Best Fellowships To Get Out Of EM

[cyanide12345678]

What are some fellowships that people have considered to get out of full time EM. Things like US or EMS are mostly just attempts at getting specialized into academics, but realistically, you're still practicing emergency medicine.

Can we compile a list of fellowships that help you get out - Please list pros, cons, career outlook and field saturation, lifestyle, compensation, work hours, career longevity, training length, fellowship competitiveness etc.

Are pain and palliative the only two options that truly get us out of Emergency medicine? What else is out there?

If you had to pick, which one would you pick? What's stopping you from going down that path if you haven't done so already?

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[Birdstrike]

What are some fellowships that people have considered to get out of full time EM. Things like US or EMS are mostly just attempts at getting specialized into academics, but realistically, you're still practicing emergency medicine.

Can we compile a list of fellowships that help you get out - Please list pros, cons, lifestyle, compensation, work hours, career longevity, training length, fellowship competitiveness etc.

Are pain and palliative the only two options that truly get us out of Emergency medicine? What else is out there?

Pain

Pros
-Cool procedures (Epidurals, spinal cord stimulators, kyphoplasties, nerve blocks/ablations, joint injections, etc) which are 1/3 your time.
-Derm-perfect hours
-No call
-No nights
-No weekend
-No holidays. Ever.
-Normal life
-100% predictable schedule control.
***-Always well rested***
***-You'll never feel that awful, oppressive, heavy, weight of dysthymic, circadian-rhythm shift-work, jet-lag
-Pays very well
***-90% less stress than EM***
-1 year fellowship
-Work hours (for me M-Th 8am-12pm, 1pm-4/5pm; Fri 8am-12pm)
-Longevity: completely sustainable for as long as any MD remains healthy, like Derm or any other no-call specialty; subjectively, it feels I could do this 20-30 years longer than EM, if I needed or wanted to (I don't, but still).
-You pick and choose your patients and can reject any consult beforehand, screen patients/referrals and discharge any patient for any, or not reason at all.
-No EMTALA
-Outpatient, free of administrator and hospital types
-Never feel overwhelmed
-No work related PTSD or having to go into the bathroom to puke, cry or suppress emotions from tragic unexpected, and impossible to reconcile peds deaths
-It buys you a second specialty; ie, if you don't like it, no biggie, just go back and work ED shifts.

Cons
-Clinic days can be on the boring side
-You will get drug seekers but in my experience and with my practice patterns it's about 1% of what EM folks think it would be and I can honestly say I see far less abusive med abusers/dealers than I did in the ED (yeah, really).
-Having to deal with EM people who don't have the faintest clue what you do, because they think Pain equals seeing ED drug seekers all day, when actually EM is the only specialty that equals seeing ED drug seekers all day

For me, it's worked out real well, has been life changing and life and career saving in a big way and restored my positive outlook on life. It's worth considering the 1 year fellowship if you're lucky enough to get a longshot fellowship spot. Anyone who knew me from my EM posting days 10 years ago, knows I was a burned out shell of a human, and spent about 2 years writing EM related stories to post here, EP Monthly and Kevin MD to rid myself of years of ED induced PTSD (it worked actually, and the stories are all on here, EP monthly and Kevin MD).

 

[cyanide12345678]

Pain

Pros
-Cool procedures (Epidurals, spinal cord stimulators, kyphoplasties, nerve blocks/ablations, joint injections, etc) which are 1/3 your time.
-Derm-perfect hours
-No call
-No nights
-No weekend
-No holidays. Ever.
-Normal life
-100% predictable schedule control.
***-Always well rested***
***-You'll never feel that awful, oppressive, heavy, weight of dysthymic, circadian-rhythm shift-work, jet-lag
-Pays very well
***-90% less stress than EM***
-1 year fellowship
-Work hours (for me M-Th 8am-12pm, 1pm-4/5pm; Fri 8am-12pm)
-Longevity: completely sustainable for as long as any MD remains healthy, like Derm or any other no-call specialty; subjectively, it feels I could do this 20-30 years longer than EM, if I needed or wanted to (I don't, but still).
-You pick and choose your patients and can reject any consult beforehand, screen patients/referrals and discharge any patient for any, or not reason at all.
-No EMTALA
-Outpatient, free of administrator and hospital types
-Never feel overwhelmed
-No work related PTSD or having to go into the bathroom to puke, cry or suppress emotions from tragic unexpected, and impossible to reconcile peds deaths
-It buys you a second specialty; ie, if you don't like it, no biggie, just go back and work ED shifts.

Cons
-Clinic days can be on the boring side
-You will get drug seekers but in my experience and with my practice patterns it's about 1% of what EM folks think it would be and I can honestly say I see far less abusive med abusers/dealers than I did in the ED (yeah, really).
-Having to deal with EM people who don't have the faintest clue what you do, because they think Pain equals seeing ED drug seekers all day, when actually EM is the only specialty that equals seeing ED drug seekers all day

For me, it's worked out real well, has been life changing and life and career saving in a big way and restored my positive outlook on life. It's worth considering the 1 year fellowship if you're lucky enough to get a longshot fellowship spot. Anyone who knew me from my EM posting days 10 years ago, knows I was a burned out shell of a human, and spent about 2 years writing EM related stories to post here, EP Monthly and Kevin MD to rid myself of years of ED induced PTSD (it worked actually, and the stories are all on here, EP monthly and Kevin MD).

