Another One Bites the Dust: My Emergency Medicine Eulogy

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EmergentMagician

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TL;DR : EM sucks. I’m out. In Fellowship. Good luck to you all.

I have spent 10+ years lurking here and have benefited greatly from reading other Emergency Physicians’ trials and tribulations. I take a lot of solace in hearing others’ angst, in an addictive voyeur-like way. This forum provides an echo chamber (for better or for worse) and some validation for a lot of the feelings I've had in emergency medicine. I am very grateful for all the practical advice I've heard as well, in terms of taxes, SDGs, second career paths, etc. Perhaps my story can help others.

I finished residency seven years ago at a very academic (~powerhouse light?) four year program. I was a solid, above average resident. Not the all-star. Confident and capable. I worked the full spectrum of emergency rooms during and after residency, from very high acuity/high volume to low volume government facilities that barely resemble an ER. I have worked for corporate medical entities, government, and community hospitals. I was exposed to many SDG's in residency and flirted with several of them afterwards, though never signed on. I feel like I have a good grasp of what the world of emergency medicine offers, despite my relatively short career.

I have found that low acuity/low volume places do not necessarily mean less angst. Perhaps this is personality driven. These shops frequently come with their own headaches, or frustration with inappropriate utilization of the emergency room, or inappropriate patient expectations. I think I hit a good stride when I was splitting shifts between both low acuity facilities and high acuity facilities. IE, when I was tired of dealing with high maintenance/low acuity patients I would then work a couple shifts at a high acuity ER and do a lot of procedures/resus etcetera. It provided a good balance. I think that this is sort of the sweet spot for EM practice in terms of job satisfaction.

I flirted with academics for the past several years, ultimately working as academic faculty. I thought that this was maybe a path to satisfaction/sustainability. When I was working with pgy 3/4s, this was wonderful. IE, not calling consults, no scut work, basically just verifying and occasionally redirecting everything the resident does. I tried my hardest to hide my cynicism from them and taught them well. I would see my own patients in the waiting room to help move the meat along. I think that this is a sustainable model, though a lot of caution needs to be taken in making sure your skill set is preserved. I unexpectedly found that I disliked teaching the very junior learners- med students, pgy1s, and off service residents.

I feel a lot of shame in leaving EM. It makes me feel like a failure. I see a lot of my peers doing the job and succeeding. I don't know why I cannot derive any feelings of satisfaction anymore from the field. It feels like death from a thousand cuts. I have had no bad outcomes or lawsuits. I perform well on metrics. However, only a few times a year do I feel like I make any difference in the world. I feel like I am just moving the meat along in a stupid dysfunctional system.

Here we go…

Inappropriate use of the ER. ‘1 hr pediatric fever’, ‘wants pregnancy test’, every drizzle of vaginal bleeding wanting an OB Ultrasound, 1 year of knee pain, etc. Many patients have no understanding of what primary care is or see the ER as the most convenient path to care. We are simply the building with the red cross on it. ‘This is where you do medical stuff’. When certain patients are given free and unlimited access, this is the type of behavior it fosters.

Midlevels. The presence of the ER as a safety net makes the entire medical system’s use of midlevels possible. They can basically offload anything involving actual decision making to the ER. Or worse yet, fixing blatant midlevel f-ups day in and day out. I have started to see patients come to the ER with a pile of lab work and imaging, just wanting a physician to interpret “what is actually going on”. Very rarely have I ever felt an MD inappropriately sent a patient to the ER.

Old People. I hate myself for getting frustrated by old people in the ER. After my 10th patient on shift in their 80s/ 90s, I just can't do it anymore. I consider it the other type of “homeboy drop-off”, where a family member or SNF just dumps an old person in the ER and leaves. It is a losing game for the Emergency Physician. They have a very high pretest probability of pathology, but cannot relate ANY of their symptoms to you in any comprehensible fashion. Good luck on getting ANY coherent medical history. I have thought we should microchip the elderly like we do our dogs as a prerequisite to get Medicare. This chip could be scanned on arrival and would have all of their meds, PMH/PSH, etc. Sometimes SNF's and families just want to get an MD on the chart to offload all of the risk. They can do this any time of the day or night, as often as they want, and for FREE. Sometimes the families are seeking a clean bill of health, however this cannot possibly be done.

Increasing Volume and Litigation Risk. When I was a medical student, I didn’t understand that the actual day to day mechanics of being an Emergency Physician more closely resembled being a waiter: Imagine being the only waiter at a PACKED 30-table Denny’s at 2am. There is a line going out the door, and Denny’s corporate wants you to take their orders in the street. They are all HUNGRY and upset before they even get to Denny’s. Many of them are DRUNK. You receive nasty emails from corporate if you didn’t take their orders fast enough. There are homeless people in the bathroom smoking meth and smearing poop on the walls. You run from table to table, shoving food down fat people’s throats, trying to keep everyone happy. Then a child chokes on a sausage link. The child dies. Then you get sued. That is Emergency Medicine today.

