Don't Let It Take Everything

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bravotwozero said:
All specialties, except maybe CC, are getting squeezed in one way or another. But as others have pointed out many times over, the cluster funk that is EM is unique to the field. Exploding HCA diploma mill residencies, plus midlevel encroachment, PLUS the inability to own your own practice. Not too many fields have all 3 elements as problems. At least you can hang your own shingle as a pain doc somewhere.
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True. In my opinion, job search competitiveness shouldn't scare someone away from Pain. Yes, it's something to be aware of. You shouldn't ignore it. But desirable, niche specialties often are very competitive. By your nature, having gotten to where you are, in a competitive field, competition shouldn't deter your. It's what you do.

Is Plastic surgery not competitive in L.A.? Hollywood? NYC? Derm, in Florida? Ortho, in ski country?

Sure they are. Because everyone wants to be there. Yet still, specialists still flock to those places and seem to manage.

The EM job crunch is a whole different animal. You have no control over your volume. You can't advertise for your "practice." How hard you "hustle" and 'network,' to "get your name out there" isn't going to bring you more work. You can't add ancillary services to your practice. You can alter your situation by doing those (and other) things if you're a referral based specialists. But as an ED doc, if the ED patients aren't there, and no job is there, your options are limited. Patients don't choose you. They choose the ED.
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This.
I would advise any medical student to pick a field where they can own their own practice, whether it's ortho, urology, pain, psych, or family medicine. Avoid critical care, anesthesia, and especially EM.
 
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VYM

It may have a lower yield (3%) but still grows at 7% year after year over the long haul.

7% + 3% yield = 10%, year over year

Might also have the lowest expense ratio I've ever seen, at 0.06%

I don't own any of this right now, but I'm browsing funds for the day retirement comes, which unfortunately is still a long way off.

What do y'all think of VYM?
 
Birdstrike said:
VYM

It may have a lower yield (3%) but still grows at 7% year after year over the long haul.

7% + 3% yield = 10%, year over year

Might also have the lowest expense ratio I've ever seen, at 0.06%

I don't own any of this right now, but I'm browsing funds for the day retirement comes, which unfortunately is still a long way off.

What do y'all think of VYM?
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I generally like Vanguard's products, and have a lot of VTI and VBR. YVR invests in stocks which return high dividends. That leads to their 3% overall dividend. The downside to these ETFs is that they are volatile with the stock market, and dividend stocks generally don't appreciate as much as regular equities.
 
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GeneralVeers said:
I generally like Vanguard's products, and have a lot of VTI and VBR. YVR invests in stocks which return high dividends. That leads to their 3% overall dividend. The downside to these ETFs is that they are volatile with the stock market, and dividend stocks generally don't appreciate as much as regular equities.
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I've always thought LT appreciation would win over dividends, not to mention that it's much better tax wise. I'm curious as to your thoughts....
 
miacomet said:
I've always thought LT appreciation would win over dividends, not to mention that it's much better tax wise. I'm curious as to your thoughts....
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I'm assuming by LT you mean long-term? It depends on how close you are to retirement/FIRE. I consider myself to be at least 10 years away from that, so I've optimized my stock portfolio for gains via growth stocks, dividend or otherwise, as I have time to ride out the stock market dips. Now, if I were a year to two years away, you bet I'm going to change portfolio allocation to a 50/50 stocks vs bonds/fixed income funds.
 
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bravotwozero said:
I'm assuming by LT you mean long-term? It depends on how close you are to retirement/FIRE. I consider myself to be at least 10 years away from that, so I've optimized my stock portfolio for gains via growth stocks, dividend or otherwise, as I have time to ride out the stock market dips. Now, if I were a year to two years away, you bet I'm going to change portfolio allocation to a 50/50 stocks vs bonds/fixed income funds.
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Agreed.
I just meant why dividend not growth stocks.
Not arguing against bonds at all.
Ten more years, ooph.
 
miacomet said:
I've always thought LT appreciation would win over dividends, not to mention that it's much better tax wise. I'm curious as to your thoughts....
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Short term they are equal, we pay 23% capital gains on them. Interest on the other hand sucks. Interest from savings bonds is taxed at regular income levels.
 
