Advice for EM residencies

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EMmed2026

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Hi, I am an M4 applying for EM this year. I am currently doing away rotations and got to experience academic vs community residencies. I was hoping it would clarify what kind of programs to apply to. At the academic hospital, I saw that there was a higher reliance on consultants but more autonomy than I expected the residents to have. My thoughts are that if I go to an academic center, I can see the sickest patients, traumas, and have the ability to do a fellowship after if I choose to do global medicine. But there is part of me that really enjoys the community setting. I noticed that there are fewer residents at community hospitals so the residents are closer to each other and their attendings.

I guess my question is, what are the pros/cons of doing community vs the academic? Are your chances of doing a fellowship after being at a community hospital less?
 
Imagine doing a 4-year EM residency, and then some BS 1-year global medicine "fellowship" where you work at a discount rate for this institution as an attending, gaining a "skill" and experience that no market would ever support. What a hilarious waste of time. Do you really think the people of Uganda give a **** about your ability to measure VTI on your pocket ultrasound?

5 years of training only to enter into an EM market where your CMG medical directors don't value you any more than a midlevel armed with the newest "how to practice EM" AI-based app. You're insane. But since you asked nicely...

Real advice: you could ask any LLM this question, "what are the pros and cons of academic or community residency training for emergency medicine" and get a very detailed answer (I just tried this with both ChatGPT and Claude, both gave accurate responses).

There are at least 20+ threads here already on SDN regarding this topic, and probably 100+ reddit threads within the last 5 years where this has been hashed out over and over and over.

Lastly, your chances of doing any specific fellowship coming out of a community program are effectively the same as coming out of an academic program, but that question is so varied and individual that it's hard to answer further without details.

Is your goal anesthesia critical care at MGH? Then you might need to go to a name-brand academic residency and produce some impressive academic work to get noticed for an interview.

Is your goal a community-based Ultrasound fellowship? Then you can waltz into any number of them that go unfilled each year.

Is your goal any fellowship in a top-tier city (NYC, SF, LA, Denver, Austin etc), well then program name clout and published academic projects or other impressive achievements will matter more.

My recommendation: prioritize your geographic location above all else. That matters far more for your residency happiness and satisfaction, which will show itself when it comes to your desire and motivation to achieve the next step in your career (even if that is going to a "Global Fellowship")
 
HemorrhagicShock said:
Imagine doing a 4-year EM residency, and then some BS 1-year global medicine "fellowship" where you work at a discount rate for this institution as an attending, gaining a "skill" and experience that no market would ever support. What a hilarious waste of time. Do you really think the people of Uganda give a **** about your ability to measure VTI on your pocket ultrasound?

5 years of training only to enter into an EM market where your CMG medical directors don't value you any more than a midlevel armed with the newest "how to practice EM" AI-based app. You're insane. But since you asked nicely...

Real advice: you could ask any LLM this question, "what are the pros and cons of academic or community residency training for emergency medicine" and get a very detailed answer (I just tried this with both ChatGPT and Claude, both gave accurate responses).

There are at least 20+ threads here already on SDN regarding this topic, and probably 100+ reddit threads within the last 5 years where this has been hashed out over and over and over.

Lastly, your chances of doing any specific fellowship coming out of a community program are effectively the same as coming out of an academic program, but that question is so varied and individual that it's hard to answer further without details.

Is your goal anesthesia critical care at MGH? Then you might need to go to a name-brand academic residency and produce some impressive academic work to get noticed for an interview.

Is your goal a community-based Ultrasound fellowship? Then you can waltz into any number of them that go unfilled each year.

Is your goal any fellowship in a top-tier city (NYC, SF, LA, Denver, Austin etc), well then program name clout and published academic projects or other impressive achievements will matter more.

My recommendation: prioritize your geographic location above all else. That matters far more for your residency happiness and satisfaction, which will show itself when it comes to your desire and motivation to achieve the next step in your career (even if that is going to a "Global Fellowship")
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yeesh doc

giphy.gif
 
RustedFox said:
So I was right.
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and I’ll point out those docs could have done those same things on their own time. I see some international projects which are cool but not something on there that says man this person is a superstar. They may be. But the cynical community guy in me says these people could have done something way more meaningful if they worked a normal job and used their income to do something that these international people needed. I also see suckers who work for below market rates to enhance the rep of the program. Again I know I’m being a cynical a hole.
 
endo said:
Was there ever a specialty which boasted more useless / less lucrative fellowships than EM?
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I’m actually shocked someone hasn’t come out with a Social Justice fellowship or something similar.
 
