EM docs practicing outside of the ER

[jascher]

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Hey people,

This is my first post apart from the mandatory introduction I was directed to give. I'm a 4th year medical student just now applying for the 2008 match in emergency medicine. I don't care to ask about how competitive I am, or where you think I would be happy (since you obviously already know).

Instead, I was wondering how many emergency physicians out there practice either exclusively, or primarily, in a non-ER setting. Of course, I'd extend that question to residents who plan on pursuing such a career.
To explain myself, I'm not suggesting that my goal is to avoid working in the ER--my month's experience there during 3rd year is what convinced me that EM was for me. But I do have this fantasy of dodging a life of nights, weekends, and holidays by working in a more-or-less private urgent care setting. I'm sure that has its challenges.

On the other hand, it's not as glamorous a goal to shoot for as some other scenarios I've read (e.g. the EM doc who works as staff physician for a ski resort in Colorado for one season, then becomes a staff physician on a cruise ship the next).

Personally, I see myself enjoying the emergency room for the early portion of my career, then wanting to settle into something private/flexible. I'm also contemplating a sports medicine fellowship...so the options appear to be out there.

What do you guys say? Any experiences to share? And what are the challenges to establish/maintain that kind of a career?

Thanks!
Joel

 

[deleted109597]

You want to do urgent care? Go FM.

 

[Xerxes1729]

I don't know about your broader job prospects, but I lived near a ski resort in Colorado before med school, and the resort's "medical director" was one of the local ortho guys. It's not a full-time or even half-time job. On the other hand, if you were a doctor in town and went through ski patrol orientation, you could get a free season pass by agreeing to be on the mountain a certain number of days each season while carrying a radio. I think the resort got some sort of insurance discount for having a physician on site.

 

[iatrosB]

Don't think that you can escape nights and weekends in an urgent care center.

 

[kungfufishing]

Please do not delude yourself as to the schedule in EM.

 

[ccfccp]

I think the thing I would remind you of is that you're going to work occasional nights and weekends in almost any specialty you choose (excepting maybe derm and a couple others)... especially if you go private practice and you have to worry about being on call for your patients and splitting call with your practice.

The big thing to remember about the schedule in EM (and I can't imagine it would be too much different in an urgent care clinic) is that the hours are somewhat erratic. There usually isn't a 9-5 type job.

But hey... I'm a 3rd year... I just think it would be nice to not be losing $110 per day.

 

[ccfccp]

Ooh! that was my 100th post. Yay me.

(I know... I'll try to contain the enthusiasm... I'm post-call...)

 

[jascher]

I see the slight tone of facetiousness escaped some of you. I used the word "fantasy" with intent. Now to respond to some of the responses:

First, I'll reiterate that I do enjoy working in the ER...thus family medicine would be somewhat impractical. Regardless, I hope you're not suggesting that emergency trained physicians are not well-suited to (or oft-found in) urgent care settings. And I would wager that most EM docs feel they would do a better job than family docs in that arena.

Please do not delude yourself as to the schedule in EM.

I think this is good advice...but I'm not sure what you mean since I made no speculations regarding EM schedules other than the concession that one may be expected to work nights, weekends, and holidays. Obviously the ER is still open at these times. I get the impression that you're telling me I'm a wimp and I should reconsider my career choice for even raising the question that I did. Maybe you can elaborate.

Another poster cautions against the belief that one can escape nights and weekends in urgent care. Well, from my little bit of research and experience, this is probably a fair warning, but hours of operation are rather variable. Most of what I've read/seen involves an extended daytime operation (i.e. 7 AM to 8 PM) during the week, and shorter hours (8 to 4) on weekends. And these centers are usually staffed by more than just one physician. Can anyone relate some experiences here? Anything more substantial than a one-liner challenging the original question rather than answering it?

As for the journeyman-resort-physician concept, I appreciate the info but I mentioned that just as a random example of an even more fantastical job choice than, well, urgent care for example. I did read about the idea on an EM residency site though.

Really, I don't want to ruffle any feathers here...just satisfy my curiosity as to whether EM physicians do work outside of ERs, and in what capacity. I'd like to take this beyond the urgent care thing, too. Like I said, I've read of examples where this occurs, but I was hoping someone could speak from experience. Might just be my perception, but I feel like I'm already on the defense and that wasn't my expectation. I'm not looking for advice on which specialty to pursue (that's why I'm in the EM forum) or suggestions that I'm completely misguided, though I admit I'm uninformed (again, that's why I'm in the EM forum).

And since I must seem like the guy who wants to duck the hours, I'll leave everyone with this... the only place in medicine where I heard a doctor complain about working 160 hours a month was in the ER. I worked 72 there that week (plus 3 for grand rounds)...didn't get paid and still had a great time. 😉

 

[kungfufishing]

The point wasnt to insult you. Weird schedules are a reality in this specialty.

It sounds like you would like to practice boutique EM, which to my knowledge doesnt really exist.