Truth be told, the procedures you mention almost sound intimidating to learn in a year to me.

Maybe because i suck at LPs ? Even as attending my success rate is around 60 percent.

Plus it feels like it's a long shot for EM. Though i did have stellar board scores back in the day....

Any concern for saturation in the field? What's the job market like in desirable cities?

 

[Birdstrike]

Truth be told, the procedures you mention almost sound intimidating to learn in a year to me.

Maybe because i suck at LPs ? Even as attending my success rate is around 60 percent.

Dude. I have x-ray vision. How does 100% sound? (Okay, maybe 99.9%, but still, fluoroscopy is a game changer). Once you learn how to guide a needle under fluoro, which I got very comfortable with after about 6 months, learning any fluoroguide procedure becomes infinitely more learnable.

Truth be told, the procedures you mention almost sound intimidating to learn in a year to me.

If you can do EM procedures, you can learn these. Learning these is not different than learning any EM procedure, and easier than learning LPs (because like I said already, fluoro allows the blind to see).

Plus it feels like it's a long shot for EM. Though i did have stellar board scores back in the day....

Yep. But I decided, so frickin what. What do I have to lose by throwing a bunch of spaghetti noodles at a wall and seeing if one sticks. Guess what? One stuck. I'm in.

Any concern for saturation in the field?

Not anymore than any other specialty. You hear the same percentage of people saying the sky is always falling and it never gets 2% as bad as they predict.

What's the job market like in desirable cities?

It's competitive, but the hard part is getting the fellowship. Once you've got an accredited fellowship spot, you'll be board certified and that puts you in a small group of the most competitive.

All valid concerns. All I can say though, being able to have a normal life again, saved my life.

 

[Siggy]

-You will get drug seekers but in my experience and with my practice patterns it's about 1% of what EM folks think it would be and I can honestly say I see far less abusive med abusers/dealers than I did in the ED (yeah, really).

Will confirm. I did a month of pain management during medical school and during my TRI (same hospital, saw all of the clinic patients and inpatient consults with an NP. The physicians where doing procedurals, and clinic included the workup/recommendation for the procedures). I saw more seekers in residency than in those 2 months of pain clinic... and they were quickly discharged from the clinic.

The concept that all of pain management clinic are drug seekers is simply false. Also if you do pallative care consults, I've been throwing out cosults/easy money like candy to our pallative care specialist since the recent study showing that pretty much all ICU patients should have a palliative care consult.

 

[HemorrhagicShock]

Good luck getting into a pain fellowship. As Birdstrike said it's a one-in-a-million type shot for an EM physician. Take a look at the pain medicine forum here to see their fellowship application threads. Always 1-2 EM applicants per year and they have a huge uphill battle. I can imagine post-COVID competition will be even higher as multiple specialties look to "get out" to a lucrative banker's hours procedural specialty. Doesn't mean you shouldn't try, but know that you will be competing against those 260 step 1 AOA types from MGH anesthesia, with programs run by an all-anesthesia faculty.

 

[Birdstrike]

Good luck getting into a pain fellowship. As Birdstrike said it's a one-in-a-million type shot for an EM physician.

I didn't say it's "one in a million." I think I referred to it as a "longshot." But here's the thing. It may not be as long odds as many think. At many programs your odds are near zero. But some programs hold open one or two spots for non-traditional specialties. In competing for those spots, your odds are very high, even possibly higher than the odds some anesthesia and PM&R people have. The hard thing is, these programs don't put this information out there and it might change from year to year. The only way to find them is to apply to all programs (80 or 90?)

Let me just tell you this. Over the past 8 years, I've counseled numerous EM/Pain applicants via private message right here on SDN. And I'll tell you, there's about a 50% acceptance rate among those applicants. I can't say that applies to everyone. But off the top of my head, it's about 50/50 for the 8-10 people that have asked me for advice privately. Some of these are right here on this EM forum and have not announced to a soul on here, that they've applied, been accepted and started fellowship. They've wanted to keep a low for anonymity.

Like I said, it's competitive. Acceptance is no guarantee. But the odds may be better than one thinks. And an applicant has little if anything to lose in trying. After all, I got in, I'll be totally honest, I was no superstar applicant on paper. But one program thought I was good enough. One is all you need and all you can use.

 

[SamtheWise]

I feel like crit care gets you out of EM, but into a whole new, different world of suck.

 

[cyanide12345678]

Good luck getting into a pain fellowship. As Birdstrike said it's a one-in-a-million type shot for an EM physician. Take a look at the pain medicine forum here to see their fellowship application threads. Always 1-2 EM applicants per year and they have a huge uphill battle. I can imagine post-COVID competition will be even higher as multiple specialties look to "get out" to a lucrative banker's hours procedural specialty. Doesn't mean you shouldn't try, but know that you will be competing against those 260 step 1 AOA types from MGH anesthesia, with programs run by an all-anesthesia faculty.

Good thing I'm in the 260+ top quartile club then

But I'm not jumping ship just yet. I'm just curious about the thoughts of other people. I would rather first try a really slow 10k volume ER first before jumping ship. One more year before my contract ends, off to a very slow ER after that.

Anyone else want to throw in other fellowships other than pain? I mean pain isn't the easiest to get for us.

