Can EM Physicians eventually open their own practice or clinic?

[LikeAirIRise]

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Hi,

I'm entering my first year of medical school in several months and while I am aware I have a lot of time to decide my specialty choice, I have absolutely no idea of the direction I will go in. One deciding factor for me to choose emergency medicine is whether or not they have the ability to open a practice or clinic eventually? Even if it is a general private practice. Is that an option for them?
And also, do they have the option to work shifts that are less than 12 hours? I haven't read about EM Physicians working 8 hour shifts before but it does seem likely that it is realistic.

Thanks in advance everyone, I can't say enough how grateful I am for this site as well as how excited I am to begin the academic journey towards becoming a physician.

 

[gamerEMdoc]

Sure. You certainly could open an Urgent Care clinic that you own and help staff, if that is what you mean.

And yes, shift length is highly variable. I never, ever, ever, work 12 hour shifts. Avoided them by choosing a residency that didn't do 12's, and would never work at a place that works 12's (unless its really slow there and you can sleep). Its just too long for me. I prefer 8 or 9's.

 

[LikeAirIRise]

Sure. You certainly could open an Urgent Care clinic that you own and help staff, if that is what you mean.

And yes, shift length is highly variable. I never, ever, ever, work 12 hour shifts. Avoided them by choosing a residency that didn't do 12's, and would never work at a place that works 12's (unless its really slow there and you can sleep). Its just too long for me. I prefer 8 or 9's.

Wow, ok thanks! That's extremely satisfying to know. How do you like it? I'm going to disregard the pros of the specialty for a minute here because I love all of them, but I've heard of the position being very high stress and not allowing for a great work-family balance?
And again I've heard some amazing things and outside of what I heard about the shifts it embodies everything I would like to do as a physician,

 

[gamerEMdoc]

Your just in your first year of medical school. Until you get your feet on the ground doing real clinical work, I don't think you can really appreciate the pros and cons of a specialty, or compare specialties, with any real perspective. It's hard enough for someone to figure out what they want to do with their life throughout their third year, let alone at this point just starting out.

But as I see it, here are the pro's/con's:

Pros:
- We make a lot of money for the number of hours we are in the hospital
- Flexible life style because you don't take call and your work hours are reasonable for a full time doc (usually around 32-35 hrs/week)
- No call. When you leave the hospital, you are done. No one is bothering you at home.
- Excellent mix of medicine. You'll see a little bit of every single specialty in medicine.
- Good mix of medicine and procedures
- Every once in awhile, you get to do something that truly makes you feel heroic. It's not often. But its a huge high when it happens.
- Flexibility in scheduling. You can decide how much you want to work. Want to work 6 shifts a month? 25 shifts a month? You can basically choose how much you want to work.
- Variety of practice. Want crazy acquity? Sleepy country ED? Academics? A mix of different environments? Urgent Care? You can even get a mix of any and all if you do locums work and bounce around.
- Awesome. Stories. At. Parties.

Cons:
- High liability field
- Shift work sleep issues
- Contract management groups are becoming the dominant employers in many regions
- You deal with all of the patients no one wants to deal with.
- Sometimes can be a violent place to work.
- Staffing is always changing.
- It's a really hard job. And stressful. Until you do it for awhile, you can't appreciate how much this will take a toll on you.

 

[LikeAirIRise]

Your just in your first year of medical school. Until you get your feet on the ground doing real clinical work, I don't think you can really appreciate the pros and cons of a specialty, or compare specialties, with any real perspective. It's hard enough for someone to figure out what they want to do with their life throughout their third year, let alone at this point just starting out.