JacobMcCandles said:
I’m actually shocked someone hasn’t come out with a Social Justice fellowship or something similar.
Click to expand...

There are plenty:

Health Equity and Social Emergency Medicine Fellowship

The GW Health Equity and Social Emergency Medicine fellowship should prepare a participant to become a leader in advancing equity and improving population health through research, advocacy, and structurally competent clinical practice. They will also gain skills in developing collaboration...
emed.smhs.gwu.edu emed.smhs.gwu.edu

Social EM & Population Health

med.stanford.edu med.stanford.edu

and many more
 
HemorrhagicShock said:
There are plenty:

Health Equity and Social Emergency Medicine Fellowship

The GW Health Equity and Social Emergency Medicine fellowship should prepare a participant to become a leader in advancing equity and improving population health through research, advocacy, and structurally competent clinical practice. They will also gain skills in developing collaboration...
emed.smhs.gwu.edu emed.smhs.gwu.edu

Social EM & Population Health

med.stanford.edu med.stanford.edu

and many more
Click to expand...

Physician Wellness

emed.stanford.edu emed.stanford.edu

physician wellness fellowship, it just gets better
 
EctopicFetus said:
and I’ll point out those docs could have done those same things on their own time. I see some international projects which are cool but not something on there that says man this person is a superstar. They may be. But the cynical community guy in me says these people could have done something way more meaningful if they worked a normal job and used their income to do something that these international people needed. I also see suckers who work for below market rates to enhance the rep of the program. Again I know I’m being a cynical a hole.
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I think “realistic” is a better word here. It’s played out like this for ages with most of our sub-specialties. Instead of being paid peanuts for a year after graduating residency, just make attending money and put aside a bunch to serve whatever foreign community you want. It’s not like physiology is different in Uganda; the training seems really unnecessary. Do it on your own terms and without the opportunity cost.
 
EthylMethylMan said:
I think “realistic” is a better word here. It’s played out like this for ages with most of our sub-specialties. Instead of being paid peanuts for a year after graduating residency, just make attending money and put aside a bunch to serve whatever foreign community you want. It’s not like physiology is different in Uganda; the training seems really unnecessary. Do it on your own terms and without the opportunity cost.
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This is similar to what I have planned for the later stages of my career. I often thought about quitting and doing medical mission work. Then I realized I could donate the money I make and it be much much better to serve the poor.
 
I think there IS clearly a role for public health trained physicians but it’s much more in government, system design, running a massive national vaccination program, etc.

The type of thing a good MPH would help with.

Medical mission work is different.
 
Enough people have come down hard on OP so I won't do the same, even though everything above is accurate.

OP: Consider this. I know I guy who has done the most badass international work. He started a helicopter rescue program in the mountains of Asia, then started an EM residency there, then worked in Uganda, then worked in war torn Ukraine. When he comes home, he pulls some shifts in a community ER.

Don't let some idiot academic tell you you need to do a four year residency, followed by some nonsense meaningless fellowship, followed by years on the grant application hamster wheel. I am doing some side projects that I'm sure some ivory tower has invented a fellowship for. You can do very meaningful work by carving your own path and just raising your hand when volunteers are asked for.
 
EMmed2026 said:
Hi, I am an M4 applying for EM this year. I am currently doing away rotations and got to experience academic vs community residencies. I was hoping it would clarify what kind of programs to apply to. At the academic hospital, I saw that there was a higher reliance on consultants but more autonomy than I expected the residents to have. My thoughts are that if I go to an academic center, I can see the sickest patients, traumas, and have the ability to do a fellowship after if I choose to do global medicine. But there is part of me that really enjoys the community setting. I noticed that there are fewer residents at community hospitals so the residents are closer to each other and their attendings.

I guess my question is, what are the pros/cons of doing community vs the academic? Are your chances of doing a fellowship after being at a community hospital less?
Click to expand...