 

[bravotwozero]

I know EMS medical director has been talked about before, but can that be a full time job on its own?

 

[Birdstrike]

Any fellowship that allows you get better control of your schedule and proper sleep + circadian rhythms is worth it’s weight in gold. Those two things alone, are guaranteed to increase ones average daily mood by at least 2 points on a scale of 1 to 10 with no other life changes required.

 

[cyanide12345678]

I know EMS medical director has been talked about before, but can that be a full time job on its own?

So what exactly is the job of an EMS medical director? Are you picking up more liability essentially? Are you employed by the city as the medical director in most circumstances? I've seen a few medical directors that are not EMS fellowship trained, so i would think it's not essential for the job.

What happens if you're medical director of the crew that picked up george floyd and family sues EMS for not starting CPR in a timely fashion and doing a split second pulse check and not assessing his breathing, and failing to bag the patient when he was not spontaneously breathing. Whose liability is it when EMS Screws up?

 

[Fox800]

I'm really only considering IM-CCM. Pain sounds interesting, sometimes.

 

[turkeyjerky]

Honest question--do step scores, med school grades, etc...matter for fellowship applications from mid-career docs?

 

[Hercules]

What are some fellowships that people have considered to get out of full time EM. Things like US or EMS are mostly just attempts at getting specialized into academics, but realistically, you're still practicing emergency medicine.

Can we compile a list of fellowships that help you get out - Please list pros, cons, career outlook and field saturation, lifestyle, compensation, work hours, career longevity, training length, fellowship competitiveness etc.

Are pain and palliative the only two options that truly get us out of Emergency medicine? What else is out there?

If you had to pick, which one would you pick? What's stopping you from going down that path if you haven't done so already?

I don’t mean to derail the thread too far, but whenever I hear these discussions I’m always curious to ask what’s the overall goal in going back and doing a fellowship? The reason I bring that up is that a fellowship may not solve the problem as well as an alternate source of income would. When you elect to do a fellowship you are giving up 1-2 years of EM income (which could be anywhere from $300k-$1M). If you’re willing to set aside that amount of money, you should be able to develop some really significant income streams that should go a long way towards making you financially independent. Once you’re financially independent then you can dictate the terms of working. If you’re dictating the terms, then you’re likely no longer the bitter/burned out person that you’re trying to escape from. Just pointing out that there may be other roads than a fellowship to happiness.

 

[Birdstrike]

I don’t mean to derail the thread too far, but whenever I hear these discussions I’m always curious to ask what’s the overall goal in going back and doing a fellowship? The reason I bring that up is that a fellowship may not solve the problem as well as an alternate source of income would. When you elect to do a fellowship you are giving up 1-2 years of EM income (which could be anywhere from $300k-$1M). If you’re willing to set aside that amount of money, you should be able to develop some really significant income streams that should go a long way towards making you financially independent. Once you’re financially independent then you can dictate the terms of working. If you’re dictating the terms, then you’re likely no longer the bitter/burned out person that you’re trying to escape from. Just pointing out that there may be other roads than a fellowship to happiness.

There are often many paths to a destination.

 

[gassedout2015]

I don’t mean to derail the thread too far, but whenever I hear these discussions I’m always curious to ask what’s the overall goal in going back and doing a fellowship? The reason I bring that up is that a fellowship may not solve the problem as well as an alternate source of income would. When you elect to do a fellowship you are giving up 1-2 years of EM income (which could be anywhere from $300k-$1M). If you’re willing to set aside that amount of money, you should be able to develop some really significant income streams that should go a long way towards making you financially independent. Once you’re financially independent then you can dictate the terms of working. If you’re dictating the terms, then you’re likely no longer the bitter/burned out person that you’re trying to escape from. Just pointing out that there may be other roads than a fellowship to happiness.

1-2 years of EM income is $300k - $1M??

 

[cyanide12345678]

1-2 years of EM income is $300k - $1M??

Yes. Most EM doctors make between 300-500k right now.

 

[Fox800]

1-2 years of EM income is $300k - $1M??

More like $700,000-$1M depending on the group.

It's easy to find a job with $350,000 in benefits when you consider 401(k) matching and stuff like that.
$325,000 base salary + benefits. That's at $225 an hour, 120 hours a month, 12 months a year. And that's not even a good-paying job. Some of my classmates took $190-200/hr + benefits "because it's in the PNW".

 

[cyanide12345678]

I don’t mean to derail the thread too far, but whenever I hear these discussions I’m always curious to ask what’s the overall goal in going back and doing a fellowship? The reason I bring that up is that a fellowship may not solve the problem as well as an alternate source of income would. When you elect to do a fellowship you are giving up 1-2 years of EM income (which could be anywhere from $300k-$1M). If you’re willing to set aside that amount of money, you should be able to develop some really significant income streams that should go a long way towards making you financially independent. Once you’re financially independent then you can dictate the terms of working. If you’re dictating the terms, then you’re likely no longer the bitter/burned out person that you’re trying to escape from. Just pointing out that there may be other roads than a fellowship to happiness.

I agree. I started the thread to get people talking about options like pain, sports medicine, pallitive care, critical care etc. I wanted to hear opinions about the pros and cons for each. I also personally wanted to see how many EM docs would pick things like palliative despite an incredible loss of income.

