Best Fellowships To Get Out Of EM

[TheComebacKid]

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?

I don't know the specifics again, but my understanding is that you are protected by your protocols, provided they are well written and evidence based. If a paramedic deviates from that protocol, they are at fault, not you.

Nobody goes into EMS to make money. If anything, you may make less. Think about it... How much do you think the fire department is going to throw at you? Tax payer money is at a premium, and nobody wants to dish it out to a doctor of all people in this day age (us wealthy bastards), despite the fact that you went through additional training and acquired the expertise, and sat for EMS boards blah blah blah. Often times, it's government work. You get the bureaucracy and compensation that comes with it.

There are private agencies as well, but I don't think they pay any better.

You are absolutely correct, many people are medical directors for rural agencies (and even non-rural agencies) on a voluntary basis. It's because they like EMS work. If you look at premier EMS agencies like Medic One in Seattle, AirCare in Cincinnati, etc. these people do it because they want to be on the cutting edge of prehospital medicine.

I don't think a medical director, even one for a major metropolitan EMS agency, is making more than 60K for their time. But that is just speculation. The medical directors for these agencies, probably get paid standard academic salaries in the 200s, work full time at their EMS agency, and then pick up 8 shifts a month in the department. You can still obviously work in the community as well, and make more money than academics, but your EMS time isn't paying your bills.

Nothing you do coming out of EM in terms of fellowship will put you in a position to make more money, IMO. Seeing patients in the department, moving the meat etc, is where you get compensated.

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[hundreddaysoff]

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.

The "nicest" ER docs try to do the surface-level nicest things for patients, like order more tests to reassure them even when not needed.

Patients eat this up, even though more tests often are not in their best interest. They send these "nice" ER docs nice comments and PG ratings in return and that reinforces the overtesting.

Often the real long-term nicest thing to do for the patient is to explain why they don't need the test and then not order it. But "nice" people often don't think that way.

Would love to write you more info in my rads orders but unfortunately HCA's Meditech has like a 50-character limit... IDK why.

 

[turkeyjerky]

On the Rads note--anyone have any insight into what the hell happened with their job market?

 

[SeekerOfTheTree]

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.

I agree with you. I know locums providers who are not getting the same work they were before. Even pre-covid when I was doing locums the crazy rates were drying up. We are in a bit of tough spot and won't recover from this. The residencies kept growing unchecked and here we are now. We will be FP salary soon (in some places already there).

 

[bravotwozero]

I agree with you. I know locums providers who are not getting the same work they were before. Even pre-covid when I was doing locums the crazy rates were drying up. We are in a bit of tough spot and won't recover from this. The residencies kept growing unchecked and here we are now. We will be FP salary soon (in some places already there).

Better get the $100,000 a year laundromat while it's still up for sale!

 

[Backpack234]

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.

I don’t know much about the radiology job market. Any idea what happened there?

 

[cyanide12345678]

Better get the $100,000 a year laundromat while it's still up for sale!

Why settle with just a 100k of annual profit?

Absentee Laundromat with 118 Machines in Brooklyn, New York - BizBuySell

Brooklyn, NY:This Laundromat that has it ALL… Great Location, Operates Absentee, 118 Machines, Wash and Fold Service. All the equipment is in excellent conditio

www.bizbuysell.com

Absentee Owned Laundromat w/ Drop-Off Services & Shower Facilities in North Dakota - BizBuySell

Priced at $735,000, a 10% down payment of $73,500 returns $215,536 in the first year after debt payments – a 293% return on investment! The owner of t

www.bizbuysell.com

Big Laundry, High Profits, Absentee Run, Great Price in Bergen County, New Jersey - BizBuySell

Bergen County, NJ:This Mega Laundry is 15 years old with excellent equipment due to the number of washers and dryers spreading the daily use over many machines. The in

www.bizbuysell.com

Not bad gigs for absentee ownership if you ask me.

 

[hundreddaysoff]

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.

Dang, you're saying laundromats average 20--25% cash on cash return? Or is that 40--50k before expenses? 20% would be a stupid good expected return.