Patient Expectations: It seems stupid, but my PTSD/ burnout is actually more from situations like the mom of the two year old literally yelling at me in the waiting room for not getting her discharge paperwork in a timely fashion. This is usually for a child that I wrote an antibiotic prescription for, when they absolutely did not need it, however I dreaded the inevitable argument and patient complaint that would ensue if I didn’t write the Rx, etc.etc.etc.. Meanwhile I am dealing with several ICU holds that the hospitalist (not intensivist) still hasn’t seen, central lines in the ICU, NSTEMIs marinating in the waiting room, stroke “codes” sepsis “codes”, no available beds, homeless people smoking meth in the ER, poop streaks in the hallway, etcetera etcetera. Society has absolutely no idea what we deal with on a day-to-day basis. Other physicians usually have no idea as well.

My dad had to go to the ER last year for chest pain. The only thing he could talk about was the time waiting in between physician contact/blood draw, imaging, etc. He had literally no understanding or clue about what actually constituted quality of care, despite hearing me bitch and moan about my experiences working in the ER for the past decade.

ER Blaming: One of my biggest flex points for failure in this field has been the complete disrespect of the emergency medicine profession by other specialties. I can't handle it when a hospitalist or intensivist treats me like an underling. I can't handle it when sub specialists such as ENT or urology are completely absent or do not take any ownership over their post operative complications. It seems that their algorithm basically says go to the ER for any concerns. I think this behavior has been worsening over the past 5 years. Didn't these people used to be available to their patients? A lot of my college buddies are urology, ortho, ENT, etc. They all have their stories about stupid consults from the ER or stupid **** the ER does. I like to tell them that we can always go back to the 1970s or European model where they are on call for basically everything related to their field. These specialists do not acknowledge the value we provide to the system, and need to understand that the whole system would completely fall apart if we were not there. If you want to know the dysfunction of any particular medical system, just go to the ER and you will find us there dealing with it directly.

Another flex point for failure has been treatment by the hospital system when things go wrong with patients. We are occasionally expected to do heroic things- ED thoracotomy, cric, Lateral canthotomy, pediatric resuscitations, etcetera. These are procedures that even the specialist will get nervous and anxious about. However, when we step up to the plate and perform these, the immediate response from the sub specialists is doubt and skepticism. When a child dies in the emergency room, it is met with suspicion. When i cric someone, I have to defend my actions.

COVID: Don’t even get me started.

What I am doing now: Palliative Care Fellowship. I am by far the oldest one in my fellowship class. Thank you Frazier for all of the posts. This isn’t a running away/snap decision, and is very likely a WRONG decision for many people leaving EM. You must want to do this type of work, and you need to have the disposition for it. I repeat: Do not run away to a Palliative Care Fellowship just to get away from EM. As a premed I was doing Hospice stuff, palliative rotations in med school, carried this interest through ICU rotations, etc

I used to think EM docs in their 50s/60s were outdated dinosaurs, but I increasingly find myself in awe of them. How the hell did they stick it out for so long? I have not decided if I'm going to give up on EM, as I could still see a role for me working in rural low volume places. I got my resuscitative reps and experience working in busy ERs. I stood the watch.

For me, right now, the juice is NOT WORTH the squeeze. I am lucky enough to have paid off all my loans, and have a small nest egg after being frugal during residency and in my 7 years as an attending. I have a spouse that earns 100k. We will be OK. I am incredibly grateful that she didn’t marry me for money or prestige, otherwise this could have gone a lot worse.

It is important to note that I did not burn out from working too many shifts. I typically worked 12-15 8s. There were periods where I flexed up to 15+ 12’s, but this was extremely rare and limited. I rarely worked more than 2 nights/month, and went several months at a time with no nights. (Though I do think nights are terrible for your health and undoubtedly lead to burnout). I tried many ways to change my schedule around to avoid burnout, however even cutting back to 7-9 shifts a month did not cure the negative feelings. If anything, it led to more career anxiety and longer periods of self-loathing between shifts. I spent a lot of Tuesday afternoons drinking beer by myself and wondering why I was a failure and couldn’t be happy in EM.

I hope everyone can keep fighting the good fight. I truly believe that there is no more difficult or important job in medicine than what we do.

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Emergency medicine is incredibly difficult which is why there is such a burn out. And medical school we were lie to seeing if he did a residency an emergency medicine, you are less likely to burn out.

Lol
 
Congrats on getting out.

I hope you find success and happiness in whatever it is you have chosen to do. Best of luck!
 
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my PTSD/ burnout
I see PTSD every day now, in my job (@RustedFox knows as well). If you really have PTSD (one study said 17% of EPs meet the criteria - that's one in six), then you, honestly, need some legit professional help. If you are just saying it as a throwaway or pithy line, then I can show you some victims who really have it. It ain't pretty.
 
