EM Attending AMA

[Rendar5]

Although there’s a pretty robust Emergency Medicine board around, I thought it might not be a bad idea to have an AMA thread on this forum for general questions in my specialty.

A little summary of my practice for some perspective: I’m an attending in a suburban community hospital and am almost 6 years out of residency. My practice is mostly community with some academics mixed in, and I have worked in suburban and urban settings, and both tertiary care, freestanding, trauma, and non-trauma settings. If anyone has any questions about my field, I’m happy to answer them to the best of my ability.

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[solitarius]

EM is known to be flexible, but I have a hard time processing that given how Type A and one-dimensional most people medicine tend to be.

1. If someone is interested in dual boarding (say EM/IM or EM/CC), how easy / hard is it to do both?
2. How flexible is it do EM? Can I find a FT job where I schedule 8 months of hard work and 4 months off?
3. I find academic medicine to be generally distasteful. Unless you enjoy research or teaching, what appeal does it offer for the typical EM doc?

 

[W19]

Soon too be an IM resident but I have heard about high burn out in EM... Can you talk a little bit about that?

 

[MareNostrummm]

Have you worked with a medical scribe?

 

[Rendar5]

EM is known to be flexible, but I have a hard time processing that given how Type A and one-dimensional most people medicine tend to be.

1. If someone is interested in dual boarding (say EM/IM or EM/CC), how easy / hard is it to do both?
2. How flexible is it do EM? Can I find a FT job where I schedule 8 months of hard work and 4 months off?
3. I find academic medicine to be generally distasteful. Unless you enjoy research or teaching, what appeal does it offer for the typical EM doc?

1. Dual boarding is not that hard, you just need to find the right program and do what you can to get rotations there. There are combined residencies for EM/IM and EM/FM out there. Critical Care can be obtained as a fellowship currently after residency and is a very popular fellowship the last few years. As for actually working both at the same time after residency, I don’t know of too many people who have done that but I know it is possible. It may be easier to do academics after that as you have created a niche for yourself. But I’m sure you can create job for yourself doing both part-time.

2. It would be very tricky to find a full time job with that schedule because that would put your partners in a bind for 4 months. It may be possible to do that through a Locums Tenems agency where they find positions for you. I do know a few rare physicians who are credentialed at several hospitals in an area and just cover shifts as needed whenever called, but this would be tricky and would most likely require to get established somewhere first and work for a corporate medical group more so than a particular hospital. So in short, it is possible but difficult to work your way into this type of setting and would probably not let you have a full time job at a specific site. Your best bet would be to look in a place like Florida where there is a season influx of patients for several months at a time.

3. Mental masturbation pretty much, which may actually be enjoyable for some personalities out there. Theoretically you can be a bit lazier by letting other residents do most of the patient interaction, procedures, and other stuff, but if you’re too lazy about it you may not actually be a good role model or teacher. In short, if you want to mostly deal with patients and act as a direct doctor do community. If you want to wax poetic about medicine, or really enjoy teaching or research, then academics may be a good fit.

 

[Rendar5]

Soon too be an IM resident but I have heard about high burn out in EM... Can you talk a little bit about that?

Burnout basically results when what you expect or want to get out of a job doesn’t meet your day to day experience. Many of the factors that result in burnout in Emergency medicine are increased emphasis on metrics (door to doc time, getting patients discharged or admitted within a certain period of time), patients with egregious behavior, people above you (mostly administrators sometimes directors) caring more about patient satisfaction than actual patient care, government and insurance intrusion into how you practice (e.g. certain insurances only paying for a 2 day admission and not a 1 night “observation” admission, making it a core measure to counsel people on hypertension if their BP is 1 point about 120mmHg, trying to get sepsis bundles completed within 1 hour of arrival to the ED even though it takes at least an hour to even establish a diagnosis of septic shock in a good portion of cases). The key honestly is to 1. Find a good job where they will actually balance stuff like metrics and patient satisfaction with the reality of medicine. 2. Have reasonable expectations of the day-to-day grind of emergency medicine. 3. Have an out. If your job is burning you out, don’t be afraid to significantly reduce your hours, switch hospitals/groups, or find an out (such as academics, urgent care, fellowships, or non-clinical work).

Have you worked with a medical scribe

Yes, I am fortunate enough to work with medical scribes at my main job. They can make my workflow much easier by allowing me to actually deal with patient care or mentally thinking about a case instead of spending time documenting. I end up seeing more patients per hour when they’re around, and on ridiculously busy days I don’t have to stay late catching up on charting.