The schedule is an integral trade off in the job - do you think that most who do it wouldnt like it even better if it were 9-5 without weekends and holidays?

Taking an EM slot without the intent of becoming a practicing EP is a waste of your time, not to mention the time and effort spent by faculty, nurses, support staff in training you.

Why would you focus your training - a significant endeavor - on an environment that you dont intend to practice in?

 

[TysonCook]

Just don't be the like the Urgent Care doc who sent a 38 yo f to me tonight with a note written "patient with abdominal symptoms. Go to ER and have pelvic US to rule out cancer".

Apparently she went to the care center, where the MD asked her some questions, ignored the fact that she had urinary sx, didn't dip her urine, and worst of all, didn't even do a physical exam. Just sent her our way.

Seriously, not dipping a urine, and NO EXAM, then gives her an ulcer by stating she may have cancer...😱

My attending an I both convinced her to go back and get her $ back. (and no we didn't scan her, urine was dirty as well as vag DC)

 

[deleted6669]

for what it's worth I have worked in several urgent care settings over the years with both family medicine and em docs. all these places were either open 24/7 or opened at 7 am and closed late(between 9pm and 1 am). they were all open 365 days/yr including holidays obviously.
the 9-5 schedule only really exists in some ambulatory family medicine same day clinics.
it's the nature of both em and urgent care to work long hrs and have lots of time off. where else can you have a full time job and have 18 days off every month?
it's a fair trade off even after 20 yrs.

 

[deleted109597]

First, I'll reiterate that I do enjoy working in the ER...thus family medicine would be somewhat impractical. Regardless, I hope you're not suggesting that emergency trained physicians are not well-suited to (or oft-found in) urgent care settings. And I would wager that most EM docs feel they would do a better job than family docs in that arena.

That's a negative, because urgent care is more medication followups than the ED. Specifically, the stuff people think they need to get taken care of, but not so urgently that they need to go to the "emergency" place. Usually this involves the sniffles and whatnot. EM would be overtrained to the acuity, but undertrained for BP med maintenance, DM maintenenance, etc.

 

[jascher]

The point wasnt to insult you. Weird schedules are a reality in this specialty.

It sounds like you would like to practice boutique EM, which to my knowledge doesnt really exist.

The schedule is an integral trade off in the job - do you think that most who do it wouldnt like it even better if it were 9-5 without weekends and holidays?

Taking an EM slot without the intent of becoming a practicing EP is a waste of your time, not to mention the time and effort spent by faculty, nurses, support staff in training you.

Why would you focus your training - a significant endeavor - on an environment that you dont intend to practice in?

Thanks for the elaboration! Your first point is well taken. Again, just looking for more experiences to back up my reading that some EM docs actually do work outside of the ER, even if only part of the time. It's a curiosity thing.

As for your last 2 paragraphs, I feel obligated to respond a little more harshly. I know you're an avid poster (and presumably a knowledgable one), but the statement/question you pose suggest that you did not read what I previously said, or that you simply don't believe me. I enjoy working in the ER, and plan to do so for many years despite having other interests/desires for the latter portion of my career. Thus, the "waste of time" comment, while true as a generality, is irrelevant at best here. And your closing question, while probably rhetorical, has the same lack of applicability (see above, plus previous 2 posts for my repeated explanations that I do "intend to practice in" the ER).

Forgive me for thinking ahead, and outside of the box.

 

[Apollyon]

for what it's worth I have worked in several urgent care settings over the years with both family medicine and em docs. all these places were either open 24/7 or opened at 7 am and closed late(between 9pm and 1 am). they were all open 365 days/yr including holidays obviously.
the 9-5 schedule only really exists in some ambulatory family medicine same day clinics.
it's the nature of both em and urgent care to work long hrs and have lots of time off. where else can you have a full time job and have 18 days off every month?
it's a fair trade off even after 20 yrs.

In my area, ALL of the Urgent Cares - bar none - are closed by 9pm, every night.

This is just to be illustrative and non-deceptive. Were there a 24h UC here, I would keep them in business in spades.

 

[Apollyon]

Forgive me for thinking ahead, and outside of the box.

Give your ego a LARGE rest.

 

[zinjanthropus]

Give your ego a LARGE rest.

actually, given the fairly stale replies thus far, I would have to say the OP is trying to see things a little differently and I don't think we should go into EM residencies just to become shift-after-shift EM physicians if that's not what we want out of a program (not that there is a problem with that if that is what you are looking for)...our training can encompass more than what is expected of us and that is how a field moves forward and evolves....so, let's not crush each other here when a different take on something is offered

 

[Apollyon]

actually, given the fairly stale replies thus far, I would have to say the OP is trying to see things a little differently and I don't think we should go into EM residencies just to become shift-after-shift EM physicians if that's not what we want out of a program (not that there is a problem with that if that is what you are looking for)...our training can encompass more than what is expected of us and that is how a field moves forward and evolves....so, let's not crush each other here when a different take on something is offered

Between this and your take on doling out pain meds by the handful, I think that you - as a student - do not have a very good image of what the realities of emergency medicine are.