I see PTSD every day now, in my job (@RustedFox knows as well). If you really have PTSD (one study said 17% of EPs meet the criteria - that's one in six), then you, honestly, need some legit professional help. If you are just saying it as a throwaway or pithy line, then I can show you some victims who really have it. It ain't pretty.
Did not intend to disparage those with actual PTSD. Definitely familiar with the actual diagnosis.

Along the lines of alternate careers- in what capacity/where are you seeing all of this PTSD?
 
TL;DR : EM sucks. I’m out. In Fellowship. Good luck to you all.

I have spent 10+ years lurking here and have benefited greatly from reading other Emergency Physicians’ trials and tribulations. I take a lot of solace in hearing others’ angst, in an addictive voyeur-like way. This forum provides an echo chamber (for better or for worse) and some validation for a lot of the feelings I've had in emergency medicine. I am very grateful for all the practical advice I've heard as well, in terms of taxes, SDGs, second career paths, etc. Perhaps my story can help others.

I finished residency seven years ago at a very academic (~powerhouse light?) four year program. I was a solid, above average resident. Not the all-star. Confident and capable. I worked the full spectrum of emergency rooms during and after residency, from very high acuity/high volume to low volume government facilities that barely resemble an ER. I have worked for corporate medical entities, government, and community hospitals. I was exposed to many SDG's in residency and flirted with several of them afterwards, though never signed on. I feel like I have a good grasp of what the world of emergency medicine offers, despite my relatively short career.

I have found that low acuity/low volume places do not necessarily mean less angst. Perhaps this is personality driven. These shops frequently come with their own headaches, or frustration with inappropriate utilization of the emergency room, or inappropriate patient expectations. I think I hit a good stride when I was splitting shifts between both low acuity facilities and high acuity facilities. IE, when I was tired of dealing with high maintenance/low acuity patients I would then work a couple shifts at a high acuity ER and do a lot of procedures/resus etcetera. It provided a good balance. I think that this is sort of the sweet spot for EM practice in terms of job satisfaction.

I flirted with academics for the past several years, ultimately working as academic faculty. I thought that this was maybe a path to satisfaction/sustainability. When I was working with pgy 3/4s, this was wonderful. IE, not calling consults, no scut work, basically just verifying and occasionally redirecting everything the resident does. I tried my hardest to hide my cynicism from them and taught them well. I would see my own patients in the waiting room to help move the meat along. I think that this is a sustainable model, though a lot of caution needs to be taken in making sure your skill set is preserved. I unexpectedly found that I disliked teaching the very junior learners- med students, pgy1s, and off service residents.

I feel a lot of shame in leaving EM. It makes me feel like a failure. I see a lot of my peers doing the job and succeeding. I don't know why I cannot derive any feelings of satisfaction anymore from the field. It feels like death from a thousand cuts. I have had no bad outcomes or lawsuits. I perform well on metrics. However, only a few times a year do I feel like I make any difference in the world. I feel like I am just moving the meat along in a stupid dysfunctional system.

Here we go…

Inappropriate use of the ER. ‘1 hr pediatric fever’, ‘wants pregnancy test’, every drizzle of vaginal bleeding wanting an OB Ultrasound, 1 year of knee pain, etc. Many patients have no understanding of what primary care is or see the ER as the most convenient path to care. We are simply the building with the red cross on it. ‘This is where you do medical stuff’. When certain patients are given free and unlimited access, this is the type of behavior it fosters.

Midlevels. The presence of the ER as a safety net makes the entire medical system’s use of midlevels possible. They can basically offload anything involving actual decision making to the ER. Or worse yet, fixing blatant midlevel f-ups day in and day out. I have started to see patients come to the ER with a pile of lab work and imaging, just wanting a physician to interpret “what is actually going on”. Very rarely have I ever felt an MD inappropriately sent a patient to the ER.

Old People. I hate myself for getting frustrated by old people in the ER. After my 10th patient on shift in their 80s/ 90s, I just can't do it anymore. I consider it the other type of “homeboy drop-off”, where a family member or SNF just dumps an old person in the ER and leaves. It is a losing game for the Emergency Physician. They have a very high pretest probability of pathology, but cannot relate ANY of their symptoms to you in any comprehensible fashion. Good luck on getting ANY coherent medical history. I have thought we should microchip the elderly like we do our dogs as a prerequisite to get Medicare. This chip could be scanned on arrival and would have all of their meds, PMH/PSH, etc. Sometimes SNF's and families just want to get an MD on the chart to offload all of the risk. They can do this any time of the day or night, as often as they want, and for FREE. Sometimes the families are seeking a clean bill of health, however this cannot possibly be done.