As usual the typical bunch of blow-hards will enter...

Generally speaking, it can be helpful to have gone to some "academic" program if you want to do academics. But, you can get a job with academics coming from a community program. Additionally, there aren't any EM fellowships that are actually tough to get into. Maybe certain programs are competitive, but whatever fellowship on the whole will not be.

Programs in a hospital with residents from all specialties are generally going to be more consult heavy than a place without residents in other specialties. Calling another specialist to come handle something so you can go see another patient is always going to be easier and we generally like things to be easy. (Also, once you're an attending, seeing another patient will often yield more RVUs than whatever cool procedure.) Additionally, some things within scope of practice for EM are especially risky when you have a specialist in house. Some procedures are rare. There can be (bad) complications. If theres a specialist quickly available (even if a resident), why wouldn't you call them?

As far as global medicine - I'd disregard many of the comments on that here. (It's wild how some of these people have so much time to post here multiple times a day for decades of their life.) Anyways, in most cases fellowship will not gain you more pay for sure. Can you do "global medicine" things without it? Yes. The benefit with the fellowship is probably more with networking or expediting your learning of certain topics, processes, etc. and can fast track yourself to doing work you *want* to do sooner in your career. I know people who have done fellowship in some of these areas and enjoyed the fellowship and continue to do work in the area of the fellowship because they *gasp* enjoy it even though it may not pay much (if at all in some cases). I also know people that didnt do fellowship and have gotten into things like global medicine. Some of them have been successful enough that they don't have to work clinical EM full-time.
 
carbonizedeyesockets said:
Additionally, some things within scope of practice for EM are especially risky when you have a specialist in house. Some procedures are rare. There can be (bad) complications. If theres a specialist quickly available (even if a resident), why wouldn't you call them?
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Cannot agree more. I don’t **** around any more with airways— just call anesthesia! They’ll do your lines too. Obviously if they need a surgical airway I’ll call ENT. Sure I feel a little emasculated when I call the ortho intern to come down and reduce the Colles fracture for me, but they are the specialist after all.

Also, don’t forget to call cardiology for every chest pain to get them ‘onboard early’. Honestly now that I have all their phone numbers I just text them every EKG so that I can document my discussion in the note and then move on to the next consult.. I mean patient.
 
Jabbed said:
Cannot agree more. I don’t **** around any more with airways— just call anesthesia! They’ll do your lines too. Obviously if they need a surgical airway I’ll call ENT. Sure I feel a little emasculated when I call the ortho intern to come down and reduce the Colles fracture for me, but they are the specialist after all.

Also, don’t forget to call cardiology for every chest pain to get them ‘onboard early’. Honestly now that I have all their phone numbers I just text them every EKG so that I can document my discussion in the note and then move on to the next consult.. I mean patient.
Click to expand...
Not quite what I'm referring to and you know it.
 
EMmed2026 said:
Hi, I am an M4 applying for EM this year. I am currently doing away rotations and got to experience academic vs community residencies. I was hoping it would clarify what kind of programs to apply to. At the academic hospital, I saw that there was a higher reliance on consultants but more autonomy than I expected the residents to have. My thoughts are that if I go to an academic center, I can see the sickest patients, traumas, and have the ability to do a fellowship after if I choose to do global medicine. But there is part of me that really enjoys the community setting. I noticed that there are fewer residents at community hospitals so the residents are closer to each other and their attendings.

I guess my question is, what are the pros/cons of doing community vs the academic? Are your chances of doing a fellowship after being at a community hospital less?
Click to expand...

Why do useless fellowships like global medicine? What’s the point?
 
EctopicFetus said:
and I’ll point out those docs could have done those same things on their own time. I see some international projects which are cool but not something on there that says man this person is a superstar. They may be. But the cynical community guy in me says these people could have done something way more meaningful if they worked a normal job and used their income to do something that these international people needed. I also see suckers who work for below market rates to enhance the rep of the program. Again I know I’m being a cynical a hole.
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I think it can make sense for that special breed who wants to work academically, especially at a sought after institution.
 
Pinner Doc said:
I think it can make sense for that special breed who wants to work academically, especially at a sought after institution.
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Right. A very tiny number. In EM I have no idea what a “sought after institution” is. The general big name academic centers are generally not the “wow you did EM there?” OMG amazing! It just doesnt work that way.

