Can this still be a lifestyle job?

[Waterlover]

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I mean maybe? This isn't good catch all advice for all comers. You either need to a) come from means or have an already established nest egg, b) be married to someone who can provide reasonably priced health insurance, or c) don't get sick.

In addition:

1) it's not inherently easy to get a rotation of 5-6 places to string together a FT or close to FT compliment of hours. And it will become harder and harder to achieve this with the glut of residents being graduated. Shops hate PRN / locums and you'll be the first out.

2) These sort of "locums lifers" have a reputation. In my experience, many have weird personalities, are weak clinically, and downright combative w staff, patients and other doctors. They don't tend to play well in the sandbox.

That all being said, I do think if you have a nice 2-3 million or more in assets and are sorta on that "coast FIRE" path, it can be a good move for a mid to late career physician, so long as you can tolerate the potential monthly swings in income. Or maybe you're a young buck who doesn't care that much about living an inflated lifestyle and are happy w a modest existence (likely without kids cause those things are luxury items believe me). It definitely is a tradeoff between freedom and predictable income.

Hmm partially agree and partially disagree. If you are smart with locums, the locums gigs tend to pay higher than the W2 gigs. Very easy to find $300+/hr in locums vs W2 jobs that want to pay as low as $120/hr in Denver or on average what I see is $200-220/hr then run like crazy to get RVU. So you could work 6-8 Locums shifts and get paid the same for what you have to work 15 W2 shifts to get.

I don't agree with the reputation always. I do both W2 and 1099 and I can tell you the middle of nowhere locums have to be a lot more comfortable seeing random things than W2 at a big center that can pawn everything off to specialists and residents.

Only part I agree with is the part that shops hate PRN/locums. Which is why you pick places that are undesirable locations/difficult to get to. Also in locums smart ones know to be credentialed at multiple hospitals at all times. Also agree with the health insurance part.

If done correctly, 1099 is better than W2 if we are talking about lifestyle and money.

Sorry for late reply I'm not on this regularly

 

[MeinTraum]

Back to the topic...

I worked academics for several years and have been PRN in the community the last few years working as a 1099 for an SDG. Academics is overall more tolerable for a long term career imo. Can't speak to an SDG partnership gig, though.

You have two main options in academia:
1. Full time clinical, permanently an assistant professor, never join a committee, do bare minimum lectures, clock in and clock out mentality, etc. Not a bad choice if you have residents doing all your scut. Plus having learners around can be rewarding sometimes and makes the job less lonely.

2. Carve out a niche, climb the academic ladder with the goal of accruing buy-down time. This is getting harder without a fellowship, connection, or super suck up mentality.

The way you mess up academics is landing in between 1 and 2. You try to do a little extra or care a little too much, but not enough (or not recognized) to get you firmly on the #2 track.

Income is hugely site specific. At my prior academic job I made as much as the surrounding CMG or hospital employed jobs, plus had better benefits.

Thank you! Good information. And thank you to everyone else as well for your insight…

 

[Janders]

Hmm partially agree and partially disagree. If you are smart with locums, the locums gigs tend to pay higher than the W2 gigs. Very easy to find $300+/hr in locums vs W2 jobs that want to pay as low as $120/hr in Denver or on average what I see is $200-220/hr then run like crazy to get RVU. So you could work 6-8 Locums shifts and get paid the same for what you have to work 15 W2 shifts to get.

I don't agree with the reputation always. I do both W2 and 1099 and I can tell you the middle of nowhere locums have to be a lot more comfortable seeing random things than W2 at a big center that can pawn everything off to specialists and residents.

Only part I agree with is the part that shops hate PRN/locums. Which is why you pick places that are undesirable locations/difficult to get to. Also in locums smart ones know to be credentialed at multiple hospitals at all times. Also agree with the health insurance part.

If done correctly, 1099 is better than W2 if we are talking about lifestyle and money.

Sorry for late reply I'm not on this regularly

I think this is very location dependent. Around here, the best paid jobs are a couple SDGs and SDG-like setups. You have to drive many hours to get 1099 locums shift that approach the actual value of the best w2 job (wage + benefit + retirement), and it can be tough to string enough together etc etc. Yes, rare double pay emergency shifts are cool, but reasonably rare in this specific environment at this time.

That said, the average 1099 “decent” paying locums around here might be a little better than the meh W2 jobs around here.

I think IF you have a super flexible personality, and enjoy networking, and don’t have constant childcare needs— the locums 1099 grind of finding a few shops, keeping them all on trickle, and then churning for bonus shifts or last second coverage can be, technically speaking, the most lucrative.

On the other side of the bell curve, if you want 20 days off a month and want to pick your shifts and don’t care too much about total comp, the locums life can give you ultimate flexibility vis-à-vis your schedule.

 

[EctopicFetus]

I think this is very location dependent. Around here, the best paid jobs are a couple SDGs and SDG-like setups. You have to drive many hours to get 1099 locums shift that approach the actual value of the best w2 job (wage + benefit + retirement), and it can be tough to string enough together etc etc. Yes, rare double pay emergency shifts are cool, but reasonably rare in this specific environment at this time.

That said, the average 1099 “decent” paying locums around here might be a little better than the meh W2 jobs around here.

I think IF you have a super flexible personality, and enjoy networking, and don’t have constant childcare needs— the locums 1099 grind of finding a few shops, keeping them all on trickle, and then churning for bonus shifts or last second coverage can be, technically speaking, the most lucrative.

On the other side of the bell curve, if you want 20 days off a month and want to pick your shifts and don’t care too much about total comp, the locums life can give you ultimate flexibility vis-à-vis your schedule.

I think the type of locums people are talking about here is the opposite of a lifestyle job. Going to work last minute and spending time negotiating a rate and talking to people non stop doesnt seem fun.

I like knowing my schedule, not going to the “middle of nowhere” etc. Perhaps I’m jaded cause my 2 cities i have been in post residency had trashy locums options and i didnt want to travel far to go to work. That time away from family matters to me.

The best locums gig near me recently was about 2.5 hours away with the option for 24s and their offer was 275/hr for 10 pts/24 hours. The recruiter said they could maybe get more if i was interested. Just doesnt make a ton of sense. My kids are older now but my need for money is less and my main gig is good enough.

IIRC when people posted their rates plenty of people on here are making upper 200s/low 300s. How much more do you need. I say that making the assumption that if i am making 300/hr at my main gig.. how much does a locums gig have to pay to get me there to work? Is it volume dependent? For me it comes down to how long can i work so i dont have to come back. I would consider a 72 hour shift at 300/hr. I think that would be my minimum to consider locums. In those 72 hours I would have to see no more than 40 patients (13/day avg volume).

For me to get on a plane and spend that amount of time away they number would have to be so astronomical i am not sure I ever gave a locums recruiter a number. I guess I can see with locums the beauty (in my mind) is I can work whatever number of shifts i want every month AND i make more than standard pay by a little bit but the real value is in control. Not working nights or not working holidays.

Is the win really in the money cause i guess i dont see it but that might be from being ~15 years out.

 

[Arcan57]

I think the type of locums people are talking about here is the opposite of a lifestyle job. Going to work last minute and spending time negotiating a rate and talking to people non stop doesnt seem fun.

I like knowing my schedule, not going to the “middle of nowhere” etc. Perhaps I’m jaded cause my 2 cities i have been in post residency had trashy locums options and i didnt want to travel far to go to work. That time away from family matters to me.