Increasing Volume and Litigation Risk. When I was a medical student, I didn’t understand that the actual day to day mechanics of being an Emergency Physician more closely resembled being a waiter: Imagine being the only waiter at a PACKED 30-table Denny’s at 2am. There is a line going out the door, and Denny’s corporate wants you to take their orders in the street. They are all HUNGRY and upset before they even get to Denny’s. Many of them are DRUNK. You receive nasty emails from corporate if you didn’t take their orders fast enough. There are homeless people in the bathroom smoking meth and smearing poop on the walls. You run from table to table, shoving food down fat people’s throats, trying to keep everyone happy. Then a child chokes on a sausage link. The child dies. Then you get sued. That is Emergency Medicine today.

Patient Expectations: It seems stupid, but my PTSD/ burnout is actually more from situations like the mom of the two year old literally yelling at me in the waiting room for not getting her discharge paperwork in a timely fashion. This is usually for a child that I wrote an antibiotic prescription for, when they absolutely did not need it, however I dreaded the inevitable argument and patient complaint that would ensue if I didn’t write the Rx, etc.etc.etc.. Meanwhile I am dealing with several ICU holds that the hospitalist (not intensivist) still hasn’t seen, central lines in the ICU, NSTEMIs marinating in the waiting room, stroke “codes” sepsis “codes”, no available beds, homeless people smoking meth in the ER, poop streaks in the hallway, etcetera etcetera. Society has absolutely no idea what we deal with on a day-to-day basis. Other physicians usually have no idea as well.

My dad had to go to the ER last year for chest pain. The only thing he could talk about was the time waiting in between physician contact/blood draw, imaging, etc. He had literally no understanding or clue about what actually constituted quality of care, despite hearing me bitch and moan about my experiences working in the ER for the past decade.

ER Blaming: One of my biggest flex points for failure in this field has been the complete disrespect of the emergency medicine profession by other specialties. I can't handle it when a hospitalist or intensivist treats me like an underling. I can't handle it when sub specialists such as ENT or urology are completely absent or do not take any ownership over their post operative complications. It seems that their algorithm basically says go to the ER for any concerns. I think this behavior has been worsening over the past 5 years. Didn't these people used to be available to their patients? A lot of my college buddies are urology, ortho, ENT, etc. They all have their stories about stupid consults from the ER or stupid **** the ER does. I like to tell them that we can always go back to the 1970s or European model where they are on call for basically everything related to their field. These specialists do not acknowledge the value we provide to the system, and need to understand that the whole system would completely fall apart if we were not there. If you want to know the dysfunction of any particular medical system, just go to the ER and you will find us there dealing with it directly.

Another flex point for failure has been treatment by the hospital system when things go wrong with patients. We are occasionally expected to do heroic things- ED thoracotomy, cric, Lateral canthotomy, pediatric resuscitations, etcetera. These are procedures that even the specialist will get nervous and anxious about. However, when we step up to the plate and perform these, the immediate response from the sub specialists is doubt and skepticism. When a child dies in the emergency room, it is met with suspicion. When i cric someone, I have to defend my actions.

COVID: Don’t even get me started.

What I am doing now: Palliative Care Fellowship. I am by far the oldest one in my fellowship class. Thank you Frazier for all of the posts. This isn’t a running away/snap decision, and is very likely a WRONG decision for many people leaving EM. You must want to do this type of work, and you need to have the disposition for it. I repeat: Do not run away to a Palliative Care Fellowship just to get away from EM. As a premed I was doing Hospice stuff, palliative rotations in med school, carried this interest through ICU rotations, etc

I used to think EM docs in their 50s/60s were outdated dinosaurs, but I increasingly find myself in awe of them. How the hell did they stick it out for so long? I have not decided if I'm going to give up on EM, as I could still see a role for me working in rural low volume places. I got my resuscitative reps and experience working in busy ERs. I stood the watch.

For me, right now, the juice is NOT WORTH the squeeze. I am lucky enough to have paid off all my loans, and have a small nest egg after being frugal during residency and in my 7 years as an attending. I have a spouse that earns 100k. We will be OK. I am incredibly grateful that she didn’t marry me for money or prestige, otherwise this could have gone a lot worse.

It is important to note that I did not burn out from working too many shifts. I typically worked 12-15 8s. There were periods where I flexed up to 15+ 12’s, but this was extremely rare and limited. I rarely worked more than 2 nights/month, and went several months at a time with no nights. (Though I do think nights are terrible for your health and undoubtedly lead to burnout). I tried many ways to change my schedule around to avoid burnout, however even cutting back to 7-9 shifts a month did not cure the negative feelings. If anything, it led to more career anxiety and longer periods of self-loathing between shifts. I spent a lot of Tuesday afternoons drinking beer by myself and wondering why I was a failure and couldn’t be happy in EM.

I hope everyone can keep fighting the good fight. I truly believe that there is no more difficult or important job in medicine than what we do.
I read this and your feelings are 100% valid. Good luck on you new path.
 
