Applying to EM now

[bravotwozero]

---

Members don't see this ad.

If you do a US residency are you guaranteed that you can stay in the US and practice?

Yeah, therein lies the rub. I mean FMGs with green cards or US citizenship will have no issues there, but anyone else needs visa sponsorship and government approval, which not every hospital is able to do. Even for HCA, that kind of process might not be worthwhile, particularly when the FMGs might not meet criteria for it, so this will become a rate limiting step.

US citizen Caribbean grads could also fill the unfilled spots, along with DO school grads, but their massive student loans would be a deterrent at some point, when there may be better options.

 

[Dr Mantis Toboggan]

Yeah, therein lies the rub. I mean FMGs with green cards or US citizenship will have no issues there, but anyone else needs visa sponsorship and government approval, which not every hospital is able to do. Even for HCA, that kind of process might not be worthwhile, particularly when the FMGs might not meet criteria for it.

Hey I love the idea of training EP’s and sending them out into the world to raise the standard of care of their home countries. Staying here and taking my job, not so much.

 

[cyanide12345678]

If you do a US residency are you guaranteed that you can stay in the US and practice?

I don't know a single pakistani who has not been able to find a j1 waiver job to get a work permit and then eventually get sponsored. But that process requires an employer to prove that that job does have a shortage. It's impossible to not find work after a US residency right now. It may change in the future. But if you get your foot through the door, most likely you will stay.

And i know at least 15-20 Pakistani relatives and friends who did med school in pakistan and then residency here. Everyone ends up staying.

 

[turkeyjerky]

I could also see reverse subsidies becoming a reality, where hospitals with great payer mixes start awarding contracts to the highest bidder.

So, for example- today you have a SDG staffing a hospital in a upscale suburb in the Bay Area, Connecticut, Aspen, etc. that currently supports an hourly rate of $325 for its docs with no stipend. As the market is flooded with EP’s, hospitals could be emboldened to charge a six or seven figure fee for the “privilege” of staffing its ED, driving those hourly rates down to the mean.

nobody is safe

This already is happening through CMGs taking hospitalist contracts along with EM, using the latter to subsidize the former. Decent number of SDGs (or pseudo ones, by this point) do the same, and more will be foreced to in order to protect their contract. This is why I predict eventual parity between EP and Hospitalist pay.

Youre assuming you actually get to do it. Meaning actually have a job.

Exactly. Anyone still planning on applying to EM needs to understand that there's a very high likelihood that they'll be working in an urgent care. Taking a crappy job in BFE supervising 4 midlevels for HCA making 150/hr might be the best case scenario.

 

[VA Hopeful Dr]

Why do veterinarians get paid like garbage yet carry similar student debt and grueling competition to become one.

Because they have the same “do what you love” attitude and “I am a snowflake” outlook

Or because there are limits on what people will pay for medical care for their pets since its still majority cash pay. I'm in a hunt club with two veterinarians who don't fit your description in the slightest and they've said they would love to charge more but basically can't.

A number of years ago I left a vet and found a new one when they charged me $350 to spay my dog at the time and my current vet charged me $150 for the same procedure.

I had a cash only FM practice for a few years and its not much different in people who are paying for everything out of pocket.

 

[oldtown]

This already is happening through CMGs taking hospitalist contracts along with EM, using the latter to subsidize the former. Decent number of SDGs (or pseudo ones, by this point) do the same, and more will be foreced to in order to protect their contract. This is why I predict eventual parity between EP and Hospitalist pay.

What I’m proposing may start happening is a little different. I’m well aware of this type of cross subsidization you refer to:

Hospital to CMG/SDG: “We’ll give you the lucrative ER contract if you take the money losing hospitalist contract
that we used to have to subsidize, for free”

What I’m saying may start happening as the market is flooded is:

Hospital to CMG/SDG: “You want the lucrative ED contract? How much you got?”

Cash money out of pocket for the group. Guess what SDG- that sweet insulated gig that used to pay $300+ per hour that was stable because you did it without subsidy, did a good job and were integrated in hospital affairs- now you’re going to have to pay to play and your hourly rate is $200. Next contract renewal, TeamHealth comes in with a better offer that you have to match to keep the contract? Now your effective hourly rate is $160. Lather, rinse and repeat.