You call them "stale replies", and those of us in "the real world" are telling it like it is. There's a disconnection in there, and I think (although it's only my opinion) that people that are "in it" have a little more weight.

And, I don't know where you come from, but someone patting themselves on the back for being "forward thinking" and "thinking outside the box" DO need an ego rest. After all, the following sentiment does have some merit: "If you are doing that good of a job, you don't need to pat yourself on the back, because someone else will be doing it". That is not the case for the OP (at least here).

 

[zinjanthropus]

Between this and your take on doling out pain meds by the handful, I think that you - as a student - do not have a very good image of what the realities of emergency medicine are.

You call them "stale replies", and those of us in "the real world" are telling it like it is. There's a disconnection in there, and I think (although it's only my opinion) that people that are "in it" have a little more weight.

And, I don't know where you come from, but someone patting themselves on the back for being "forward thinking" and "thinking outside the box" DO need an ego rest. After all, the following sentiment does have some merit: "If you are doing that good of a job, you don't need to pat yourself on the back, because someone else will be doing it". That is not the case for the OP (at least here).

I have never condoned "handing out pain meds". You need to read with less antagonism in your head when you approach a post about why we should NOT be scared of pain meds and another thread dedicated to alternative ways of practicing EM as a career.

Anyway, I'm not trying to start an internet shouting match - I just didn't find the previous responses very useful for the OPs original point and my goal was simply to move the thread back to thinking of interesting things physicians do other than show up, work a shift and leave.

You have attempted to "win" your argument twice in two threads now by "pulling rank" - even though I discussed my perspective as "borrowed" from a veteran EM physician, offering their view on the subject matter that is shaping my own. If you are really interested in being a leader or dominating by rank, than lead by the examples you give instead of the conflict you are creating.

 

[Apollyon]

I have never condoned "handing out pain meds". You need to read with less antagonism in your head when you approach a post about why we should NOT be scared of pain meds and another about ways to practice EM differently.

Anyway, I'm not trying to start an internet shouting match - I just didn't find the previous responses very useful for the OPs original point and my goal was simply to move the thread back to thinking of interesting things physicians do other than show up, work a shift and leave.

You have attempted to "win" your argument twice in two threads now by "pulling rank" - even though I discussed my perspective as "borrowed" from a veteran EM physician, offering their view on the subject matter that is shaping my own. If you are really interested in being a leader or dominating by rank, than lead by the examples you give instead of the conflict you are creating.

Whatever, dude. If you read acrimony into what I write, you do that. All I know is what I see day in and day out. EM is largely "show up, work a shift and leave". If you don't get that yet, you will.

Don't psychoanalyze me - if I was "really interested in being a leader" I would do it. From now, I shall not address your naïveté - it is good that you are developing such lofty (and mildly abstract) ideals. I just don't want you to be distressed when reality sets in.

 

[EM_Rebuilder]

OP:

I will try to stay on target here and just go for answering your question. I am an intern so you know my perspective.

It sounds to me that you are much more looking for a 'Doc in the Box' type practice. Possibly your own corner store, emergent care $49 for whatever ails you. Open 9-5, never on weekends or hoilidays. I believe such a 'practice' does indeed exist however, I would strongly consider Family Medicine to gear you for such a practice. Much of what EM sees is primary care, but in what you discuss, you should be more inclined to refills BP meds, DM meds, etc...where EMs background is to not do the such.

Also, the acuity you see will be mucho lower than what you should see in an EM trained setting.


Also, techincally if you open just a cash shop, you could do a preliminary year and then quite residency. That is state specific, but most require only USMLE passes and one year of post grad training (assuming you are a US grad).


So I think the take home that others are saying to you is why bother which a much more intense and competitive residency training such as Emergency Medicine, and do a Family Medicine residency in a more rural type setting where you can hopefully get lots of 'urgent care' type stuff.... in the end, you goals will probably be met better.


I once considered FM rather strongly as my end goals are to be very mobile in my career and to be able to work as little or as much as I want (I almost fell in the trap of 'do family medicine and just work in the ER'). In the end, I saw that I would be considerably more marketable as an EM boarded doc. We differ though in that I hope to work all weekends and nights are cool with me as well. I would like to be a professional moonlighter that works any place that needs me....Podunk or Level I trauma center.......We'll see.

Good Luck whatever you do...

 

[jascher]

Don't psychoanalyze me

The irony just made me puke in my mouth a little bit. Didn't that little spat start with a comment on my "ego?" The point is, some of you are missing the point. Let's forget about hours altogether. And I think enough has been said about urgent care. Is there anybody who happens to be the team doctor for a local high school football team on the side? I know an EM doc from back home who does that. Anyone actually spend time on staff at a camp, resort, or wilderness expedition? I mean, anything...bland or outlandish...any experiences to speak of?