If all this is true, why are more people not investing in these? What do you think is the rate of laundromat failure or otherwise risk of, um, losing one's shirt?

 

[cyanide12345678]

Dang, you're saying laundromats average 20--25% cash on cash return? Or is that 40--50k before expenses? 20% would be a stupid good expected return.

If all this is true, why are more people not investing in these? What do you think is the rate of laundromat failure or otherwise risk of, um, losing one's shirt?

Look at my post above where i copy paste three listings for sale. Actual listings with revenue, expenses and profit/cash flow. All absentee ownership laundromats basically 3x cash flow cost. Obviously i haven't done any due diligence since I'm not exactly buying one soon.

I'm not kidding when i say id rather buy a laundromat than do a fellowship.

 

[Birdstrike]

Look at my post above where i copy paste three listings for sale. Actual listings with revenue, expenses and profit/cash flow. All absentee ownership laundromats basically 3x cash flow cost. Obviously i haven't done any due diligence since I'm not exactly buying one soon.

I'm not kidding when i say id rather buy a laundromat than do a fellowship.

I'd love something that brings me passive income with no day-to-day work, and only an initial investment and loan to pay off. But, if these laundromats are such easy money and a great deal, why are those people selling them? I'm wondering how low maintenance they can really be. If a machine breaks down or a pipe leaks, who gets the phone to call fix it or find someone to fix it? What's the catch? Personally, I'm extremely hesitant to invest 0.5-1 million dollars in a business I don't know, when I already have a career which is established and doing well. But it might work for some people.

 

[Doctor Bob]

So I've been doing CCM for over 5 years now.

I would rather do this job for 50k per year than a full time EM job for 500k per year. And you couldn't pay me enough to make me want to have a pain practice. So this gets to why you do a fellowship and which one... you do a fellowship because it lets you have the kind of job that makes you happy. That answer will be different for everyone and unfathomable to people with different interests. Forget about how much money you're missing out because you're doing the extra training; it's far better for you in the long run to enjoy your job rather than just tolerate it (or even worse, hate it).

The kind of patient that I like to deal with? The seriously ill that are at imminent risk of dying. I saw a lot of that in the ED and I enjoyed it for the years that I did EM exclusively. But over time the percent of people seeking convenience care kept increasing, and pressure from up high to cater to them thereby reducing the time I could devote to the critically ill continued to increase. So I did a fellowship so I could get out of the ED.

The hours in the ICU are longer, there's stress of a different kind (but the kind that my personality is better suited to tolerate).

I still enjoy EM in general... but now I enjoy that I don't rely on it and I can work the occasional shift and I don't care about productivity bonuses, or press-ganey scores from the walking well. If at any point someone comes and tells me that I spend too much time stabilizing the ESI 1s and 2s and the ESI 5 patients were complaining about the wait time for their med refills, I would walk.

 

[blue.jay]

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.

Here you go, another one...

June 29 - South Georgia Medical Center Partners with Mercer to Offer Residency Programs

June 29, 2020 - South Georgia Medical Center (SGMC) and Mercer University School of Medicine (MUSM) recently announced a partnership that will bring internal medicine and emergency medicine residency programs

www.savannahbusinessjournal.com

 

[Birdstrike]

A question for @Birdstrike and others that have done a fellowship after years of practicing primarily EM. Did you strongly consider any fellowships immediately at the end of residency or not until later in your careers? Did your interest in specific fellowships change over time?

The only fellowship I’ve ever really been interested in is critical care (maybe slight interest in the field of palliative medicine towards the end of my medical career, but not sure if I’d be willing to do a fellowship). I wonder though if over the years I’ll gradually lose my interest in critical care and develop some other interest, or just continue to practice EM until I finally up and leave for CCM or something outside of medicine.

I considered all EM fellowships during training, but didn't give the idea much credit. I generally bought the conventional wisdom at the time, that they were a waste of time since none of them led to an increase in pay to justify the year. And back then (early '00s) none of the ones that could allow you to have a normal life (Pain, Palliative) were well publicized. Also, I had been in training long enough, I just wanted to be done and start earning money.

