Do not go into Emergency Medicine

[andrewemergencymd]

Greetings SDN Community,


First let me start by introducing myself. I am a new PGY-3 in Emergency Medicine out of a program based in the Northeast. I am writing this out of concern for future physicians as I believe there is a lot of misinformation being conveyed to medical students, who do not have the full set of facts in front of them.

Let me be very clear. Going into Emergency Medicine is a mistake for 90% of applicants at this time. I want MS4's in particular to think very deeply about their decision before deciding to go into this field. The job market is a disaster and those individuals who would casually dismiss this are ignorant of the dynamics at play. At my home institution, I have had numerous conversations with MS4's in an advisement capacity and am truly shocked at some of the advice that they are receiving. One MS4, who very intelligently decided not to go into Emergency Medicine, was frankly told "not to worry about the job market."

Be very careful about who is providing you information. What position are they in? How established are they in their position? The advisor of this above mentioned MS4 is greater than ten years out training, fellowship trained, with a well established side gig, who has been at the same institution since training...Oh and their partner is a surgical subspecialist. When was the last time this person applied for a job in Emergency Medicine? Just a few days ago, I spoke with a recruiter at a rural health network, which, to be frank, is in a dismal part of the country tell me they recently received over 70 applications for a position. If there were half that number of applicants, what type of bargaining position would you be in? What if there were 25% of the applicants?

I have heard many MS4's, with their head in the sand, dismiss the current dynamics in Emergency Medicine to COVID. These people have no grasp of the factors involved. This totally ignores mid-level providers, corporate influence, the increased longevity of careers and the growth in residency positions.

Let me be clear, I am writing this out of concern for students. You have worked very hard to get where you are and it would be truly tragic to enter a field where you are underpaid, underappreciated, and will have diminishing opportunities going forward.

You hate rounding? You've already done away rotations? You want to deal with sick patients? You want variety? You want shift work? These are not good enough reasons to choose EM. Please take this unbiased advice from someone who actually is applying in this field. Make this decision as if your career and quality of life depends on it, because it does. Do not go into Emergency Medicine.

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[tomballunger]

Any thoughts on going into an EM residency in order to work urgent care afterwards? and if one hates rounding, wants variety, wants sick patients, wants shift work (thus might not be a great fit for IM, FM) what should one choose asides from EM? Maybe med students who find IM/FM not a great fit could do radiology, anesthesia, psych or take an extra year to try to go into surgical subs like ent uro ortho ophtho nsg direct IR? stable IM fellowships like heme onc, GI, cards, allergy have varying competitiveness, not a guarantee for anyone.

And for those who are already EM residents, what's the alternatives? second residencies? Crit care / pain fellowships, unaccredited EM fellowships? Those crit care /pain fellowships are going to be very competitive too.

 

[CopaceticOne]

I'll chime in on this topic since I have a bunch of very close friends who finished up EM residency prior to and during COVID.

Fundamentally, at the end of the day, the BUSINESS of emergency medicine has had a paradigm shift in large part due to 2 factors: 1) non-EM physician providers and 2) economics.

(NOTE: Below, when I say non-EM provider I mean everyone that did not complete an ACGME/AOGME EM residency)

I'll start with economics: Most EM docs are employed in some fashion, rather that being true full partners in a private practice group. The folks who are in charge are tasked with generating the most amount of revenue as possible - fundamentally this means spend less & bill more. What general business principles have taught them is something along the lines of: why pay 3 physicians to see 10 patients each a shift when I can have 2 physicians see 15 patients each a shift? That cuts out 1/3 of my costs but we still maintain the same billing. Also, because of COVID, they learned that they didn't have to keep their staffing numbers of these facilities as high: If we reduce our staffing by 50% but that only causes a 20% decrease in billing then we are actually ahead financially. Once people get used to the workload demands, we can increase our staffing a bit but maintain our INCREASED BILLING per provider.

Next onto non-EM providers: This has been debated and discussed ad nauseam. Irrespective of the clinical impacts and actual good patient care arguments, from a BUSINESS aspect, they are a great idea looking purely at financials. Spend less in salary/compensation for each non-EM provider. Now, for each patient visit, these non-EM providers can bill close to or the same as an EM doc. So what the money folks see is INCREASED REVENUE yet again.

Now with both of those you have created the perfect conditions for a deteriorating job market for new grads. Less overall need for EM docs because of 1) using non-EM providers and 2) less staffing slots that need to be filled. Now, add in all of the hungry brand new EM grads who were told they get to have this amazing lifestyle of a few shifts a month getting great pay while living in awesome locations and you get... competition for the prime locations. This leads to the employer having more power during the hiring process leading to reduced wages for more work being offered. Heck, if you don't take it someone else will right now.

And that is how the EM job market is these days: Money, Location, Lifestyle - pick one. If you are lucky you just might be able to have two of them. If you get all three go out right now any buy a lottery ticket.

I'm not trying to be all doom & gloom, but students are being done a disservice by pretending these things and situations don't exist. The fundamental way that health care is being provided to patients in the USA is not what it was 20-30yrs ago. You see it in every field of medicine. In the end choose a field of medicine that you enjoy the majority of things and can tolerate its BS the best. New grads likely won't be making mid-high 6 figures. But you aren't going to be impoverished by any stretch of the imagination.

 

[FrkyBgStok]

You say that EM is not right for 90% of applicants. I guarantee that 90% of the people reading this are thinking “I am part of the 10% it is right for.”