I think it's ridiculous that so many people post and so few attempt to answer the question. I also think it's ridiculous that I've had to say this more than once. I thought this was a relatively simple topic. If you think it's rare or unusual for an EM doctor to practice outside of an ER, you can probably find tactful ways of saying it. If you know some examples of EM physicians who do just that (and despite the protest, it apparently does happen), you should happily share.

Whether or not my ego is at play here, I wouldn't back down from my view that this curiosity stems from a certain sense of foresight. And I wouldn't call it "thinking outside the box" if so many of you didn't seem stuck in one. Can't make me feel bad about that. 😀

P.S. Relax. I'm only half-serious.

 

[Apollyon]

The irony just made me puke in my mouth a little bit. Didn't that little spat start with a comment on my "ego?" The point is, some of you are missing the point. Let's forget about hours altogether. And I think enough has been said about urgent care. Is there anybody who happens to be the team doctor for a local high school football team on the side? I know an EM doc from back home who does that. Anyone actually spend time on staff at a camp, resort, or wilderness expedition? I mean, anything...bland or outlandish...any experiences to speak of?

Against my better judgment...

I don't care if you puke all over yourself or the floor. What you asked was "exclusively, or primarily" outside the ED setting. That number is close to zero. Now you come back and say local football team, camp, resort, wilderness expedition...almost no one (maybe no one) can make a living on that, and have to work in "the pit".

That's not forward thinking or outside the box - just use the search function. Had you done that, none of this would have come about. Use the search function, and you will find that people have done that. However, NOT "exclusively, or primarily" - which WAS your initial question, and NOT what you are asking now.

"Exclusively, or primarily", to do EM, then not work in one (or equivalent, like a cruise ship - but they won't hire you unless you have worked in an ED), is, most likely, heavily overkill.

 

[jascher]

Against my better judgment...

I don't care if you puke all over yourself or the floor. What you asked was "exclusively, or primarily" outside the ED setting. That number is close to zero. Now you come back and say local football team, camp, resort, wilderness expedition...almost no one (maybe no one) can make a living on that, and have to work in "the pit".

That's not forward thinking or outside the box - just use the search function. Had you done that, none of this would have come about. Use the search function, and you will find that people have done that. However, NOT "exclusively, or primarily" - which WAS your initial question, and NOT what you are asking now.

"Exclusively, or primarily", to do EM, then not work in one (or equivalent, like a cruise ship - but they won't hire you unless you have worked in an ED), is, most likely, heavily overkill.

You're absolutely right about my original question...and I haven't deviated from my desire to hear of any examples message boarders might have. The examples in my last post were admittedly a stretch intended to spark anything at all relevant to the subject of the original post, "EM docs practicing outside of the ER." I know you're probably getting picky because of some deeper emotional issues and a burning desire to transform dialog into (winnable) argument.

Truth is, I'd like to hear about all of it, and I certainly wouldn't oppose a career that begins with 10-15 years of ER work, and continues with 10-15 more outside of one (though preferably without a 2nd residency). Then after 20-30 years of medicine, I'll enter the NBA draft. I mean, you don't have to be a jerk for the sake of being a jerk. I searched online, and read about some examples of what I've been talking about, then brought the question to a forum to gain more insight.

Anyway, I never used the term "forward thinking" but when I said I was "thinking ahead" and demonstrating "foresight," that there meant I was considering my future. Why are you telling me that I'm not thinking about my future?

And I can tell you're really offended that I'd claim to be "thinking outside of the box." I was merely defending myself (god knows why)...like I said, it wouldn't feel that way if so many people didn't have such a narrow view of the field. Then you tell me that the number of people who do what I originally inquired about is "close to zero" and say it's not "thinking outside the box" to ponder those alternatives...that there is contradiction. Besides, I'm only entertaining ideas.

So go ahead and find something else to quibble on (I know you will), or insult me if that feels good. You sound more bitter and anal than a surgeon. 😉

 

[chumbojumbo]

You're absolutely right about my original question...and I haven't deviated from my desire to hear of any examples message boarders might have. The examples in my last post were admittedly a stretch intended to spark anything at all relevant to the subject of the original post, "EM docs practicing outside of the ER." I know you're probably getting picky because of some deeper emotional issues and a burning desire to transform dialog into (winnable) argument.

Truth is, I'd like to hear about all of it, and I certainly wouldn't oppose a career that begins with 10-15 years of ER work, and continues with 10-15 more outside of one (though preferably without a 2nd residency). Then after 20-30 years of medicine, I'll enter the NBA draft. I mean, you don't have to be a jerk for the sake of being a jerk. I searched online, and read about some examples of what I've been talking about, then brought the question to a forum to gain more insight.

Anyway, I never used the term "forward thinking" but when I said I was "thinking ahead" and demonstrating "foresight," that there meant I was considering my future. Why are you telling me that I'm not thinking about my future?