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Well done, OP. It’s not easy to walk away from something we have committed ourselves to, heart and soul. Many of your comments resonated with me, particularly those about mid levels. I’ve argued elsewhere that our compensation shouldn’t just reflect the RVU’s we generate but also the value we add by letting ****ty mid levels, and IME physicians, practice elsewhere. We have become “expedited, complex work up doctors” and it grates on me more and more, even though I take great pride in my ability to elegantly solve other physicians’ problems.

Congratulations and best of luck on the new path! I am scheduled for 2 more shifts in the ED and I doubt I will be asking for any more. I’m going to pay the $300 for one more year of ABEM cert. I’m not sure what to call myself now; for the longest time I’ve been an “ER Doc” but now not sure what to say. Implicit in the “I’m an ER Doc” is “I am a badass and no matter what’s in front of me that makes my sphincter super tight, I’m going to step forward and tackle the problem where other doctors won’t”. That’s a hard identity to give up. I’m still practicing medicine but kind of hard to describe (wfh/telemedicine and some contract consulting) so for now I’m going with “mostly retired ER doc”.
 
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This is a great post, thank you for talking the time to write it.

I do have to wonder if 11 years in a career (counting residency) before moving on really means it was a wrong path. I’d guess most people in most fields are ready for a change after that long.
 
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It’s a tough field and certainly not for everyone. Unfortunately, you won’t know if it’s for you or not until it’s too late. I’m glad you recognized it and are doing something you’ll hopefully enjoy more.
 
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Appreciate the write up, glad you found a way out
 
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As someone who managed in the pit for 14 years including residency, before completely leaving, I think a decade may be enough for some of us. It was for me. I spent about 3 years in transition to my subspecialty - I don't really do palliative per se, and really I focus on GIP (inpatient) hospice rather than outpatient. I think my EM years were essential to lay the critical care foundation for me, since I do a lot of complex inpatient level management, and am sometimes still trying to buy time for people, ie the CHF exacerbation, COPD exacerbation, intracranial pressure, sepsis, etc. Sometimes it's for something very specific - a wedding, a graduation, holidays, etc.

Anyway, welcome to the continuum. I think HPM really is a continuum of EM - and it felt like a pretty natural progression to me. It took me YEARS to accept that I am not really an EM doc anymore - I'm a hospice doctor, and that identity change was really, really hard. Because being an ER doc is by definition being a bad@ss Macgyver who can solve anything. I still think outside the box, and your mindset will help you. A lot. And you nailed it with the death by a thousand cuts.

Good luck my friend. You need to bounce anything vent, or have any private practice questions - especially Hospice (ahem, my group is always looking for docs, central Florida!), my inbox is always open.
 
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TL;DR : EM sucks. I’m out. In Fellowship. Good luck to you all.

I have spent 10+ years lurking here and have benefited greatly from reading other Emergency Physicians’ trials and tribulations. I take a lot of solace in hearing others’ angst, in an addictive voyeur-like way. This forum provides an echo chamber (for better or for worse) and some validation for a lot of the feelings I've had in emergency medicine. I am very grateful for all the practical advice I've heard as well, in terms of taxes, SDGs, second career paths, etc. Perhaps my story can help others.

I finished residency seven years ago at a very academic (~powerhouse light?) four year program. I was a solid, above average resident. Not the all-star. Confident and capable. I worked the full spectrum of emergency rooms during and after residency, from very high acuity/high volume to low volume government facilities that barely resemble an ER. I have worked for corporate medical entities, government, and community hospitals. I was exposed to many SDG's in residency and flirted with several of them afterwards, though never signed on. I feel like I have a good grasp of what the world of emergency medicine offers, despite my relatively short career.

I have found that low acuity/low volume places do not necessarily mean less angst. Perhaps this is personality driven. These shops frequently come with their own headaches, or frustration with inappropriate utilization of the emergency room, or inappropriate patient expectations. I think I hit a good stride when I was splitting shifts between both low acuity facilities and high acuity facilities. IE, when I was tired of dealing with high maintenance/low acuity patients I would then work a couple shifts at a high acuity ER and do a lot of procedures/resus etcetera. It provided a good balance. I think that this is sort of the sweet spot for EM practice in terms of job satisfaction.

I flirted with academics for the past several years, ultimately working as academic faculty. I thought that this was maybe a path to satisfaction/sustainability. When I was working with pgy 3/4s, this was wonderful. IE, not calling consults, no scut work, basically just verifying and occasionally redirecting everything the resident does. I tried my hardest to hide my cynicism from them and taught them well. I would see my own patients in the waiting room to help move the meat along. I think that this is a sustainable model, though a lot of caution needs to be taken in making sure your skill set is preserved. I unexpectedly found that I disliked teaching the very junior learners- med students, pgy1s, and off service residents.

I feel a lot of shame in leaving EM. It makes me feel like a failure. I see a lot of my peers doing the job and succeeding. I don't know why I cannot derive any feelings of satisfaction anymore from the field. It feels like death from a thousand cuts. I have had no bad outcomes or lawsuits. I perform well on metrics. However, only a few times a year do I feel like I make any difference in the world. I feel like I am just moving the meat along in a stupid dysfunctional system.