I’ll simply say the point of my post is if you are willing to volunteer your time for no money or near no money there is no shortage of opportunities for you. If you love the work go for it. Go do a fellowship I couldnt care less but do understand that these exist as ways to further the institutions goals and rep and the fellows are mere cheap labor suckers.

It’s fine. and i think it’s awesome if you enjoy this work but I would caution against wasting your time doing this. Instead go get a job at the institution as an attending and just volunteer. You’ll make more money while working and be treated more akin to an attending rather than a learner and get this.. you can still learn. You may not get the laserjet printed $0.25 piece of paper to frame but you can do more work, earn more and be much more meaningful.

I would suggest if you want to get a job at a hospital thats hard to get the best way to get your foot in the door is to allow them to abuse you (for a fake fellowship at low pay) so they know they can keep abusing you.
 
Community vs academic is an almost meaningless distinction. Solid programs are solid programs and which specific one you trained at isn't going to matter for fellowship or beyond.

Fellowship is a long ways down the road but there are very specific and very good reasons to do a global health fellowship for the right person. And there are plenty of people who waste there time in a wide variety of fellowships. Go to conferences, talk to real people, and get meaningful advice about whether the fellowship makes sense for your goals. This place is mostly people who couldn't manage their own career ranting about career paths they don't understand and then complaining about being trapped in their terrible career while somehow never being able to draw a line connecting the two sides of the Mobius strip that is their personality.


1754010917271.png
 
DeadCactus said:
Community vs academic is an almost meaningless distinction. Solid programs are solid programs and which specific one you trained at isn't going to matter for fellowship or beyond.

Fellowship is a long ways down the road but there are very specific and very good reasons to do a global health fellowship for the right person. And there are plenty of people who waste there time in a wide variety of fellowships. Go to conferences, talk to real people, and get meaningful advice about whether the fellowship makes sense for your goals. This place is mostly people who couldn't manage their own career ranting about career paths they don't understand and then complaining about being trapped in their terrible career while somehow never being able to draw a line connecting the two sides of the Mobius strip that is their personality.


View attachment 407300
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Meh. Much like you get one flavor of advice here if you go to a conference full of fellows they will think their path is awesome. The ones who did it and hated it wont be at the said conference.

Point stands.. its unneeded but if getting a worthless piece of paper fulfills you.. by all means.
 
The unaccredited EM fellowship programs like international medicine and wilderness medicine really only benefit people who plan on careers working and teaching at university hospitals or want to start a fellowship program.

Most docs outside academics really only benefit from the university diploma courses like DTMPH or DIMM which can easily be completed standalone over 6-12 months even with a full time community job.
 
alpinism said:
The unaccredited EM fellowship programs like international medicine and wilderness medicine really only benefit people who plan on careers working and teaching at university hospitals or want to start a fellowship program.

Most docs outside academics really only benefit from the university diploma courses like DTMPH or DIMM which can easily be completed standalone over 6-12 months even with a full time community job.
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I think depends on goals. If you want to be a CMO or similar an MBA goes a long way. That being said I dont think you need a “real” MBA. You can get one from some no name online school like the NPs tend to do. If you want the real MBA experience thats different and would position you for real corporate jobs but the “fake” MBAs from Chamberlain and such are enough to get you into your local C suite.
 
alpinism said:
The unaccredited EM fellowship programs like international medicine and wilderness medicine really only benefit people who plan on careers working and teaching at university hospitals or want to start a fellowship program.

Most docs outside academics really only benefit from the university diploma courses like DTMPH or DIMM which can easily be completed standalone over 6-12 months even with a full time community job.
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Especially for international medicine where if you just enjoy teaching abroad (it is fun, and a good way to see some interesting pathology) all you need to do is work as an attending at a center that has an international program. Usually there will be 1-2 attendings that run it, you just ask them if they can set you up at one of their sites.

I guess if you want to be that guy/gal at an academic program that’s the QB for a program like that then that is the only reason for the fellowship, but that’s a really limited market.