No reason hospitals will stop there either. Maybe group will have to pay for the privilege to staff the ED AND take on that hospitalist contract. Hourly rate: $120

 

[wamcp]

Or because there are limits on what people will pay for medical care for their pets since its still majority cash pay. I'm in a hunt club with two veterinarians who don't fit your description in the slightest and they've said they would love to charge more but basically can't.

A number of years ago I left a vet and found a new one when they charged me $350 to spay my dog at the time and my current vet charged me $150 for the same procedure.

I had a cash only FM practice for a few years and its not much different in people who are paying for everything out of pocket.

I don’t...get it. How does that refute what I said? Anyone going into EM or become a vet, with the facts of pay/employment available to them must carry an attitude or are just completely ignorant

 

[VA Hopeful Dr]

I don’t...get it. How does that refute what I said? Anyone going into EM or become a vet, with the facts of pay/employment available to them must carry an attitude or are just completely ignorant

I was going after the "I'm a snowflake" part which seemed unnecessary. They're obviously a case of "do what you love".

 

[Redpancreas]

Hey all I'm a rising MS4 who was formerly all-in for EM until the recent oversaturation woes. Would it be best to apply only to top rated EM programs at this point in order to minimize the odds of being unemployed upon residency completion?

Even if I am able to secure a job, I'm not mentally prepared to live in a place like rural Montana (not that there's anything wrong with living there, but it's just somewhere that I personally wouldn't be happy). I have been contemplating switching to IM, a close second-choice for me (mainly due to the fellowship opportunities). I love a lot about EM, specifically the fast-paced environment and the undifferentiated patients, but do sometimes miss the intellectual stimulation of IM (then I remember how much I hate rounding, long notes, etc.). Ultimately, I would rather go into a specialty that I am less passionate about which allows me to have significantly more job security and geographic preference.

Could the job market recover by the time current MS3s/MS4s complete residency or will things continuously worsen? Any advice appreciated, thanks.

Not sure corporate interests will differentiate between someone who graduates from UCLA Harbor/Hennepin County vs. HCA residencies when push comes to shove.

And you obviously don't realize that if there are residency spots to fill, a good 80-90 percent of those will still fill regardless of how crappy a specialty is.

Let's see ... all the Indian, Pakistani, Bangladeshi and other foreign 3rd world countries can either practice in their home countries and make $1000-2500/month or they can move to the US, do residency and make $20k/month.

This once conventional wisdom is starting to evaporate. In pockets surrounding urban centers in these "3rd world (south asian) countries", there is an incredible demand for competent medical care. As these country's middle class grows, there will be incredibly lucrative opportunities for simply providing high volume, competent medical care with private practice/administrator opportunities similar to the US in the late 20th century. I project in the next decade or so, second generation American grads with ties to these places may consider moving back.

If you do a US residency are you guaranteed that you can stay in the US and practice?

Pretty much. The hurdle is getting into residency. Once you're trained, you're a highly valued commodity.

 

[Redpancreas]

Yeah, therein lies the rub. I mean FMGs with green cards or US citizenship will have no issues there, but anyone else needs visa sponsorship and government approval, which not every hospital is able to do. Even for HCA, that kind of process might not be worthwhile, particularly when the FMGs might not meet criteria for it, so this will become a rate limiting step.

US citizen Caribbean grads could also fill the unfilled spots, along with DO school grads, but their massive student loans would be a deterrent at some point, when there may be better options.

They all find jobs.

 

[hebel]

I can't emphasize this enough. You really need to choose a career in medicine that you will enjoy doing. If you are picking a career based on job availability, you will be so friggin miserable every single day with your job that you don't want to do. If EM is your calling and you've done your rotations and you enjoy working in the ER and you don't want to work behind a desk in a clinic or do surgery, then do EM.

There's lots of doom and gloom, but you think doctors in other fields are uniformly happy with their careers?

I think this take is lacking some nuance. Enjoying your job is usually not an either-or choice. There's many specialties to chose from, and I'm sure most people could find a specialty they enjoy that doesn't have an unfavorable future outlook.

I wouldn't pick a specialty I hated because the market seemed good, but the options usually aren't limited to: EM or hate your job doing another specialty.

 

[TheComebacKid]

In my opinion, it's really, really shortsighted to NOT go into EM (or any specialty you love) because of concern of poor job outlook, and to choose another career that you may like less and be more miserable in, that will ultimately also have a very poor job outlook.

EM doesn't live in a bubble. Things are bad right now, and it's really easy to look for greener pastures elsewhere. Everyone is getting hit hard right now. And specialties that aren't, will also get overrun with midlevels and physician oversupply. Market forces have not singled out EM over other specialties. Everyone is fair game.