And I can tell you're really offended that I'd claim to be "thinking outside of the box." I was merely defending myself (god knows why)...like I said, it wouldn't feel that way if so many people didn't have such a narrow view of the field. Then you tell me that the number of people who do what I originally inquired about is "close to zero" and say it's not "thinking outside the box" to ponder those alternatives...that there is contradiction. Besides, I'm only entertaining ideas.

So go ahead and find something else to quibble on (I know you will), or insult me if that feels good. You sound more bitter and anal than a surgeon. 😉

so, ahhh...can we all go out for some beers now?😀

 

[Bigbaitbigfish]

Ok, after wading through the BS - 1 option, you can do a hyperbaric fellowship and run wound care clinics. Set whatever hours you want, but you'd be on call a little bit. Or, if you don't mind not making as much, do it no call and let the scuba dudes and life threatening wounds go somewhere else.

 

[DrQuinn]

Personally, I see myself enjoying the emergency room for the early portion of my career, then wanting to settle into something private/flexible. I'm also contemplating a sports medicine fellowship...so the options appear to be out there.

What do you guys say? Any experiences to share? And what are the challenges to establish/maintain that kind of a career?

Thanks!
Joel

Joel-

I am 15 months out. I work primarily (i.e. 100%) in the "pit" for 100% of my income.

Of all the docs that work with me, as far as I know, 100% of them get 100% of their income from working in the ED.

Anecdotally, I have heard of a handful of doctors who either open up urgent care clinics, or open up med spas, or just work as a "grunt" in someone else's urgent care clinics.

I also know of some EP's after several years who work in the Kaiser Permanente urgent care clinics.

It would be very difficult to earn an attending's salary being a high school football team doctor, or any of the side jobs that were mentioned so far in this thread. As much as I would love to do that sort of thing, I can't take hte pay cut, as my time off is pretty precious to me (I work full time, and have a 5 month old at home with a wifey), so, unless it makes financial sense for me, at this point in my career, I'm not going to do it. I have a new mortgage, two car payments, my loans, and my wife's loans. So, the best wya to tackle that sort of thing is to work full time in an ED. 5-10 years down the road (maybe sooner) I may stretch out and do "something on the side" but at this point, its still in the planning stages.

Good luck! And, in my opinion, I do think an EM residency is a good fit for you. It allows you a broad knowledge base, and the opportunity for fellowships is broader for EM than FP.

Q

 

[Apollyon]

In the interest of collegiality (in between my fits of "deep emotional issues" <-- ??), I shall respond to the OP's question in long detail.

In short, for the EM grad directly out of residency, options for non-EM (exclusively or primarily) jobs are essentially nil. Many of the options that will get you out of the ED need a fellowship (accredited or not), but, with one exception, they still require time in the ED for a few reasons (not enough work in the outside fields to sustain, and the skills edge needs to be maintained in the ED for the outside job to want you).

Accredited fellowships now are sports medicine, toxicology, hyperbarics/undersea, and peds. Of the first three, none has enough business to work only and exclusively in that field - it's either an "as needed" thing (tox and hyperbarics), or a clinic thing (and sports med is limited because you're non-op - anything that is beyond PT/OT goes to ortho for definitive treatment). Not enough work for full-time sports comes from anecdotal evidence from several EM-based, fellowship trained sports docs. That may vary elsewhere.

There just aren't enough people suffering hyperbarism or nitrogen narcosis or bad enough gangrene to need high pressure O2 for it to be a full-time thing. Tox is a consult service, and goes case to case. I mean, if there were that many toxic overdoses, everywhere would have a tox person, right? Instead, if you call 1-800-222-1222 (which will get you the closest poison center to you, anywhere in the US), you get a nurse screener, with the tox person on-call. I mean, they can give advice, but, as an EM doc, you can implement it.

Other EM positions from unaccredited fellowships are variable, like EMS, tactical, event/group, wilderness, cardiovascular disease, acute neurovascular, administration, and, now, geriatrics, to name a bunch. The cardio, neuro, and geri directly need you to be in the ED or in the pipeline - but those fellowships are designed to bring "it" to the patient - not the patient to "it". For EMS/tactical/event/wilderness, you need to keep your edge on to be effective - they are "in addition to", not "instead of". Again, also, you need to pay the bills.

The one option I've not yet discussed is critical care. There is a lack of intensivists in the US. Anyone who can get credentialed for critical care can get hired in the US. However, wanting to do critical care - exclusively - by the EM route from the get-go is definitely the hard way. Definitely. If you want critical care in 5 years, IM is the way to go, and you will have many, many, many more options as far as programs go (IM-based critical care fellowships are closed to everyone except IM grads now - until 3 years ago, they had to have 75% IM grads - now it's 100%; the only exception is geriatrics - FM can still do that IM fellowship, but that's the only one). I don't have actual numbers, but I thought that the number of EM-CCM grads that exclusively work in the unit and do zero time in the ED can be counted on one hand.

