EM at the VA, future career advice

[dirtbagmedstudent]

Hey current M3 here, I’m on a full scholarship to work for the VA after residency… starting to narrow down speciality choices and torn between FM and EM. Like the variety of patient presentations for both specialties and always wanted to do small town ER coverage at some point in my career, which I could do from either specialty. Any insight into working at a VA ED straight out of residency!?

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[Tenk]

If you want to work in an ED, do emergency medicine. If you want to work somewhere else, do something else.

 

[EctopicFetus]

Hey current M3 here, I’m on a full scholarship to work for the VA after residency… starting to narrow down speciality choices and torn between FM and EM. Like the variety of patient presentations for both specialties and always wanted to do small town ER coverage at some point in my career, which I could do from either specialty. Any insight into working at a VA ED straight out of residency!?

Most VAs dont technically operate an ED. It will become tougher and tougher to find Em work for non EM people in the future. My 2cents. Also, if you think doing FM will prep you for working in a low resource low volume ED you will surely kill someone if you work there long enough.

 

[Arcan57]

3 years into working at the VA. The ED experience varies wildly. Some are almost like EDs if you squint hard enough, some of them are glorified bus shelters that offer ambulance service to real EDs. In my VISN, primary care is a dumpster fire contaminated with radium and drug resistent gonorrhea. The ED has a lot of problems but we're well staffed with primarily EM trained docs. Other VISNs may have the opposite experience. But honestly, FM and EM have almost nothing in common. Pick the type of medicine you best tolerate and run with it.

 

[pkwraith]

My experience working as resident at a VA ED that was staffed by Emergency boarded physicians only: not a bad gig. Attending pay surprisingly competitive. Benefits great, especially Pension (Gov't Pension is based on your salary and the EM salary results in a very generous pension). Minimal obgyn. Psych is super easy (someone else takes care of it). EMR is absolutely terrible (at least the original CPRS), everything about it including CPOE and documentaiton. Plenty of bureaucracy (try to figure out all the forms to fill out for massive transfusion). The patients are for the most part, very nice and patient. Guaranteed followup.

For the VA ED not staffed by Boarded physicians. Terrible is what I heard. Glorified family medicine clinic with random orders and bad airways, and people just sitting in waiting rooms all day.

My local VA just has an urgent care that sends garbage all the time to the ED.

 

[endo]

I am EM boarded and recently transitioned to working for the VA after 17 years at a very busy, high acuity shop. You could go straight from residency to the VA but you will be better prepared if you get at least a little experience in the community. Consider a part-time start with the VA and maybe doing some locums / part time community work. You still get pro-rated benefits at the VA.

Advantages to VA:

1. Patients are better / more pleasant
2. No worries on tort (FTCA)
3. My pph is ~0.6 (community was 2.1 avg)
4. Pay is commensurate w lower paying community jobs ($250/hr)

Disadvantages you probably know already - govt bureaucracy, EMR slow / outdated, some people get too lazy in those jobs, etc.

 

[GonnaBeADoc2222]

I am EM boarded and recently transitioned to working for the VA after 17 years at a very busy, high acuity shop. You could go straight from residency to the VA but you will be better prepared if you get at least a little experience in the community. Consider a part-time start with the VA and maybe doing some locums / part time community work. You still get pro-rated benefits at the VA.

Advantages to VA:

1. Patients are better / more pleasant
2. No worries on tort (FTCA)
3. My pph is ~0.6 (community was 2.1 avg)
4. Pay is commensurate w lower paying community jobs ($250/hr)

Disadvantages you probably know already - govt bureaucracy, EMR slow / outdated, some people get too lazy in those jobs, etc.

1) 250/hr is definitely not a "lower paying community job."

2) VA pay varies widely by location. Some sites are 190-200/hr. This is a "lower paying community job."