Why pay a dermatologist to prescribe steroids and do skin biopsies when an NP can do it? Do you really need a physician to order inflammatory markers at a rheumatologist office? Can't an ID NP just adjust antibiotics based on culture sensitivities? NPs are already putting in central lines and arterial lines in ICUs around the country (thanks to us training them on US). Anesthesia is arguably just as bad if not worse than EM when it comes to midlevel encroachment.

Some surgical subspecialties (urology, ENT, ortho) will enjoy the good days perhaps a bit longer than the others. But I don't think they are immune to the same market forces as everyone else. Their time will come too.

I would probably lose my mind if I ditched EM to go into something else that I disliked more, because of some promise that it's going to have a better job outlook, only to find out not only do I hate my job but the job prospects are just as bad if not worse than EM. It's a losing proposition.

 

[2021Doctor]

In my opinion, it's really, really shortsighted to NOT go into EM (or any specialty you love) because of concern of poor job outlook, and to choose another career that you may like less and be more miserable in, that will ultimately also have a very poor job outlook.

EM doesn't live in a bubble. Things are bad right now, and it's really easy to look for greener pastures elsewhere. Everyone is getting hit hard right now. And specialties that aren't, will also get overrun with midlevels and physician oversupply. Market forces have not singled out EM over other specialties. Everyone is fair game.

Why pay a dermatologist to prescribe steroids and do skin biopsies when an NP can do it? Do you really need a physician to order inflammatory markers at a rheumatologist office? Can't an ID NP just adjust antibiotics based on culture sensitivities? NPs are already putting in central lines and arterial lines in ICUs around the country (thanks to us training them on US). Anesthesia is arguably just as bad if not worse than EM when it comes to midlevel encroachment.

Some surgical subspecialties (urology, ENT, ortho) will enjoy the good days perhaps a bit longer than the others. But I don't think they are immune to the same market forces as everyone else. Their time will come too.

I would probably lose my mind if I ditched EM to go into something else that I disliked more, because of some promise that it's going to have a better job outlook, only to find out not only do I hate my job but the job prospects are just as bad if not worse than EM. It's a losing proposition.

I would say that having a job you hate is better than having no job at all.

 

[Rekt]

In my opinion, it's really, really shortsighted to NOT go into EM (or any specialty you love) because of concern of poor job outlook, and to choose another career that you may like less and be more miserable in, that will ultimately also have a very poor job outlook.

EM doesn't live in a bubble. Things are bad right now, and it's really easy to look for greener pastures elsewhere. Everyone is getting hit hard right now. And specialties that aren't, will also get overrun with midlevels and physician oversupply. Market forces have not singled out EM over other specialties. Everyone is fair game.

Why pay a dermatologist to prescribe steroids and do skin biopsies when an NP can do it? Do you really need a physician to order inflammatory markers at a rheumatologist office? Can't an ID NP just adjust antibiotics based on culture sensitivities? NPs are already putting in central lines and arterial lines in ICUs around the country (thanks to us training them on US). Anesthesia is arguably just as bad if not worse than EM when it comes to midlevel encroachment.

Some surgical subspecialties (urology, ENT, ortho) will enjoy the good days perhaps a bit longer than the others. But I don't think they are immune to the same market forces as everyone else. Their time will come too.

I would probably lose my mind if I ditched EM to go into something else that I disliked more, because of some promise that it's going to have a better job outlook, only to find out not only do I hate my job but the job prospects are just as bad if not worse than EM. It's a losing proposition.

IM: "Dang IM isn't what I thought. Guess I'll work as a hospitalist for 250k".

EM: "Dang I literally have no job at all".


Not sure how this "Do what you love" nonsense is still being said unless you're grossly misunderstanding the data.

You won't be the special snowflake that gets the job out of the other hundreds to thousands of unemployed docs.

 

[sylvanthus]

You cant do what you love if you dont have a job. Reallllyyy bad advice.

 

[skougess]

“Do what you love” is a scam. I love video games. No one is going to pay me for it.

The real advice is find a job that pays well that you don’t hate.

 

[cyanide12345678]

Everyone preaching "do what you love".... Do you really LOVE your job??? Love is a strong word. When you love something, you pick it over everything else. So would you pick your job over traveling, vacation, your wife/husband, your kids, your hobbies?

