hey all... advantages of becoming an ED director? Why do people go into this? What's the salary difference? how many shifts do they end up doing? Does the the compensation tend to be about the same as regular staff ED doc, just mixed up hours between shifts and admin? Less burn out because doing different things? I've read something about usually about 50k salary which doesn't sound like a lot to really be able to reduce number of shifts if you're wanting to make the same amount.
ED director
- Thread starter EMFreakz
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Just like every group is different in the way they staff and compensate every director job is different too. For example if you are the director for a solid contract where everything works well it may be a matter of attending a meeting a month and fielding some phone calls. If you preside over a tenuous contract where administration is threatening you daily and trying to micromanage the ED docs then it's a living hell.
The money is variable. Interestingly it does NOT tend to correspond to how tough the directorship is. That's because the stable, easy contracts tend to be able to pay more than the young, unstable, high stress contracts. In my group where the contracts are stable but there is a lok of work to be done keeping up with stuff like core measures, stroke and chest pain center issues, new programs like ultrasound and therapeutic hypothermia, etc. we pay about the equivalent of 3 shifts as the director stipend. Pretty much all of the directors have to go to +/- 5 meetings a month too. So, in our group, you don't do it for the money.
One advantage directors have is that you get to know all of the administrators and other docs outside of the ED, ie. in meeting and social settings. That really makes it easier when there's a problem. For example a consultant is a lot less likely to fight you really hard when they know you from a committee you sit on together. Administrators are more likely to give you the benefit of the doubt when you're an actual person rather than just a name attached to an incident report.
Our directors also get the benefit of a failry set schedule. Most work the day shift on weekdays. We do that so that they are available to the hospital administrators. At least once a year we have them work some nights so they can see what's going on but it's mostly weekdays.
With a lot of groups there are also educational opportunities. Once a year my corporate overlord flys us all to exotic Dallas for a leadership convention which is actually usually pretty fun. We also have a meeting once a year for our regional section that is in Santa Barbara. That one's always fun.
However, the biggest reason I see as to why people do it is that they take a lot of pride in creating a good ED. It's harder than it looks. It's a real challenge and it's pretty rewarding when you see something like a stroke center, that takes a huge amount of work to get going, come together.
The money is variable. Interestingly it does NOT tend to correspond to how tough the directorship is. That's because the stable, easy contracts tend to be able to pay more than the young, unstable, high stress contracts. In my group where the contracts are stable but there is a lok of work to be done keeping up with stuff like core measures, stroke and chest pain center issues, new programs like ultrasound and therapeutic hypothermia, etc. we pay about the equivalent of 3 shifts as the director stipend. Pretty much all of the directors have to go to +/- 5 meetings a month too. So, in our group, you don't do it for the money.
One advantage directors have is that you get to know all of the administrators and other docs outside of the ED, ie. in meeting and social settings. That really makes it easier when there's a problem. For example a consultant is a lot less likely to fight you really hard when they know you from a committee you sit on together. Administrators are more likely to give you the benefit of the doubt when you're an actual person rather than just a name attached to an incident report.
Our directors also get the benefit of a failry set schedule. Most work the day shift on weekdays. We do that so that they are available to the hospital administrators. At least once a year we have them work some nights so they can see what's going on but it's mostly weekdays.
With a lot of groups there are also educational opportunities. Once a year my corporate overlord flys us all to exotic Dallas for a leadership convention which is actually usually pretty fun. We also have a meeting once a year for our regional section that is in Santa Barbara. That one's always fun.
However, the biggest reason I see as to why people do it is that they take a lot of pride in creating a good ED. It's harder than it looks. It's a real challenge and it's pretty rewarding when you see something like a stroke center, that takes a huge amount of work to get going, come together.
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I've been a director. It's a thankless job. The pay is never enough for the hassle. Remember that really cool thing about EM.....that when you're off you're off. Well, that doesn't apply if you're the director. So, sure, you're working 13 shifts instead of 16, but you're in the department 23.
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Thought I'd necro this thread in a spinoff to the Pain/EM Chair discussion. It seems like there are a lot of current and former directors on the forum which provides some expertise in the subject. There is also a lot of mystery surrounding what exactly being a director means in emergency medicine. There are many different styles of directors depending on size of shop and who owns the contract. A lot of people simplify director to "boss of the ED". In rare instances that's true, but for many of us we're the "boss of the ED" in the same way that a rodeo cowboy is the "boss of the bull". You can sort of direct it where it naturally wants to go, but a lot is out of your control. To be clear and as stated above, being a director is not necessarily an upgrade.
