But the more you own, the more you are on the hook to work. That is why these Places Need ED doc buy in. There is no way to staff these places well without ED docs and esp when the ED docs are not invested in the process.

The reason why FSEDS are better options over a hospital based EDs are the owners work there. They have an incentive to treat pts well, be quick, do a good job, be pleasant. Otherwise, what would the use of a FSED be?

That is why if a CMG start to open FSEDS without doctor buy in, you are stuck with hiring docs for a flat rate. You know what happens when a doc is guaranteed a salary without incentives. They become lazy. They get grouchy at 1am for the sore throat. Do that enough and word will get around that that FSED sucks.

FSEDs without ED doc involvement is set to fail IMO. That is the beauty of FSEDS.

I pray CMS/Gov doesn't crack down on this for atleast 5 yrs. I just need a good 5 yrs and I can retire in my mid 40's and enjoy life watching my kids grow u