Our residency had some contacts in a few countries in South America, they would send residents down to do international electives down there. More like a neat hobby than a true subspeciality - although some programs pair it with an MPH which guess kind of makes sense if you wanted to get grants and do research or something.
 
dozitgetchahi said:
Peds probably rivals in the “less lucrative” category.
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Get this.

There's a special breed who will do a peds residency, followed by an anesthesia residency, then PICU fellowship, then Peds Cardiac ICU fellowship just so that they can work in a PICU.
 
I remember during EM residency when we did our PEM months. Talked to a PEM upper level and thought maybe an PEM fellowship was worth considering. While picking his brain, I was searching for the holy grail to justify another 2 years. Points I got from him was
1. EM makes more than PEM
2. EM can work in Peds ERs
3. PEM can not work in adult ERs
4. PEM had to deal with crying kids on top of crazy parents
5. Peds ER was hard to find and only in major cities. Job market was worse.

So I could spend 2 more years to make less money in a worse job market? This literally must have been the most useless fellowship unless you are looking to go the educational route.
 
emergentmd said:
I remember during EM residency when we did our PEM months. Talked to a PEM upper level and thought maybe an PEM fellowship was worth considering. While picking his brain, I was searching for the holy grail to justify another 2 years. Points I got from him was
1. EM makes more than PEM
2. EM can work in Peds ERs
3. PEM can not work in adult ERs
4. PEM had to deal with crying kids on top of crazy parents
5. Peds ER was hard to find and only in major cities. Job market was worse.

So I could spend 2 more years to make less money in a worse job market? This literally must have been the most useless fellowship unless you are looking to go the educational route.
Click to expand...

I know this may sound like a shock to you

But

And this is true

I've personally seen this

I've personally verified their reasons

Some people, believe it or not, actually are more motivated by treating children than money

Both the people I know (anecdote, yes) are weirdly okay with treating children and not printing cash owning a freestanding network unlike yourself.

"Most useless fellowship unless you're looking to go into an education route?" Didn't even consider some people like working with kids and don't worship money? Like....really, re-read what you wrote and see if you can tell if it comes off deeply condescending and insulting to people that work with kids, because that's the only way I can interpret that. 100% of people going into PEM are aware it's paid lower, talking like you discovered some deep hidden lore secret of PEM comes off badly.
 
AlmostAnMD said:
I know this may sound like a shock to you

But

And this is true

I've personally seen this

I've personally verified their reasons

Some people, believe it or not, actually are more motivated by treating children than money

Both the people I know (anecdote, yes) are weirdly okay with treating children and not printing cash owning a freestanding network unlike yourself.

"Most useless fellowship unless you're looking to go into an education route?" Didn't even consider some people like working with kids and don't worship money? Like....really, re-read what you wrote and see if you can tell if it comes off deeply condescending and insulting to people that work with kids, because that's the only way I can interpret that. 100% of people going into PEM are aware it's paid lower, talking like you discovered some deep hidden lore secret of PEM comes off badly.
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The thing is though that you can see a fair amount of kids in regular EM. I see kids everyday. Self selecting to see only kids is just...kinda weird.
 
WhatJobDoIPick said:
The thing is though that you can see a fair amount of kids in regular EM. I see kids everyday. Self selecting to see only kids is just...kinda weird.
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Everyone has a thing i guess.

I love my children but would never want to see kids in an er. My buds are adamant about not seeing adults and are pissed when adults wander into their ed for help which apparently happens frequently.

Me personally I actually decided I didn't like seeing peds or adults and went into UM lololololol
 
emergentmd said:
I remember during EM residency when we did our PEM months. Talked to a PEM upper level and thought maybe an PEM fellowship was worth considering. While picking his brain, I was searching for the holy grail to justify another 2 years. Points I got from him was
1. EM makes more than PEM
2. EM can work in Peds ERs
3. PEM can not work in adult ERs
4. PEM had to deal with crying kids on top of crazy parents
5. Peds ER was hard to find and only in major cities. Job market was worse.

So I could spend 2 more years to make less money in a worse job market? This literally must have been the most useless fellowship unless you are looking to go the educational route.
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This is niche, but PEM docs are a precious commodity.