That's the gist. One final note: there's one guy in my EM group (huge group, private, democratic) that is EM-trained, but works only fast track; as he says, "I don't have to think". However, all of our other fast track docs, bar none, are family medicine. You can get a job in a doc-in-the-box or freestanding urgent care, but, if you are EM-residency trained, it is unlikely that the group will hire you for fast track/urgent care only, as FM docs are cheaper on two fronts (salary, generally, and malpractice - cheaper, because they're not credentialed for more challenging/possibly deleterious procedures).

Essentially, without idiosyncratic exceptions, there's no way to train in EM, then work in the field without being in the ED (especially fresh out).

 

[jascher]

Wow, a detailed exposition on the matter-at-hand. This is more of what I was looking for. Not sure why it took some bickering and banter to draw that out of you, but I appreciate it. Now are you gonna take that "deep emotional issues" thing seriously? Ha, I thought I was laying it on pretty thick there...this whole conversation has been fun for me despite having to put a little more effort into coaxing responses than I would've liked.

To others who have shared ideas, experiences, and opinions--thanks!

I'll probably talk a lot less but follow on this thread pretty closely over the next week or two if anyone else has things to add. Unless I need to defend myself or stir up more controversy, of course. One more time for the road though: I'm not talking about direct-from-residency gigs and I do wish to work in an ER for a significant length of time. Thanks again.

In the interest of collegiality (in between my fits of "deep emotional issues" <-- ??), I shall respond to the OP's question in long detail.

In short, for the EM grad directly out of residency, options for non-EM (exclusively or primarily) jobs are essentially nil. Many of the options that will get you out of the ED need a fellowship (accredited or not), but, with one exception, they still require time in the ED for a few reasons (not enough work in the outside fields to sustain, and the skills edge needs to be maintained in the ED for the outside job to want you).

Accredited fellowships now are sports medicine, toxicology, hyperbarics/undersea, and peds. Of the first three, none has enough business to work only and exclusively in that field - it's either an "as needed" thing (tox and hyperbarics), or a clinic thing (and sports med is limited because you're non-op - anything that is beyond PT/OT goes to ortho for definitive treatment). Not enough work for full-time sports comes from anecdotal evidence from several EM-based, fellowship trained sports docs. That may vary elsewhere.

There just aren't enough people suffering hyperbarism or nitrogen narcosis or bad enough gangrene to need high pressure O2 for it to be a full-time thing. Tox is a consult service, and goes case to case. I mean, if there were that many toxic overdoses, everywhere would have a tox person, right? Instead, if you call 1-800-222-1222 (which will get you the closest poison center to you, anywhere in the US), you get a nurse screener, with the tox person on-call. I mean, they can give advice, but, as an EM doc, you can implement it.

Other EM positions from unaccredited fellowships are variable, like EMS, tactical, event/group, wilderness, cardiovascular disease, acute neurovascular, administration, and, now, geriatrics, to name a bunch. The cardio, neuro, and geri directly need you to be in the ED or in the pipeline - but those fellowships are designed to bring "it" to the patient - not the patient to "it". For EMS/tactical/event/wilderness, you need to keep your edge on to be effective - they are "in addition to", not "instead of". Again, also, you need to pay the bills.

The one option I've not yet discussed is critical care. There is a lack of intensivists in the US. Anyone who can get credentialed for critical care can get hired in the US. However, wanting to do critical care - exclusively - by the EM route from the get-go is definitely the hard way. Definitely. If you want critical care in 5 years, IM is the way to go, and you will have many, many, many more options as far as programs go (IM-based critical care fellowships are closed to everyone except IM grads now - until 3 years ago, they had to have 75% IM grads - now it's 100%; the only exception is geriatrics - FM can still do that IM fellowship, but that's the only one). I don't have actual numbers, but I thought that the number of EM-CCM grads that exclusively work in the unit and do zero time in the ED can be counted on one hand.

That's the gist. One final note: there's one guy in my EM group (huge group, private, democratic) that is EM-trained, but works only fast track; as he says, "I don't have to think". However, all of our other fast track docs, bar none, are family medicine. You can get a job in a doc-in-the-box or freestanding urgent care, but, if you are EM-residency trained, it is unlikely that the group will hire you for fast track/urgent care only, as FM docs are cheaper on two fronts (salary, generally, and malpractice - cheaper, because they're not credentialed for more challenging/possibly deleterious procedures).

Essentially, without idiosyncratic exceptions, there's no way to train in EM, then work in the field without being in the ED (especially fresh out).

 

[BADMD]

Is there anybody who happens to be the team doctor for a local high school football team on the side?

This kind of employment is usually poorly or unpaid. Those in EM who actually make money doing this typically have additional training in Sports Medicine. The camp and cruise ship things do exist, but aren't particularly prevelent and don't pay very well (unless you are a nephrologist and do dialysis friendly cruises).