 

[Agent Michael Scarn]

Thanks for doing this. Adding EM to my interest list after originally coming in considering IM and a surgical sub (just finished M1).

-How much do you know about patients after you admit them? I have done a few shifts in the ER this year and there have been a few patients with wacky presentations who got admitted and I was interested to know what their eventual diagnosis was.
-There's a lot of med student "sky is falling" talk around EM and midlevels. As someone who is actually in the field, what do you think the future of the field is going to be for people who are just getting into it? e.g. job market, salary, etc. I have heard there is residency expansion going on too.
-What characteristics do you think drew you to EM over IM or surgery?

Thanks!

 

[CharlieBillings]

.

 

[Rendar5]

Thanks for doing this. Adding EM to my interest list after originally coming in considering IM and a surgical sub (just finished M1).

-How much do you know about patients after you admit them? I have done a few shifts in the ER this year and there have been a few patients with wacky presentations who got admitted and I was interested to know what their eventual diagnosis was.
-There's a lot of med student "sky is falling" talk around EM and midlevels. As someone who is actually in the field, what do you think the future of the field is going to be for people who are just getting into it? e.g. job market, salary, etc. I have heard there is residency expansion going on too.
-What characteristics do you think drew you to EM over IM or surgery?

Thanks!

1. You can know as much or as little about your patients afer you admit them as you want. It's not too hard if you desire to check up on their charts after to see their eventual diagnosis. I sometimes chat with surgeons or doctors about interesting cases I admitted to them to see how everything turned out. In rare situations I'll visit someone in the ICU a day or two later to see how they're doing (though most docs don't do that).

2. The sky isn't falling. Midlevels in ED are usually major assets to overall patient care and I've never heard of doctors being pushed out to make room for midlevels. That said at all the EDs I've worked they are very experienced. They'll usually come to me once or twice a shift to go over difficult cases and I'll see a few of their patients. The big issue with the future of the field is the continuing advancement of CMG's (corporate medical groups) and the overall incorporation of medical care, but that's not anythign new and has been going on for a decade. Salaries are very good and unless you want to work in a super tight job market, you'll be able to find a job where you want after residency. There are a lot fo new residencies opening up everywhere, a lot of them kind of created by corporate medical groups to get new docs in to their folds, but plenty are simply just new programs designed to meet needs for more docs. Probably a good thing as it is an increasingly competitive field to get into.

3. General variety of care. I like pretty much every field of medicine, and do enjoy occasional procedures but have no desire to work in an OR ever. It's pretty hard to find a field that has to have a knowledge of as many fields of medicine as EM. Shiftwork, lack of being on-call, being able to forget about patient care when I go home are nice bonuses.

Does the shift schedule of EM cause difficulty in your relationships?

I think being a doctor in general causes difficulty with relationships because you are working a lot. Shift scheduling itself isn't necessarily any worse for this. In someways it can be easier because you will have plenty of days off every month, though you may be working 12 hour shifts, weekends, nights. You just have to have a significant other who is understanding and make sure you make a schedule that gives you enough time off for others (easier said than done)

 

[Money Moniker]

I'd do EM in a heartbeat if I wasn't worried about the future of the field. Here's a quote I read today from another EM attending discussing his predictions for the next 5-10 years. Depressingly, this post is in a thread titled "Are locums rates really declining" where a couple of current docs say they have noticed hourly rates going down. It's one thing to make prognostications about the future, but if there are noticeable declines in the present then that's an entirely different ballgame.

The EM bubble is going to pop in 5-10 years. There are approximately 2300 EM residency positions for PGY-1 with >15 applications for new programs. There are over 23,000 nurse practitioners and 8,000 physician assistants graduating annually. 15% of these traditionally choose emergency medicine. 22 states now allow a nurse practitioner to practice autonomously.

Large insurers are purposefully downcoding charts and not paying providers/emergency visits. Attrition rates for emergency physicians is 1.7% annually, but this has increased in the last few years due to the increasing demands on patient satisfaction, regulatory requirements, etc. This comes from 2010 data.

What I'm getting at here is that there is a big threat on the horizon. NP's will continue to advance to autonomous practice in many states, hospitals may follow a CRNA model and place NP's in emergency departments with emergency physician telemedicine oversight, and there will be a flood of emergency medicine graduates that will likely surpass the attrition rate (currently 40,000 physicians practicing emergency medicine, at 2% annually that's only 800 leaving annually with 2300 entering the market annually).