But as I see it, here are the pro's/con's:

Pros:
- We make a lot of money for the number of hours we are in the hospital
- Flexible life style because you don't take call and your work hours are reasonable for a full time doc (usually around 32-35 hrs/week)
- No call. When you leave the hospital, you are done. No one is bothering you at home.
- Excellent mix of medicine. You'll see a little bit of every single specialty in medicine.
- Good mix of medicine and procedures
- Every once in awhile, you get to do something that truly makes you feel heroic. It's not often. But its a huge high when it happens.
- Flexibility in scheduling. You can decide how much you want to work. Want to work 6 shifts a month? 25 shifts a month? You can basically choose how much you want to work.
- Variety of practice. Want crazy acquity? Sleepy country ED? Academics? A mix of different environments? Urgent Care? You can even get a mix of any and all if you do locums work and bounce around.
- Awesome. Stories. At. Parties.

Cons:
- High liability field
- Shift work sleep issues
- Contract management groups are becoming the dominant employers in many regions
- You deal with all of the patients no one wants to deal with.
- Sometimes can be a violent place to work.
- Staffing is always changing.
- It's a really hard job. And stressful. Until you do it for awhile, you can't appreciate how much this will take a toll on you.

Thanks a ton!
Yeah I know I’m a bit early to really weigh pros and cons of any specialty, it’s probably the anxiety of finally starting school this year.
Last thing! Could you just elaborate on how it’s a “high liability field”? I’m not the most literate when it comes to professional terminology haha

 

[RustedFox]

Thanks a ton!
Yeah I know I’m a bit early to really weigh pros and cons of any specialty, it’s probably the anxiety of finally starting school this year.
Last thing! Could you just elaborate on how it’s a “high liability field”? I’m not the most literate when it comes to professional terminology haha

The average Emergency Physician is sued once every 6-7 years. That's pretty high.

 

[gamerEMdoc]

Last thing! Could you just elaborate on how it’s a “high liability field”? I’m not the most literate when it comes to professional terminology haha

The average Emergency Physician is sued once every 6-7 years. That's pretty high.

This!

In EM, you have no prior relationship with the patient. So, they don't know you. Primary docs are less likely to be sued because they have a long standing relationship with their patient. Plus, because you know nothing about the patient, it puts you at a disadvantage in terms of treating them. You have very limited time to see and treat most cases, and when someone comes in with years of medical history and is really complex, you are at a big disadvantage.

Lastly, you can't refuse to see someone. A surgeon can say a case is too high risk to operate on. Primary docs can fire a patient that is beligerant. They can send people to specialists if they are uncomfortable treating something. But in the ED, you can't refuse to see anything. So when the most high risk stuff comes through the door, its yours. Drunk person on anticoagulation who hit his head, spits on a nurse and is refusing all testing, threatening to sue if you touch him (but is going to sue when you miss his head bleed). That's case is all yours!

 

[LikeAirIRise]

The average Emergency Physician is sued once every 6-7 years. That's pretty high.

This!

In EM, you have no prior relationship with the patient. So, they don't know you. Primary docs are less likely to be sued because they have a long standing relationship with their patient. Plus, because you know nothing about the patient, it puts you at a disadvantage in terms of treating them. You have very limited time to see and treat most cases, and when someone comes in with years of medical history and is really complex, you are at a big disadvantage.

Lastly, you can't refuse to see someone. A surgeon can say a case is too high risk to operate on. Primary docs can fire a patient that is beligerant. They can send people to specialists if they are uncomfortable treating something. But in the ED, you can't refuse to see anything. So when the most high risk stuff comes through the door, its yours. Drunk person on anticoagulation who hit his head, spits on a nurse and is refusing all testing, threatening to sue if you touch him (but is going to sue when you miss his head bleed). That's case is all yours!

Oh ok I see... that's pretty significant. Makes the decision much tougher. Well I mean I have 4 years to decide, no rush I guess. Thanks for all your help

 

[Brigade4Radiant]

Emergency Medicine is about average risk in terms of physician lawsuits.

 

[enalli]

Wow, ok thanks! That's extremely satisfying to know. How do you like it? I'm going to disregard the pros of the specialty for a minute here because I love all of them, but I've heard of the position being very high stress and not allowing for a great work-family balance?
And again I've heard some amazing things and outside of what I heard about the shifts it embodies everything I would like to do as a physician,

Say you're working 14 8-hour shifts a month.