Here we go…

Inappropriate use of the ER. ‘1 hr pediatric fever’, ‘wants pregnancy test’, every drizzle of vaginal bleeding wanting an OB Ultrasound, 1 year of knee pain, etc. Many patients have no understanding of what primary care is or see the ER as the most convenient path to care. We are simply the building with the red cross on it. ‘This is where you do medical stuff’. When certain patients are given free and unlimited access, this is the type of behavior it fosters.

Midlevels. The presence of the ER as a safety net makes the entire medical system’s use of midlevels possible. They can basically offload anything involving actual decision making to the ER. Or worse yet, fixing blatant midlevel f-ups day in and day out. I have started to see patients come to the ER with a pile of lab work and imaging, just wanting a physician to interpret “what is actually going on”. Very rarely have I ever felt an MD inappropriately sent a patient to the ER.

Old People. I hate myself for getting frustrated by old people in the ER. After my 10th patient on shift in their 80s/ 90s, I just can't do it anymore. I consider it the other type of “homeboy drop-off”, where a family member or SNF just dumps an old person in the ER and leaves. It is a losing game for the Emergency Physician. They have a very high pretest probability of pathology, but cannot relate ANY of their symptoms to you in any comprehensible fashion. Good luck on getting ANY coherent medical history. I have thought we should microchip the elderly like we do our dogs as a prerequisite to get Medicare. This chip could be scanned on arrival and would have all of their meds, PMH/PSH, etc. Sometimes SNF's and families just want to get an MD on the chart to offload all of the risk. They can do this any time of the day or night, as often as they want, and for FREE. Sometimes the families are seeking a clean bill of health, however this cannot possibly be done.

Increasing Volume and Litigation Risk. When I was a medical student, I didn’t understand that the actual day to day mechanics of being an Emergency Physician more closely resembled being a waiter: Imagine being the only waiter at a PACKED 30-table Denny’s at 2am. There is a line going out the door, and Denny’s corporate wants you to take their orders in the street. They are all HUNGRY and upset before they even get to Denny’s. Many of them are DRUNK. You receive nasty emails from corporate if you didn’t take their orders fast enough. There are homeless people in the bathroom smoking meth and smearing poop on the walls. You run from table to table, shoving food down fat people’s throats, trying to keep everyone happy. Then a child chokes on a sausage link. The child dies. Then you get sued. That is Emergency Medicine today.

Patient Expectations: It seems stupid, but my PTSD/ burnout is actually more from situations like the mom of the two year old literally yelling at me in the waiting room for not getting her discharge paperwork in a timely fashion. This is usually for a child that I wrote an antibiotic prescription for, when they absolutely did not need it, however I dreaded the inevitable argument and patient complaint that would ensue if I didn’t write the Rx, etc.etc.etc.. Meanwhile I am dealing with several ICU holds that the hospitalist (not intensivist) still hasn’t seen, central lines in the ICU, NSTEMIs marinating in the waiting room, stroke “codes” sepsis “codes”, no available beds, homeless people smoking meth in the ER, poop streaks in the hallway, etcetera etcetera. Society has absolutely no idea what we deal with on a day-to-day basis. Other physicians usually have no idea as well.

My dad had to go to the ER last year for chest pain. The only thing he could talk about was the time waiting in between physician contact/blood draw, imaging, etc. He had literally no understanding or clue about what actually constituted quality of care, despite hearing me bitch and moan about my experiences working in the ER for the past decade.

ER Blaming: One of my biggest flex points for failure in this field has been the complete disrespect of the emergency medicine profession by other specialties. I can't handle it when a hospitalist or intensivist treats me like an underling. I can't handle it when sub specialists such as ENT or urology are completely absent or do not take any ownership over their post operative complications. It seems that their algorithm basically says go to the ER for any concerns. I think this behavior has been worsening over the past 5 years. Didn't these people used to be available to their patients? A lot of my college buddies are urology, ortho, ENT, etc. They all have their stories about stupid consults from the ER or stupid **** the ER does. I like to tell them that we can always go back to the 1970s or European model where they are on call for basically everything related to their field. These specialists do not acknowledge the value we provide to the system, and need to understand that the whole system would completely fall apart if we were not there. If you want to know the dysfunction of any particular medical system, just go to the ER and you will find us there dealing with it directly.

Another flex point for failure has been treatment by the hospital system when things go wrong with patients. We are occasionally expected to do heroic things- ED thoracotomy, cric, Lateral canthotomy, pediatric resuscitations, etcetera. These are procedures that even the specialist will get nervous and anxious about. However, when we step up to the plate and perform these, the immediate response from the sub specialists is doubt and skepticism. When a child dies in the emergency room, it is met with suspicion. When i cric someone, I have to defend my actions.

COVID: Don’t even get me started.