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miacomet said:
Agreed.
I just meant why dividend not growth stocks.
Not arguing against bonds at all.
Ten more years, ooph.
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Long term, need growth. Short term, in retirement, favor income.
 
Birdstrike said:
Long term, need growth. Short term, in retirement, favor income.
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Correct. I'm planning to be unemployed within the next 1-2 years so need income, not growth.

I took out an interest only mortgage on my home at 2.65% interest. It's a great deal as the mortgage is tax deductible making the rate effectively <2%. Investing those in dividend funds will yield effectively 6% after taxes.
 
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I'm sure the female docs on here are either a part of, or familiar with a facebook group called Physician Mom's Group (PMG). My wife is a PCP and she's on there. Just told me there was a female EP on there, who mentioned that her husband, also an EP, killed himself. She has kids, who are now devastated and don't want her to go to work. What does she get told? "Well, you need to still fill the shifts"?

Absolutely effing disgusting. No wonder stuff like this keeps happening. No sense of compassion from the employer. We truly just are cogs to them.

'Doc killed himself? Welp, he should have attended our mindfulness webinar...'
 
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bravotwozero said:
We truly just are cogs to them.
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We are just rented mules, cogs and button pushers. A lot of workers are so why is this so bad? I get slammed a lot for my cynicism, particularly at home, with a lot of "Every job has its downsides," "This is EM, you signed up for this," "Just punch the clock and go home. Why do you let it bother you?"

Because this isn't what I signed up for.

When I went into this EPs weren't nettled by metrics and you were a professional, not an assembly line worker. And patient satisfaction was achieved when they lived, not after they didn't like their bill or their sandwich.

I don't know if my generation of EPs can be happy or fulfilled by modern EM as it's changed under our feet. Maybe the next generation will do better as they will have different, lower expectations.

Now excuse me I have to go respond to 10 emails so far this morning about missed HEART scores, sepsis fallouts, downcodes and (I s**t you not) an email from dietary about how I ordered a patient's diet wrong in the computer.
 
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Learned Helplessness is a cause of depression and can be used as a form of psychological abuse intended to control someone.

Patient satisfaction scores appear to hurt patients, so why do we still use them? Perhaps because they teach learned helplessness to EP's and cause us to be more easily controlled?

Don't do what I did for the 1st 7 years of my career and try to comply with metrics that you have no control over. Please recognize that you're a smart, capable, hard working person and that all those apparently insurmountable barriers to choosing a career path that you value are mere molehills compared to the mountains you climbed to become a BCEP.

I won't do what you tell me
 
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Wow, your jobs sound miserable. Need new med directors or something
 
docB said:
We are just rented mules, cogs and button pushers. A lot of workers are so why is this so bad? I get slammed a lot for my cynicism, particularly at home, with a lot of "Every job has its downsides," "This is EM, you signed up for this," "Just punch the clock and go home. Why do you let it bother you?"

Because this isn't what I signed up for.

When I went into this EPs weren't nettled by metrics and you were a professional, not an assembly line worker. And patient satisfaction was achieved when they lived, not after they didn't like their bill or their sandwich.

I don't know if my generation of EPs can be happy or fulfilled by modern EM as it's changed under our feet. Maybe the next generation will do better as they will have different, lower expectations.

Now excuse me I have to go respond to 10 emails so far this morning about missed HEART scores, sepsis fallouts, downcodes and (I s**t you not) an email from dietary about how I ordered a patient's diet wrong in the computer.
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Yup. The 90s were very very different...
 
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docB said:
We are just rented mules, cogs and button pushers. A lot of workers are so why is this so bad? I get slammed a lot for my cynicism, particularly at home, with a lot of "Every job has its downsides," "This is EM, you signed up for this," "Just punch the clock and go home. Why do you let it bother you?"

