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I saw some interesting posts about EM in the match list threads so I wanted to learn more from you all here. Cons for EM? Some of the posts hinted at oversaturation?
cons for emergency medicine?
- Thread starter theonlytycrane
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risk of oversat
burnout
shift work
dealing with the public
drug seeking patients
quick churning of patients
trying to spot zebras
some midlevel creep
burnout
shift work
dealing with the public
drug seeking patients
quick churning of patients
trying to spot zebras
some midlevel creep
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Caveat: This is something I had heard, but have not actually read and am way too lazy to even look for a source because I don't really care but...an EM attending when I was a MS4 said a study showed that the number one reason people choose EM is because of shift work, and the number one reason why people leave EM is also because of shift work. Some of the attendings here at my institution try to obviate this by working only nights and the senior guys work days only. I feel badly for those in the middle that have to switch on and off all the time. It's not physiologic.
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deleted245139
The shift swap is tough.
Nights, days, weekends, holidays... Everything is fair game. It can be grating not only personally but family as well. Your weekend is now a random Tues then Thurs. Or only sat. It can be a glass half full or empty but it's all how you percieve it.
To that end, the shifts are intrinsically tough. Your brain is switching tracks multiple times, interruptions, it can be mentally taxing.
It can also be emotionally taxing. I think it's more the compartmentalizing of emotions but none the less... You will code and lose a 2 yo, break the news to the family and crush them, and then move to the next room with a 20yo with a cold, complaining about the sandwich selection.
It's a tough job. No doubt.
There also isn't another job on Earth like it and I LOVE it. Cognitivly challenging, rewarding, always entertaining, and some of the most capable staff in the hospital. Wouldn't trade it for the world 🙂
Nights, days, weekends, holidays... Everything is fair game. It can be grating not only personally but family as well. Your weekend is now a random Tues then Thurs. Or only sat. It can be a glass half full or empty but it's all how you percieve it.
To that end, the shifts are intrinsically tough. Your brain is switching tracks multiple times, interruptions, it can be mentally taxing.
It can also be emotionally taxing. I think it's more the compartmentalizing of emotions but none the less... You will code and lose a 2 yo, break the news to the family and crush them, and then move to the next room with a 20yo with a cold, complaining about the sandwich selection.
It's a tough job. No doubt.
There also isn't another job on Earth like it and I LOVE it. Cognitivly challenging, rewarding, always entertaining, and some of the most capable staff in the hospital. Wouldn't trade it for the world 🙂
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slurpy15
Strengths:
Easyish to match
Lots of jobs
Lots of locums
Easy to relocate
Some like the medicine/environment
For now, decent coin
Weaknesses:
Shift work
Circadian issues
Few opportunities for advancement
Unstable life/contracts
CMGs
CMS/lots of regs
High, high liability
Very little to exit to as you age
Stressful
Certain areas of the country have almost no decent jobs (NY, NJ, CT) so you have to travel if you want to work
Burnout
Midlevel creep
Inability to control your work environment
Risk of oversaturation
You always have a boss
Druggies
Dealing with the public
Hard to run your own shop
EM docs aren't the brightest, but medicine in general doesn't attract the brightest
Risk of oversaturation
It's really, really hard
Easyish to match
Lots of jobs
Lots of locums
Easy to relocate
Some like the medicine/environment
For now, decent coin
Weaknesses:
Shift work
Circadian issues
Few opportunities for advancement
Unstable life/contracts
CMGs
CMS/lots of regs
High, high liability
Very little to exit to as you age
Stressful
Certain areas of the country have almost no decent jobs (NY, NJ, CT) so you have to travel if you want to work
Burnout
Midlevel creep
Inability to control your work environment
Risk of oversaturation
You always have a boss
Druggies
Dealing with the public
Hard to run your own shop
EM docs aren't the brightest, but medicine in general doesn't attract the brightest
Risk of oversaturation
It's really, really hard
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I assume day shifts are given out based on seniority so right after residency one would have to take a mix of day/night shifts?
What is a typical work week- three 12's a week?
noobie question: What does "dealing with the public" mean? Just any type of patient coming in at any hour?
great responses so far- ty 🙂
What is a typical work week- three 12's a week?
noobie question: What does "dealing with the public" mean? Just any type of patient coming in at any hour?
great responses so far- ty 🙂
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slurpy15
-Every group varies on nights/days. Basically, it's politics. Don't go into EM unless you like nights. Night folks are the happiest in EM.