Within the first few years of being an attending, it became clear the EM lifestyle was not going to be sustainable for me, due to the circadian rhythm dysthymia, pace and emergencies becoming less important than administrators bonuses from non-emergencies, my new mantra became get-out-before-ya-stroke-out. As a young person, making sacrifices to save lives was worth it to me. It became clear to me 95% of EM was something other than that. It was turned into something else by forces out of my control. EM became "fast food medicine to make mad cash for administrators while you suffer dysthymic burnout and by the way hurry, hurry, HURRY! don't forget about those dying patients too, and do it in record speed with a smile while you get sued for doing the right thing, doc!" At that point I considered any exit plan that would allow me to have a normal life. Pain just happened to work, and I got lucky with it. But it could have been anything else that allowed me to have a normal life again.

I liked critical care a lot. But I chose not to do it because I wasn't looking for a different type of Medicine that I liked more, for the sake of the Medicine. I was looking for a way to have a normal life, where I could live without the heavy weight of the EM hangover bringing me down all the time. All the "days off" that were ruined because I worked until 4 am, on my "day off." All my weeks off that were ruined because the post-nights hangover bled into the first 3 days of the week. All the fuzzy headed mornings where I tried to tell myself, "this is normal" as I recovered from some bizarre, unnaturally timed shift. All those days off where I could think of nothing but how I "got destroyed" on my last shift, with volume, acuity, pace, EM insanity or all four. All thoses days I knew I did heroes work but the message from implied message from admin was that we all did a s**t job because some useless metric or survey was off by 0.5% according to some "higher up" that never cared enough to show his face. Critical care would not have allowed me a normal life. I would have still had to work many nights, weekends and holidays and deal with circadian rhythm hangovers on days off.

It's not about the Medicine for me. For a lot of people, it's about the Medicine. The Medicine itself is there whole life. They look for fulfillment in the work itself. If your work is more important to you than the life you live which the work is supposed to make possible, then search for better work. If the life outside of work, that your work supports, is more important, then find work that better supports your non-work life. That's what it was about for me. I have a great life. The Medicine is here to support that great life, not to be the life.

 

[Groove]

I would rather do this job for 50k per year than a full time EM job for 500k per year.

Now that was spoken with the zeal of a true academic! I wish I could say that about something, but alas...I'd take the Benjamins.

In all seriousness @Doctor Bob, how old were you when you went CCM and how long did you practice EM before switching?

 

[Birdstrike]

The circadian rhythm disruptions and dysthymia is real. It becomes worse as the years add up and with age. I've come to quasi peace with it by taking control over my schedule working blocks of nights for several years, but even then it isn't ideal. I always thought I would be willing to pay others to work my nights, but then found the constant switching from days to swings mixed with 1-2 nights a month was even more disruptive. I also like the atmosphere and flow of nights more. All that being said, switching back from nights to days takes its toll. Sometimes there isn't a recovery within 1 day. My day/night schedule can still be off for 2-4 days into my week off. I won't be doing nights forever. I really can't even envision doing EM after age 50. I also don't plan to be full time in EM throughout my 40s with the plan to likely switch back to days and work part time. I may switch over to doing admin for our group to reduce shift burden at some point, but that also has its headaches compared to just working clinically.

I think the last paragraph really hits the nail on the head. I think this is the question many of us struggle answering and is helpful for everyone to think about. I agree with you that "The Medicine is here to support that great life, not to be the life."

That's where I think EM leadership has really failed multiple generations of EM physicians. I don't think it should even be considered a realistic expectation to work full time EM from age 26-60. It should be a built in expectation with ready made tracks set up that allow one to transition out of circadian rhythm shift work mid-career. It should be built into the system and part of the culture. The culture shouldn't be "Full speed ahead" as we watch people head for their mid-career crash as they desperately reach to find the eject button. It seems our young doctors deserve better than, "Look, there goes another one. What a shame. Good thing we just expanded graduates by 10,000 new bodies to take his place." That's why I warn people about EM realities and if they choose it, advise them to do some EM fellowship or other diversification to increase their talent stack. That allows you the most control and better options to work a full career with the least collateral damage to your quality of life. But that's just one man's opinions. Others may disagree.