At the basic level, a director is the physician chosen by the group to keep the contract with the hospital. If you're in an employee model then the hospital picked you. If you're in a SDG or CMG model then the group and the hospital picked you. Once you're chosen, you're typically in charge of the things needed to keep the contract that aren't naturally taken care of by the docs. The better and more engaged your docs the less falls on your plate. These typically include:
1) Recruiting - almost every group is going to need to add a new doc at some point. Whether you're the endpoint for a national machine (Team or Envision) or are finding docs through contacts and personal referrals, you have to vet and decide who you want working in your ED. That may mean spending a ton of time in the winter months interviewing every Tom, Dick, and Henrietta new grad that the CMG can drum up to "keep the pipeline open". It may mean screening through a bunch of questionably sourced referrals from a headhunter, or manning a booth at ACEP. One constant is without proper staffing your life as a director sucks. Overworked docs burn out more quickly and cleaning up after a burned out doc is a constant source of pain.
2) Partnering with the hospital's leadership structure - your ED nursing director is your work spouse and the relationship needs to be airtight to move the ED forward. You need to be seen as an effective problem solver by the C-suite (CEO, CNO, CMO, COO). If you're not providing solutions then solutions will be provided for you (which are often heavy handed and ineffective) or you'll be replaced by someone that's more "collaborative". Keep in mind that the hospital's problems are very much your problems - inadequate staffing, insufficient physical plant, improperly scheduled ancillary staff, etc. Much of your middle career as a director will be spent managing perception as various other fiefdoms reframe hospital wide problems as problems with the ED. Example would be lack of inpatient beds due to disproportionate surgical load early in the week causing extensive prolonged holding combined with forcing the ED nurses to perform inpatient care (often on a separate documentation system then they're used to) leading to poor outcomes as patients that have been holding for multiple ED shifts either crump in the ED or immediately on arriving to the floor.
3) Dealing with patient complaints - can be a major time sink. If your relationship with your nursing director is good, they can often run interference on a lot of the more BS complaints. People unhappy about their bill, people who complain of reverse racism after being documented as verbally and physically abuse to staff, psych patients that write 10 page letters blaming one of your docs for causing the end of days. If the nursing director is pissed at you all they need to do is just refer all of these people up to you and watch as you go from being a leader to simply putting out the fire in front of you. The problem is that you're not the stopping point for these complaints. Stuff you don't handle in a timely and effective fashion usually gets escalated to hospital leadership. The hospital leadership got where they were by being good at dealing with unreasonable people, but they'll make you pay if too many complaints are making it up to them.
4) Dealing with physician complaints - see above. Complicated by perceived power differential between the "money" specialties (surgery, cards, etc.) and the ED. Dealing with these require enormous amounts of EQ as well as a realistic view of the political terrain of the hospital. Push back too strongly or inappropriately and you'll be ousted. Don't stand up for your docs and watch as morale plummets and people start heading for the door. Reframing issues in terms of patient safety can help in the short term. Teaching your docs to escalate to you in realtime and document appropriate, nonjudgemental but accurate accounts of interactions can help build a paper trail for the more abusive members of the med staff. Recorded lines are your friend but it's not uncommon to find that the call didn't record,the recording is unintelligible, or it only picked up one side of the conversation.
5) Managing the ED physicians - can range from bimonthly informational meetings in a hi speed,low drag group to spending hours a day on chart review, face to face meetings, and implementing corrective action plans. This can be an opportunity for the good parts of the job - mentoring, increasing group engagement, satisfaction of managing a well run team. It can also be some of the most emotionally difficult - docs with substance abuse issues, personality disorders, or even just completely burned out can make the job suck as their problems become your problems. Calling back a patient who is begging for answers when one of your docs completely disregarded any reasonable standard of care is a sickening feeling. You probably didn't have a lecture in medical school about what to do when one of your doc's productivity is slow to the point of endangering patient safety because they're being physically and emotionally abused at home.
6) Improving patient care, improving the lives of your colleagues, the satisfaction of creating or managing a highly complex successful system - these are the stretch goals that motivated us to become directors. When you're accomplishing these, the BS parts of 1-5 are tolerable. When you're not able to advance on these goals, you burn out at hyperspeed.