Most children’s hospitals are staffed only by PEM-trained docs. There are far fewer PEM docs than EM docs. From a hospital perspective, having a group that staffs your children’s ED with PEM-trained docs is an anchor that would discourage the hospital admin from changing groups.

PEM docs in our group are paid comparably to the adult side as they are considered full partners.
 
AlmostAnMD said:
"Most useless fellowship unless you're looking to go into an education route?" Didn't even consider some people like working with kids and don't worship money? Like....really, re-read what you wrote and see if you can tell if it comes off deeply condescending and insulting to people that work with kids, because that's the only way I can interpret that. 100% of people going into PEM are aware it's paid lower, talking like you discovered some deep hidden lore secret of PEM comes off badly.
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Do you need a hug? You don't think I see about 20% kids? This may shock you but my community hospital had a Peds ER and I worked shifts there. You want to hear something else shocking? The EM trained docs without fellowships that was covering the Peds ER was making $70+/hr more than the PEM docs.

But hey, if an EM doc wants to spend 2 more years in fellowship to make less money, then more power to them.
 
What the hell, guys?

Yes… I recognize that peds fellowships pay less for more invested time. The fellows and future EM-peds also understand that.

The criticism should be a reflection of the poor structure of reimbursements, not the choice of the fellows to pursue the course. There are actually doctors that prioritize sick kids over money. 🤷

I have *mad* respect for my peds-fellowship-trained colleagues, and still call them probably twice a year from an outside site for advice.

And I work mostly community sites where I see a fair amount of kids.

If anything, I give extra props to my colleagues that sacrificed even more to fill a niche.

🤷
 
AlmostAnMD said:
I know this may sound like a shock to you

But

And this is true

I've personally seen this

I've personally verified their reasons

Some people, believe it or not, actually are more motivated by treating children than money

Both the people I know (anecdote, yes) are weirdly okay with treating children and not printing cash owning a freestanding network unlike yourself.

"Most useless fellowship unless you're looking to go into an education route?" Didn't even consider some people like working with kids and don't worship money? Like....really, re-read what you wrote and see if you can tell if it comes off deeply condescending and insulting to people that work with kids, because that's the only way I can interpret that. 100% of people going into PEM are aware it's paid lower, talking like you discovered some deep hidden lore secret of PEM comes off badly.
Click to expand...
Just a point you can work in a PED ED with a normal Em residency. Keep in mind most of the people who do PEM fellowships are pediatricians and not EM docs. You arent wrong.. i will say many people who think the fellowships are the holy grail to save their careers often dont realize they are running away from something rather than toward something. If you are running toward something go for it. When I did my PEM time as a resident I loved working with the kids, prior to that I almost applied for a peds fellowship. I could not get over the parents. I can say in my current career i often dont enjoy seeing peds because of the parents. With the rampant burnout in medicine chasing the dollar seems wiser and wiser. Surely some people find their glory and happiness in their social EM, international medicine, US fellowships. Truly good for them. Some of the most inspirational people I have met have pursued the useless fellowships but found happiness. On the other hand, about 90% of the people I know that did fellowships either dont use them, do that role begrudgingly, or flat out say it was stupid. If you are gonna land in the 10% go for it. If you are running away from EM its not gonna be a great ending. In my experience the only fellowship that this doesnt apply to is ICU. The people who did this whether it was due to running from EM or toward something do ICU (none I know work in the ED anything but extremely sparingly (like 1 shift per month or less). But IMO thats like saying I hate IM but being a cardiologist is cool. It’s a totally different career. The ICU dudes seem fairly happy in my personal experience.
 
TeddyBoomBoom said:
What the hell, guys?

Yes… I recognize that peds fellowships pay less for more invested time. The fellows and future EM-peds also understand that.

The criticism should be a reflection of the poor structure of reimbursements, not the choice of the fellows to pursue the course. There are actually doctors that prioritize sick kids over money. 🤷

I have *mad* respect for my peds-fellowship-trained colleagues, and still call them probably twice a year from an outside site for advice.

And I work mostly community sites where I see a fair amount of kids.

If anything, I give extra props to my colleagues that sacrificed even more to fill a niche.