I personally am much more likely to even buy an established laundromat or another absentee owned positive cash flow business bringing in 100-150k (cost should be around 3 x cash flow) than to go back into training. So i personally 100 percent agree with your sentiment.

 

[Fox800]

I agree. I started the thread to get people talking about options like pain, sports medicine, pallitive care, critical care etc. I wanted to hear opinions about the pros and cons for each. I also personally wanted to see how many EM docs would pick things like palliative despite an incredible loss of income.

I personally am much more likely to even buy an established laundromat or another absentee owned positive cash flow business bringing in 100-150k (cost should be around 3 x cash flow) than to go back into training. So i personally 100 percent agree with your sentiment.

If I were at the point in my career where my loans were paid off, I had a good amount of money in my 401(k), I'd consider CCM. But it would have to be the right program where you're treated like junior faculty and I would have to be mentally and professionally engaged enough to keep me interested. CCM fascinates me but I'm not ready to be a resident again for another 24 months.

Maybe pain if I could do a bunch of procedures and not write schedule II Rx's all day. No thank you.

 

[Birdstrike]

It wasn't about the money for me. The peace of mind I've gained by having control and predictability of schedule, normal circadian rhythms, a normal life and to always feel rested, is priceless. And I'm not exactly starving for income.

 

[Hercules]

More like $700,000-$1M depending on the group.

It's easy to find a job with $350,000 in benefits when you consider 401(k) matching and stuff like that.
$325,000 base salary + benefits. That's at $225 an hour, 120 hours a month, 12 months a year. And that's not even a good-paying job. Some of my classmates took $190-200/hr + benefits "because it's in the PNW".

I included the low end to cover even the terribly underpaid desirable locations that some like to take (plus I assume you’re getting paid during fellowship so I just did the difference between the two).

 

[dchristismi]

I was at a point in my career where my loans were long paid off and had plenty of money in investments, along with a couple rental properties.
I did not, however, do a fellowship. I still sub-sub-specialized into a small niche, and am so much happier.

Control of my schedule wasn't quite as big a deal for me (as an IC, I wielded quite a bit of control), but having a pile of FU money sure made the jump easier. Besides, I don't live extravagantly, so the difference between 200K and 400K is how much goes to charity when I die.

 

[Frazier]

The loss of potential overall income with fellowship is not exactly true, if the subspecialty is one that you are willing to do for a substantially longer time (ie actually enjoy it).

For example, with palliative, say one makes 230k per year (average) compared to EM at 350k (likely going to be going down further unfortunately)...

EM let's be generous and say the person "looking to get out" can muster up 10 years if they really have to do so, then retire completely because they are burnt to a complete crisp doing what they don't like for a decade.

3,500,000 lifetime income before taxes.

Now let's compare with pallimed, which pays less than pain, let's say 230k. the schedule and lifestyle are very doable and you have a passion for the work. You enjoy the patient population and going onto service every day. You make a 30 year career out of it.

6,900,000 lifetime earnings before taxes.
Number even higher with other subspecialties.

If you need to get your money fast and dont like the practice of modern day medicine itself, EM is better option. If you like the crux of being a physician and are okay with coming out far ahead via the marathon instead of a sprint -- become a subspecialist. That said, palliative in particular should only be pursued if you have an actual passion for the field and patient population/families.

Wound management/hyperbarics would be another option. They can open a clinic.

 

[Birdstrike]

The loss of potential overall income with fellowship is not exactly true, if the subspecialty is one that you are willing to do for a substantially longer time (ie actually enjoy it).

For example, with palliative, say one makes 230k per year (average) compared to EM at 350k (likely going to be going down further unfortunately)...

EM let's be generous and say the person "looking to get out" can muster up 10 years if they really have to do so, then retire completely because they are burnt to a complete crisp doing what they don't like for a decade.

3,500,000 lifetime income before taxes.

Now let's compare with pallimed, which pays less than pain, let's say 230k. the schedule and lifestyle are very doable and you have a passion for the work. You enjoy the patient population and going onto service every day. You make a 30 year career out of it.

6,900,000 lifetime earnings before taxes.
Number even higher with other subspecialties.

If you need to get your money fast and dont like the practice of modern day medicine itself, EM is better option. If you like the crux of being a physician and are okay with coming out far ahead via the marathon instead of a sprint -- become a subspecialist.

Wound management/hyperbarics would be another option. They can open a clinic.

Every hour in an ED, takes the physical, emotional and spiritual toll of 1.5-2 hours doing anything else.

 

[chudat]

Every hour in an ED, takes the physical, emotional and spiritual toll of 1.5-2 hours doing anything else.

lol how do you think radiology feels when you guys order nonstop studies with indications such as 'dizziness, pain'.

 

[bravotwozero]

you can make $100k from running a laundromat? Really?

 

[blue.jay]

The loss of potential overall income with fellowship is not exactly true, if the subspecialty is one that you are willing to do for a substantially longer time (ie actually enjoy it).

For example, with palliative, say one makes 230k per year (average) compared to EM at 350k (likely going to be going down further unfortunately)...

EM let's be generous and say the person "looking to get out" can muster up 10 years if they really have to do so, then retire completely because they are burnt to a complete crisp doing what they don't like for a decade.

3,500,000 lifetime income before taxes.