The best locums gig near me recently was about 2.5 hours away with the option for 24s and their offer was 275/hr for 10 pts/24 hours. The recruiter said they could maybe get more if i was interested. Just doesnt make a ton of sense. My kids are older now but my need for money is less and my main gig is good enough.

IIRC when people posted their rates plenty of people on here are making upper 200s/low 300s. How much more do you need. I say that making the assumption that if i am making 300/hr at my main gig.. how much does a locums gig have to pay to get me there to work? Is it volume dependent? For me it comes down to how long can i work so i dont have to come back. I would consider a 72 hour shift at 300/hr. I think that would be my minimum to consider locums. In those 72 hours I would have to see no more than 40 patients (13/day avg volume).

For me to get on a plane and spend that amount of time away they number would have to be so astronomical i am not sure I ever gave a locums recruiter a number. I guess I can see with locums the beauty (in my mind) is I can work whatever number of shifts i want every month AND i make more than standard pay by a little bit but the real value is in control. Not working nights or not working holidays.

Is the win really in the money cause i guess i dont see it but that might be from being ~15 years out.

I was thinking the same thing, that any job that involves traveling constantly is only "lifestyle" for one particular value of lifestyle.

Also, if you tossed in a few more random CMG vs. SDG posts, this thread would be a perfect encapsulation of all the conversations around time, money, work environment and leisure on SDN in the last 15+ years. To sum up:

1) The ED is a toxic place to work
2) Because it's toxic, the best way to deal with the toxicity is to greatly increase your exposure for the first 5 or so years when you're the most vulnerable and inexperienced.
3) Unicorn jobs where you're making $500 (k/yr or $/hr) and don't work nights or weekends exist, so if you're not living that life then it's because of some character flaw inside yourself.
4) Having any attachment to people or places other than a perfectly compliant spouse +/- kids is a character flaw.
5) Creating a life that's not centered around net worth but has reached a rough equilibrium with family/play/work is weird, but occassionally acceptable.

 

[EctopicFetus]

I was thinking the same thing, that any job that involves traveling constantly is only "lifestyle" for one particular value of lifestyle.

Also, if you tossed in a few more random CMG vs. SDG posts, this thread would be a perfect encapsulation of all the conversations around time, money, work environment and leisure on SDN in the last 15+ years. To sum up:

1) The ED is a toxic place to work
2) Because it's toxic, the best way to deal with the toxicity is to greatly increase your exposure for the first 5 or so years when you're the most vulnerable and inexperienced.
3) Unicorn jobs where you're making $500 (k/yr or $/hr) and don't work nights or weekends exist, so if you're not living that life then it's because of some character flaw inside yourself.
4) Having any attachment to people or places other than a perfectly compliant spouse +/- kids is a character flaw.
5) Creating a life that's not centered around net worth but has reached a rough equilibrium with family/play/work is weird, but occassionally acceptable.

I think most of us work in environments that are very flawed. It’s the ED. I also think whining about this is akin to whining about taking care of the low income/uninsured/homeless/ abusers of the ED. Makes me wonder if those docs did their med school ED rotations and hospital rotations at some fairytale place where that doesnt make up a decent minority of the patients you see.

As Arcan said… hard to see how locums is “lifestyle”. Perhaps there needs to be reconsideration of priorities. I worked like a b@@@ch right out of residency, we had no money, 2 little kids and ~500k in debt. Over time priorities changed as I didnt have to worry about paying my bills, kept my lifestyle below my income and let my investments do what they do.

Work is but one part of your life. Remember that.. you are easily replaced. Even the most important doc in an organization or group is replaceable and other than a cheap pen or fake gold watch no one will show you any more appreciation. I help my partners when they need it, they do the same.

I also do think you have to take your job and be happy with it. If you arent find the next one. If you happen to be “stuck” in a location thats fine.. get the best job you can near you.. That can be high pay, easy shifts or whatever mix is there. Lamenting and brooding over your unhappiness will destroy you, your family and your relationships.

No one cares… When I have a hard shift I share that with my family, when I get super frustrated with work, I might mention it to my wife but I dont ver bring it up with my kids. Most of the details are just discussed with my work friends. We commiserate. Being in a bad spot mentally with work will destroy you and lead to burnout.

if you are stuck here, time for fellowship, a med spa, DPC or non clinical work. You have 1 life to live dont waste it in a job you are unhappy with.

 

[WhatJobDoIPick]

No job is perfect.

Min/max your way to happiness.

I work harder at my SDG job than my hospital employed job, but I feel more fulfilled.

 

[Waterlover]

I think this is very location dependent. Around here, the best paid jobs are a couple SDGs and SDG-like setups. You have to drive many hours to get 1099 locums shift that approach the actual value of the best w2 job (wage + benefit + retirement), and it can be tough to string enough together etc etc. Yes, rare double pay emergency shifts are cool, but reasonably rare in this specific environment at this time.

That said, the average 1099 “decent” paying locums around here might be a little better than the meh W2 jobs around here.

I think IF you have a super flexible personality, and enjoy networking, and don’t have constant childcare needs— the locums 1099 grind of finding a few shops, keeping them all on trickle, and then churning for bonus shifts or last second coverage can be, technically speaking, the most lucrative.

On the other side of the bell curve, if you want 20 days off a month and want to pick your shifts and don’t care too much about total comp, the locums life can give you ultimate flexibility vis-à-vis your schedule.

Yeah true, for me I'm currently young, single and no kids. I have what I'd consider a low paying W2 and a very high 1099 PRN and I definitely question my life choices lol. I get to ask for shifts in advance for the 1099 and I haven't had any issues, I don't scramble for anything, and occasionally I happen to get bonus shifts on top of already high pay. W2 job gives me health insurance, 1099 job gives me financial security and play money.

I learned this on my own. No one in residency tells you or teaches you the locums side. If I knew from the jump I would've done locums straight out.

IF it's done correctly, 1099 is better, and it can give you the "lifestyle" people imagine in ER. And it can be done without having to fly if you find multiple gigs around you. But you have to know what you're doing. As someone doing both.

 

[EM:RAT]

Hey docs, I’m a recent grad out of fellowship and working 120 hrs/month. For the seasoned docs out here, do you think this can still be a lifestyle specialty working 80-100 hours a month? I know it’s generally not a good time for EM right now but hard to beat 8-10 days a month of clinical work.

To address the OP, I would say this is still possible in the right niche. I'm about 10 yrs. out of residency, working 8-10 shifts/month plus one on-call day. Almost never work an overnight. I'm also a single parent with several avid hobbies and a side gig. The amount of freedom this schedule provides makes the downsides of EM worthwhile for me. Don't want to give all the details publicly, but this is with a corporate group, Vituity. The other factor is that to get your "dream schedule," you won't have as much choice in location.

 

[cyanide12345678]

To address the OP, I would say this is still possible in the right niche. I'm about 10 yrs. out of residency, working 8-10 shifts/month plus one on-call day. Almost never work an overnight. I'm also a single parent with several avid hobbies and a side gig. The amount of freedom this schedule provides makes the downsides of EM worthwhile for me. Don't want to give all the details publicly, but this is with a corporate group, Vituity. The other factor is that to get your "dream schedule," you won't have as much choice in location.

Call in EM? How does that work?

 

[oldtown]

Call in EM? How does that work?

In my experience, it involves having one person each day on call to cover a shift if someone can’t make it last minute (illness, injury, family emergency, etc).
A pseudo-day off in which you can’t leave town or get drunk/stoned, but have that fear of the phone ringing lingering over you even if call ins are rare.