 

[deleted50541]

And that is how the EM job market is these days: Money, Location, Lifestyle - pick one. If you are lucky you just might be able to have two of them. If you get all three go out right now any buy a lottery ticket.

I'm not trying to be all doom & gloom, but students are being done a disservice by pretending these things and situations don't exist. The fundamental way that health care is being provided to patients in the USA is not what it was 20-30yrs ago. You see it in every field of medicine. In the end choose a field of medicine that you enjoy the majority of things and can tolerate its BS the best.

Great breakdown. I'm in a surgical sub-specialty that isn't facing this kind of scenario necessarily. But having been through the job market recently, I can completely relate.

My first job out of fellowship was an academic position at my training institution. Loved my colleagues and the support staff I worked with. But the hospital system was undergoing rapid expansion including the takeover of a hospital about 20 miles away. I was never interested in working at multiple hospitals, but all of a sudden my partner and I were being told (not asked) to provide coverage at this hospital as well without a guarantee of extra pay or supporting staff. This was in addition to providing coverage for a VA hospital about 40 miles away, which fortunately did pay since it was a separate pay line. We were both stunned that we had no input into this decision and didn't see how it'd be feasible to do with just two people while supporting our primary activities at the main academic hospital. I'd dealt with a lot of BS already, but this was the final straw.

Since this was not what I signed up for, I made the decision with my wife to look for another job. Found a great position closer to family with a much better lifestyle and never looked back. When I left, administration backed down on my partner and hired a dedicated CT surgeon for their new hospital.

 

[SkullbaseFoLyfe]

Honestly very surprised to hear this. Know nothing about the EM job market but would have assumed that it is fairly decent given the sheer number of ERs that exist around the country. Curious to hear what types of job offers people are getting in desirable cities vs. 'middle of nowhere'.

 

[CyrilFiggis]

. What general business principles have taught them is something along the lines of: why pay 3 physicians to see 10 patients each a shift when I can have 2 physicians see 15 patients each a shift? That cuts out 1/3 of my costs but we still maintain the same billing. .

This statement was obviously written by someone who doesn’t work in an ED. If I only saw 10 patients in a shift as a resident I would have been held back.

All EDs are loss-leaders for a hospital. I agree with OP that corporate EM is a malignancy in our profession. However, I’m also at northeast EM program and have seen all my peers find gigs easily. What I would tell applicants is to stay away from new programs. They have no reputation, no network, and can’t provide those opportunities for new grads.

 

[workaholic007]

This statement was obviously written by someone who doesn’t work in an ED. If I only saw 10 patients in a shift as a resident I would have been held back.

All EDs are loss-leaders for a hospital. I agree with OP that corporate EM is a malignancy in our profession. However, I’m also at northeast EM program and have seen all my peers find gigs easily. What I would tell applicants is to stay away from new programs. They have no reputation, no network, and can’t provide those opportunities for new grads.

i heard the same. new programs hard to find jobs. established programs i heard are fine

 

[Lexdiamondz]

This statement was obviously written by someone who doesn’t work in an ED. If I only saw 10 patients in a shift as a resident I would have been held back.

All EDs are loss-leaders for a hospital. I agree with OP that corporate EM is a malignancy in our profession. However, I’m also at northeast EM program and have seen all my peers find gigs easily. What I would tell applicants is to stay away from new programs. They have no reputation, no network, and can’t provide those opportunities for new grads.

Not true in the least. This may be the case at academic centres, but in the community there are plenty of ERs that operate in the black. Were that not the case, freestanding ERs wouldnt be popping up all over the place.


RE: the job market - as a 2021 grad from a very established program I gotta say the job market isn't great. It's better for people from "good" residencies, but it's certainly not good and even going to an established program won't guarantee a good job.

 

[Doctorswithborders013]

Not true in the least. This may be the case at academic centres, but in the community there are plenty of ERs that operate in the black. Were that not the case, freestanding ERs wouldnt be popping up all over the place.

Is this true? Or are ED's running very much in the red but can accumulate enough overall income from admits/specialty referrals that hospitals keep building them? Isn't the whole point of these community EDs to just increase the range of the hospital network?....go to your local emergency for a broken hand and choose to go to the closest one...its a "Medicine for Money Hospitals" ED so now you are getting splinted/prescribed "I feel nothing" meds/told you are the best person in the whole world and also leaving with a referral to "Medicine for Money Hospitals" very own Hand Surgeon. Also, aren't a lot of these contracted docs anyways?

 

[Lexdiamondz]

Is this true? Or are ED's running very much in the red but can accumulate enough overall income from admits/specialty referrals that hospitals keep building them? Isn't the whole point of these community EDs to just increase the range of the hospital network?....go to your local emergency for a broken hand and choose to go to the closest one...its a "Medicine for Money Hospitals" ED so now you are getting splinted/prescribed "I feel nothing" meds/told you are the best person in the whole world and also leaving with a referral to "Medicine for Money Hospitals" very own Hand Surgeon. Also, aren't a lot of these contracted docs anyways?

I think you're confusing a FSED with a community ER when they aren't one and the same.

When it comes to community ERs sure there is a wide range of ERs that run the whole gamut financially speaking. FSEDs for the most part are not always tied to any hospital system, so the argument that they earn $$$ from admits and specialty referrals is incorrect.