-Yes, but you will burn out FAST working three 12s.
-If you have to ask, you don't understand. The public is drunk, mean, entitled, not very intelligent, and often manipulative.
-Yes, but you will burn out FAST working three 12s.
-If you have to ask, you don't understand. The public is drunk, mean, entitled, not very intelligent, and often manipulative.
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its like working retail, you dont know what dingus is going to walk through the doors and ruin your day.
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Good list.
Only thing I'd like to add is that an EM doc in another forum said this about EM: It's a great deal when you're young because you don't work often and can bounce back from the nights fairly quickly, but as you age the nights and the lack of weekend kill you.
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slurpy15
The biggest issue with EM is the lack of an exit strategy. It's a decent gig for a decade, but then what do you do?
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Where I work, all of the EM docs work varying shifts. Half of the month they are on days, half of the month they are on nights. They also work a few mid-day shifts on occasion.
This exactly.
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My medical director said if he had to do it all over again that he would pick anesthesia.
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-> EM director, or go work in some urgent care setting?
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What exit strategy do other specialties have as they age?
God gas is so boring though...
The mediolegal environment where you work largely determines the urgent care framework, and its hard to determine if its a sustainable model in alot of places.
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slurpy15
Anesthesia has it's negatives (tight job market) and I personally couldn't deal with that kind of stress, bu
Other specialties don't need an exit strategy. That's the point.
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I mean I would venture to say that the high-stress/mortality specialties like neurosurgery, trauma, CT, vascular, ortho all lead to a fairly significant level of burn out that could be described as needing an "exit strategy". I don't have any hard evidence on this but I can't imagine most of those specialties people practicing till 75.
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So far down the list, but extremely important. There's been huge residency expansion in EM. Even today a program opened looking for fifteen MS4s to fill a new program. I'd expect this to continue and have some adverse effects in regards to EM physician pay.
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slurpy15
Trauma you can scale back to Gen Surg. CT and Ortho are not known for high burnout. Neurosurgeons are nuts and do burn out, but they make a ton. Vascular can do a ton of clinic stuff.
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One of the EM docs I knew went into hospital admin and ended up as the CMO. Only so many of those jobs and probably carry a bit of a pay cut.
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I saw you post that on the EM forum and it literally made me choke on the salmon steak (baked to perfection btw) I'm currently eating. These massive corporate groups are literally starting to mass produce EM residency programs the way McDonald's has training programs for shift managers and Walmart for department managers. It's no longer possible to deny that these corporations have sat down and made the deliberate decision to begin flooding the market with new residencies to drive down hourly rates. I'm not aware that any other specialty has this kind of phenomenon. This might be my "yep, EM is dead, the only question is how soon" moment. Fark!
https://i.redd.it/py3ncok5cxm01.jpg
^^Look at this crap! They announced the creation of this program today and they're trolling for unmatched MS4s on Facebook so that they can get this corporate sweatshop of a "residency" going in just a few months from now rather than wait for the 2019 match! Unreal. Only the best candidates need apply! lol
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slurpy15
Agreed. Glad I have saved a healthy seven figures.
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What people don't emphasize enough is that the circadian rhythm issues carry a huge toll on your physical health as well. You're at higher risk for many chronic diseases just because your sleep isn't regular.
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The thing that turns me off about ER is the fact that it's literally non-stop. When you're on, YOU ARE ON.
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Yup, HCA. Not just EM programs either. They’ve been doing that all over.
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Emergency is great when all the cool stuff is happening. But reality is a bunch of druggies, old ladies with Falls, dealing with random shifts and crap schedules. I love the work of er when it was good, but it takes a special person who likes that kind of intensity day in and day out
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Doing an EM rotation now M-F 8hrs/day and all I can say is: Kudos to the EM physicians out there! You guys/gals earn that $200-250/hr.
How are these programs popping up so easily? Aren't there burdensome accreditation processes, or are these programs meeting all the standards (at least on paper)?