At the basic level, a director is the physician chosen by the group to keep the contract with the hospital. If you're in an employee model then the hospital picked you. If you're in a SDG or CMG model then the group and the hospital picked you. Once you're chosen, you're typically in charge of the things needed to keep the contract that aren't naturally taken care of by the docs. The better and more engaged your docs the less falls on your plate. These typically include:
1) Recruiting - almost every group is going to need to add a new doc at some point. Whether you're the endpoint for a national machine (Team or Envision) or are finding docs through contacts and personal referrals, you have to vet and decide who you want working in your ED. That may mean spending a ton of time in the winter months interviewing every Tom, Dick, and Henrietta new grad that the CMG can drum up to "keep the pipeline open". It may mean screening through a bunch of questionably sourced referrals from a headhunter, or manning a booth at ACEP. One constant is without proper staffing your life as a director sucks. Overworked docs burn out more quickly and cleaning up after a burned out doc is a constant source of pain.
2) Partnering with the hospital's leadership structure - your ED nursing director is your work spouse and the relationship needs to be airtight to move the ED forward. You need to be seen as an effective problem solver by the C-suite (CEO, CNO, CMO, COO). If you're not providing solutions then solutions will be provided for you (which are often heavy handed and ineffective) or you'll be replaced by someone that's more "collaborative". Keep in mind that the hospital's problems are very much your problems - inadequate staffing, insufficient physical plant, improperly scheduled ancillary staff, etc. Much of your middle career as a director will be spent managing perception as various other fiefdoms reframe hospital wide problems as problems with the ED. Example would be lack of inpatient beds due to disproportionate surgical load early in the week causing extensive prolonged holding combined with forcing the ED nurses to perform inpatient care (often on a separate documentation system then they're used to) leading to poor outcomes as patients that have been holding for multiple ED shifts either crump in the ED or immediately on arriving to the floor.
3) Dealing with patient complaints - can be a major time sink. If your relationship with your nursing director is good, they can often run interference on a lot of the more BS complaints. People unhappy about their bill, people who complain of reverse racism after being documented as verbally and physically abuse to staff, psych patients that write 10 page letters blaming one of your docs for causing the end of days. If the nursing director is pissed at you all they need to do is just refer all of these people up to you and watch as you go from being a leader to simply putting out the fire in front of you. The problem is that you're not the stopping point for these complaints. Stuff you don't handle in a timely and effective fashion usually gets escalated to hospital leadership. The hospital leadership got where they were by being good at dealing with unreasonable people, but they'll make you pay if too many complaints are making it up to them.
4) Dealing with physician complaints - see above. Complicated by perceived power differential between the "money" specialties (surgery, cards, etc.) and the ED. Dealing with these require enormous amounts of EQ as well as a realistic view of the political terrain of the hospital. Push back too strongly or inappropriately and you'll be ousted. Don't stand up for your docs and watch as morale plummets and people start heading for the door. Reframing issues in terms of patient safety can help in the short term. Teaching your docs to escalate to you in realtime and document appropriate, nonjudgemental but accurate accounts of interactions can help build a paper trail for the more abusive members of the med staff. Recorded lines are your friend but it's not uncommon to find that the call didn't record,the recording is unintelligible, or it only picked up one side of the conversation.
5) Managing the ED physicians - can range from bimonthly informational meetings in a hi speed,low drag group to spending hours a day on chart review, face to face meetings, and implementing corrective action plans. This can be an opportunity for the good parts of the job - mentoring, increasing group engagement, satisfaction of managing a well run team. It can also be some of the most emotionally difficult - docs with substance abuse issues, personality disorders, or even just completely burned out can make the job suck as their problems become your problems. Calling back a patient who is begging for answers when one of your docs completely disregarded any reasonable standard of care is a sickening feeling. You probably didn't have a lecture in medical school about what to do when one of your doc's productivity is slow to the point of endangering patient safety because they're being physically and emotionally abused at home.
6) Improving patient care, improving the lives of your colleagues, the satisfaction of creating or managing a highly complex successful system - these are the stretch goals that motivated us to become directors. When you're accomplishing these, the BS parts of 1-5 are tolerable. When you're not able to advance on these goals, you burn out at hyperspeed.
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Arcan is right on. I did it for 5 years. Never again.
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This is a great post by Arcan. I'm going to generalize this a bit broader and discuss the "do more" phenomenon that seems to permeate medical careers. We are all type-A, driven, personalities - we wouldn't have made it this far not being so. Even after making it through the trials of medical school and residency, we often feel an internal motivation to find that next step of the ladder to climb.
The hospitals, groups, etc. know this. They know how to capitalize on this.