 

[thegenius]

I would rather do this job for 50k per year than a full time EM job for 500k per year.

 

[bravotwozero]

Also good points. The systemic problem is harder to address on an individual level. I think that’s why the answer has been to pump out more grads rather than improve the quality for those in their mid-late careers. Most cases in the ED aren’t emergencies. Somehow I feel we need to change the culture of making all non-emergencies wait overnight until the morning to see an EP, or even better their PCP. The flip side being we would take a pay cut unless society valued our expertise handling emergencies even more. If there was buy-in from society it would dramatically improve the quality of shift work. For what it’s worth in our on-demand culture, I don’t see this happening.

Another general question for everyone. What is the optimal career length? If you reach FIRE in your 40s-50s is that the goal? If you stop working and retire ‘early’ do you just start dying? Should you work right up until the day you die because you have found what you love and would do it for free. Given we don’t know our life expectancy is the dream to just work until you magically line up having a few golden years after you retire before you die? It’s probably unique to everyone, but seems relevant when discussing the sustainability of working in EM.

Yeah if I hit FIRE at age 50 or before, I am either just going to work at FSEDs or 100% getting the eff out of this giant burning dumpster fire that is now EM.

 

[WilcoWorld]

A question for @Birdstrike and others that have done a fellowship after years of practicing primarily EM. Did you strongly consider any fellowships immediately at the end of residency or not until later in your careers? Did your interest in specific fellowships change over time?

The only fellowship I’ve ever really been interested in is critical care (maybe slight interest in the field of palliative medicine towards the end of my medical career, but not sure if I’d be willing to do a fellowship). I wonder though if over the years I’ll gradually lose my interest in critical care and develop some other interest, or just continue to practice EM until I finally up and leave for CCM or something outside of medicine.

I practiced for over a decade (and passed my ABEM Recert ) before fellowship in Hospice & Palliative. But I did it because I was drawn towards HPM, not because I was trying to escape the ED.

Over the course of residency I strongly considered Tox, Sports and Simulation fellowships, but decided against fellowship for a variety of non-generalizable reasons. I am admittedly someone who probably likes reading and learning to an abnormal and potentially unhealthy degree. So more training/learning has an intrinsic appeal to me.

FYI - it's still quite doable to become a Hospice Medical Director without fellowship training. OTOH getting hired as a consulting Palliative doc is getting hard without board certification (which requires fellowship). I think HPM is particularly well-suited to docs with a few years of experience under their belt. If you're not feeling it now, just let it simmer. This isn't something you need to rush into.

 

[Apollyon]

I practiced for over a decade (and passed my ABEM Recert ) before fellowship in Hospice & Palliative. But I did it because I was drawn towards HPM, not because I was trying to escape the ED.

Over the course of residency I strongly considered Tox, Sports and Simulation fellowships, but decided against fellowship for a variety of non-generalizable reasons. I am admittedly someone who probably likes reading and learning to an abnormal and potentially unhealthy degree. So more training/learning has an intrinsic appeal to me.

FYI - it's still quite doable to become a Hospice Medical Director without fellowship training. OTOH getting hired as a consulting Palliative doc is getting hard without board certification (which requires fellowship). I think HPM is particularly well-suited to docs with a few years of experience under their belt. If you're not feeling it now, just let it simmer. This isn't something you need to rush into.

God's honest truth, I don't know you, IRL, at all, but, I thought that you would NEVER leave the academic pit. I thought that you would, literally, die there (like, on the job). If you are now HPM, dude! With all respect and props, if I was looking to take a "dirt nap", you'd be top of my list to guide that. God bless.

 

[Doctor_Strange]

I'm in the middle of my EM rotation right now...these posts always give me a bit of anxiety and forlorn outlook.