🤷
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Call me cold hearted, these people like 99% of other docs arent choosing this career for others. They find their own satisfaction. There is nothing wrong with that. But these arent purely altruistic people. They get satisfaction, they get to avoid the drug seekers etc. Again, when you talk to these folks and get their personal motivation, no one is like gosh I know society needs PEM docs so im gonna fill that role. Again, just putting it out there as i have no problem with that but these aren’t a bunch of mother Theresa types. I say this as someone who had options, many of us did. EM used to be a competitive field. I know guys who gave up doing ortho to do EM. The structure of reimbursement is set, why do you think it is broken?

The issue with peds isnt that the reimbursement doesnt work its that people with insurance see their pediatrician, people with no insurance and Medicaid go to the ED. Luckily there just arent a ton of truly “sick” kids.
 
EctopicFetus said:
In my experience the only fellowship that this doesnt apply to is ICU. The people who did this whether it was due to running from EM or toward something do ICU (none I know work in the ED anything but extremely sparingly (like 1 shift per month or less). But IMO thats like saying I hate IM but being a cardiologist is cool. It’s a totally different career. The ICU dudes seem fairly happy in my personal experience.
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I’d add HPM to this list (disclosure- I’m currently a palliative fellow as a PGY18). I’m someone who was both running from EM and toward HPM. I am loving my life right now. Reliable schedule, meaningful work, patients are appreciative, the services who consult me are so grateful and kind in their interactions. I almost don’t mind the dip in pay this year, but loans were paid off 10 years ago fortunately.

Like ICU, it DOES feel like a totally different career.
 
BoardingDoc said:
You know a lot of EM docs that did a pain fellowship who still work in the ED regularly?
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To be fair I don’t know personally of anyone who did this. Obviously some on this forum. But I don’t know a single one.
 
EctopicFetus said:
On the other hand, about 90% of the people I know that did fellowships either dont use them, do that role begrudgingly, or flat out say it was stupid.
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I think "fellowship" is too broad of a term for this type of discussion. I'd put non-ABMS/ACGME things like Ultrasound, Wilderness, and Global Health in an entirely different category from things like Critical Care, Palliative Care, and Sports Medicine. I'd say the overwhelming majority of people in the former group still do the same thing as non-fellowship people, while it's the opposite for the people in the latter group.

I've talked to a few people who did Wilderness and Ultrasound and their reasoning basically boiled down to "I wanted to work at an academic hospital straight out of training but they only hire people with fellowships".
 
AlmostAnMD said:
I know this may sound like a shock to you

But

And this is true

I've personally seen this

I've personally verified their reasons

Some people, believe it or not, actually are more motivated by treating children than money

Both the people I know (anecdote, yes) are weirdly okay with treating children and not printing cash owning a freestanding network unlike yourself.

"Most useless fellowship unless you're looking to go into an education route?" Didn't even consider some people like working with kids and don't worship money? Like....really, re-read what you wrote and see if you can tell if it comes off deeply condescending and insulting to people that work with kids, because that's the only way I can interpret that. 100% of people going into PEM are aware it's paid lower, talking like you discovered some deep hidden lore secret of PEM comes off badly.
Click to expand...

I know this may sound like a shock to you

But many of us graduated with hundreds of thousands of dollars in debt and don’t have a set of rich parents or spouse who are going to pay it off.

We need a plan to pay our ****

And training to do medicine is a long, hard road

Some of us actually want a good return on investment for all the blood sweat and tears (and years) that went into it.

There’s nothing wrong with this

We need to stop chastising doctors for wanting to actually be paid properly (and for choosing to avoid avenues where they will be paid a lot worse).
 
dozitgetchahi said:
I know this may sound like a shock to you

But many of us graduated with hundreds of thousands of dollars in debt and don’t have a set of rich parents or spouse who are going to pay it off.

We need a plan to pay our ****

And training to do medicine is a long, hard road

Some of us actually want a good return on investment for all the blood sweat and tears (and years) that went into it.

There’s nothing wrong with this

We need to stop chastising doctors for wanting to actually be paid properly (and for choosing to avoid avenues where they will be paid a lot worse).
Click to expand...

I didn't have rich parents. I'm unclear why you insinuated this.

Took out loans. Like you.

Paid off all 400k (base + interest). Took 4 years. What's your excuse? Make better decisions.