Anecdotally I see this phenomenon more often in academics and non-EM fields. Physicians are forced to take on more tasks (staying late clinically without incentive pay, more call, meetings, administrative duties), without fair compensation, in the name of "being a team player." In my limited experience, the academic mega centers (who btw, make no mistake, have begun to act like mini-CMGs themselves) seem to be the most guilty of this, but I bet it's generalizable.
Oh, we're "tight on funds?" Tell me, how much the the department chair pulling and how many night shifts / holidays / weekends are they working? How much is the CEO/CMO making? This is a scam, my friends.
I'm not sure how much can be done about this systemically, but on a personal level, I resolve never to be victim to it.
We are professionals. You will compensate us accordingly for our professional time.
The hospitals, groups, etc. know this. They know how to capitalize on this.
Anecdotally I see this phenomenon more often in academics and non-EM fields. Physicians are forced to take on more tasks (staying late clinically without incentive pay, more call, meetings, administrative duties), without fair compensation, in the name of "being a team player." In my limited experience, the academic mega centers (who btw, make no mistake, have begun to act like mini-CMGs themselves) seem to be the most guilty of this, but I bet it's generalizable.
Oh, we're "tight on funds?" Tell me, how much the the department chair pulling and how many night shifts / holidays / weekends are they working? How much is the CEO/CMO making? This is a scam, my friends.
I'm not sure how much can be done about this systemically, but on a personal level, I resolve never to be victim to it.
We are professionals. You will compensate us accordingly for our professional time.
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Can any of you guys with directorship experience comment on the medicolegal exposure/risk assumed when taking such a role? I know it's not uncommon for the director to get named in suits involving some of the docs or MLPs whether he/she was working on shift that day or not. I'm sure it's probably easy to get dropped from those suits but it just seems like a lot of added stress that you wouldn't have to worry about as much as a pit doc.
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I did this for 6 years pre CMG Takeover, crazy metrics so an extra 6k/mo was somewhat worth it. But Now
1) Recruiting - Didn't do it
2) Partnering with the hospital's leadership structure - need 2k/mo
3) Dealing with patient complaints - need 2k/mo
4) Dealing with physician complaints - no biggie
5) Managing the ED physicians - no biggie
6) Meeting, metric expectation,shielding my docs from the craziness, More meetings - Need atleast 15k/mo.
They would have to pay me about 20k/mo for me to ever do this again.
I do locums now and work 12-15 shifts a month and made 500K last year. I don't answer emails anymore, no more meetings, no more patient complaints, no more metrics. I go to work, go home.
1) Recruiting - Didn't do it
2) Partnering with the hospital's leadership structure - need 2k/mo
3) Dealing with patient complaints - need 2k/mo
4) Dealing with physician complaints - no biggie
5) Managing the ED physicians - no biggie
6) Meeting, metric expectation,shielding my docs from the craziness, More meetings - Need atleast 15k/mo.
They would have to pay me about 20k/mo for me to ever do this again.
I do locums now and work 12-15 shifts a month and made 500K last year. I don't answer emails anymore, no more meetings, no more patient complaints, no more metrics. I go to work, go home.
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I got named in a lawsuit and was eventually dismissed solely because the triage nurse put my name as the attending on the triage screen when I wasn’t working. I’m not aware of any one of the directors in my previous gig that ever got roped into a suit that made it to trial because of something someone else did.
Emegentmd brings up a good point that the amount of money it would take to get a sane person to be director is usually much higher than the group would be willing to pay out of their hourly rate for a director. For a shop with 36 hrs of physician coverage per day, taking $10/hr off the top for the director still only yields a monthly stipend of $11k. Figure 100 hrs a month of admin time and decide if the stress is worth the rate.
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I thought about pursuing administration at one point, to reduce shifts and reduce exposure to burnout. But when I started hearing from guys that had done the job, that all of a sudden your phone can ring 24 hours per day requiring you to have to put out fires and deal with various administrative headaches, that it wasn't going to give me the piece of mind or normal life that I was looking for. It took me over a decade to realize it, but I'm someone who needs to have a normal life, predictable schedule and have a normal, restful, sleep/wake schedule. It might have been easier if I had come to that realization 10 years earlier, but maybe things happen for a reason. I don't know.
Regardless, being an ED director, probably wouldn't have been a good fit for me. It's a very hard job, and I'm glad there are people with the skills and desire to do it. After all, that's what makes the world go 'round.
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I also thought working fewer shifts would make me less prone to burnout. Having been a director for the last 2 years, though, I've found that working shifts are the easiest part of this job, or at least the least emotionally draining. Chew on that for a bit
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I've heard other ED Directors say that also.