 

[AlmostAnMD]

In my experience, it involves having one person each day on call to cover a shift if someone can’t make it last minute (illness, injury, family emergency, etc).
A pseudo-day off in which you can’t leave town or get drunk/stoned, but have that fear of the phone ringing lingering over you even if call ins are rare.

Yup

My group has called activated like 20% of the time. Group is so large it's hard to avoid.

 

[Arcan57]

That's an awful activation rate unless each person is on call once every couple of months.

 

[Apollyon]

That's an awful activation rate unless each person is on call once every couple of months.

My first job, we had about 60 docs (largest group in the state that wasn't a CMG). Since the Peds EM folks couldn't cover the adult shifts, it was only the EM people. We were on call on average once every 6 weeks. We got called in about 1/3, so, infrequently.

 

[AlmostAnMD]

That's an awful activation rate unless each person is on call once every couple of months.

Monthly split between two people and day. Some days both are used.

It's awful for a reason.

 

[oldtown]

Monthly split between two people and day. Some days both are ABused.

It's awful for a reason.

I fixed that for you.

Seriously, if a call system is used to make up for understaffing at baseline, that’s abuse and I don’t know why people would tolerate it. If it’s to ensure coverage for the once in a blue moon call off for emergencies, then I dot have a big problem with it (the place that I have experience with on call, the button was pushed maybe 5-10 times per year for emergencies/illnesses. Fine)

And if your coworkers abuse it by using it for ticky tack stuff (I forgot to request the day off and there’s a parent teacher conference scheduled tonight or the like), that’s BS too.

 

[deleted239798]

Locums doesn’t turn EM into a derm lifestyle, but it does give you the ability to shape your career a little more. Don’t want nights or want more scheduling flexibility? Locums does make that more accessible. The cost is potentially travel, less stability, and worse sites. It doesn’t require 5 sites to string together a ft equivalent either; most places aren’t going to want to bother credentialing unless you commit to a decent number of shifts initially in my experience.

What I find funny about this conversation is people on this site are constantly discussing exits whether it’s real estate, fellowship, etc, yet a pretty personally adaptable alternative is brought up and it is a bad idea because it isn’t.. perfect? Traveling and sleeping in a holiday inn kind of sucks. So does investing in a multi family and losing money. So does spending a year in a fellowship you’re not that passionate about and taking a pay cut. So does being an anesthesiologist (supposedly an amazing lifestyle) and having to take call. And anytime younger med students or residents are brought up the attitude is “those kids want to have their cake and eat it too”, but that’s exactly the attitude here. What is this supposed lifestyle job with regular hours and reasonable call and solid future prospects and good geographic flexibility and equivalent pay, etc etc? It’s not real.

If you want to make this a lifestyle job you have to take risks or sacrifice/ whether financially or some other component of the perfect life vision that is being imagined. Personally, i prefer 1099 work over pain fellowship or investing. But yeah, everything can be crapped on for not being perfect. Being happy vs not being happy doesn’t come down to what residency you picked, especially when in EM you can make 200k a year working 5 day shifts a month (unfortunately you might need to drive a couple hours or fly somewhere to make it happen).

 

[EctopicFetus]

Locums doesn’t turn EM into a derm lifestyle, but it does give you the ability to shape your career a little more. Don’t want nights or want more scheduling flexibility? Locums does make that more accessible. The cost is potentially travel, less stability, and worse sites. It doesn’t require 5 sites to string together a ft equivalent either; most places aren’t going to want to bother credentialing unless you commit to a decent number of shifts initially in my experience.

What I find funny about this conversation is people on this site are constantly discussing exits whether it’s real estate, fellowship, etc, yet a pretty personally adaptable alternative is brought up and it is a bad idea because it isn’t.. perfect? Traveling and sleeping in a holiday inn kind of sucks. So does investing in a multi family and losing money. So does spending a year in a fellowship you’re not that passionate about and taking a pay cut. So does being an anesthesiologist (supposedly an amazing lifestyle) and having to take call. And anytime younger med students or residents are brought up the attitude is “those kids want to have their cake and eat it too”, but that’s exactly the attitude here. What is this supposed lifestyle job with regular hours and reasonable call and solid future prospects and good geographic flexibility and equivalent pay, etc etc? It’s not real.

If you want to make this a lifestyle job you have to take risks or sacrifice/ whether financially or some other component of the perfect life vision that is being imagined. Personally, i prefer 1099 work over pain fellowship or investing. But yeah, everything can be crapped on for not being perfect. Being happy vs not being happy doesn’t come down to what residency you picked, especially when in EM you can make 200k a year working 5 day shifts a month (unfortunately you might need to drive a couple hours or fly somewhere to make it happen).

Agreed but the difference between investing and working a job is my investments make passive income. Is real estate truly passive? Of course it depends. I think the discussion between investing / real estate and locums is apples and oranges. We ALL are (or should be) saving and investing. How we do that is a different discussion.

Some prefer VTSAX and chill, other a little more involved with REITS or even stock picking and some even more with day trading or owning real estate.

Thats a different discussion than how we all want to earn our money and what that job / lifestyle means. Great jobs with a great set up are hard to find. The few I know of have a tough path to make partner and get to that great job.

Locums is an option for some, others like myself dont see the beauty but everyone is different. The positives and negatives for locums have been discussed before. I dont begrudge anyone for how they choose to make their dough. But I’ll stick to the idea that locums isnt a lifestyle gig in EM.

What everyone should be doing is working for their groups/ sites to become as “lifestyle friendly” as possible. Often this is more money for the younger docs to work the crappy shifts. In general younger docs want to make money to pay off loans or to get ahead in their FIRE / savings and older docs dont want to work weekends/holidays. Much of this changes based on how much money you have and your family situation.

I think we can all agree that you can find 12s making 250/hr which is 3k a shift and as you pointed out you can work 5 days a month and make 200k.

I’ll say outside of EM there are pretty good lifestyle specialities. Some pay more (Derm) and some dont (endocrine). Friends I know went into endocrine cause no call, normal hours, no weekends, nights, holidays. We chose a different path. It’s what it is.

 

[deleted239798]

Agreed but the difference between investing and working a job is my investments make passive income. Is real estate truly passive? Of course it depends. I think the discussion between investing / real estate and locums is apples and oranges. We ALL are (or should be) saving and investing. How we do that is a different discussion.

Some prefer VTSAX and chill, other a little more involved with REITS or even stock picking and some even more with day trading or owning real estate.

Thats a different discussion than how we all want to earn our money and what that job / lifestyle means. Great jobs with a great set up are hard to find. The few I know of have a tough path to make partner and get to that great job.

Locums is an option for some, others like myself dont see the beauty but everyone is different. The positives and negatives for locums have been discussed before. I dont begrudge anyone for how they choose to make their dough. But I’ll stick to the idea that locums isnt a lifestyle gig in EM.

What everyone should be doing is working for their groups/ sites to become as “lifestyle friendly” as possible. Often this is more money for the younger docs to work the crappy shifts. In general younger docs want to make money to pay off loans or to get ahead in their FIRE / savings and older docs dont want to work weekends/holidays. Much of this changes based on how much money you have and your family situation.

I think we can all agree that you can find 12s making 250/hr which is 3k a shift and as you pointed out you can work 5 days a month and make 200k.

I’ll say outside of EM there are pretty good lifestyle specialities. Some pay more (Derm) and some dont (endocrine). Friends I know went into endocrine cause no call, normal hours, no weekends, nights, holidays. We chose a different path. It’s what it is.