Salaries will decrease significantly in the next 5-10 years. Even at a 5% attrition rate, we are still flooding the market. Granted, some of these practicing emergency physicians are non-emergency medicine trained physicians, and the overall goal was to provide board-certified emergency physicians to staff those ER's. However, the end result will be an imbalance with supply (too many docs) and demand (too few positions) that will drive down salaries.

I can't really disagree with any of his points. As someone who would be earning my first real paycheck 5 years from now assuming a 3 year EM residency and would probably reach the magic "zero net worth" number 8-10 years from now, would I be taking a huge risk by choosing EM? I realize that EM is currently a very sweet gig financially speaking, but don't the long term trends worry you at all?

 

[Rendar5]

I'd do EM in a heartbeat if I wasn't worried about the future of the field. Here's a quote I read today from another EM attending discussing his predictions for the next 5-10 years. Depressingly, this post is in a thread titled "Are locums rates really declining" where a couple of current docs say they have noticed hourly rates going down. It's one thing to make prognostications about the future, but if there are noticeable declines in the present then that's an entirely different ballgame.



I can't really disagree with any of his points. As someone who would be earning my first real paycheck 5 years from now assuming a 3 year EM residency and would probably reach the magic "zero net worth" number 8-10 years from now, would I be taking a huge risk by choosing EM? I realize that EM is currently a very sweet gig financially speaking, but don't the long term trends worry you at all?

No worry about the long term trends honestly. That's all predicated on a static number of positions for an increasing number of providers, but there are more patients to see and that has been pretty much been continuously on the rise this whole time. All hospitals I've worked at have increased number of providers, increased hours, and added more midlevels (who have never taken the place of a doc). Maybe salaries in my field will drop in the near future, but I've seen no indications for it yet, nor do I think midlevels will take over. All fields are always in flux, GI and cards used to be money makers, now EM is, something else will be in the future.

 

[southerndoc]

No worry about the long term trends honestly. That's all predicated on a static number of positions for an increasing number of providers, but there are more patients to see and that has been pretty much been continuously on the rise this whole time. All hospitals I've worked at have increased number of providers, increased hours, and added more midlevels (who have never taken the place of a doc). Maybe salaries in my field will drop in the near future, but I've seen no indications for it yet, nor do I think midlevels will take over. All fields are always in flux, GI and cards used to be money makers, now EM is, something else will be in the future.

Bookmark this page and come visit it on 20 May 2023. See what I have predicted and see what has come to fruition. Yes, here are more patients (volumes are up 5-10% annually), but payments are down (23% in some states that are subject to Anthem's new policy). You'll be seeing more patients for less money.

I'm not trying to be a pessimist. Was just trying to convey importance of staying involved with your state legislature to limit autonomy of nurse practitioners in emergency departments. Payments will continue to decline while volumes are going up. There just isn't enough money in the pot to pay everyone what they've been paying. Patients have gotten sicker overall, and when they present to the ER, they are more complicated.

 

[Montana7000]

Any advice for matching EM?

 

[bananafish94]

I'm relatively interested in EM, but my only experience is essentially shadowing. I feel like I can't truly gauge how interested I am or if I could really see myself doing the job until I do an actual rotation. The problem is, my school doesn't have an EM rotation until 4th year which means that I wouldn't really be able to experience it until only a few months before we have to send in residency applications. And I know that EM is big on things like away rotations, etc. that have to be planned and arranged ahead of time which means I would be scrambling at the last second if I do indeed want to apply for EM. Is this a common issue? Any advice on how to approach that? Thanks!

 

[Rendar5]

Any advice for matching EM?

There's no special way to get into EM other than to make sure you do as well as possible on your USMLE's and to try and do more than one audition rotation if you can (both home and away) so that you can get good LOR's. When on those rotations just try and be as on top of your patients as you can, and trying to have plans of action on what you want to do for the patients when presenting them to the residents or attendings you work with (It is always more impressive when I have a med student tell me an H&P AND a work-up, treatment, and disposition plan, then just an H&P with sometimes a work-up plan alone)

I'm relatively interested in EM, but my only experience is essentially shadowing. I feel like I can't truly gauge how interested I am or if I could really see myself doing the job until I do an actual rotation. The problem is, my school doesn't have an EM rotation until 4th year which means that I wouldn't really be able to experience it until only a few months before we have to send in residency applications. And I know that EM is big on things like away rotations, etc. that have to be planned and arranged ahead of time which means I would be scrambling at the last second if I do indeed want to apply for EM. Is this a common issue? Any advice on how to approach that? Thanks!