 

[WilcoWorld]

God's honest truth, I don't know you, IRL, at all, but, I thought that you would NEVER leave the academic pit. I thought that you would, literally, die there (like, on the job). If you are now HPM, dude! With all respect and props, if I was looking to take a "dirt nap", you'd be top of my list to guide that. God bless.

Thanks man! And I guess you got me pegged - I'm still in the pit, but only half time now.

 

[GatorCHOMPions]

I considered all EM fellowships during training, but didn't give the idea much credit. I generally bought the conventional wisdom at the time, that they were a waste of time since none of them led to an increase in pay to justify the year. And back then (early '00s) none of the ones that could allow you to have a normal life (Pain, Palliative) were well publicized. Also, I had been in training long enough, I just wanted to be done and start earning money.

Within the first few years of being an attending, it became clear the EM lifestyle was not going to be sustainable for me, due to the circadian rhythm dysthymia, pace and emergencies becoming less important than administrators bonuses from non-emergencies, my new mantra became get-out-before-ya-stroke-out. As a young person, making sacrifices to save lives was worth it to me. It became clear to me 95% of EM was something other than that. It was turned into something else by forces out of my control. EM became "fast food medicine to make mad cash for administrators while you suffer dysthymic burnout and by the way hurry, hurry, HURRY! don't forget about those dying patients too, and do it in record speed with a smile while you get sued for doing the right thing, doc!" At that point I considered any exit plan that would allow me to have a normal life. Pain just happened to work, and I got lucky with it. But it could have been anything else that allowed me to have a normal life again.

I liked critical care a lot. But I chose not to do it because I wasn't looking for a different type of Medicine that I liked more, for the sake of the Medicine. I was looking for a way to have a normal life, where I could live without the heavy weight of the EM hangover bringing me down all the time. All the "days off" that were ruined because I worked until 4 am, on my "day off." All my weeks off that were ruined because the post-nights hangover bled into the first 3 days of the week. All the fuzzy headed mornings where I tried to tell myself, "this is normal" as I recovered from some bizarre, unnaturally timed shift. All those days off where I could think of nothing but how I "got destroyed" on my last shift, with volume, acuity, pace, EM insanity or all four. All thoses days I knew I did heroes work but the message from implied message from admin was that we all did a s**t job because some useless metric or survey was off by 0.5% according to some "higher up" that never cared enough to show his face. Critical care would not have allowed me a normal life. I would have still had to work many nights, weekends and holidays and deal with circadian rhythm hangovers on days off.

It's not about the Medicine for me. For a lot of people, it's about the Medicine. The Medicine itself is there whole life. They look for fulfillment in the work itself. If your work is more important to you than the life you live which the work is supposed to make possible, then search for better work. If the life outside of work, that your work supports, is more important, then find work that better supports your non-work life. That's what it was about for me. I have a great life. The Medicine is here to support that great life, not to be the life.

I felt kind of burned out at the end of residency and was afraid of the circadian disruption, focus on moving the meat, lack of control of work environment, etc., but thought it was just residency blues. The blues never really went away my first few years out so I made the leap and applied to pain fellowships this cycle. I also really like the procedures, the ability to start one's own private practice, and unlike most of the other possible fellowships there is a potential for pay raise from this one. Plus the value of being the patient's Doctor and long term continuity of care never really stuck with me as a student or during training until I realized how being the anonymous pit doctor hurts both emotionally and financially (justifies being treated as a replaceable "cog"). And "difficult" patients don't bother me at all. We probably see the highest proportion of them in the ED, anyway.

It really is an uphill battle getting into pain from EM, but I have given myself a decent chance. Happy to share more details via PM. The match is in mid-October, wish me luck!