 

[rojamd]

Ive worked at va ER for almost ten years. stopped due to covid (not hiring locums). I agree with what others are saying here. Sounds like you are locked in. As someone who has done both primary care and EM, they have very little in common pratice wise. IMO, going from something to EM without training is dangersous and please don't torture poor rural communities. If you aren't well versed in intubations, codes etc, you are better off working in an urban ER that doesn't have single coverage. So many rural nightmares from providers who were sold this lie. Single coverage rural healthcare can be brutal (done it for 12 years). I wouldn't even recommend a graduate from EM residency work in a rural single coverage ER. Figure out what you like best by doing rotations and each and go with that.

 

[dozitgetchahi]

My experience working as resident at a VA ED that was staffed by Emergency boarded physicians only: not a bad gig. Attending pay surprisingly competitive. Benefits great, especially Pension (Gov't Pension is based on your salary and the EM salary results in a very generous pension). Minimal obgyn. Psych is super easy (someone else takes care of it). EMR is absolutely terrible (at least the original CPRS), everything about it including CPOE and documentaiton. Plenty of bureaucracy (try to figure out all the forms to fill out for massive transfusion). The patients are for the most part, very nice and patient. Guaranteed followup.

For the VA ED not staffed by Boarded physicians. Terrible is what I heard. Glorified family medicine clinic with random orders and bad airways, and people just sitting in waiting rooms all day.

My local VA just has an urgent care that sends garbage all the time to the ED.

When I was an IM resident, our VAMC ER was staffed by washed up FM docs that had lost their licenses in several states and basically couldn’t work anywhere but the VA. It was a well known fact that if they admitted a patient, you got them the hell out of the ERs and to the floor before someone killed them down there.

As far as the “VA clientele”…heh. Certainly there is a segment of the clientele who are pleasant…there is also a large contingent of (as one of my co-residents once put it) “angry old men with cancer”. Agree that the EMR is godawful and the bureaucracy is stifling at best.

 

[betamale]

Agree. If you would like to practice emergency medicine, please stay in a community hospital, otherwise, there will be a significant skill atrophy.

 

[cyanide12345678]

I can’t for the life of me get some recruiter on a phone regarding the VA.

How did you land a VA gig like that?

 

[endo]

The VA is still hindered by its long-standing reputation of providing sub-optimal care. It may still be true in some VAs, but times have changed in many of them. The worsening of community jobs has made the VA a hidden gem in some cases. Salary comparison from CMG to VA is not a simple task - it’s not apples to apples. I can tell you as an experienced ER doc that working at the VA can help mitigate burnout, which you will most-assuredly develop within a few years of finishing residency. But your skill will atrophy, so if you come in with limited experience you likely won’t get the skills you need in the first place.

 

[Arcan57]

The VA is still hindered by its long-standing reputation of providing sub-optimal care. It may still be true in some VAs, but times have changed in many of them. The worsening of community jobs has made the VA a hidden gem in some cases. Salary comparison from CMG to VA is not a simple task - it’s not apples to apples. I can tell you as an experienced ER doc that working at the VA can help mitigate burnout, which you will most-assuredly develop within a few years of finishing residency. But your skill will atrophy, so if you come in with limited experience you likely won’t get the skills you need in the first place.

The harder the private sector sucks, the better a government job looks. Pension, good health insurance, sovereign immunity, the fact that your pay isn't going to get cut because some division across the country from you whiffed on their productivity calculations... there are worse things.

 

[JacobMcCandles]

The harder the private sector sucks, the better a government job looks. Pension, good health insurance, sovereign immunity, the fact that your pay isn't going to get cut because some division across the country from you whiffed on their productivity calculations... there are worse things.

It's almost a Catch 22 with government jobs because the more higher paying, insurance for life, more money for less work, etc. government jobs you have, the higher the burden is on the taxpayer and the worse things likely will be in the long run.

 

[Mtbk]

I can’t for the life of me get some recruiter on a phone regarding the VA.

How did you land a VA gig like that?