What I am doing now: Palliative Care Fellowship. I am by far the oldest one in my fellowship class. Thank you Frazier for all of the posts. This isn’t a running away/snap decision, and is very likely a WRONG decision for many people leaving EM. You must want to do this type of work, and you need to have the disposition for it. I repeat: Do not run away to a Palliative Care Fellowship just to get away from EM. As a premed I was doing Hospice stuff, palliative rotations in med school, carried this interest through ICU rotations, etc

I used to think EM docs in their 50s/60s were outdated dinosaurs, but I increasingly find myself in awe of them. How the hell did they stick it out for so long? I have not decided if I'm going to give up on EM, as I could still see a role for me working in rural low volume places. I got my resuscitative reps and experience working in busy ERs. I stood the watch.

For me, right now, the juice is NOT WORTH the squeeze. I am lucky enough to have paid off all my loans, and have a small nest egg after being frugal during residency and in my 7 years as an attending. I have a spouse that earns 100k. We will be OK. I am incredibly grateful that she didn’t marry me for money or prestige, otherwise this could have gone a lot worse.

It is important to note that I did not burn out from working too many shifts. I typically worked 12-15 8s. There were periods where I flexed up to 15+ 12’s, but this was extremely rare and limited. I rarely worked more than 2 nights/month, and went several months at a time with no nights. (Though I do think nights are terrible for your health and undoubtedly lead to burnout). I tried many ways to change my schedule around to avoid burnout, however even cutting back to 7-9 shifts a month did not cure the negative feelings. If anything, it led to more career anxiety and longer periods of self-loathing between shifts. I spent a lot of Tuesday afternoons drinking beer by myself and wondering why I was a failure and couldn’t be happy in EM.

I hope everyone can keep fighting the good fight. I truly believe that there is no more difficult or important job in medicine than what we do.
Really well written OP. I think at times we in ER have all thought each of these aspects at some point and this puts it together with a bow on top. Best of luck with your next career
 
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Remember that there is much variety across HPM jobs... academic, gov, community... big groups, solo doc... inpatient, outpatient clinic, home-based... low volume, busy services... GOC only, sxs management, a mix... no procedures, some potential procedures... decent pay, low pay... great hours, okay hours... call, zero call... strong IDT, no IDT...

Be prepared to leave your first HPM job. Fellowship is a year and you'll have a decent idea of what you like more (and what you like less). After your first year practicing solo, you'll be a lot closer to knowing if that first job is going to be a keeper or a stepping stone as you proceed on your journey. Give it time. Every job I've started at a new hospital/system I had some grieving about what I had left behind right before, that is normal and will quiet... What we want to avoid is the dread creeping up sunday night that monday is nearly upon us or trouble getting out of the car monday morning because you hate your job -- that's pathognomonic for a position that should be left in the dust.

Thanks for the shout-out and good luck @EmergentMagician !
 
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Just replying to re-emphasize how important the OP is. This is a post that should be stickied until we get out of this mess (so at least for the next 10-20 years)
 
You believe there is an exit and that things will get better?

The factors that led us to where we are now are multifactorial. Like there's no ONE main reason, and because of that it's impossible to know the answer to your question. Anything can happen to a specialty on a 10-year time frame, and that's doubly true on a 20-year time frame.

Maybe organized medicine is somehow able to push a new CMS metric that measures physician satisfaction as part of reimbursement. Imagine how EM would change if a hospital's reimbursement was based (in part) on how satisfied their physicians were with their practice at that specific location?

What if we juiced that even more with physician retention? Oh, your hospital has had more than 25% turnover of your ER docs in the last 2 years? Okay, we're paying you less.

Maybe, somehow, a bill gets in front of the president's desk that mandates funding for EMTALA. Imagine how EM would change if every MSE resulted in some level of reimbursement for the physician and the facility (as opposed to the $0 they both get currently)

I could go on and on and on but there are all sorts of game-changing regulatory/legal/systems things that could change and really put EM back on the correct path. Of course, there's 8 more layers to this simplification, but hopefully you get the idea.

Ultimately your question was, do you "believe" there's an exit? And yes, there's going to be some exit, and I don't think it's going to be a positive one. I continue to predict the slow and catastrophic decline of the system into something completely untenable. I'm not sure how that looks, but I would be a lot of money that it's not going to get "better" in any sense of the word during our working careers.
 
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Ultimately your question was, do you "believe" there's an exit? And yes, there's going to be some exit, and I don't think it's going to be a positive one. I continue to predict the slow and catastrophic decline of the system into something completely untenable. I'm not sure how that looks, but I would be a lot of money that it's not going to get "better" in any sense of the word during our working careers.
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Update:

Starting a full time inpatient Palliative job this summer:

300k, M-Th, no nights/weekends/call

Trying to calibrate what the minimum # of EM shifts I need to be working to maintain the EM skill set. I may just give it up.

From what I have seen, the ER docs who still have a soul tend to make great palliative physicians. If you're a metrics monkey and obsessed with making $$ (which is totally fine- the world needs these types of ER docs too) the field is not for you.