Assume your spouse is at work 9-5 M-F and your kids are in school 8-4 also M-F.

5 of your shifts are 7am-3pm: 4 are weekdays, 1 is a weekend
7 of your shifts are 3pm-11pm: 5 are weekdays, 2 are weekends
2 of your shifts are 3pm-7am: 1 is a weekday, 1 is a weekend

- That's 4 partial weekend days that you are missing
- On the 5 weekday 3-11 shifts you won't see your family at night
- You will actually be able to see your family before and after the overnights, but you may lose a bunch of hours the next days while recovering and switching your schedule

In total, you will significantly miss out on quality time on seeing your family for 9 to 11 days out of the month. Contrast that with working M-F 8-5. You will be at work approximately 70 more hours per month but will gain those 9-11 days with your family back.

Obviously this depends on your family's schedule and your own schedule, but I don't think this scenario is that out of the norm.

 

[LikeAirIRise]

Say you're working 14 8-hour shifts a month.

Assume your spouse is at work 9-5 M-F and your kids are in school 8-4 also M-F.

5 of your shifts are 7am-3pm: 4 are weekdays, 1 is a weekend
7 of your shifts are 3pm-11pm: 5 are weekdays, 2 are weekends
2 of your shifts are 3pm-7am: 1 is a weekday, 1 is a weekend

- That's 4 partial weekend days that you are missing
- On the 5 weekday 3-11 shifts you won't see your family at night
- You will actually be able to see your family before and after the overnights, but you may lose a bunch of hours the next days while recovering and switching your schedule

In total, you will significantly miss out on quality time on seeing your family for 9 to 11 days out of the month. Contrast that with working M-F 8-5. You will be at work approximately 70 more hours per month but will gain those 9-11 days with your family back.

Obviously this depends on your family's schedule and your own schedule, but I don't think this scenario is that out of the norm.

Ahh I see. I didn't even think about it that way. I imagined that physicians in this field have more negotiating power when it come to scheduling due to the shortage, but at the same time the shortage could be the reason they are required to work those shifts, so it all comes full circle.
This is a lot to consider, thanks!

 

[gamerEMdoc]

No. They work those shifts because unlike just about every field of medicine, EM is 24/7, 365. Someone has to work the mornings, afternoons, evenings, nights. And jobs where you can say “I’m only going to work daytime from 8-4” are pretty hard to come by.

 

[bravotwozero]

sure you can. It's called a Freestanding ED.

 

[deleted109597]

sure you can. It's called a Freestanding ED.

Offer not valid in ~45 states

 

[GeneralVeers]

Offer not valid in ~45 states

Or TX due to market saturation and mass bankruptcies of FSD companies.

 

[deleted109597]

Or TX due to market saturation and mass bankruptcies of FSD companies.

There are a ton of markets that haven't been tapped. Some of them even have pretty good insuranced percentages.
Most of the companies that went out of business were the corporate ones, IE Texas Health and First Choice.

 

[Osteoth]

sure you can. It's called a Freestanding ED.

Offer not valid in ~45 states

Or TX due to market saturation and mass bankruptcies of FSD companies.

So FSEDs are not too hot anymore? I used to hear recent grads discussing the glory of the south for FSED & EM pay

 

[RocuROMANium]

No. They work those shifts because unlike just about every field of medicine, EM is 24/7, 365. Someone has to work the mornings, afternoons, evenings, nights. And jobs where you can say “I’m only going to work daytime from 8-4” are pretty hard to come by.

I have never fully understood why you guys alternate shifts like that. In nursing, you have day shift and night shift nurses. They usually start out night shift and when they get sick of it they apply to go day shift. Why can't you guys do that?

 

[VA Hopeful Dr]

I have never fully understood why you guys alternate shifts like that. In nursing, you have day shift and night shift nurses. They usually start out night shift and when they get sick of it they apply to go day shift. Why can't you guys do that?

Because very few people want to work all nights.

 

[Old_Mil]

The window for the FSED has probably closed for the most part unless states change their laws (which I doubt they will).

