.... I can’t speak to “away rotations” because I never did any and can’t imagine how that would work once you graduate from medical school. That is to say, most residents don’t do away rotations as auditions for fellowship like students do for residency. My recommendation is that you hook up with attendings in your future specialty at your current institution and ask to join them on rounds, get involved in their research or admin work, etc. ...
I'm working on that, and quietly trying to build relationships with these folks. I'll be asking for LORs in the spring from a few key folks at work, but otherwise I don't want to broadcast to the group yet that I might be leaving, or at least not until it's more of a done deal.
Honestly, most fellowship directors will be trying to determine if your are leaving EM because to are simply burned out and running from your problems. You will need to come up with a compelling story as to why you belong and leaving your specialty. Any whiff that you are burned out of EM will be a problem with most reputable places. That’s because physicians who think that fleeing EM to another specialty will fix their burnout are wrong - their issues persist because they’re unhappy with much more than just their specialty.
That is why my program in particular only takes fellows right out of residency training. The resident usually did an elective or had a rotation on our service and fell in love with that type of medicine. How an attending grinding in their primary specialty can suddenly develop a "passion" for a completely distinct type of medicine doesn't make any sense, therefore a compelling story is unquestionably necessary.
(I'll attempt a TL;DR summary, more details below if you're bored )...
[I started into medicine because of an MSK type background and interest. I miss the MSK focused complaints. Work in the ED is exhausting and stressful, and I don't see it getting much better in the next few decades. While I still have the energy and ability, I'm planning a thoughtful exit from the ED and stepping aside to a new path that is more clinic based, likely with less stress. I'm looking for a practice that I can age in, and not regularly get mentally and physically beaten up while at work. My health and wellbeing outside of work is now more important to me than being the flashy trauma resuscitationist that I wanted to be in residency.]
Both of these are excellent points. This is part of the reason that I've been taking a longer road to apply, instead of rushing into it this year. Trying to get all my ducks in a row, so to speak. It's also given me plenty of down time to think about why I'm doing this and to make sure I'm not just running from problems. I know you guys don't need an explanation, but I think writing it out might help me organize my thoughts. Feel free to help me focus these ramblings if you so choose.
I came to medicine from a math based field after joining the ski patrol and taking their medical course. I was fascinated by the anatomy and physiology, and to be completely honest, the days where we were seeing multiple ortho injuries (frequent at a small local place with inexperienced "skiers") were some of my favorite days. I'd always been active, but finally getting to learn how to take care of injuries I had seen or suffered was what tipped me over to switching into a medical direction. Most of my peers were medics or firefighters, so naturally they always talked up EM. I had a job as a tech for a while that felt right, and I wanted to be like the docs I was working with. Fast forward to 3rd and 4th year of school, and my draw to EM was still there. I had multiple audition rotations that all felt right/good, and although I enjoyed my surgical rotations, I just had blinders on for EM. I didn't really have any great peers to discuss options at that point, but I felt like I was making the right call as a mid 20s medical student who knows nothing.
My draw to EM included the schedule and scheduling possibilities, working about a third of the month, and lots of "free time" for travel and recreation. I really liked the idea of no call and not having a long term longitudinal clinic like in family medicine. To be clear, I have a great job at the moment, I've made partner, we have a supportive hospital and nursing administration that works closely with us for staffing and throughput, and our admin team is pretty rock solid. It's a good gig. And the pay is good.
But. Some of those same things have started to make me reconsider another 20-30 years (who gets to retire anymore these days?) in this style of practice.
- The build up of chronic fatigue from all of the switching was making me miserable. We have more than a dozen shifts each day where I work. Initially I fixed the chaos of the constantly rotating and unpredictable schedule by going to full time nights. I set my own schedule and can write my ticket as far as work goes. It's what has kept me sane over the last few years. I have a pretty set group of nurses that I work with regularly who trust me and I trust them. It has made my practice so much more tolerable. I never thought that I would enjoy a set schedule, but getting on a good gym rotation, better food rotation and a predictable schedule for my wife has been life changing. I regularly sleep 8-10 hours between shifts, and I also am a night owl, so nights work for me. What can I say? The trade off is, well, nights. My wife and I are on opposite schedules a few days a week, but we do get days off together regularly. While I typically only work 3 days a week, I lose the first post shift day to either sleep or because I'm so tired I can't do much if I stay up. Which is basically four days of my week. two full free days, and then the last free day I lose the evening napping before my next shift. Again, it's crazy, but it's been working for me. I'm consistent at the gym and with meal prep, house chores are getting done, and the wife is definitely happier this way since I'm so much more tolerable and less grumpy, despite me being gone a few nights a week.