I’ll send you a pm

 

[Mtbk]

I’ve been with the VA for a couple of years. Contrary to a previous post, most actual VA hospitals do in fact have an ED. That being said, every VA ED is different. There is significant variation in pay, relative staffing levels, percentage of EM trained docs, as well as specialist coverage. Some are probably unicorn gigs, others are bad. The acuity in most is relatively low. I would not recommend it for someone straight out of training. It has it’s pros and cons, and there is a major amount of bureaucratic bs. Overall I’d say it’s much better than working for a CMG at this point. You have a guaranteed salary with built-in yearly raises, great healthcare coverage, TSP with match, government pension, great job security. It’s pretty much immune from a lot of the market forces coming down the road. If anyone has questions, then let me know.

 

[Arcan57]

It's almost a Catch 22 with government jobs because the more higher paying, insurance for life, more money for less work, etc. government jobs you have, the higher the burden is on the taxpayer and the worse things likely will be in the long run.

The more money gets extracted out of the economy, the higher the burden is on those who are actually contributing to maintaining a functional government. If you've ever held a government job, it's pretty apparent that it's far more efficient to siphon money as a contractor than it is to be employed by them. Goverment mandates an 80hr/pay period (2 week) effort for ALL physicians, so the more money for less work thing doesn't quite work out.

 

[JacobMcCandles]

Goverment mandates an 80hr/pay period (2 week) effort for ALL physicians, so the more money for less work thing doesn't quite work out.

I mean work in a productivity sense and not necessarily in an hourly sense.

 

[comp1]

The contractor thing is interesting. I can tell you WITHIN the VA there is a constant massive push to reduce contracting. Everyone who works at the VA believes the VA provides superior care to contractors in general and there is immense literature to support this. The problem is that there are big monied interests politically who want a piece (or all) of VA funding. Then there are patients who aren't familiar with the wider world of medicine, get fed the media reports with the VA under the microscope, and who assume the grass is always greener that go along with outside referrals just to find out that sure enough there's an even longer wait for what they're looking for out in the community.

 

[Dr Mantis Toboggan]

The contractor thing is interesting. I can tell you WITHIN the VA there is a constant massive push to reduce contracting. Everyone who works at the VA believes the VA provide superior care to contractors in general and there is immense literature to support this. The problem is that there are big monied interests politically who want a piece (or all) of VA funding. Then there are patients who aren't familiar with the wider world of medicine, get fed the media reports with the VA under the microscope, and who assume the grass is always greener that go along with outside referrals just to find out that sure enough there's an even longer wait for what they're looking for out in the community.

Yeah vets who got fee basis’d out to the community were often disappointed by the lack of individual attention etc they got. During my VA time I think the primary care folks rarely saw more than 10-12 patients a day, which obviously isn’t enough to keep the lights on for most private practice etc.

 

[Zebra Hunter]

How many years of employment at the VA are required for pension?

 

[Mtbk]

How many years of employment at the VA are required for pension?

5 years. It would be worth 15-20k per year at that point. It goes up the longer you work there

 

[comp1]

Federal pension vests at 5 years (DCP/TSP vests at 1 year). The pension is 1% of your top 3 salary average per year worked. Once you are there for 20 years, you get a bonus 2 years, ie it goes up to 1.1% of your salary. If you leave before 5 years, you can get what you paid into the pension back, not that this is recommended because you lose all of your time in case you decided to come back to the loving embrace of the feds and have to start over with vesting.

 

[GBR0321]

I currently work full-time VA EM. I imagine experiences vary depending on location. I’m in a fairly big city. Our shop is a mix of EM and FM docs that have been doing EM for decades. I think it’s a hidden gem, but I’m glad I got experience first in the community because the acuity is lower over all (still get a good amount of sick patients). With the state of affairs of EM today, I think it’s a great place to be. Most of us moonlight elsewhere to keep skills up, make extra money, or just for more variety. Benefits are great, great malpractice environment, and there is lots of paid time off. Overall the patients are nice and appreciative. We don’t get traumas, peds, and very little women’s health. That can be a plus or negative depending on what you like. We don’t get hammered with squads. Don’t have to worry about follow up. I feel way less burnout. Downside is lower pay (I think it’s comparable though with benefits and time off), bureaucracy, and we get dumped on by the clinics quite a bit. Our shop has a bunch of moonlighters which is a good way to see if you like VA medicine.