I agree that what constitutes a good lifestyle is very personal, but for EM the gripes seem to mostly center on circadian disruption, metrics, evenings/weekends, unreasonable patients, replaceable to hospital, etc etc. I’m definitely not a locums proponent - what works for someone is going to be very individualized. My point is that it is an option that like all options has inherent drawbacks. Even SDGs if you can land with an awesome one might not be a good option for a new attending who really values schedule flexibility, for instance.

Obviously the best lifestyle is making money through passive income and having tons of free time. And having a lambo would also be nice. So would a six pack and chiseled jaw. The reality is, unless you are a savvy investor (requiring substantial time to learn, risk, luck, and a degree of genuine interest that most of us don’t have), you're exceedingly unlikely to be successful and have a high likelihood of worsening your financial position. I think it’s more a reflection of wild swings in the housing market where some people got lucky with timing and not much savvy and stumbled into owning income generating properties, but at this point if you are a few years into attendinghood without a lot of capital, it is a hard road to passive income.

My overall point which I probably didn’t make well, is that there are absolutely options within EM that confer a decent lifestyle if someone is willing to apply the same level of creative thinking/risk taking that they’re thinking of applying to an ‘escape’ job. Working 5 days a month and earning a bit less than an endocrinologist working 4 days a week is not a horrible deal. It’s also not the right decision for some. But on this forum, the burned out folks have lost all perspective (not their fault, that’s the nature of burnout) and have decided that anything involving clinical EM is awful and that entering this specialty is the road to a life of misery and that this is a universal truth. And it has gotten to the point where counterfactual claims about locums, like it’s a bad idea because of the prohibitive cost of private health insurance (as a locums making 300/hr this makes no sense), requires mass credentialing to eke out enough shifts, requires networking, means having to show up for a shift at the drop of a hat, etc etc, are upvoted because people are so bitter about this field that even things that are absurd or false are supported through confirmation bias. And to top it off there’s the naivety about how “it all would have been perfect had I only become an *insert specialty that EM inclined med student would never pick*. And I’m saying this as someone who wouldn’t advise a med student to choose em, but still likes to live in objective reality.

 

[GatorCHOMPions]

All good comments recently. There are no easy paths to good money AND lifestyle/location.

 

[miacomet]

This never was a lifestyle job. My guess is within the decade there will be more fellowships to help people exit EM. At that point it can totally can be a lifestyle job- crank for a few years, then transition to whatever new fellowships, hopefully a bunch, are coming down the pike. But I wouldn't hold my breath for that to happen.

 

[cyanide12345678]

This never was a lifestyle job. My guess is within the decade there will be more fellowships to help people exit EM. At that point it can totally can be a lifestyle job- crank for a few years, then transition to whatever new fellowships, hopefully a bunch, are coming down the pike. But I wouldn't hold my breath for that to happen.

Were you the one figuring out sleep medicine? Any progress in that front?

 

[EctopicFetus]

I agree that what constitutes a good lifestyle is very personal, but for EM the gripes seem to mostly center on circadian disruption, metrics, evenings/weekends, unreasonable patients, replaceable to hospital, etc etc. I’m definitely not a locums proponent - what works for someone is going to be very individualized. My point is that it is an option that like all options has inherent drawbacks. Even SDGs if you can land with an awesome one might not be a good option for a new attending who really values schedule flexibility, for instance.

Obviously the best lifestyle is making money through passive income and having tons of free time. And having a lambo would also be nice. So would a six pack and chiseled jaw. The reality is, unless you are a savvy investor (requiring substantial time to learn, risk, luck, and a degree of genuine interest that most of us don’t have), you're exceedingly unlikely to be successful and have a high likelihood of worsening your financial position. I think it’s more a reflection of wild swings in the housing market where some people got lucky with timing and not much savvy and stumbled into owning income generating properties, but at this point if you are a few years into attendinghood without a lot of capital, it is a hard road to passive income.

My overall point which I probably didn’t make well, is that there are absolutely options within EM that confer a decent lifestyle if someone is willing to apply the same level of creative thinking/risk taking that they’re thinking of applying to an ‘escape’ job. Working 5 days a month and earning a bit less than an endocrinologist working 4 days a week is not a horrible deal. It’s also not the right decision for some. But on this forum, the burned out folks have lost all perspective (not their fault, that’s the nature of burnout) and have decided that anything involving clinical EM is awful and that entering this specialty is the road to a life of misery and that this is a universal truth. And it has gotten to the point where counterfactual claims about locums, like it’s a bad idea because of the prohibitive cost of private health insurance (as a locums making 300/hr this makes no sense), requires mass credentialing to eke out enough shifts, requires networking, means having to show up for a shift at the drop of a hat, etc etc, are upvoted because people are so bitter about this field that even things that are absurd or false are supported through confirmation bias. And to top it off there’s the naivety about how “it all would have been perfect had I only become an *insert specialty that EM inclined med student would never pick*. And I’m saying this as someone who wouldn’t advise a med student to choose em, but still likes to live in objective reality.

I think the biggest risk is the over supply of docs. Hard to see thats not real. Even perhaps scarier is the revision assumes a 5% attrition. The data interpretation is pretty dumb..

First it says a lot of bad about our specialty when the career is 20 years *(5% attrition). The other thing is that looks at a lot of older docs.. The glut of young docs wont be retiring so fast. EM had a ton of old docs which is also why the 5% attrition was very very overstated.

Forget the quality of jobs.. Once the oversupply hits, locums will be a challenge, pay will drop though they will use some other excuse. I tell people to avoid EM for that reason.

 

[deleted239798]

I think the biggest risk is the over supply of docs. Hard to see thats not real. Even perhaps scarier is the revision assumes a 5% attrition. The data interpretation is pretty dumb..

First it says a lot of bad about our specialty when the career is 20 years *(5% attrition). The other thing is that looks at a lot of older docs.. The glut of young docs wont be retiring so fast. EM had a ton of old docs which is also why the 5% attrition was very very overstated.

Forget the quality of jobs.. Once the oversupply hits, locums will be a challenge, pay will drop though they will use some other excuse. I tell people to avoid EM for that reason.

I would tell any med student that the job market uncertainty is a huge reason not to do EM. But I was focusing on those of us already here in the specialty when talking about whether it can be a lifestyle specialty or not.

Attrition historically was 5% but went up to 8% during Covid. I see an ACEP report saying it remains elevated but don’t have access to the actual numbers. I completely agree that any specialty with that much turnover should give anyone considering EM significant pause.

That said, the workforce report of oversupply in 2030 is obviously not panning out. Anyone who works outside of a major metro can attest to that. ERs with significant volume affiliated with major hospital systems are still employing elderly FM and IM docs. Right now there aren’t even enough EM docs to staff ERs, let alone push out locums. I’m not sure I agree that younger docs will last longer. There was a recent study showing women spend about 12 years in the EM workforce. Men spent longer but still less than other specialties. That’s a huge amount of turnover. People who never wanted to match EM and SOAPed seem like they’d be at even greater risk of burnout than docs who wanted to do it in the first place and they’re just now finishing residency. Whether they’re able to make long careers out of it is tbd but considering that people who were once enthusiastic about EM can’t, my money is on no.

All that said, I’m betting that the workforce issue ends up not being as much of an existential threat, exactly because working conditions for so many docs are poor and the specialty has super high burnout - that’ll end up saving the specialty in a weird way.