Because this isn't what I signed up for.

When I went into this EPs weren't nettled by metrics and you were a professional, not an assembly line worker. And patient satisfaction was achieved when they lived, not after they didn't like their bill or their sandwich.

I don't know if my generation of EPs can be happy or fulfilled by modern EM as it's changed under our feet. Maybe the next generation will do better as they will have different, lower expectations.

Now excuse me I have to go respond to 10 emails so far this morning about missed HEART scores, sepsis fallouts, downcodes and (I s**t you not) an email from dietary about how I ordered a patient's diet wrong in the computer.
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EM in the '90's:

"See the sick quick. Everyone else can wait."


'00's:

"See everyone in 15 minutes, even if impossible."


'10's

"You're to blame for everything, you unimportant cog. Fix our impossible mess or you're fired."



I was okay with sacrifice for the greater good of helping the sick. When the job became self-destruction, and accepting constant abuse and scapegoating by business people for the purpose of making them richer, I was done.

Perhaps I'm an unlucky outlier, the only one who ever experienced it this way.
 
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So, he hasn't been here in awhile - but McNinja and I are in semi-regular contact.

He's doing okay. Told me about what happened at his job site. He wanted me to share this with SDN:


" I saw something today that I'm not sure anyone else has dealt with. Our doc died while putting in a central line just an hour or so into the overnight shift. Coded him; never got him back. Skinny, healthy 61 year old doc. Literally died at work.

You know what the CMG's biggest concern was?

He's scheduled the next 9 nights.

By 2pm they had the shifts posted and we were forced to cover his shifts; less than 12 hours after his death."

Edited for completion.
 
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RustedFox said:
So, he hasn't been here in awhile - but McNinja and I are in semi-regular contact.

He's doing okay. Told me about what happened at his job site. He wanted me to share this with SDN:


" I saw something today that I'm not sure anyone else has dealt with. Our doc died while putting in a central line just an hour or so into the overnight shift. Coded him; never got him back. Skinny, healthy 61 year old doc. Literally died at work.

You know what the CMG's biggest concern was?

He's scheduled the next 9 nights.

."
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Omg..I have no words..what did he die from?
 
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Birdstrike said:
VYM

It may have a lower yield (3%) but still grows at 7% year after year over the long haul.

7% + 3% yield = 10%, year over year

Might also have the lowest expense ratio I've ever seen, at 0.06%

I don't own any of this right now, but I'm browsing funds for the day retirement comes, which unfortunately is still a long way off.

What do y'all think of VYM?
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VYM is fine, safe good thing to put money into and set it and forget it.
Same with SCHD.

Only problem with getting into them now is they are near or at an all time high. But if you dollar cost average in over time you'll be rewarded. Both are great investments. Just look at the holdings and you'll see that they are good investments.
 
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thegenius said:
VYM is fine, safe good thing to put money into and set it and forget it.
Same with SCHD.

Only problem with getting into them now is they are near or at an all time high. But if you dollar cost average in over time you'll be rewarded. Both are great investments. Just look at the holdings and you'll see that they are good investments.
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I don't really see the draw of a dividend fund. Dividends are taxable and generally just proportionately reduce the stock price.

VYM is is large cap value. Growth has been way stronger past 10 years but I realize that doesn't predict future.

That said i'm almost entirely in VTSAX and VTIAX aside from my 'f-around' percentage.
 
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What do you guys think of Target Retirement funds? I own some of Vanguard's.
 
Birdstrike said:
What do you guys think of Target Retirement funds? I own some of Vanguard's.
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They are fine but imo only worth using if you don't otherwise intend to manage your own portfolio and rebalance. Those funds rebalance automatically which is a nice feature but you have to take that into account of your broader portfolio if you are doing your own rebalancing on another portion.

vanguard 2050 is just 54% VTSAX, 34% VTIAX and 8% bonds. Vanguard 2030 is 40% VTSAX, 27% VTIAX and 33% bonds.