If the answer to the above question is no - then do you really LOVE your job? It's just a means to an end. Work is work. There's a reason someone has to pay you to do it. I wouldn't do this for free. I wouldn't even do it for less than $200/hr honestly. Maybe if you guys LOVE work so much, you should do it for free.

 

[2021Doctor]

One shocking change is that a field (EM) that has been attracting many of the best and the brightest will be SOAPing at unprecedented levels next year (change happens fast - look at radonc match in 2019 vs 2020 and 2021). And if you look at radonc, the PDs tend to fill their slots.

 

[wamcp]

One shocking change is that a field (EM) that has been attracting many of the best and the brightest will be SOAPing at unprecedented levels next year (change happens fast - look at radonc match in 2019 vs 2020 and 2021). And if you look at radonc, the PDs tend to fill their slots.

Why did so many med students still charge into EM this year and filled every spot, despite knowing the job outlook. Shouldn’t there have been a change by now?

 

[sloh]

Why did so many med students still charge into EM this year and filled every spot, despite knowing the job outlook. Shouldn’t there have been a change by now?

Naïveté, ignorance, sunk cost, “it’s not all about the money,” “follow your passion,” “don’t read SDN, it’s a bunch of pessimism.”

 

[Dr Mantis Toboggan]

Naïveté, ignorance, sunk cost, “it’s not all about the money,” “follow your passion,” “don’t read SDN, it’s a bunch of pessimism.”

Yes this board has been the canary in the coal mine for the past few years. Now with ACEP finally admitting there’s a big problem the situation cannot be ignored. I still fear many naive/unscrupulous PD’s will not provide applicants a clear picture of the future of the specialty but we will see what happens.

 

[turkeyjerky]

Anyone with a notion that it will be possible to 'love' whatever emergency medicine becomes in 2028 is living in a fantasy-land.

 

[TheComebacKid]

IM: "Dang IM isn't what I thought. Guess I'll work as a hospitalist for 250k".

EM: "Dang I literally have no job at all".


Not sure how this "Do what you love" nonsense is still being said unless you're grossly misunderstanding the data.

You won't be the special snowflake that gets the job out of the other hundreds to thousands of unemployed docs.

I'm looking at it more from the perspective of:

EM: Dang, I really love EM, but there are no jobs.
Anesthesia: Dang I really don't like anesthesia, but maybe the job outlook will be better than than EM so what the hell. (Goes into Anesthesia). Man, there are no jobs.

It's not a good situation in either scenario. One is worse than the other, IMO.

This isn't supposed to be a "feel good" post about following your heart. The "do what you love" sentiment really triggered people, and I see why, but that's not really the point of the post. The pandemic as a whole really exposed a lot of issues that are affecting not just EM, but many specialties.

I think it's incredibly short sighted for people to assume that it's going to be easy to find a hospitalist job for 250k in 5 years. Midlevel encroachment, number of IM residencies/foreign trained grads etc are a threat to IM as well. I think the corporatized nature of EM made us one of the first ones to fall, but IM is very ripe for being taken over by midlevels as well. The problems we are facing in EM are a manifestation of system wide issues. Nobody is immune.

As someone working in academics, I won't be painting a rosy picture to medical students interested in EM (I know some of my colleagues will continue to do this, which is irresponsible). The numbers are clear that things aren't looking good. But I'm not going to tell them "Go be a hospitalist, even if you dislike it, because you can totally make 250k without a problem."

 

[Taurus]

I'm looking at it more from the perspective of:

EM: Dang, I really love EM, but there are no jobs.
Anesthesia: Dang I really don't like anesthesia, but maybe the job outlook will be better than than EM so what the hell. (Goes into Anesthesia). Man, there are no jobs.

It's not a good situation in either scenario. One is worse than the other, IMO.

This isn't supposed to be a "feel good" post about following your heart. The "do what you love" sentiment really triggered people, and I see why, but that's not really the point of the post. The pandemic as a whole really exposed a lot of issues that are affecting not just EM, but many specialties.

I think it's incredibly short sighted for people to assume that it's going to be easy to find a hospitalist job for 250k in 5 years. Midlevel encroachment, number of IM residencies/foreign trained grads etc are a threat to IM as well. I think the corporatized nature of EM made us one of the first ones to fall, but IM is very ripe for being taken over by midlevels as well. The problems we are facing in EM are a manifestation of system wide issues. Nobody is immune.