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I'm not gonna pretend that I have any insight as to whether HCA and other corporations are meeting the stated requirements. For all I know, maybe they are. All I can tell you is that regulations that apply to the ''little guy" don't apply to multi-billion dollar companies. That's why on paper, H1B visas can only be granted for jobs where absolutely no American workers can be found, but in reality Disney can fire hundreds of American workers and get a 1:1 ratio of H1Bs to replace them and it's all hunky-dory.
Judge Says Disney Didn’t Violate Visa Laws in Layoffs
Now that medicine is becoming dominated by billion dollar corporations like HCA, TeamHealth etc and the "little guy" is on the way out, expect the fukery to mount. We ain't seen nothing yet. I'm making the prediction right now: the next step is lobbying to remove the requirement that FMGs have to complete an American residency to obtain a medical license here. We've seen this lobbying in big tech and big agribusiness, it's only a matter of time before big medicine gets in on the act.
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slurpy15
Suggestions for survival? Hey, at least I'm debt free and mid-career. But I still need 15 more years.
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Nah, I wouldn't be surprised if they're moving in on trying to increase mid-level autonomy so they can become independent practitioners, regardless of their online degrees.
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I dont think they would be able to go that far in terms of removing requirements for residency for FMGs. I do think that @Rekt's interpretation of increasing midlevel independence to accomplish the same goals would be easier and more doable. I bet they are giving money or atleast supporting lobbying efforts by NPs.
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slurpy15
At least there is some pushback by licensing boards for the crappy midlevel programs.
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What is funny NPs are going to a similar model where Doctoral degree and some residency will be required in the future to gain more legitimacy. Why go through all that when you can become an MD you arent saving much time at that point to fill the "shortage".
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Oh, absolutely, but that is not the "next step," they are already doing that. Removing the licensing hurdles for FMGs is something that isn't yet happening but will definitely receive the ole college try at some point, particularly since midlevels are not a realistic option to cut physician salary in certain fields, notably surgery.
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slurpy15
Meh. There are minimal licensing hurdles for FMGs in the UK and Australia compared to the US (don't need to redo residency), and they still have physician shortages. Not everyone wants to come to the US, especially since it's almost impossible to get permanent residency/citizenship coming from India, Nigeria, Ghana, Pakistan, and the Philippines, which send the most docs here.
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slurpy15
Because it's a far better decision financially to become an NP. Start RN program at 18. Start working at 20. Do online BSN. Then do online NP degree, all while working full time and not accruing debt.
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I agree... But if medicine was 3+3 instead of 4+4, that would discourage people from using these 'back doors' to practice medicine. 3+3 would be more appealing for a lot of people who choose to do PA/NP.
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Well f*ck
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Agreed.
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EM is not oversaturated at all. I get calls and email on my phone daily that I ignore and block to go work someplace.
Cons:
-Shift work: some people handle this better than others. If you have never stayed up every night for 4-5 nights in a row, try it. There are ways around this like working at a place with nocturnists but may involve a pay cut.
-Patient population: it sucks and it seems to get worse over time.
-Malpractice: higher risk.
-Patient deaths: these will bother you. Especially peds. You will watch children die and you will have to face their parents. It is terrible.
-Stress: we are forced a lot of times to manage multiple sick patients at once. High stress job.
-CMGs: they are terrible and invading our field.
-Metrics: you feel like a pawn in a numbers game.
-Phone: being tied down to a phone making multiple calls to arrange care sucks.
-Consultants: some can be jerks. Most I would say are not. There are ways around this like making an effort to meet people in your hospital face to face and talk to them a bit. Seems to help.
I think those are the major cons. Lot of pros though. I think the pros outweigh the cons for me at least.
Cons:
-Shift work: some people handle this better than others. If you have never stayed up every night for 4-5 nights in a row, try it. There are ways around this like working at a place with nocturnists but may involve a pay cut.
-Patient population: it sucks and it seems to get worse over time.
-Malpractice: higher risk.
-Patient deaths: these will bother you. Especially peds. You will watch children die and you will have to face their parents. It is terrible.
-Stress: we are forced a lot of times to manage multiple sick patients at once. High stress job.
-CMGs: they are terrible and invading our field.
-Metrics: you feel like a pawn in a numbers game.
-Phone: being tied down to a phone making multiple calls to arrange care sucks.
-Consultants: some can be jerks. Most I would say are not. There are ways around this like making an effort to meet people in your hospital face to face and talk to them a bit. Seems to help.