 

[EctopicFetus]

I think the workforce issues are real and are coming to fruition. In my local market jobs are tough within an hour of the city center. The only jobs available are at the dumpster fire locations. The prior crappy jobs that were looking for people have filled up. A few of the IM/FP docs I know quit their EM jobs (unsure if pushed out) and went back to primary care. As we put out more and more docs each year (note the 2030 workforce data didnt account for continued expansion of residencies which has happened) jobs are tougher and tougher to get and more importantly the quality of job is decreasing. I say this as I help my residents look at and evaluate jobs.

undoubtedly jobs in small cities are still unfilled. But try to get a job in Chicago, Atlanta, Nashville, Philly, DC and they are few and far between. I wont even get into a decent job in California. We are 6 years away from 2030. Pre covid I recall the avg age of an EP was pretty up there. Maybe mid 50s. I remember it was shockingly high. Now we are pumping out 30 year olds to replace them. One thing I have also noticed is the younger docs are looking to work 120 hours a month instead of the 150-160 my colleagues were doing when I graduated. That being said this means we are much closer to replacing 1 doc for 1 doc. The younger docs wont have a choice, they will have to last longer. Debt is often 400-500k. A few will do the WCI/Dave Ramsey and work like dogs to pay off their loans. Agreed on the SOAP people burning out. That being said it was only a major problem for 1 year. Last year that N was small. The bigger issue is the overall quality of EM doc is slipping.

The only reason i think the new crop can last longer is they arent sprinting in the beginning. I warn my residents that doing locums or working too much early on puts them at risk of a bad case. Some people cant mentally overcome a bad outcome. I think the workforce issues is the single biggest issue we face as a speciality. I think by 2026 we will see the real impact. Anything before then IMO is noise and hyper local. I have been calling 2026/2027 since the report came out. It’s just math..

 

[EctopicFetus]

Results: A total of 25,839 (70.2%) male and 10,954 (29.8%) female EPs were included. During the study years, 5905 male EPs exhibited attrition at a median (interquartile range [IQR]) age of 56.4 (44.5-65.4) years, and 2463 female EPs exhibited attrition at a median (IQR) age of 44.0 (38.0-53.9) years. Female gender (adjusted odds ratio 2.30, 95% confidence interval 1.82-2.91) was significantly associated with attrition from the workforce. Male and female EPs had respective median (IQR) post-residency graduation times in the workforce of 17.5 (9.5-25.5) years and 10.5 (5.5-18.5) years among those who exhibited attrition and one in 13 males and one in 10 females exited clinical practice within 5 years of residency graduation.

Emergency medicine physician workforce attrition differences by age and gender - PubMed

Female physicians exhibited attrition from the EM workforce at an age approximately 12 years younger than male physicians. These data identify widespread disparities regarding EM workforce attrition that are critical to address to ensure stability, longevity, and diversity in the EP workforce.

pubmed.ncbi.nlm.nih.gov

Good study but if i am reading this right.. Male docs left at a median of 56 but worked for 17.5 years, which would mean they finished residency at 40? And women left at 44 but practiced for 10 years meaning they finished residency at 34.

This study shows we are the 10th youngest specialty and will be getting younger.. as we pump out new grads.

Average age of doctors and providers by medical specialty

Uncover the average ages of doctors in different specialties. Discover the provider specialties that average older and younger.

www.definitivehc.com

Avg age is 48.

IN 2013 for AAMC There were 5600 docs in training and EM had 37k docs practicing.

https://www.aamc.org/media/8386/download?attachment

On page 14 of the AAMC guide 24% of EM docs were 55+.

In the 2022 report.. We have 46K em docs. Up by 10k. 36% are 55+. 30k of the docs are under 55. But the number of 55+ is super high. Of course it doesnt take into account how much they work.

They compare from 2016 to 2021 and EM is up 14% in the number of docs in our specialty. Also 8658 in training or just under 3k a year.

We will see but the workforce freight train is coming. My 2 cents.

 

[cyanide12345678]

Results: A total of 25,839 (70.2%) male and 10,954 (29.8%) female EPs were included. During the study years, 5905 male EPs exhibited attrition at a median (interquartile range [IQR]) age of 56.4 (44.5-65.4) years, and 2463 female EPs exhibited attrition at a median (IQR) age of 44.0 (38.0-53.9) years. Female gender (adjusted odds ratio 2.30, 95% confidence interval 1.82-2.91) was significantly associated with attrition from the workforce. Male and female EPs had respective median (IQR) post-residency graduation times in the workforce of 17.5 (9.5-25.5) years and 10.5 (5.5-18.5) years among those who exhibited attrition and one in 13 males and one in 10 females exited clinical practice within 5 years of residency graduation.

Emergency medicine physician workforce attrition differences by age and gender - PubMed

Female physicians exhibited attrition from the EM workforce at an age approximately 12 years younger than male physicians. These data identify widespread disparities regarding EM workforce attrition that are critical to address to ensure stability, longevity, and diversity in the EP workforce.

pubmed.ncbi.nlm.nih.gov

Good study but if i am reading this right.. Male docs left at a median of 56 but worked for 17.5 years, which would mean they finished residency at 40? And women left at 44 but practiced for 10 years meaning they finished residency at 34.

This study shows we are the 10th youngest specialty and will be getting younger.. as we pump out new grads.

Average age of doctors and providers by medical specialty

Uncover the average ages of doctors in different specialties. Discover the provider specialties that average older and younger.

www.definitivehc.com

Avg age is 48.

IN 2013 for AAMC There were 5600 docs in training and EM had 37k docs practicing.

https://www.aamc.org/media/8386/download?attachment

On page 14 of the AAMC guide 24% of EM docs were 55+.

In the 2022 report.. We have 46K em docs. Up by 10k. 36% are 55+. 30k of the docs are under 55. But the number of 55+ is super high. Of course it doesnt take into account how much they work.

They compare from 2016 to 2021 and EM is up 14% in the number of docs in our specialty. Also 8658 in training or just under 3k a year.

We will see but the workforce freight train is coming. My 2 cents.

I 100% agree with you. People keep talking about burn out and ignoring the ridiculous residency expansion.

The work force freight train indeed is coming - probably 2027 onwards will keep getting harder and harder to find reasonable employment.

I believe our attrition stands somewhere near 6.7% and with the current 37k work force, somewhere around 2400-2600 residency spots was the sweet zone. 2021 had 2826 spots, which is only slightly above that sweet equilibrium spot so we’re not feeling it yet.

Next few years we get the following classes graduate:

2025 graduates 2900
2026 graduates 3000.

The surplus will start showing then.

 

[deleted1140701]

I 100% agree with you. People keep talking about burn out and ignoring the ridiculous residency expansion.

The work force freight train indeed is coming - probably 2027 onwards will keep getting harder and harder to find reasonable employment.

I believe our attrition stands somewhere near 6.7% and with the current 37k work force, somewhere around 2400-2600 residency spots was the sweet zone. 2021 had 2826 spots, which is only slightly above that sweet equilibrium spot so we’re not feeling it yet.

Next few years we get the following classes graduate:

2025 graduates 2900
2026 graduates 3000.

The surplus will start showing then.

You guys make me nervous. I don't want to go back to residency for a different field. I'm hoping most of these new grads just hate it so much and leave the profession/go part time soon after graduating. Hopefully with ABEM oral boards going in person again that'll deter more people. Bad things to wish for.. I know. Even with massive amounts of debt, you can't do something you hate. Some new grads I'm working with that just graduated over the summer already hate it. They're in hundreds of thousands in debt and I know they're barely denting their loans with cost of living here. Some of them routinely stay an hour after shift finishing up too. They're not going to last very long. My current full time site can't even keep people on staff for more than a couple months at a time and it's in a big city. At least in my area, I'm seeing more job opportunities now than 2 years ago. Even at my locums site, people start and quit soon after.

