As a resident currently likely pursuing academics in the future, I think I have some insight on this.
Happiness scale:
I rotate at both an academic center and a community hospital. When it comes to happiness, hands down the people in the academic environment are WAY happier. Less metrics, less BS, less control by corporate overlords. I can't even imagine being a slave for a CMG just to get paid more money to deal with everything they put you through. All of the academic attendings i've talked to feel like they are appreciated and valued by our department chair, and that they have a voice in what goes on in our department. For some this is worth the salary cut, for others it isn't, depends on what your priorities are. I'm sure there are great community jobs out there, but I get the sense that many of them are diminishing.
Malpractice:
Most of the academic attendings I talk to really love the way malpractice is handled. They get dropped from the lawsuit every single time, have a meeting with the risk management department, and then the physician group deals with the rest. While malpractice probably sucks everywhere, I would argue in the academic realm it's slightly easier to cope with.
Procedures:
Yes, we take away lots of procedures from the attendings. But we are at such a high acuity shop that I feel like most of our attendings are still doing a similar number of procedures as many community EM attendings. When I miss an airway, which still unfortunately happens, it's not like the attending who takes over is sitting there struggling trying to figure out where the epiglottis is. They usually get it first try without difficulty. Plus, many of our attendings work out in the community on their own without residents and keep their skills up.
Money:
Academics make less. Period. There's no way around it. People always try to figure out "why" but the answer is simple. They often work less clinical shifts (which is where reimbursement comes from) in usually highly desirable cities where supply/demand economics favor the employer setting the salary. Research doesn't pay anything. Teaching residents doesn't pay anything. That being said, the majority of academic EM attendings still live comfortably, travel frequently, and have enough in retirement and loans paid off in a timely manner. They get lots of retirement benefits, tuition benefits for kids, and so forth. I still don't understand how many community ED docs say they can't imagine "surviving" on an academic salary.
Burnout:
WAY less in academics. Many of my attendings are in their 70s, mostly doing administrative stuff in the office a few days a week, picking up a shift every so often for the fun of it. They love what they do and wouldn't have it any other way. While some may be happy to retire in their 50s, in academics you give yourself longevity because you offset your clinical duties with other interesting things. Depending on how academically productive you are and how much you buy down clinical time, you can work 6-8 shifts/month in academics which to me sounds pretty sweet.
Skillset:
This one is controversial. I have lots of admiration for the community EM docs that are able to manage crashing patients well in resource-limited settings. At the ivory tower, you have all the tools at your disposal and all the consultants available which in many ways makes it much easier. That being said, many community EM docs I work with (who graduated from residency ~5-10 years ago) can't even do a bladder ultrasound. Academicians are often more up to date on newer developments because they have the time and the resources. I would say this is a toss up and both arenas bring variable degrees of competence. Many community EM attendings are more competent than academic attendings and vice versa.
For me, I think that a community/academic hybrid in many ways is an ideal set up, and I'm looking into that option as well. Hopefully those jobs still exist. The current trajectory of CMGs taking over many physician groups means that working straight in the community probably isn't a viable option for me since I detest these organizations so much.