Now let's compare with pallimed, which pays less than pain, let's say 230k. the schedule and lifestyle are very doable and you have a passion for the work. You enjoy the patient population and going onto service every day. You make a 30 year career out of it.

6,900,000 lifetime earnings before taxes.
Number even higher with other subspecialties.

If you need to get your money fast and dont like the practice of modern day medicine itself, EM is better option. If you like the crux of being a physician and are okay with coming out far ahead via the marathon instead of a sprint -- become a subspecialist.

Wound management/hyperbarics would be another option. They can open a clinic.

Palliative care is mostly overrun by NPs these days. They didn't leave any lucrative or lifestyle from encroachment.

 

[chudat]

My uncle runs a laundromat but he also has a small bubble tea/snack shop set up in the laundromat so you buy something to drink/eat while waiting for ur laundry....and he does well for himself

 

[Fox800]

lol how do you think radiology feels when you guys order nonstop studies with indications such as 'dizziness, pain'.

They should be reveling in their job security.
You can thank the American people for wanting a zero miss rate and allowing frivolous lawsuits for ridiculous things.

 

[Gambino.]

I know EMS medical director has been talked about before, but can that be a full time job on its own?

Our EMS director for a large suburban area worked primarily in the ED and would go on ambulance runs 1 day/week with maybe a few hours sprinkled throughout the week for the actual job itself. He said it was more of a passion thing rather than being a full time job but I'm unsure how much variance there is in that line of work.

 

[Fox800]

Just out of curiosity, how much would it annoy my radiology colleagues if I started putting “please correlate radiologically” in all of my indications?

Left wrist pain, please correlate radiologically

Pleuritic chest pain, please correlate radiologically

Midline back pain with BLE weakness and bladder dysfunction, please correlate radiologically

As much as I hope it annoys the rad techs when I select "wagon" for the "mode of transport" field when I order a study.

 

[WilcoWorld]

Palliative is definitely an option to get out of EM, but I would caution against viewing it as an escape route. I'm now practicing both Palliative and EM and plan to continue practicing EM for quite a while. However, Palliative Med has given me a second lease on medicine and I expect it will extend my career in medicine by 10-20y from what a solely EM career would've been.

For the right type of person, the practice of HPM is a privilege and a gift.

Palliative Medicine can be incredibly draining, or it can be incredibly fulfilling. I worry that if it is pursued as a "plan B", then it will be draining. OTOH if you pursue Palliative because you feel drawn to providing logical, rational care in the service of relieving suffering, then you are in for a life-changing career path.

Pros: You get to make profoundly meaningful differences in the lives and deaths of patients, families...and doctors. As opposed to consultants being annoyed at hearing from me in the ED, those same docs are incredibly appreciative of my help as a palliative doc and often appear to be in awe of what I can do (I am NOT in awe of what I can do, BTW). I get thanked more times in 1 month as a palliative doc than I do in 5 years as an EM doc. Also, the pathology I get to see and think about and take care of as a Palliative doc is just fascinating. The schedule is about as good as it can get in medicine. Liability is very low. The specialty is rather young so the field is wide open to forge your own path.

Cons: Lower pay. Oh yeah, and death, anger, frustration, fears, tears, suffering, pain, grief. Did I mention death? More of my palliative patients die in a month than I've seen in over 10 years as an EM doc. If you're afraid of death, this is not a good field for you. Also, the pathology I mentioned above will be a con for some type of people. When a patient has non-survivable necrotizing fasciitis and selects comfort care, we're the ones that will go into that anaerobic aroma infused room and sit with him every day to make sure he's being well taken care of.

Palliative and EM share the features that, in theory, both allow us to use our knowledge and judgement to provide pragmatic care and both give you the opportunity to hear some amazing stories. The thing is that when I'm practicing HPM I actually get the time to listen to those stories. Plus, most administrators are so afraid of death that they leave me the F alone when I'm caring for dying patients.

 

[Birdstrike]

lol how do you think radiology feels when you guys order nonstop studies with indications such as 'dizziness, pain'.

lol I don’t care

 

[Frazier]

Palliative is definitely an option to get out of EM, but I would caution against viewing it as an escape route. I'm now practicing both Palliative and EM and plan to continue practicing EM for quite a while. However, Palliative Med has given me a second lease on medicine and I expect it will extend my career in medicine by 10-20y from what a solely EM career would've been.

For the right type of person, the practice of HPM is a privilege and a gift.

Palliative Medicine can be incredibly draining, or it can be incredibly fulfilling. I worry that if it is pursued as a "plan B", then it will be draining. OTOH if you pursue Palliative because you feel drawn to providing logical, rational care in the service of relieving suffering, then you are in for a life-changing career path.

Pros: You get to make profoundly meaningful differences in the lives and deaths of patients, families...and doctors. As opposed to consultants being annoyed at hearing from me in the ED, those same docs are incredibly appreciative of my help as a palliative doc and often appear to be in awe of what I can do (I am NOT in awe of what I can do, BTW). I get thanked more times in 1 month as a palliative doc than I do in 5 years as an EM doc. Also, the pathology I get to see and think about and take care of as a Palliative doc is just fascinating. The schedule is about as good as it can get in medicine. Liability is very low. The specialty is rather young so the field is wide open to forge your own path.