 

[cyanide12345678]

You guys make me nervous. I don't want to go back to residency for a different field. I'm hoping most of these new grads just hate it so much and leave the profession/go part time soon after graduating. Hopefully with ABEM oral boards going in person again that'll deter more people. Bad things to wish for.. I know. Even with massive amounts of debt, you can't do something you hate. Some new grads I'm working with that just graduated over the summer already hate it. They're in hundreds of thousands in debt and I know they're barely denting their loans with cost of living here. Some of them routinely stay an hour after shift finishing up too. They're not going to last very long. My current full time site can't even keep people on staff for more than a couple months at a time and it's in a big city. At least in my area, I'm seeing more job opportunities now than 2 years ago. Even at my locums site, people start and quit soon after.

Well the reality is that 2020 match graduating last year in 2023 was basically still break even for supply and demand if you consider the average average of an EM doc to be 15 yrs (6.67% attrition rate. 2020 had 2567 spots, so up until 2023 graduating class, we were in equilibrium. It’s just simple math. With each graduating class now, the market will get worse and worse because every class from here onwards is a surplus. 2024 graduating class in fact was the first ‘surplus’ above a 6.67% attrition rate.

I’m coming to this attrition rate by assuming 70 percent of EM docs are men and 30 percent women. So (0.7 x 17.5) + (0.3 x 10.5) is basically 15.4 yrs average lifespan.

 

[deleted1140701]

Well the reality is that 2020 match graduating last year in 2023 was basically still break even for supply and demand if you consider the average average of an EM doc to be 15 yrs (6.67% attrition rate. 2020 had 2567 spots, so up until 2023 graduating class, we were in equilibrium. It’s just simple math. With each graduating class now, the market will get worse and worse because every class from here onwards is a surplus. 2024 graduating class in fact was the first ‘surplus’ above a 6.67% attrition rate.

I’m coming to this attrition rate by assuming 70 percent of EM docs are men and 30 percent women. So (0.7 x 17.5) + (0.3 x 10.5) is basically 15.4 yrs average lifespan.

Do you think this is a permanent problem and we’re basically screwed, or do you think it’ll be a cycle and eventually correct itself? I need about 6 years before my SO starts making good money and I can be comfortable making half of what I am currently.

 

[cyanide12345678]

Do you think this is a permanent problem and we’re basically screwed, or do you think it’ll be a cycle and eventually correct itself? I need about 6 years before my SO starts making good money and I can be comfortable making half of what I am currently.

The number of residency spots isn’t going down. Even though we’ve known for a couple of years about an obvious over supply, there has been a continuing increase in the number of spots. When financially conscious US med students didn’t go as much in EM, that void was quickly filled by IMGs who saw an opportunity to get a residency spot. So the over supply is likely not going away for 10-15 years.

What might change over time is increasing fellowship pathways and more ‘ways out’. More viable fellowship alternatives will likely spawn over 10-15 years to eventually have a new equilibrium where a large number of people choose fellowship training or telemedicine.

But honestly if something was going to change then it would have happened. We got lucky with a wave of post covid retirement that brought life into the EM job market. But it’s only temporary. But it also allowed acep and the big wigs in EM to turn a blind eye to the inevitable over supply and pretend that things are all good.

They aren’t. Time will prove it - 2028 onward grads are the ones that will really feel the reality of EM in my opinion

 

[HemorrhagicShock]

Do you think this is a permanent problem and we’re basically screwed, or do you think it’ll be a cycle and eventually correct itself? I need about 6 years before my SO starts making good money and I can be comfortable making half of what I am currently.

What I think a lot of academics who are advising medical students don't realize is that this isn't a "cyclical" thing for EM.

These are deeply entrenched, systemic, and highly complex issues that, in some cases, are accelerating.

The only way this corrects, as @cyanide12345678 alludes to above, is not with the inflow (we can't control that, it will be full of IMGs and low-tier mouth-breather candidates, of which there are an infinite amount) but with the outflow.

More fellowships to get out of EM.

More demand for the skillset of an ER doc outside of the ED.

More non-clinical roles opening up or focusing on hiring ER docs.

I hate to say it, but I don't see any of these as omnibus solutions for various reasons, the biggest of which is ABEM, which doesn't seem keen on getting involved with this issue.

Any non-clinical role an ER doc can do is one that any clinician can do for the most part, and these might lend themselves to clinicians with more clout or leadership ability or some other aspect of their CV, which ER docs likely don't have.

As for the clinical skillset outside of the ED, insurers aren't going to contract with you to do anything outside of your scope. Go try and see if you can make a contract with a larger insurer in your area to see office visits, or do outpatient skin excision for who knows what. You'll get laughed in the face.

It's pretty bleak for the ER doc unless you're willing to take massive entrepreneurial risks, and/or suck it up in the pit and hope you can FIRE quickly.

 

[cyanide12345678]

What I think a lot of academics who are advising medical students don't realize is that this isn't a "cyclical" thing for EM.

These are deeply entrenched, systemic, and highly complex issues that, in some cases, are accelerating.

The only way this corrects, as @cyanide12345678 alludes to above, is not with the inflow (we can't control that, it will be full of IMGs and low-tier mouth-breather candidates, of which there are an infinite amount) but with the outflow.

More fellowships to get out of EM.

More demand for the skillset of an ER doc outside of the ED.

More non-clinical roles opening up or focusing on hiring ER docs.

I hate to say it, but I don't see any of these as omnibus solutions for various reasons, the biggest of which is ABEM, which doesn't seem keen on getting involved with this issue.

Any non-clinical role an ER doc can do is one that any clinician can do for the most part, and these might lend themselves to clinicians with more clout or leadership ability or some other aspect of their CV, which ER docs likely don't have.

As for the clinical skillset outside of the ED, insurers aren't going to contract with you to do anything outside of your scope. Go try and see if you can make a contract with a larger insurer in your area to see office visits, or do outpatient skin excision for who knows what. You'll get laughed in the face.

It's pretty bleak for the ER doc unless you're willing to take massive entrepreneurial risks, and/or suck it up in the pit and hope you can FIRE quickly.

The only other way it corrects if the IIRC tightens up the requirements to finish residency and all of a sudden a lot of spots are closed.

Leadership however so far hasnt seemed to explore what is likely the best solution for the specialty.

Otherwise every level 2 hospital run by team health and the likes could slowly add a residency - and essentially decrease attending hours while increasing resident hours.

My training attendings saw 3.5 pph - mostly because residents 100% managed everything. So there’s obvious incentive to turn a shop where an attending sees 2 pph to a shop where an attending sees 3.5-4 pph

 

[deleted1140701]

The number of residency spots isn’t going down. Even though we’ve known for a couple of years about an obvious over supply, there has been a continuing increase in the number of spots. When financially conscious US med students didn’t go as much in EM, that void was quickly filled by IMGs who saw an opportunity to get a residency spot. So the over supply is likely not going away for 10-15 years.

What might change over time is increasing fellowship pathways and more ‘ways out’. More viable fellowship alternatives will likely spawn over 10-15 years to eventually have a new equilibrium where a large number of people choose fellowship training or telemedicine.

But honestly if something was going to change then it would have happened. We got lucky with a wave of post covid retirement that brought life into the EM job market. But it’s only temporary. But it also allowed acep and the big wigs in EM to turn a blind eye to the inevitable over supply and pretend that things are all good.

They aren’t. Time will prove it - 2028 onward grads are the ones that will really feel the reality of EM in my opinion.