So that leaves you with urgent care, or if you want to venture into pain management.

Really, between the large number of new - often CMG or for profit hospital affiliated - residencies opening, the combination of EMTALA and the ACA, and the increasing predominance of 1099 work, EM isn't a particularly attractive field anymore.

Certainly if you are currently in medical school the landscape will worsen by the time you finish residency and enter practice.

The best thing you can probably do is to pick a non hospital based practice.

If you still decide to do an EM residency knowing this, you probably should work out your exit strategy for clinical medicine ahead of time so that when you see those realities for yourself, you have that JD, MBA, or MPH and can do something different.

 

[Old_Mil]

I have never fully understood why you guys alternate shifts like that. In nursing, you have day shift and night shift nurses. They usually start out night shift and when they get sick of it they apply to go day shift. Why can't you guys do that?

A nurse is 20-22 years old when she finishes her training and starts work. At a minimum, an EP is 29-30 when he finishes his. In many cases, that's the difference between a younger single person who has no family and can work a nocturnist schedule and someone who may have a spouse +/- kids who doesn't want to..

 

[ski89]

Really, between the large number of new - often CMG or for profit hospital affiliated - residencies opening, the combination of EMTALA and the ACA, and the increasing predominance of 1099 work, EM isn't a particularly attractive field anymore.

Care to elaborate on how each of these factors will effect that field of EM? And what do you mean as not particularly attractive? As I understand it, EM salaries continue to increase across the nation, the population is getting sicker and older. I can admit to a certain level of ignorance not being in your position, but how are you so certain of the future?

 

[deleted109597]

I have never fully understood why you guys alternate shifts like that. In nursing, you have day shift and night shift nurses. They usually start out night shift and when they get sick of it they apply to go day shift. Why can't you guys do that?

Also, when the night nurse moves on, she can go pretty much anywhere she chooses. I can't up and go into cardiac doctoring. Or ICU doctoring. Or open a clinic. They've got a much, much larger conveyor belt of nurses coming to take those spots.

 

[gamerEMdoc]

Care to elaborate on how each of these factors will effect that field of EM? And what do you mean as not particularly attractive? As I understand it, EM salaries continue to increase across the nation, the population is getting sicker and older. I can admit to a certain level of ignorance not being in your position, but how are you so certain of the future?

To some the sky is always falling. To others, there's always a bright side. The truth usually lies somewhere in between. Yes there are negative things about the field. Yes there is also some great things about the field, which is why it remains a competitive choice among applicants.

 

[hundreddaysoff]

I have never fully understood why you guys alternate shifts like that. In nursing, you have day shift and night shift nurses. They usually start out night shift and when they get sick of it they apply to go day shift. Why can't you guys do that?

Truth be told I never understood it either. Others have put forth theories but I think it's mostly about pride and machismo, honestly. I'd much rather work all nights or days than shift around. I figured this out in residency and always offered to take all the night shifts, but the other residents (many of whom had families) resisted. "This is what EM is! Don't take our random hours away from us! I need to work nights this week so I can take off next weekend to fly to my cousin's sister's dog's wedding!" they shouted at me. I thought they were silly.

Now I'm a nocturnist. I work T-F most weeks, 9 or 12h shifts. I always get Sa-M off. I get to sleep a fair bit especially at the FSEDs we staff. I ~always finish all my notes before I go home when things have died down at 5 AM. I BS w/ the nurses a lot. It's pretty sweet.

Wife mildly dislikes my schedule but she really hated it when I worked random shifts at the beginning. I stay awake mornings and we hang out before she goes to work. One or both of us will always be home when the first kid pops later this year. What's not to like?

 

[Hercules]

Truth be told I never understood it either. Others have put forth theories but I think it's mostly about pride and machismo, honestly.. ?

There’s nothing theoretical about it. It is quite simply a supply and demand issue. There aren’t enough ED nocturnists out there to soak up all the night shifts in this country. I assure you 100% that it has nothing to do with pride or machismo. If that has been your personal experience, yours is the vast outlier.