 

[Birdstrike]

I felt kind of burned out at the end of residency and was afraid of the circadian disruption, focus on moving the meat, lack of control of work environment, etc., but thought it was just residency blues. The blues never really went away my first few years out so I made the leap and applied to pain fellowships this cycle. I also really like the procedures, the ability to start one's own private practice, and unlike most of the other possible fellowships there is a potential for pay raise from this one. Plus the value of being the patient's Doctor and long term continuity of care never really stuck with me as a student or during training until I realized how being the anonymous pit doctor hurts both emotionally and financially (justifies being treated as a replaceable "cog"). And "difficult" patients don't bother me at all. We probably see the highest proportion of them in the ED, anyway.

It really is an uphill battle getting into pain from EM, but I have given myself a decent chance. Happy to share more details via PM. The match is in mid-October, wish me luck!

Good luck x 1,000! Happy to chat via PM anytime!

 

[Doctor Bob]

Now that was spoken with the zeal of a true academic! I wish I could say that about something, but alas...I'd take the Benjamins.

In all seriousness @Doctor Bob, how old were you when you went CCM and how long did you practice EM before switching?

I did 2 years straight EM after residency before going to fellowship. Throughout fellowship I would still moonlight in the ED and after fellowship I've always maintained a PRN EM job.

Really (gif)? I find that story really hard to believe (gif). Well ok that's fine (gif)

Having done both jobs for less than 100k and both jobs for >300k, I'm standing by my story.
When I was doing CCM for the military and EM civilian, the EM portion of my income far outweighed the CCM portion (even though CCM took up a lot more time), and I wasn't happy. Eventually I stopped picking up EM shifts, my income dropped dramatically, and my happiness exponentially increased.

Eventually I got out of the military and got a civilian CCM job which paid a lot more.

 

[joeschmoejohndoe]

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.

From your experience would you recommend going into palliative care fellowship directly after EM residency or waiting some period of time?

 

[dchristismi]

Wilco did a fellowship; I didn't.
However, he does palliative. I do hospice. (Some do both, as there is some overlap)

It really depends on what you want to do. The fellowship will give you far more breadth, but TBH, my 12 years in the pit well prepared me for my complicated inpatient hospice practice. I knew I wanted to focus on the end of life, so I didn't feel going back and doing a fellowship was worth it for me. But... I had a unicorn gig fall into my lap, so I have a rather unique perspective.

I'd have to say looking back, that gaining the gestalt that you can only hone at the bedside is absolutely invaluable. That, and socking away a nest egg on an EM salary helps. I don't usually have the luxury of labs or imaging, so that gestalt is huge. (Hm, the internal/gi bleeding/bone marrow failure/consumptive coagulopathy must be hitting a critical point since the flow murmur is a lot more pronounced today...) Also, it does help to be creative and EM types are absolutely creative. How the hell does one manage malignant cord compression when you can't call a neurosurgeon? (The answer is an obscene amount of steroids, and maybe a lot of dilaudid and a versed drip.) Massive hemorrhage from a carotid blowout after the cancer eats into big red? (Dark towels, a lot of them, and staying calm... because you've seen worse.) Comforting a spouse of 70 years who is now utterly alone and has no idea where the checkbook is? (Now that's where it's an art...and a team. HPM is very much a team sport.)

Just like any fellowship, it's a hit to the bank account, and one doesn't go into HPM for the money. You really have to love it - but if you do, go for it. I'm glad I waited, but the path is however you want to make it. Wilco nailed all the stuff I love about it. And yeah, there's a lot of death. I sign 90-120 death certs a month now... about half or more of those patients I personally took care of. And yes, there are always some that will stay with you - just like EM. But they're bittersweet. Because it's all about ameliorating suffering and making a lousy situation better.

FWIW, we're short staffed, and due to a scheduling glitch, I'm up to the last day of a 12-on-2-off-12-on stretch of rounding in my inpatient unit... and I STILL love it. I'm a little crispy and a little sad, but nowhere near as miserable I'd be after 4 in a row in the ED. I never really minded the flip flopping schedules and worked exclusively nights in my EDs the last 2 years, but I basically work better-than-banker's hours now, and it's a whole new world.

 

[WilcoWorld]

From your experience would you recommend going into palliative care fellowship directly after EM residency or waiting some period of time?