The target date funds are still really cheap but a bit higher fees than the index funds (ER .15 vs 0.04).

Actually the most interesting thing here I think is that vanguard is weighted ~60/40 US to international equities, which is probably more international exposure than most of us if I had to guess. I'm currently closer to 75/25 so I'm increasing my percentages into international to try and get that closer to 60/40.
 
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ERDude said:
I don't really see the draw of a dividend fund. Dividends are taxable and generally just proportionately reduce the stock price.

VYM is is large cap value. Growth has been way stronger past 10 years but I realize that doesn't predict future.

That said i'm almost entirely in VTSAX and VTIAX aside from my 'f-around' percentage.
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I am generally talking about the PIMCO closed-end funds. They aren't traditional dividend fund as they are closed-ended and invest in yield-bearing mortgages, corporate debt and other assets that produce income.

At this stage in my life, where I could be unemployed at any moment I need income from the investments rather than growth. It's an easy way to set it, and get relatively stable ~8% income per year without that hassle of worrying about selling stocks on a down day if I need money.
 
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Birdstrike said:
You must be new around here. He was killed by his job.
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This got a laugh, but if his death left 9 open night shifts then he probably did die in large part due to his work.
 
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ERDude said:
I don't really see the draw of a dividend fund. Dividends are taxable and generally just proportionately reduce the stock price.

VYM is is large cap value. Growth has been way stronger past 10 years but I realize that doesn't predict future.

That said i'm almost entirely in VTSAX and VTIAX aside from my 'f-around' percentage.
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Growth vs dividend value, an argument that will go on for the rest of time. All I know is that the broad stock market, on average, returns about 8% / year every ten years going back since the 30's. Some decades value does better, some decades growth does better.

A few things:
  • Growth (e.g. NASDAQ) has done well this past 10 years, but the 10 years prior (2001 - 2012) it was crap. Didn't return anything besides the measly dividends it paid out. Look at the chart of the NASDAQ below. Between the two vertical black lines is about 10 years. NASDAQ didn't do squadoosh.
NASDAQ.jpg


  • VYM vs QQQ (NASDAQ-100): An interesting debate. If you compare VYM vs QQQ since 1995....VYM vastly outperformed it. If you compare VYM and QQQ over the past 10 years...QQQ did much better. Here are the comparisons:

VYM vs QQQ Long Term.jpg



VYM vs QQQ Short Term.jpg


The reason for the difference is that QQQ had a decade where it didn't do anything.

Frankly, as a set it and forget it idea, VYM, or even for that matter QQQ, are probably good things. maybe have a blend of both. Throw in some international exposure, maybe eghhhhh! a bond fund, and you will be fine long term if you don't want to think about your portfolio.
 
Can we move the talk about stonks elsewhere? It's related; but deserves its own space.
 
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Dakota said:
This is the best thread I have ever seen on SDN.

I don’t post much and honestly had avoided the forums for a long time as overall I felt the vibe was too negative and wasn’t helpful.

Like others on here I have been working as an attending for years now. I always felt like I had a unicorn job - we aren’t beat over the head with metrics or patient complaints. I respect everyone of my physician colleagues in the department and our ED admin always goes to bat for us.

However, the schedule is really getting to me. Constantly bouncing between nights and days - it’s just not something that is sustainable for a career for me. Life was very different before being married with small children.

Rather than sticking with a routine that was not sustainable I decided to make a change. This summer I will be starting a fellowship and I couldn’t be more excited.

If you are not happy in this field for whatever reason think about making a change. Cutting hours, going back to fellowship, try out consulting, develop an app, get a clinical buy down by taking on more admin roles, there’s a lot of possibilities.

Everyone working in Emergency Medicine is smart and hard working - just those two traits will carry you far.
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Oooh, what fellowship?
 
FYI while one can certainly do a fellowship in wound care, it isn’t strictly necessary. I’ve seen wound care job offers that provide on the job training.
 
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