Sent from my iPhone using SDN mobile

 

[hundreddaysoff]

There’s nothing theoretical about it. It is quite simply a supply and demand issue. There aren’t enough ED nocturnists out there to soak up all the night shifts in this country. I assure you 100% that it has nothing to do with pride or machismo. If that has been your personal experience, yours is the vast outlier.

Sure, but that just repeats the question of why most ER docs want to do the classical random-shifts thing instead of signing on as nocturnists. My theory is... pride and machismo and that's the way we've always done things.

My point is that I thought nocturnism would suck for my lifestyle but it's actually been much better for my lifestyle than the traditional way of arranging our shifts. Others of course may have different experiences.

 

[ski89]

Sure, but that just repeats the question of why most ER docs want to do the classical random-shifts thing instead of signing on as nocturnists. My theory is... pride and machismo and that's the way we've always done things.

My point is that I thought nocturnism would suck for my lifestyle but it's actually been much better for my lifestyle than the traditional way of arranging our shifts. Others of course may have different experiences.

Out of curiousity have you found a consistent method of easing on and off of the night schedule? Also, you mentioned working 9s and 12s, is it more one or the other?

 

[deleted109597]

Sure, but that just repeats the question of why most ER docs want to do the classical random-shifts thing instead of signing on as nocturnists. My theory is... pride and machismo and that's the way we've always done things.

Because they would rather just have to work a few nights a month than to suffer through working only nights.
Not all spouses are as receptive as yours.
I agree it would be ideal, and night shift is almost always admin free. However, if you do have to go to the C suite, it won't be at night. Most mandatory meetings are during the day, etc. Hard to have food delivered/hospital cafeteria closed. There are a lot of reasons not to like nights.

 

[gamerEMdoc]

Out of curiousity have you found a consistent method of easing on and off of the night schedule?

If you are flipping between days and nights, I like a split sleep schedule. This isn't ideal if you are someone who works only nights, but if you only have 2-3 a month, this works great. Sleep 1.5-3 hours before your shift. Then sleep after your shift (you'll almost always wake up by 11am or so). You wind up sleeping like 6 hours in total, but its very easy to bounce back to a day time schedule this way.

 

[hundreddaysoff]

Out of curiousity have you found a consistent method of easing on and off of the night schedule? Also, you mentioned working 9s and 12s, is it more one or the other?

I work about 1/3 9s and 2/3 12s these days. Our 12s tend to be at our FSEDs, which are less busy (like 1pph max), so I usually get at least 3--4h of sleep on those. Every group will be different. Based on others' SDN stories my job is probably a bit of a unicorn (for a CMG job) and not sure how long it will last in the face of declining pt census.

I've never been able to sleep more than 3--4h max at a stretch during the day, even w/ a sleep mask, white noise, and all the tricks mentioned on various other threads. Probably this is a genetic thing... it's very easy for some people I know and impossible for others. Best way to maximize chance of sleep before my first night shift is to do some heavy squats/deads then eat a big carb load, drink a couple beers, and pop a melatonin. The melatonin part is probably just placebo.

OTOH, I'm a natural morning person and always sleep like a rock when the sun goes down even if I just pulled 4 nights in a row, so that part isn't an issue. I do try to delay sleep in the mornings postshift and nap in the afternoon every single day whether I'm on or not in order to have a bit more consistent sleep schedule and spend time w/ family in the mornings. And in the desert you usually don't want to be outside in the afternoon anyway.

In residency I felt like a zombie a lot due to the random shifts, but this is very rare for me w/ my current setup. So don't automatically assume that nights aren't for you based on the classical residency experience.

McNinja is right that other spouses wouldn't put up w/ this. (Or a lot of the weird things that SDNers brag about for that matter, such as moving from the coast to flyover country and trading easy access to friends and family for a great job 🙂) My wife also happens to be a morning person and works part-time in the afternoons so she likes this schedule a lot more than randomness since I get to spend more wakey time w/ her.