I think Palliative is best done by docs with some experience under their belt. So I'd work for a while first, but that's just my experience.

 

[blue.jay]

I've seen palliative care mostly run by NPs. It looks like they completely taken over that field. I saw a comment in a medscape post where a palliative doctor commented they fired him to hire an NP instead. I would love to do palliative and hospice fellowship as an IM grad but very skeptical of heavy NP encroachment in the field. It's probably a more appropriate speciality for an NP rather than seeing pts in ER, ICU or floors where they lack the breadth of knowledge. Can't think of any speciality they haven't encroached on

 

[Frazier]

I've seen palliative care mostly run by NPs. It looks like they completely taken over that field. I saw a comment in a medscape post where a palliative doctor commented they fired him to hire an NP instead. I would love to do palliative and hospice fellowship as an IM grad but very skeptical of heavy NP encroachment in the field. It's probably a more appropriate speciality for an NP rather than seeing pts in ER, ICU or floors where they lack the breadth of knowledge. Can't think of any speciality they haven't encroached on

If you don't want to work with NP's/PA's/Chaplains/Pharm/SW/Music therapy/Integrative Med/Pet Therapy/RN's/etc then HPM is not for you. To best serve the needs of patients who receive our services, it takes a village.

Also, depending on the size of the department, there will be plenty of docs on staff and the dept isn't "ran by NPs"... Often they do the more standard types of consults, still very valuable. If they are an expert communicator, then they are an expert communicator. The dual diagnosis patient with carcinomatosis, kidney failure, neutropenic 2/2 palliative chemo, here today s/p palli surg resection for BO on 3000+ OME, in florid pain crisis and refractory nausea now requiring methadone PCA and pending palliative sedation -- is likely going to have the doc on their case.

There are too many patients to be all managed entirely by the doc. Thank god for the help.

If you are highly concerned, no problem, just need to find a subspecialty that worries you less.

 

[blue.jay]

If you don't want to work with NP's/PA's/Chaplains/Pharm/SW/Music therapy/Integrative Med/Pet Therapy/RN's/etc then HPM is not for you. To best serve the needs of patients who receive our services, it takes a village.

Also, depending on the size of the department, there will be plenty of docs on staff and the dept isn't "ran by NPs"... Often they do the more standard types of consults, still very valuable. If they are an expert communicator, then they are an expert communicator. The dual diagnosis patient with carcinomatosis, kidney failure, neutropenic 2/2 palliative chemo, here today s/p palli surg resection for BO on 3000+ OME, in florid pain crisis and refractory nausea now requiring methadone PCA and pending palliative sedation -- is likely going to have the doc on their case.

There are too many patients to be all managed entirely by the doc. Thank god for the help.

If you are highly concerned, no problem, just need to find a subspecialty that worries you less.

I agree it's a team based speciality where you can only provide the best quality care as a team, working together. Every palliative team member I've seen/worked with are very nice people and very much content with their line of work. My concern is just to have a job after fellowship and I know it pays less. It's worrying when you hear that palliative docs are fired because they are expensive, because depending on your speciality it's a 200,000$ opportunity cost. Like others have said it's probably a better idea to do HPM as mid-career speciality after paying off loans and other financial goals.

 

[Frazier]

I agree it's a team based speciality where you can only provide the best quality care as a team, working together. Every palliative team member I've seen/worked with are very nice people and very much content with their line of work. My concern is just to have a job after fellowship and I know it pays less. It's worrying when you hear that palliative docs are fired because they are expensive, because depending on your speciality it's a 200,000$ opportunity cost. Like others have said it's probably a better idea to do HPM as mid-career speciality after paying off loans and other financial goals.

Gotcha. It is certainly a valid concern especially for the modern medical student in today's world of sky-rocketing debt. You are right on the mark that it does indeed pay less that straight EM currently. One nice thing is that as you and others have alluded to, it is a specialty open to entrance for the mid-career doc... So, if the time comes once you get those loans knocked out and financial goals achieved in EM, you know where to find us.