As someone working in academics, I won't be painting a rosy picture to medical students interested in EM (I know some of my colleagues will continue to do this, which is irresponsible). The numbers are clear that things aren't looking good. But I'm not going to tell them "Go be a hospitalist, even if you dislike it, because you can totally make 250k without a problem."

True, no field in medicine is perfect but the level of risks is not the same in each field. Based on the structural changes affecting EM, its limitations to expand outside of the ED and urgent care, and limited fellowship options, I would rather take my chances in IM than EM if I were a medical student right now. The lights in EM are blaring bright red. Unless they take an axe to residency spots, EM has a bleak future. RadOnc has a better chance than EM to recover and rise to prominence again by cutting spots too.

 

[bronx43]

I'm looking at it more from the perspective of:

EM: Dang, I really love EM, but there are no jobs.
Anesthesia: Dang I really don't like anesthesia, but maybe the job outlook will be better than than EM so what the hell. (Goes into Anesthesia). Man, there are no jobs.

It's not a good situation in either scenario. One is worse than the other, IMO.

This isn't supposed to be a "feel good" post about following your heart. The "do what you love" sentiment really triggered people, and I see why, but that's not really the point of the post. The pandemic as a whole really exposed a lot of issues that are affecting not just EM, but many specialties.

I think it's incredibly short sighted for people to assume that it's going to be easy to find a hospitalist job for 250k in 5 years. Midlevel encroachment, number of IM residencies/foreign trained grads etc are a threat to IM as well. I think the corporatized nature of EM made us one of the first ones to fall, but IM is very ripe for being taken over by midlevels as well. The problems we are facing in EM are a manifestation of system wide issues. Nobody is immune.

As someone working in academics, I won't be painting a rosy picture to medical students interested in EM (I know some of my colleagues will continue to do this, which is irresponsible). The numbers are clear that things aren't looking good. But I'm not going to tell them "Go be a hospitalist, even if you dislike it, because you can totally make 250k without a problem."

IM isn’t just hospital medicine... one of the big draws of IM is the versatility. It’s not perfect but it’s not as limiting as EM.

 

[Dr Mantis Toboggan]

IM isn’t just hospital medicine... one of the big draws of IM is the versatility. It’s not perfect but it’s not as limiting as EM.

Yes good smart internists as primary care providers will always be in demand.

 

[Rekt]

I'm looking at it more from the perspective of:

EM: Dang, I really love EM, but there are no jobs.
Anesthesia: Dang I really don't like anesthesia, but maybe the job outlook will be better than than EM so what the hell. (Goes into Anesthesia). Man, there are no jobs.

It's not a good situation in either scenario. One is worse than the other, IMO.

This isn't supposed to be a "feel good" post about following your heart. The "do what you love" sentiment really triggered people, and I see why, but that's not really the point of the post. The pandemic as a whole really exposed a lot of issues that are affecting not just EM, but many specialties.

I think it's incredibly short sighted for people to assume that it's going to be easy to find a hospitalist job for 250k in 5 years. Midlevel encroachment, number of IM residencies/foreign trained grads etc are a threat to IM as well. I think the corporatized nature of EM made us one of the first ones to fall, but IM is very ripe for being taken over by midlevels as well. The problems we are facing in EM are a manifestation of system wide issues. Nobody is immune.

As someone working in academics, I won't be painting a rosy picture to medical students interested in EM (I know some of my colleagues will continue to do this, which is irresponsible). The numbers are clear that things aren't looking good. But I'm not going to tell them "Go be a hospitalist, even if you dislike it, because you can totally make 250k without a problem."

All of medicine is dying. Besides medical students and residents, physicians are the lowest respected people in the hospital these days. Also physicians are standing by and handing everything over on a silver platter to mid levels. This is more for people in medical school. If someone is currently in med school, they should not do EM at all. At least get 5-10 years of pay from another specialty before it's sold out to midlevels and PE/CMCs by the same boomers using you as slave labor during training.

 

[wamcp]

I'm looking at it more from the perspective of:

EM: Dang, I really love EM, but there are no jobs.
Anesthesia: Dang I really don't like anesthesia, but maybe the job outlook will be better than than EM so what the hell. (Goes into Anesthesia). Man, there are no jobs.

It's not a good situation in either scenario. One is worse than the other, IMO.

This isn't supposed to be a "feel good" post about following your heart. The "do what you love" sentiment really triggered people, and I see why, but that's not really the point of the post. The pandemic as a whole really exposed a lot of issues that are affecting not just EM, but many specialties.