So not interested in your whining on this, sorry. When you pay your loans off you tend to care less about others complaining about it, especially since you should have known the money needs repaid. I did. And I never once complained about loan payments, check my history. It's a responsibility to pay back what you owe. I did. You should too.

If all you care about is money you should have gone into finance. EM didn't work out for me but UM is. So I'm good now.
 
dozitgetchahi said:
I know this may sound like a shock to you

But many of us graduated with hundreds of thousands of dollars in debt and don’t have a set of rich parents or spouse who are going to pay it off.

We need a plan to pay our ****
Click to expand...

I've seen your line of argument (family wealth explains specialty choice) used to argue the exact opposite point: "only rich kids feel the need to go into high-paying specialties; they need to maximize their earnings so they can maintain their privileged living standards".

Specialty choice is a complex personal decision, there's really no need to shoehorn half-baked class grandstanding into it so you can feel good about punching down on peds or other lower-paying specialties.
 
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EctopicFetus said:
Call me cold hearted, these people like 99% of other docs arent choosing this career for others. They find their own satisfaction. There is nothing wrong with that. But these arent purely altruistic people. They get satisfaction, they get to avoid the drug seekers etc. Again, when you talk to these folks and get their personal motivation, no one is like gosh I know society needs PEM docs so im gonna fill that role. Again, just putting it out there as i have no problem with that but these aren’t a bunch of mother Theresa types. I say this as someone who had options, many of us did. EM used to be a competitive field. I know guys who gave up doing ortho to do EM. The structure of reimbursement is set, why do you think it is broken?

The issue with peds isnt that the reimbursement doesnt work its that people with insurance see their pediatrician, people with no insurance and Medicaid go to the ED. Luckily there just arent a ton of truly “sick” kids.
Click to expand...

People with no insurance/Medicaid see their pediatricians too - that’s why general peds (and peds subspecialties, which is what I was really referring to above, not peds EM) is paid so poorly relative to the rest of medicine.
 
Franzd'Epinay said:
I've seen your line of argument (family wealth explains specialty choice) used to argue the exact opposite point: "only rich kids feel the need to go into high-paying specialties; they need to maximize their earnings so they can maintain their privileged living standards".

Specialty choice is a complex personal decision, there's really no need to shoehorn half-baked class grandstanding into it so you can feel good about punching down on peds or other lower-paying specialties.
Click to expand...

In medicine, I’ve seen the exact opposite happening.

A very large portion of academics in IM subspecialties either came from money or married a spouse with money. In my rheumatology department at fellowship, the majority of attendings fell into that category. I think increasingly, academic IM/subspecialty medicine is becoming a domain of rich kids and those who married an ENT/urology/neurosurgeon spouse. The academic pay is too lousy for it to make sense for anyone else. In the case of PEM, everyone knows that’s mostly academia. So the issue behind the issue is academic pay vs non academic pay. And we all know academic salaries are trash.

Nobody is “punching down” on anything. No doctors should be paid that poorly, and I’m not telling anyone they shouldn’t “follow their passion” (or making fun of them for doing so). But if you graduate with $500k of debt, you likely can’t/won’t try to make it work if you’re making peanuts in academia. That is why people are making that choice, and why you’re hearing that reasoning here. Academics can be fun, but I’m not doing it for a 50% pay cut. As a provider for my family, I can’t make that crappy level of compensation make sense. I have bills to pay.

(I’ll share an example from my rheumatology co-fellows. My first community hospital job out of fellowship started at $250k. I had a co-fellow who was going to start as a “clinical instructor” at a fancy big name institution for $125k. She was shocked that I was getting double her salary to work in the community. I was shocked that she was willing to work as a rheumatologist for basically low-end midlevel pay. Fast forward about 8 years. I now make about $750k a year in PP. She’s gotten raises, but even with those, she just cracked $200k this year. That pay gap is simply insane. Even if I was working community rheumatology, I’d likely be making $350-400k now. There is no way I could have rapidly paid off my debt etc on $125-200k a year. I have a lot of other unexpected behind the scenes expenses as well - no way could I have addressed those with that crappy amount of pay. That math ain’t mathing.)

If the math is different for you, congrats. Have at it. But that’s how the math works for me and lots of other docs.
 
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