Cons: Lower pay. Oh yeah, and death, anger, frustration, fears, tears, suffering, pain, grief. Did I mention death? More of my palliative patients die in a month than I've seen in over 10 years as an EM doc. If you're afraid of death, this is not a good field for you. Also, the pathology I mentioned above will be a con for some type of people. When a patient has non-survivable necrotizing fasciitis and selects comfort care, we're the ones that will go into that anaerobic aroma infused room and sit with him every day to make sure he's being well taken care of.

Palliative and EM share the features that, in theory, both allow us to use our knowledge and judgement to provide pragmatic care and both give you the opportunity to hear some amazing stories. The thing is that when I'm practicing HPM I actually get the time to listen to those stories. Plus, most administrators are so afraid of death that they leave me the F alone when I'm caring for dying patients.

This is a great point, if purely being seen as an escape route, palli is a bad choice. The need for emotional presence and patience will bring a new level of burn-out if needing to be feigned constantly... And dare I say the patient population really needs advocates invested in the subspecialty's care -- perhaps more than most others.

 

[Tipsy McStagger]

I guess I'll speak for CCM (specifically IM-CCM), though my experience is limited to fellowship so keep that in mind, there are several EM-CCM staff on this board somewhere whose experience will trump my own.

It's difficult to be sure, but a different type of difficult than the ED. I grew to hate the ED, for many reasons. Ultimately I stopped feeling like a human, much less a doctor. But that's just me and I pass no judgement. Ultimately the ICU is a fascinating experience of complex physiology, pathophysiology, the interventions we can and cannot do and the human condition. There are pros and cons to continuity. Some families I generally love and look forward to seeing daily, and the other end of that spectrum exists as well.

I went into it because I enjoy it, I enjoyed it since medical school. I would not recommend it to anyone who doesn't like the ICU, otherwise it's just a different recipe for burnout. The days are long and challenging, but that's nothing new to anyone in medicine. But truly I think the days are easier in a way than they are in the ED. I can work 14 hours in the unit and feel better and more rested than working 9 or 10 in the ED. I have a set circadian rhythm again and it is lovely - I honestly didn't know how much it was affecting me until I stopped the atrocity that is EM scheduling. Most of my graduating friends took jobs as week on/week off doing only CCM. No nights (depends on the place), only one took a salary <450k. Many were around 500. So the money is either the same or better, but again it's a 2 year opportunity cost that must be factored. And like EM, location matters. I doubt those numbers exist in NYC, San Francisco etc (but I'll never live there anyway). Many of them will rotate through MICU, NICU, SICU, TICU in their jobs. So your mind is decompressed from the complexity of the MICU. The flipside is that in the SICU/TICU you are managing the patients, but never really the plan-maker...

Hard to see doing CCM late into life. Like the ED it wears on the body and soul, but I think it's a little bit easier on the soul than EM (probably the body too to be honest - I get to sit down and think, take a coffee break, eat my lunch, and I can go to the bathroom generally when I feel the need). I like that I don't have to be the final dispo - like the ED. Once they're no longer critically ill then off to the floor they go, or LTAC, or SNF... I like that there is a barrier to entry - you must be sick (and I like sick people). The only worried well in the ICU are the ones that a bad hospitalist refuses to take care of on the floor (I'm looking at you asymptomatic bp of 170). I like learning, and there is so much medicine out there beyond the ED that I enjoy learning. Intensive care is a great place to learn medicine, and just like EM, it breeds calm people - I like my colleagues.

I think i'll do this for a number of years and then transition into palliative. That's (as of now) my overall 30,000ft view of my career. But we'll see if that plan survives contact. All I know is that I am grateful for my ED training... but I'll never go back willingly.

lol how do you think radiology feels when you guys order nonstop studies with indications such as 'dizziness, pain'.

Probably much better than we feel when patients are in the ED giving a history of such indications and are unable to elaborate. I'm sorry you have to read studies in the peace and quiet. If you want to see patient's there's always more, but that way lies madness and burnout. I will agree with you on brief indications. I hated to see people order studies for 'pain.' I always include a small paragraph about what's going on and what I'm looking for. Let's not argue about whose job is harder - we work in medicine, and it's all hard. Just remember these immortal words:

"Be excellent to each other"
- Bill & Ted

 

[cyanide12345678]

you can make $100k from running a laundromat? Really?

Depends on what you buy... The more the cash flow, the higher the cost of the business. Bizbuysell.com has quite a few laundromats for sale.

The run down ones are bringing in around 40-50k but can be bought for 200k or so. The nice ones, or the high volume ones in New York are sometimes bringing in 200-300k.

 

[swamprat]

Im an EM/Pain doctor. Pain is great. Very sub specialized which is awesome and I really truely feel like an expert in back/neck pain, CRPS etc but at the same time I also am very satisfied and still practice EM on the side. Pay is good. Opportunities are plentiful. I do a lot of procedures. I havent worked a night shift overnight since residency. Best fellowship we can do in my opinion - 100% polar opposite of EM and you can just do pain and never go back.

 

[sylvanthus]

Just out of curiosity, how much would it annoy my radiology colleagues if I started putting “please correlate radiologically” in all of my indications?

Left wrist pain, please correlate radiologically

Pleuritic chest pain, please correlate radiologically

Midline back pain with BLE weakness and bladder dysfunction, please correlate radiologically

Ive actually done this, hehe, didnt hear anything from them, but im curious what they thought.