- While we have a flexible schedule, not really having sick days or PTO makes travel tough. You might get 2 or three weeks over if you can split it over two months, but you pay for it an get wrecked while working your full time shifts crammed into 15-18 days for two months straight. We did that multiple times the first two or three years for big trips, and it was rough.
- You don't have to have a "practice" or clinic, and you don't have to search for patients. They find you. Again, and again. Some shifts are fine, others we get crushed and have 20-50 in the waiting room all night long. Those shifts suck. Post COVID has also had more of those type of shifts for our ED. It's mentally and emotionally exhausting. The idea that every shift was different, and no presentation is the same that was alluring at the outset, has become tedious and more stressful as it goes on. I LOVE the pathophys and medicine related to a sick, crashing patient that needs resuscitation and interventions. Having a set list in a clinic and working through you day that way? I don't hate the idea. I don't know why med student and resident me was so against it.
- Another thing I've found is that I like doing some crazy stuff like skiing, snowboarding, mountain biking, mountain climbing, hiking... you get the picture. EM has me so prepped for craziness all the time that I've been finding it more difficult to get as excited about those things the past few years. It's like my adrenaline and cortisol is used up at work, and I don't have enough to spread around for the recreational activities.
- As I mentioned above, I've finally felt stable in my practice over the past 2-3 years, and I've been able to entertain thoughts of what else I might do, or if EM is what is right for me. Talking to a few of my trainers at the gym and with med school buddies, I've realized how much I miss the MSK medicine. I want to work with people who want to get better, and are willing to take steps to make that happen, vs just walking in and expecting a pill and a miracle. I know that will happen in clinic, but I also don't have to continue seeing those patients. I want to work with athletes. I enjoy splinting, US procedures, and from what I saw on my shadowing in the clinic, I like the pathology.
I went to DO school because I really like the musculoskeletal medicine. And I still do. EM is flashy and drew me in. I wanted to be the doctor that people look to in a time of emergency or crisis to help, to stabilize, to control the situation. I feel like EM residency prepared me well for that, and I've made a great practice getting to do that. But I'm missing things and looking to the future, I can't see myself wanting to stay at this pace, in this environment for the next few decades. Does that mean I'm burned out? I hope not. I don't feel crispy/crunchy. I'm sure I have my days, but who doesn't after a rough shift? I still feel empathy for my patients, and I get a kick out of talking to some of them. I get flack from some of the nurses and more crusty partners for being a softy and letting the homeless folks hang out with us overnight instead of kicking them back out into the weather, as long as they are nice and respectful to the staff. I sit and talk to my patients regularly and probably spend way too much time at the bedside. But I'm ok with that, and it's what keeps me coming back for more shifts. I love the true emergency medicine, but the pace and constant push for more, More, MORE without real control over the pace or patient population is what's getting to me, I think.
I don't feel like I'm running. I've evaluated my options and my current mental/physical/emotional state, and I'm looking for a different type of practice. I see it more as a step to the side onto a new trail from where I am on my hike up the mountain. I think sports medicine will afford me that. It's not something that I realized would interest me or that I wanted to pursue in residency, but my life was different then. The idea of leaving trauma and crashing patients was demoralizing and the thought of clinic life as a 20 something made me nothing but bored. As I've matured, things have changed. I'm also contemplating my long term health and longevity at being able to practice medicine in a style that will let me continue well into the years without breaking me mentally and physically. Money isn't my driving factor. Insurance isn't my driving factor. Working at a smaller ED or at an Urgent Care is an option, but that feels like so much of the same-same, just on a smaller scale. So while that may help for a while, I don't think that's a good option for me long term.
I like the clinic mix of new/urgent and focused visits, procedures, splinting, some light urgent care for athletes or select patients, and working with athletes and active folks in general. I know there will be some metabolic syndrome patients with chronic hip and knee pain as well, but they typically feel better with injections, so they are happy. Or if you can't help them, they don't need more appointments. I have an interest in a few different topics and complaints that I can focus on and gear my clinic towards possibly. At the end of the day it will still be a job. But, I'll get paid well enough for me, I'll have less stress while at work, I'll have nights and holidays off with my wife and family, and I'll have a practice I can age in.
I don't know if that answers your questions, or if that's a compelling enough reason, but there are the thoughts. Sorry if they're scattered, I'm post shift and have only had a nap. I'll keep at it if the collective thinks I can focus those ideas down more. Feel free to help me be more compelling.