Well that’s tough to hear but understandable. I’m guessing by 2028 most locums will be gone. Oh well. By then hopefully I’ll have a couple million in the bank with everything paid off and my SO can make up for the lost income. These new grads will get so ****ed.

Inevitably people will stop going into the field if the job market crashes. Then it’ll probably take a few years and things will open up again and we’ll have some good years.

 

[HemorrhagicShock]

@cyanide12345678 Yea the RRC solutions that were being talked about years ago when this first became an issue ultimately seemed like non-starts simply by virtue of who sits on those committees. If it hasn't happened by now I don't expect it to happen, and/or it'll be too little too late since these kinds of changes usually take years to implement.

ACEP? Anemic and worthless, zero power among those ranks and effectively bought by the CMGs.

AAEM and Take Medicine Back? Small, but growing. However even their wins have been effortlessly squashed by legislators, regulators, and other powers that be.

This game is cooked and done.

I send a prayer to God, Osler, and Hippocrates (maybe Halsted and Cushing if they're listening):

Please watch over any medical student going into EM in 2024, and ferry them safely. They indeed are just lambs being led to the slaughter; they don't know any better. Please deliver them unto your bosom, and may they be successful in their exits from EM once you open their eyes.

 

[EctopicFetus]

One consideration is leaving EM and doing a fellowship is always less money maybe outside of CC. That being said that job market is pretty tight as well. Plus the real money there is on the pulm side which EM docs dont get training in.

The point of that is that telemedicine or other stuff like that pays less which makes it less desirable and it too will be flooded by IM/FP etc. If there is a relief valve for EM that is meaningful it hasnt yet been found yet. Even when ACEP was pushing their lies their solution was here are 10 things none of them meaningful and if all happen we will be ok.

It ignored basic math and basic understanding of human behavior.

For those who are burnt out i think we will see them take the easier lower paying jobs. Rural spots with low volume but reasonable pay. Around me if you go 90 mins out you can probably find a 1pph job for 175/hr. That might be much more desireable than another job at 2pph plus MLPs making 235/240 but closer in.

Anyone who ignored the workforce issues be very careful. It will smack you in the face. EM is a very young field (8th youngest) and getting younger. I am happy im mid/late career. The quality of job has sucked for some time. It’s about to get much much worse.

 

[alpinism]

Just a lurker here who is interested in EM. I’ve read a lot about the downsides of EM on this forum, but I’m curious if all that has been discussed about EM on SDN also applies to academic EM. Seems like everyone’s experience comes from non-academic jobs. I read Cyanides post from 2023 and am curious if all of the information he found also applies to academia, especially job security.

Academics in EM is a huge spectrum that runs from highly established ivory tower residency programs to some of the new fly by night shops that were formed with the sole purpose of providing a source of cheap labor for the hospital. The former can be a solid long term job if you enjoy the nonclinical responsibilities of the job like teaching residents and publishing research but nowadays it will often require doing 1-2 fellowships and the compensation is much lower typically around 100-200K less than community jobs. Not only that but there are only a small number of these positions available nationally so you'll likely have to be willing to move to anywhere in the United States. The latter are nearly all terrible jobs that basically consist of being forced to quickly treat large numbers of patients with large numbers of residents without any nonclinical responsibilities that let you buy down the number of shifts and spend more time working in the office on a normal schedule.

 

[Porfirio]

I have very little knowledge of the IMG doc. Don’t they have restrictions on their medical license and immigration status that require them to practice in underserved areas after finishing residency?

 

[cyanide12345678]

I have very little knowledge of the IMG doc. Don’t they have restrictions on their medical license and immigration status that require them to practice in underserved areas after finishing residency?

Some of them yes. A lot of IMGs are US citizens usually who didnt get into a US MD or DO school.

The J1 waiver jobs otherwise aren’t as middle of no where as you’d expect. Some yes, but not all of them. For example - i live in the best county of my entire state, best school district in the state. 20 minutes away from me some of my friends are doing J1 waiver jobs.

Another example is the university of Kentucky in lexington counts as a J1 waiver. So these really aren’t the worst places out there. Plus the waiver is only 3 years after which they usually get a green card.

Then there’s people like my wife who had a green card by the time she applied even though she’s a IMG. A lot of women IMGs are often moving post marriage and often will have been sponsored by someone in the US before applications.

 

[MeinTraum]

Academics in EM is a huge spectrum that runs from highly established ivory tower residency programs to some of the new fly by night shops that were formed with the sole purpose of providing a source of cheap labor for the hospital. The former can be a solid long term job if you enjoy the nonclinical responsibilities of the job like teaching residents and publishing research but nowadays it will often require doing 1-2 fellowships and the compensation is much lower typically around 100-200K less than community jobs. Not only that but there are only a small number of these positions available nationally so you'll likely have to be willing to move to anywhere in the United States. The latter are nearly all terrible jobs that basically consist of being forced to quickly treat large numbers of patients with large numbers of residents without any nonclinical responsibilities that let you buy down the number of shifts and spend more time working in the office on a normal schedule.

Lots to think about. Thank you.

 

[Waterlover]

I also think doing fellowship that can get you out the ER can help too. Now you can do Sports, Pain, Critical Care, Palliative and Addiction Medicine, all fellowships that can get you out the ER completely. 64% of us in my residency class went into fellowship only a couple of years ago.

Idk about all the jobs being taken up in the next few years. What I'm seeing with colleagues around my age and people recently graduating, no one really wants to work full time. Everyone is looking for ways to be part time or do the bare minimum for full time, trying to find side hustles, etc. At my main job there's about 12 shifts that are up for grabs this month. You have to basically beg someone or be willing to trade. No one is picking up the shifts. People rather not work than pick up an extra shift for money. Now imagine the undesirable locations... There's gonna be a lot less of the 30-35 year ED career people after the next crop of the older docs retire in the next 10 years.

None is ideal but there are ways to have a good life in EM. Will it be a W2 in Beverly Hills that never makes you work nights/weekends/holidays and pays you $500k a year to see 1.3 patients an hour? No lol. Pros and cons to everything so it depends on what's important to you, your age, family/kids or not, etc.

 

[EctopicFetus]

I also think doing fellowship that can get you out the ER can help too. Now you can do Sports, Pain, Critical Care, Palliative and Addiction Medicine, all fellowships that can get you out the ER completely. 64% of us in my residency class went into fellowship only a couple of years ago.

Idk about all the jobs being taken up in the next few years. What I'm seeing with colleagues around my age and people recently graduating, no one really wants to work full time. Everyone is looking for ways to be part time or do the bare minimum for full time, trying to find side hustles, etc. At my main job there's about 12 shifts that are up for grabs this month. You have to basically beg someone or be willing to trade. No one is picking up the shifts. People rather not work than pick up an extra shift for money. Now imagine the undesirable locations... There's gonna be a lot less of the 30-35 year ED career people after the next crop of the older docs retire in the next 10 years.

None is ideal but there are ways to have a good life in EM. Will it be a W2 in Beverly Hills that never makes you work nights/weekends/holidays and pays you $500k a year to see 1.3 patients an hour? No lol. Pros and cons to everything so it depends on what's important to you, your age, family/kids or not, etc.

Again, the data is out there.. Median age of people leaving EM is 40s for women and mid 50s (IIRC) for men.

All those fellowships other than critical care and pain (a small number of these are open) pay much less than a typical EM job.I do agree that the hunger / interest in working a lot of hours doesnt seem to be there with the younger docs. They seem to find some other balance financially but many still manage to whine about money but they dont want to work. Thats a recipe for disaster. If you can live on a low EM doc salary you can work little.. but if you want to live like a plastic surgeon and work in the ED you better work hours like you enjoy being there.