I think those are the major cons. Lot of pros though. I think the pros outweigh the cons for me at least.
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-Burnout is high: Burnout and Satisfaction With Work-Life Balance Among US Physicians Relative to the General US Population
-Full supply in 5-10 years: The Emergency Medicine Workforce: Profile and Projections. - PubMed - NCBI
-Backup plans limited without fellowship
-Shift work difficult to sustain
-Full supply in 5-10 years: The Emergency Medicine Workforce: Profile and Projections. - PubMed - NCBI
-Backup plans limited without fellowship
-Shift work difficult to sustain
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Meh, there's no real economic benefit for anyone to be doing this. Not to the point that it makes any sense at least.
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Cons:
-Lack of fulfillment
-Lack of expertise
-Never settle with a routine and the weird hours messes with any free time you do have.
-Tied to a hospital, no outpatient/PP
-ED is an uncomfortable place to spend 12 hours.
-I’m sure midlevels will be an issue in the future, but for now they seem fine so I don’t call than an issue.
Pros:
$ and free time. It would be ideal for the introvert who has like hobbies he does alone like WoW.
Goes in for his or her 12 hours, works out, stuffs his face, spends all night playing video games, goes to bed 5 am, wakes up at 3 PM the next day and does a few errands, plays some more video games, sleeps, and goes in for shift again.
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The only way to maximize the pros of EM is to say eff it to full time gigs and go exclusively locums. Stack the pain and the gain, in the sense that you cram a bunch of shifts one month and then take extended time off to travel around or do whatever it is you want to do with your time the next month, or however else you want to stack it. Working 12 shifts a month but never having more than 2 or 3 contiguous days off at a time is hardly better than a regular M-F gig and is definitely worse than the hospitalist 7 on 7 off.
There are some sweet schedules out there in various hospital based specialties though, for sure. For example: 325K for one week on, two weeks off in New England of all places for an intensivist.
Critical Care Physician | Merritt Hawkins
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This was literally my life during residency with some girls and whiskey thrown in. It was awesome.
I don't see how having money and free time is only good for introverts though. I make a lot of money and I only work 14 days a month. I have taken like 4 snowboarding vacations this season and am going again at the end of the month.
I feel fulfilled at work. I can literally bring people back to life. That is my expertise and I am pretty damn good at it. I only work afternoons, evenings and nights which is fine with me. I get plenty of sleep. I would never want to deal with outpatient. I only work 9 hour shifts and I actually feel at peace in the ED because your ED staff becomes another family. For every thing you listed, it is pretty much a blessing for me and my life.
I agree this life isn't for everyone but most of the things you listed as negatives are actually the things that draw many of my colleagues to this specialty. Food for thought!
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Working 12 shifts a month gives you 18-19 shifts off a month except Feb. That's way more time off than most other careers in medicine. I usually have at least 5-7 days off in a row every month working 14 (if not more). It is incredibly easy to vacation any time of the year and have a great life outside of work working full time in EM. My goal is to go down to 12 shifts in a few years just because I won't need the money and would rather have more time off.
Locums is good but you have to understand that traveling + work + random hospitals is HARD. You are not usually going to great hospitals with great staff. You are usually going to places where people don't want to work. It is not easy and in my opinion is probably more detrimental to your health than just working full time at a place you enjoy. I have friends who do great with locums but none of them love their hospitals like I do. They just treat it like a necessary evil and money maker. I'd rather make money and have fun doing it (well, most of the time).
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Did you end up reading the full article (2nd one)? I'm not a member of AAEM so I can only see the abstract...which basically says there will no longer be a full-blown shortage of BC EM docs in the next 5-10 years. I can see how this could lead to decreasing pay in general...but wasn't really the point of this paper based on the abstract. Could also be a good thing for the specialty. Also, why was it published in AAEM and not Annals if the findings are that important? Definitely not disagreeing with you at all; I would just like to discuss this more because this is one of the only hang-ups I have in pursuing EM at this point. Based on the abstract, which has been posted on SDN multiple times, I'm not convinced that the sky will fall.
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Another noobie Q - Are there dual residency options throughout the country for EM + FM or IM? Perhaps only working 1 or 2 shifts a week could alleviate some of the cons. I've heard of PCPs working in UC, just not sure of EM.