I think it's incredibly short sighted for people to assume that it's going to be easy to find a hospitalist job for 250k in 5 years. Midlevel encroachment, number of IM residencies/foreign trained grads etc are a threat to IM as well. I think the corporatized nature of EM made us one of the first ones to fall, but IM is very ripe for being taken over by midlevels as well. The problems we are facing in EM are a manifestation of system wide issues. Nobody is immune.

As someone working in academics, I won't be painting a rosy picture to medical students interested in EM (I know some of my colleagues will continue to do this, which is irresponsible). The numbers are clear that things aren't looking good. But I'm not going to tell them "Go be a hospitalist, even if you dislike it, because you can totally make 250k without a problem."

If there are no hospitalist jobs after graduating IM residency..you can go straight into a primary care job... do any of the several 2-3 yr IM fellowship that have actual job prospects..urgent care...SNF work..etc etc

 

[GeneralVeers]

There's a reason it's called "Work" and not "Super Happy Fun Time".

When I started I never loved EM. I found it interesting, liked the pace, and especially the pay and schedule. Most days now I'm ambivalent, and some days downright hate it. It's a job, and you aren't supposed to love your job. In fact I think most people don't love their jobs. If you truly love your job, it's something you would do for free.

 

[Birdstrike]

The people that love what EM should be, outnumber the people that love EM, one thousand to one.

 

[GatorCHOMPions]

The people that love what EM should be, outnumber the people that love EM, one thousand to one.

As usual you’re spot on. The idea of EM is amazing. The reality is not so much, and less so moving forward with all these projections. It’s a palatable job if you’re seeing a reasonable patient load, have some say in your working conditions, live within 25 miles of where you want to, and get paid fairly. Having just 1 of these is becoming increasingly rare.

 

[Tipsy McStagger]

The people that love what EM should be, outnumber the people that love EM, one thousand to one.

Does anybody actually love what EM really is in practice? EM could have been one of the coolest specialties in medicine, instead it's a failed dream of metrics, risk avoidance and impossible patient/consultant/admitting expectations.

 

[RustedFox]

As usual you’re spot on. The idea of EM is amazing. The reality is not so much, and less so moving forward with all these projections. It’s a palatable job if you’re seeing a reasonable patient load, have some say in your working conditions, live within 25 miles of where you want to, and get paid fairly. Having just 1 of these is becoming increasingly rare.

Does anybody actually love what EM really is in practice? EM could have been one of the coolest specialties in medicine, instead it's a failed dream of metrics, risk avoidance and impossible patient/consultant/admitting expectations.

Wow.
So much truth here. So very, very much.

 

[GeneralVeers]

Does anybody actually love what EM really is in practice? EM could have been one of the coolest specialties in medicine, instead it's a failed dream of metrics, risk avoidance and impossible patient/consultant/admitting expectations.

It wasn't horrible when I started 12 years ago. It's become something different.....twisted and evil.

 

[GatorCHOMPions]

Wow.
So much truth here. So very, very much.

Having some control of work conditions is the most important part of job satisfaction imo and ties into a lot of the rest of what I said. Yet this is universally lacking in EM simply by nature of the specialty (24/7 hours, EMTALA, hospital based), and any morsel of control is erased if you’re employed.

 

[Birdstrike]

EM could have been one of the coolest specialties in medicine, instead it's a failed dream of metrics, risk avoidance and impossible patient/consultant/admitting expectations.

Devastating

 

[Birdstrike]

As usual you’re spot on. The idea of EM is amazing. The reality is not so much, and less so moving forward with all these projections. It’s a palatable job if you’re seeing a reasonable patient load, have some say in your working conditions, live within 25 miles of where you want to, and get paid fairly. Having just 1 of these is becoming increasingly rare.

Does anybody actually love what EM really is in practice? EM could have been one of the coolest specialties in medicine, instead it's a failed dream of metrics, risk avoidance and impossible patient/consultant/admitting expectations.

It wasn't horrible when I started 12 years ago. It's become something different.....twisted and evil.

Wow.
So much truth here. So very, very much.

It wasn't long ago I would come on here and write stuff like this and I'd just get nuked from all angles, with rare defenders. It now seems the blasphemy of yesteryear has become today's conventional wisdom. It gives me no pleasure to write that. My goal in staying around here is if I can help 1% of people find a better way forward. I think there are multiple better ways forward. Few are easy. Most take planning. Some require risk.