Feel free to reach out. This year in fellowship has been eye opening.
 
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Feel free to reach out. This year in fellowship has been eye opening.

I would appreciate whatever long-form or short-form insights you have.

Post them here!

Not only will I find them interesting but I bet many of the members and lurkers here will see them as helpful

Hearing how somebody got out and now has an entirely new skill set that they can use to help people/still make a physician income is incredibly hopeful for us still stuck in our positions.

Thank you!
 
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I would appreciate whatever long-form or short-form insights you have.

Post them here!

Not only will I find them interesting but I bet many of the members and lurkers here will see them as helpful

Hearing how somebody got out and now has an entirely new skill set that they can use to help people/still make a physician income is incredibly hopeful for us still stuck in our positions.

Thank you!
+1.
 
Update:

Starting a full time inpatient Palliative job this summer:

300k, M-Th, no nights/weekends/call

Trying to calibrate what the minimum # of EM shifts I need to be working to maintain the EM skill set. I may just give it up.

From what I have seen, the ER docs who still have a soul tend to make great palliative physicians. If you're a metrics monkey and obsessed with making $$ (which is totally fine- the world needs these types of ER docs too) the field is not for you.

Feel free to reach out. This year in fellowship has been eye opening.

Congrats!

What locality?

Who covers F-Sun?

Inpatient only?

Consultant or primary?
 
Update:

Starting a full time inpatient Palliative job this summer:

300k, M-Th, no nights/weekends/call

Trying to calibrate what the minimum # of EM shifts I need to be working to maintain the EM skill set. I may just give it up.

From what I have seen, the ER docs who still have a soul tend to make great palliative physicians. If you're a metrics monkey and obsessed with making $$ (which is totally fine- the world needs these types of ER docs too) the field is not for you.

Feel free to reach out. This year in fellowship has been eye opening.
300k. That’s damn good for palliative. Did you get the location of your choice or had to move around?

Congratulations on finding something better.
 
Update:

Starting a full time inpatient Palliative job this summer:

300k, M-Th, no nights/weekends/call

Trying to calibrate what the minimum # of EM shifts I need to be working to maintain the EM skill set. I may just give it up.

From what I have seen, the ER docs who still have a soul tend to make great palliative physicians. If you're a metrics monkey and obsessed with making $$ (which is totally fine- the world needs these types of ER docs too) the field is not for you.

Feel free to reach out. This year in fellowship has been eye opening.

Congrats and nice work!
Your first year out you might find that your interests continue to evolve from beyond fellowship. If you look to change jobs, it isn't a failure, nor that palliative is a poor fit... rather a natural ongoing evolution of your interests within the specialty. Don't fight it. Continue to seek out what's the best position for you as a person.
 
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What kind of tldr doesn’t mention what fellowship

Edit: Ah ok, palliative. Where EM goes to die.

Congrats on the move. Hope it works out.
 
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Update:

Starting a full time inpatient Palliative job this summer:

300k, M-Th, no nights/weekends/call

Trying to calibrate what the minimum # of EM shifts I need to be working to maintain the EM skill set. I may just give it up.

From what I have seen, the ER docs who still have a soul tend to make great palliative physicians. If you're a metrics monkey and obsessed with making $$ (which is totally fine- the world needs these types of ER docs too) the field is not for you.

Feel free to reach out. This year in fellowship has been eye opening.
That seems like a unicorn Palliative job. When I was considering fellowship last year, jobs (in northeast) were 185-225 still with call ("our census is growing rapidly").
 
I have a lot to say about the non-monetary side of Palliative, and how incredibly rewarding it is in comparison to EM. Most people are asking about the $$ and schedule, so here are those details. I'll make a separate post later about the non-$$ aspects of the field.

*I am moving to a geographically undesirable area- that is why 300K for that sweet 4 day schedule w/out call. Community jobs in the locale around my fellowship, in a highly desirable area, were 230-260K. All these sites still had very explicit limits on not going above a 40 hr work week. Call requirements varied, but were minimal or none.

*Inpatient palliative is consultant based in most institutions. Some rare exceptions.

*300K was with quality metrics that are easy to hit in Palliative.

*In general, it seems Academic sites in the NE always pay garbage (<200K). I don't know why people accept that Ivy league "tax", in exchange for circle jerk prestige (that no one outside of those circles really cares about anyway).

*Compensation across most specialties (and nursing) seems to have increased quite a bit during the time I had my head down working in EM. In comparison, EM pay seems to have stagnated.

*For reference, NPs in Heme/onc at my institution are making 220K these days for <40 hrs inpatient work per week.

*There are lots of different types of schedules for Inpatient Palliative- depending on the site and staffing-
M-F 8-4
7on/7off
M-Th 10hr days
all with variable to no amount of call
 
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You don't do HPM for the money. You do it to reclaim your humanity after EM destroys it.
 
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