Administration has been the typical way that "older" EPs spend less time in the ED. Fellowship training, as long as you stay current, may allow you tailor your practice and, depending on what you are trained in, transition to a 9-5 sort of office based job.

But, it is pretty hard to make a living if you are an EP and aren't working in an ED.

 

[docB]

I work as a team doc for a pro hockey team. I get $0 but it is really fun. The FP/Sports Med doc and the Ortho who are the lead docs don't get paid by the team but they do see the patients in their clinics when necessary which pays a little. No one is making any real money doing it and certainly not at the amatuer level. If you want to make any money with sports med you need to do FP with Sports Med or Ortho and then work for a major league team. Needless to say those gigs are tough to get.

 

[FISKUS]

I knowthat most of the EM faculty at the Univ of Wisconsin work as flight physicians in addition to their ED duties.

 

[rxfudd]

One of our grads from a few years back did a sports medicine fellowship and just signed on in July as one of the team physicians for the NY Giants. My understanding is that this is a rare situation.

 

[crewmaster1]

OP-
Sorry you're getting so much **** on here for wanting to expand your opportunities a bit. We should all admit that EM tends to attract people who like diversity.

Some things to consider:
1. Do you like research....some docs end up in academics and focus more on research than clinical practice. You could start out 50/50 and as you get older and want less nights, move more towards research

2. Administration....after being out for a while you could work your way into administration of a group and spend more of your hours in the weekday 9-5 gig. In really big groups you may be able to completely leave clinical stuff and do admin, recruitment, QI, etc.

3. After you have become really established you could do stuff like trial testamony and case review. I think this is a bit harder to earn a full income on, but maybe a combo of the above.

4. My wife an ED nurse who works at another hospital told me about an ED doc who has learned how to do some cosmetic face injection stuff and is now going to be working at some local, downtown, high-end spa doing plastic type stuff and he claims he is going to triple his income. Pretty weird and out of the whole EM thing, but hey if you wanted to supplement your income and found that stuff interesting I guess you could try.

5. Work as a consultant. My sister works for Price-Waterhouse-Cooper (if that's spelled correctly) and they have several physician consultants on staff. I'm sure there are plenty of companies that hire docs (maybe not full time) for design and developement of new EDs/hospitals, equiptment in the ED.

6. Finally, if you find the right private group, maybe they make new people work crap shifts, but 20 years in when you're a senior doc you could then not be doing nights/weekends, or at least less of them.

Just a few thoughts. I really think EM is very diverse and allows you to do a lot of different things if you're willing to think outside the box. As you spend more time in the ED maybe nights will grow on you...I like them better because there are less admin people around, younger more fun nurses usually, and there is just something to be said for being up in the middle of the night when most people are asleep.

Good luck. Do EM not FP. Don't work in the urgent care centers, own them, then you can do whatever the hell you want!

 

[8744]

As to the OP's original question:

http://pandabearmd.com/blog/2007/08/18/moonlighting-and-other-topics/

 

[docB]

3. After you have become really established you could do stuff like trial testamony and case review. I think this is a bit harder to earn a full income on, but maybe a combo of the above.

Of course you have to sell your soul for that.

 

[FoughtFyr]

There is one other EM job that has the schedule you describe. Unfortunately, they are very rare positions and there are lots over-qualified people to fill them. While you'd certainly be able to "throw your hat in the ring" when a position opens, you could hardly count on it as a career. I am talking about being the EMS director for a large city or state. Most of these folks do work 9-to-5 with the exception of the rare disaster - but even with fellowship training obtaining one of these positions is a politically laden challenge.

- H

 

[every1needsadoc]

Can EM docs do hospitalist or clinic work aside from ER shifts ? My understanding is that the training isn't necessarily geared for this and it isn't the exact line of work most EM's have interest in, thus EM, but is it an option ?

 

[Apollyon]

Can EM docs do hospitalist or clinic work aside from ER shifts ? My understanding is that the training isn't necessarily geared for this and it isn't the exact line of work most EM's have interest in, thus EM, but is it an option ?

Clinic, maybe (although why is a separate question) - like "doc in a box"/urgent care. Hospitalist, almost certainly not, as it is highly unlikely that any hospital would credential an EM-trained doc for inpatient work.

 

[crewmaster1]

Can EM docs do hospitalist or clinic work aside from ER shifts ? My understanding is that the training isn't necessarily geared for this and it isn't the exact line of work most EM's have interest in, thus EM, but is it an option ?

You can train in EM/IM or EM/FP and do something like this. Some places you can do EM, then critical care fellowship and work 1/2 ED, 1/2 ICU--but not allowed at many places. Again, I love EM because I hate clinic and don't love floor stuff, but everyone has their own opinions.