 

[chudat]

Ive actually done this, hehe, didnt hear anything from them, but im curious what they thought.

Honestly those indications are great! Pleuritic chest pain is so much better than what i typically encounter.

Idk why but in my experience, its always the nicest ED docs that order the most exams.

 

[TheComebacKid]

So what exactly is the job of an EMS medical director? Are you picking up more liability essentially? Are you employed by the city as the medical director in most circumstances? I've seen a few medical directors that are not EMS fellowship trained, so i would think it's not essential for the job.

What happens if you're medical director of the crew that picked up george floyd and family sues EMS for not starting CPR in a timely fashion and doing a split second pulse check and not assessing his breathing, and failing to bag the patient when he was not spontaneously breathing. Whose liability is it when EMS Screws up?

I just started EMS fellowship (like 2 days in, seriously), so take what I say with a grain of salt. I have a lot to learn.

As an EMS medical director, essentially you are the "medical expert" for the entire agency. Firefighters get basic EMT and/or paramedic training, BLS, sometimes ACLS, etc. But beyond that, you are responsible for their continuing education. You are responsible for instituting protocols that are evidence based. You see the EMS agencies still performing spinal immobilization with backboards? Their medical directors are non-existent, and are not instituting good protocols.

An extensive part of what EMS directors do is QI/QA, reviewing calls, etc. At the vast majority of agencies, the medical director's role in the field is minimal to non-existent.

It's primarily a leadership role, also heavily administrative. Depending on the type of setting you work in, research is sometimes incorporated as well. There's politics. Meetings with city officials, etc.

There is malpractice involved, and ultimately paramedics/EMTs are giving ketamine/versed, albuterol etc in the field under your medical license. However, you explicitly state things in your protocol. Certain more "aggressive" protocols may give 400mg IM ketamine (which is a good dose) to take down violent/agitated patients. Other agencies, don't even give 25 mcg of fentanyl for a patient with an open femur fracture. When paramedics deviate from your protocol and patients do poorly, they get re-educated, reprimanded, or in some cases fired. When you generate a protocol that is followed by an EMS provider to the tee, and the patient has a bad outcome, there's nothing to say you can't get sued. There is EMS medical director specific malpractice insurance. In your George Floyd example, if a patient is not spontaneously breathing, an EMS provider who did not start bagging the patient would clearly be at fault since every single protocol would state that apneic patients should get assisted breaths.

Now that EMS fellowship leads to board certification, I suspect you will see a lot less of non-fellowship trained people out there, especially for the highly coveted jobs (think medical director for large metropolitan EMS agency). If you are the medical director for LA County Fire, you can expect a hefty clinical buy down. If you are the medical director for a no name agency in the sticks that runs maybe 1 call every 2 days, you can expect to work a full clinical schedule. There is variation in the number of clinical hours worked.

 

[TheComebacKid]

I don't get the pain fellowship route. Why not just go back and do a dermatology residency? Optho? Agree it's more training, but pain management, to me, is not an extension of emergency medicine. It's a whole different specialty.

The majority of people who go into emergency medicine, love emergency medicine. Why pick a completely different specialty?

I don't think people hate EM because they hate the actual specialty. They hate the circadian disruptions, holidays, drug seekers. The answer to that problem, IMO, is not always "do a different specialty", it's to find a way to do less EM and get clinical buy down. That can be in the form of research in academics, education, further sub specialization in US, toxicology, EMS, etc. Often times, the answer isn't to jump ship on EM completely, it's to leave your horrible CMG job where you are nothing more than a cog in the wheel.

 

[cyanide12345678]

I just started EMS fellowship (like 2 days in, seriously), so take what I say with a grain of salt. I have a lot to learn.

As an EMS medical director, essentially you are the "medical expert" for the entire agency. Firefighters get basic EMT and/or paramedic training, BLS, sometimes ACLS, etc. But beyond that, you are responsible for their continuing education. You are responsible for instituting protocols that are evidence based. You see the EMS agencies still performing spinal immobilization with backboards? Their medical directors are non-existent, and are not instituting good protocols.

An extensive part of what EMS directors do is QI/QA, reviewing calls, etc. At the vast majority of agencies, the medical director's role in the field is minimal to non-existent.

It's primarily a leadership role, also heavily administrative. Depending on the type of setting you work in, research is sometimes incorporated as well. There's politics. Meetings with city officials, etc.

There is malpractice involved, and ultimately paramedics/EMTs are giving ketamine/versed, albuterol etc in the field under your medical license. However, you explicitly state things in your protocol. Certain more "aggressive" protocols may give 400mg IM ketamine (which is a good dose) to take down violent/agitated patients. Other agencies, don't even give 25 mcg of fentanyl for a patient with an open femur fracture. When paramedics deviate from your protocol and patients do poorly, they get re-educated, reprimanded, or in some cases fired. When you generate a protocol that is followed by an EMS provider to the tee, and the patient has a bad outcome, there's nothing to say you can't get sued. There is EMS medical director specific malpractice insurance. In your George Floyd example, if a patient is not spontaneously breathing, an EMS provider who did not start bagging the patient would clearly be at fault since every single protocol would state that apneic patients should get assisted breaths.