It's always difficult if you're not sure if it's the right field for you exactly because of this issue. I was lucky in that I knew EM was the right field for me after shadowing in one several times. All I can really advise is that you spend enough time in the ED to see if you enjoy the environment, and seeing if you're comfortable with the types of patients you'll see on a daily basis, both pleasant and unpleasant ones. If you're very sure that you like EM, then just try and schedule audition rotations or away rotations as early as you can (I had 1 rotation, 1 tox rotation, and 1 EM research rotation, all 3 got me LOR's from EM attendings, but simple straight forward EM rotations are more than enough).

FOR BOTH THOSE ABOVE QUESTIONS, in the EM forums there is an AMA thread written by an Assistant Program Director that may have more specific or better answers than I am able to provide.

 

[MDjourneyman]

Thanks for taking the time to answer questions here!

Do you have any advice for thinking about how prestige of residency affects longer-term career options in EM? Is there a strong bias towards 4-year programs? Or does it not really matter?

To elaborate, I'm an MS3 at a top 5 med school and am increasingly questioning my interest in academic medicine or working with the sort of intense, neurotic personalities places like this might attract (or perhaps that's just internal medicine? hah). Would I be closing the door on future career possibilities (or pay?) if I just coasted and went to a mid-tier 3 year program?

 

[Rendar5]

Most programs are 3-year programs anyway so plenty of people in academics and most community docs are from 3 year programs. There isn’t any true advantage at 4 year programs in my mind; I only applied to 2 of them and didn’t rank them very high. If you’re really trying to go into academics and high up the chain in academics at that being at a well regarded program or at least one with a recognizable name is always a plus, it’s not really necessary by any means.

Thanks for taking the time to answer questions here!

Do you have any advice for thinking about how prestige of residency affects longer-term career options in EM? Is there a strong bias towards 4-year programs? Or does it not really matter?

To elaborate, I'm an MS3 at a top 5 med school and am increasingly questioning my interest in academic medicine or working with the sort of intense, neurotic personalities places like this might attract (or perhaps that's just internal medicine? hah). Would I be closing the door on future career possibilities (or pay?) if I just coasted and went to a mid-tier 3 year program?

 

[Got Em]

Thanks for taking the time to answer questions here!

Do you have any advice for thinking about how prestige of residency affects longer-term career options in EM? Is there a strong bias towards 4-year programs? Or does it not really matter?

To elaborate, I'm an MS3 at a top 5 med school and am increasingly questioning my interest in academic medicine or working with the sort of intense, neurotic personalities places like this might attract (or perhaps that's just internal medicine? hah). Would I be closing the door on future career possibilities (or pay?) if I just coasted and went to a mid-tier 3 year program?

Rendar already answered this question, but I'd like to add a couple of comments.

It sounds like a 3 year program may be just fine for you.

If your goal as an attending is to end up at an academic 4-year EM program, then going to a 4 year EM program may help. Also, some people may want to go Harvard, Yale, etc for other opportunities. For example, if you go to Harvard, you have guaranteed acceptance into Harvard's MPH program and with Yale, you can get into their executive MBA program. You will also have an increased chance of getting into other prestigious program if you choose to. With that said, since you already go to a top 5 med school, you can practically choose your fellowships/degree programs if you decide to go that route.

Otherwise, please do yourself a favor and do a 3 year program. You can also do a 3 year program + 1 year fellowship, if you want to have a niche.

 

[Lexdiamondz]

Thanks for taking the time to answer questions here!

Do you have any advice for thinking about how prestige of residency affects longer-term career options in EM? Is there a strong bias towards 4-year programs? Or does it not really matter?

To elaborate, I'm an MS3 at a top 5 med school and am increasingly questioning my interest in academic medicine or working with the sort of intense, neurotic personalities places like this might attract (or perhaps that's just internal medicine? hah). Would I be closing the door on future career possibilities (or pay?) if I just coasted and went to a mid-tier 3 year program?

Just an FYI, while you can somewhat "coast" your way into a mid-tier 3 year programme, you won't be coasting during residency. Remember that 3 year programmes are teaching essentially the same amount of EM-dedicated months as 4 year programmes, and typically in a community setting with fewer consulting services so you will be busy.

 

[Dr. Retractor]

Are there any challenges faced in adult EM that are not faced in peds EM? Can you touch on some of the differences, as much as you can as someone who I assume only does adult EM?

 

[mymembernames]

What other specialties were you considering before deciding on EM? If you could go back, would you still choose EM?