We can chat in 2027.. i think jobs will be few and far between then.. the real squeeze starts in 2026 (2nd half of the year).. by 2027 panic.. by 2028 the panic will become much worse.. by 2029 doom and gloom will be the baseline. Pin this.. i might be wrong but i think thats very likely whats gonna happen.

We are gonna pump out 3k residents a year for the forseeable future. Some will not practice em, some will practice a few years. All that being said only those whose head in the sand doesn’t appreciate that we are minting more EM docs than are quitting / retiring. On top of that I think we will see the proliferation of MLPs as well. They are minting more NPs than needed. Only so many of them can pursue their passions of aesthetics. Not only is pay less for them and many are seen as equivalent to docs. Their med mal costs are much lower. At best things get somewhat worse than they are now.. At worst we see rates plummet and it will be blamed on CMS and cuts to the conversion factor and the NSA which will be total BS.

 

[CliveStaples]

Lots to think about. Thank you.

+1 for understanding that not all “academic” jobs are the same, and for the most part you should do your homework on any place that started in the last 7-8 years or so. Older than that and you’re probably good. Not all of the newer programs are private hospital residency diploma mills, but a lot of them are.

Speaking as an a current academic EM physician, I think it’s a great field and at least in my geographic region my total compensation is competitive with regional community emergency medicine pay, so certainly not a 100k-200k haircut. That said, I certainly see more pph than my community counterparts, but I also have resident physicians that take on a lot of the clinical and documentation burden that would make my pph rate untenable in private practice.

Ultimately academics works for me because I like the job. I never dread going into work. I feel like I’m doing things related to my job that will advance my career and help my patients get better care and my department to improve over time. But maybe I just have a unicorn job.

 

[Arcan57]

Couple of major factors that will influence EM economics that aren't being discussed.
1)Population factors - we exist because there is a huge demand for emergencies services. The aging of America combined with the increasing medical complexity means that more emergency providers are needed. This also means there's going to be a crash when the baby boomers age out of existence.
2)As much as everyone would like us to be, EPs aren't infinitely distensible in capacity. Seeing 2.5-3.0 pph is doable with enough financial incentive but when that incentive disappears docs find other jobs.
3)While they may exist, I've never met a NP/PA that even came close to matching the average doc's productivity. Combine that with the increased testing and admissions that come with someone whose knowledge base requires more conservative decision making and I don't see the anaesthesia team model becoming the dominant paradigm in EM.

All this means that the crash is probably going to come later than the back of the envelope calculations suggest. It also means that There's a decent chance that there is a class that is about to graduate that's going to be totally hosed at both the beginning and ending of their career as they come into a saturated market and watch demand crater in their later years.

 

[alpinism]

I'll offer my own purely anecdotal view but I think it will take a few more years and probably not till 2030 before the market is saturated.

At least at the places I've worked nearly all the docs have cut down to 120+ hrs except for a few workhorses that pull 180+ hrs a month.
Lots of people happy to work the minimum shifts and never pick up extra shifts but instead do telehealth etc for extra cash if needed.
Not only that but a significant majority of those above people are openly planning on leaving the specialty within the coming years.

 

[alpinism]

To be clear though when I say the market is saturated I mean it's when a new grad is unable to find a traditional full time ED job and then will instead have to work in EDs as PT or PRN to find shifts after finishing a residency. But now if we're talking about a lack of jobs in cities that's already starting literally this year and many new grads are having to interview at jobs in rural towns often a 60+ min drive from their desired cities.

 

[EctopicFetus]

I'll offer my own purely anecdotal view but I think it will take a few more years and probably not till 2030 before the market is saturated.

At least at the places I've worked nearly all the docs have cut down to 120+ hrs except for a few workhorses that pull 180+ hrs a month.
Lots of people happy to work the minimum shifts and never pick up extra shifts but instead do telehealth etc for extra cash if needed.
Not only that but a significant majority of those above people are openly planning on leaving the specialty within the coming years.

Overall i agree but the “people are planning on quitting” are almost always people with no plan but just expressing their disgruntlement. Almost every doc i know that quit or planned to quit knocked out a few more years there at the end. The younger ones for the most part just work less but dont quit.

Telemedicine pay is a joke, urgent care is beyond stupid and pay sucks unless you own the clinic. Most people come to realize that making 230-250/hr in EM is better than working much much more in UC or telemedicine.

Some people can afford to quit but the majority of EM docs who talk about quitting have a family and if their spouse works it is at a job that doesnt pay what EM pays and therein lies the problem. Quit to do what? Most have no plan and even fewer have their financials in order before they are much older. Why are women quitting so much sooner than men? Cause kids and it is more likely they have a spouse who brings in bread.

From the 2 private groups i worked for / with which encompasses well over 100 EM attendings a fair number of the women were married to docs whereas the men tended to have stay at home wives or wives who did things like real estate or some other field that was more to have something to do rather than make a good living. It’s pure anecdote but it also frankly makes sense when i extend this to my residency friends.

I agree that many docs are cutting back their work hours. But as you mentioned jobs in cities are hard to come by, the ones my residents looked at in cities were terrible. The rural jobs are in general not just a longer commute but lower volume also means lower pay.

I am a firm believer that new grads need to work in a higher volume/ acuity setup. Those options will be limited in the future. There are not a lot of rural EDs seeing 70-100+ patients a day.

 

[Stellar Mudd]

This never was a lifestyle job. My guess is within the decade there will be more fellowships to help people exit EM. At that point it can totally can be a lifestyle job- crank for a few years, then transition to whatever new fellowships, hopefully a bunch, are coming down the pike. But I wouldn't hold my breath for that to happen.

My relative in EM did a palliative care fellowship, they thought there was a role for end of life discussions with patients by EM docs trained in it in the ED. I don’t know enough to debate that. But I wonder if it could be an escape hatch to do palliative care instead.

 

[GimpGenius]

My relative in EM did a palliative care fellowship, they thought there was a role for end of life discussions with patients by EM docs trained in it in the ED. I don’t know enough to debate that. But I wonder if it could be an escape hatch to do palliative care instead.

Not much appetite for that, from what I'm seeing (in fellowship).

ED priority is moving the meat. A good goals of care conversation can take an hour or more if you include prep time; and that's not taking into consideration the JAFERD factor ("Meemaw's a fighter/you're not the (insert specialist here) and we want to hear from them"). That's time you spend not moving meat.

You'd also have the constant interruptions during said conversation. It's hard to hold space when you have constant task switching.

If you want to do it, you'll also have to show it makes financial sense. In small to medium sized departments or smaller, community hospitals, I don't see that happening.

Sorry to be a downer. If someone's doing that kind of work, I'm all ears on how to do it!

 

[Stellar Mudd]

Not much appetite for that, from what I'm seeing (in fellowship).

ED priority is moving the meat. A good goals of care conversation can take an hour or more if you include prep time; and that's not taking into consideration the JAFERD factor ("Meemaw's a fighter/you're not the (insert specialist here) and we want to hear from them"). That's time you spend not moving meat.

You'd also have the constant interruptions during said conversation. It's hard to hold space when you have constant task switching.

If you want to do it, you'll also have to show it makes financial sense. In small to medium sized departments or smaller, community hospitals, I don't see that happening.

Sorry to be a downer. If someone's doing that kind of work, I'm all ears on how to do it!

Would EM residency the palliative care fellowship let someone stop working in the ED and just do palliative care on the floors? Does anyone know? Because that’s what I wondered but haven’t asked them. I think they might be insulted by the question.