Now that EMS fellowship leads to board certification, I suspect you will see a lot less of non-fellowship trained people out there, especially for the highly coveted jobs (think medical director for large metropolitan EMS agency). If you are the medical director for LA County Fire, you can expect a hefty clinical buy down. If you are the medical director for a no name agency in the sticks that runs maybe 1 call every 2 days, you can expect to work a full clinical schedule. There is variation in the number of clinical hours worked.

So if family sued the EMS agency, is it ultimately your medical license as medical director? Or it's your paramedic's fault for not following protocol.

What sort of compensation does the city provide for spending time to Q/A and make protocols? Is being the medical director of a small county sometimes even voluntary?

 

[Backpack234]

More like $700,000-$1M depending on the group.

It's easy to find a job with $350,000 in benefits when you consider 401(k) matching and stuff like that.
$325,000 base salary + benefits. That's at $225 an hour, 120 hours a month, 12 months a year. And that's not even a good-paying job. Some of my classmates took $190-200/hr + benefits "because it's in the PNW".

Just be careful when counting your chickens here. Napkin math usually forgets expenses and taxes. At 400k/yr, it’ll still take 4+ years to reach a net worth over 1M depending on your savings rate and such

 

[Backpack234]

I don't get the pain fellowship route. Why not just go back and do a dermatology residency? Optho? Agree it's more training, but pain management, to me, is not an extension of emergency medicine. It's a whole different specialty.

The majority of people who go into emergency medicine, love emergency medicine. Why pick a completely different specialty?

I don't think people hate EM because they hate the actual specialty. They hate the circadian disruptions, holidays, drug seekers. The answer to that problem, IMO, is not always "do a different specialty", it's to find a way to do less EM and get clinical buy down. That can be in the form of research in academics, education, further sub specialization in US, toxicology, EMS, etc. Often times, the answer isn't to jump ship on EM completely, it's to leave your horrible CMG job where you are nothing more than a cog in the wheel.

It’s really tough to separate EM from nights, weekends, holidays, drug seekers, etc.. most sub specialties in EM don’t lead to careers outside the pit.

that’s why these “whole different specialties” appeal to people trying to get out.

 

[gassedout2015]

It’s really tough to separate EM from nights, weekends, holidays, drug seekers, etc.. most sub specialties in EM don’t lead to careers outside the pit.

that’s why these “whole different specialties” appeal to people trying to get out.

Working nights, weekends, holidays....dont these apply to a multitude of specialties besides EM? Anesthesia, surgery, radiology, neuro, IM.....I mean the list goes on and on. I always find it funny to come into EM forums and all these threads are about jumping ship. Just a lesson to med students...do your due diligence before picking a specialty.

 

[cyanide12345678]

Working nights, weekends, holidays....dont these apply to a multitude of specialties besides EM? Anesthesia, surgery, radiology, neuro, IM.....I mean the list goes on and on. I always find it funny to come into EM forums and all these threads are about jumping ship. Just a lesson to med students...do your due diligence before picking a specialty.

Well it was supposed to be a great specialty 5 years ago when i started to apply.

I believe 5 years ago there were 1500-1600 residency spots. Now there are over 2000 spots.

There used to be 10 plus pages of jobs for Texas on edphysician.com, now it's hardly 3 pages

All of that changed between my doing 4th year electives in EM and now being 1 year out.

The forums were not as negative then either now they are right to be negative. Literally graduates this year struggled to find a job.

The point I'm making is the future of a specialty can dramatically change. But agreed, incoming students should pay attention and think long and hard before going down this road.

 

[chudat]

Well it was supposed to be a great specialty 5 years ago when i started to apply.

I believe 5 years ago there were 1500-1600 residency spots. Now there are over 2000 spots.

There used to be 10 plus pages of jobs for Texas on edphysician.com, now it's hardly 3 pages

All of that changed between my doing 4th year electives in EM and now being 1 year out.

The forums were not as negative then either now they are right to be negative. Literally graduates this year struggled to find a job.

The point I'm making is the future of a specialty can dramatically change. But agreed, incoming students should pay attention and think long and hard before going down this road.

Radiology was in the dumps a few years back as well. Graduating residents having to do two fellowships just to find a job....in Arkansas.

Now, radiology job market is as hot as ever. Even with Covid, most groups are now back to precovid volume status. Relocation, signing bonus, 8-12wk vacations, 1-2yr partnership, high salary, you name it, radiology is a sought out profession once again.

Point is, EM may also have its ebbs and flows too. Don't let people on the internet dissuade you from something that you feel passionate about.

 

[cyanide12345678]

Radiology was in the dumps a few years back as well. Graduating residents having to do two fellowships just to find a job....in Arkansas.

Now, radiology job market is as hot as ever. Even with Covid, most groups are now back to precovid volume status. Relocation, signing bonus, 8-12wk vacations, 1-2yr partnership, high salary, you name it, radiology is a sought out profession once again.

Point is, EM may also have its ebbs and flows too. Don't let people on the internet dissuade you from something that you feel passionate about.

Free standing ERs went bust, residency spots increased by 30 percent in just 4-5 years to create an enormous surplus, CMGs kept their proliferation going and started replacing M.Ds/D.Os with MLPs. Urgent Cares proliferated and started taking away some volume as well. I think we're not coming back from this for another 10 years. Supply and demand forces are not going to be in our benefit for the foreseeable future.