 

[EdEmEr]

I had the following idea cooking in my head:

1: Get trained
2: Do sports fellowship at a place that has an affiliation with a pro team and take lots of pictures of me with famous atheletes.
3: Get a community job and stash cash for about 5 years
4: Open a sports medicine/PT-OT and +/- cosmetic stuff clinic
5: Put pictures on wall and my last name on the building (well known family in area)
6: Continue working in ED (love it so much they will have to drag me out when my arthritis won't let me intubate)
7: Count the money that my low paid recent grad PT's make for me

I got this idea from my early exposure to orthopaedics. Ortho guys want to operate and hate clinic. However, %70 of bone/ligament/muscle injuries are non-op and these people still need a doc that is gonna do more then prescribe some NSAID's and suggest a repeat clinic visit in 3 months and a possible MRI.

Anyone that could poke holes in my idea or offer constructive criticism is welcome to.

 

[bartleby]

Unless your EM/IM or EM/FP trained, no. This makes no more sense than a hospitalist asking if he or she could work in the ED.

Can EM docs do hospitalist or clinic work aside from ER shifts ? My understanding is that the training isn't necessarily geared for this and it isn't the exact line of work most EM's have interest in, thus EM, but is it an option ?

 

[WallowaWanderer]

Unless your EM/IM or EM/FP trained, no. This makes no more sense than a hospitalist asking if he or she could work in the ED.

When I was rotating at a small community hospital, I met an EM trained (not EM/IM trained) hospitalist. Didn't get to talk to him much, but I guess it can be done - probably rare, at smaller hospitals who are in need of staff, might require you to have connections, and to take a pay cut, etc. I don't know how the legalities and malpractice insurance specifics work out for this, but I guess it can be done.

Both IM and FP docs have been known to work in EDs, but that is also rare.

Now, whether any of this makes sense is another question, but it does happen.

 

[JackBauERfan]

i dont get why you would do an ER residency if you want to do urgent/primary care. Sure you can think you might get burned out and do it later i guess, but if I wanted to do urgen care, primary care, family med would be the way to go...if you were really motivated you can do some crazy stuff in rural areas since you are the only doc and since you are family can pretty much legally do anything...of course thats if you're motivated to get the education while you are in residency to do those things...

 

[JackBauERfan]

also if you get tired of the er, you can always get a job at mcdonalds, i'm sure you're resume will get you a spot..you might want to put on it that you know cpr.

 

[docB]

also if you get tired of the er, you can always get a job at mcdonalds, i'm sure you're resume will get you a spot..you might want to put on it that you know cpr.

You could try to come back to In-N-Out as faculty but we're pretty selective.

 

[margaritaboy]

Urgent Care: I worked in an urgent care center as a moonlighter during residency. The money was decent (for a resident) but the work was intellectually mind-numbing (cold, cold, cold, ear infection, cold....). I don't think I could be happy sustaining myself working in that capacity.

Hyperbarics: I'm on staff at two hospitals in town that have hyperbaric chambers. Mostly they are used for wound care issues/healing etc for outpatients. I mean really....I'm in the desert...not much scuba diving here....The EM physicians oversee the hyperbarics, but they are seldom used emergently.

Family Practice: I have seen one EM physician that switched over to a family practice after about 10 years of EM. He was also looking for 8-5 type schedule that was better for his family.

Cruise ships: I looked in to being a physician for a cruise ship, but the money isn't so great and most companies want a minimum commitment of 8-10 months. It might be good for some, but I think it would get old for me.

Publications/malpractice: You can also publish text book chapters/review materials or review cases for malpractice defense or plaintiff's attorneys. The former are usually reserved for people who have made a name for themselves in academics. The latter can apparently pay well, but you have to be pretty seasoned and experienced to be credible and I don't think you can make a living doing only these things.

Any other ideas or options?

 

[WallowaWanderer]

Family Practice: I have me one EM physician that switched over to a family practice after about 10 years of EM.

Just curious . . . Was this person originally IM trained, or did he have to go back to residency, or did he just slide right into his own practice without any board certification?

 

[margaritaboy]

Good question. If I see him again I'll pick his brain. For all I know he could have been boarded in FM, and worked in rural EDs for awhile before comming back to FM.

 

[howelljolly]

I just came across this thread

Way to jump down the OPs throat, people! Keep telling people about themselves, and how they are lazier and dumber than you are, It'll get you far.

Asking EM folks what they can do outside the ED with their training is like asking an Ortho resident how to carreer plan for part time work. They dont know much about it because theyve never thought of it in their wildest imaginations. EM docs think ED, like Ortho docs think Wokaholic.

To answer the OP, if I can, with EM, the sky's the limit.

Take the fellowships first:

Sports Med... use your imagination, Think NFL team physician. If anyone says thats for Ortho... The Redskins have a cardiologist on staff, anyone can do it.

Toxicology... think Poison control centers , Law enforcement, Pathology, academia, industry, Lab

EMS... think Medical Director, Paramedic backup in the field, Full-time online medical control MD for the FDNY, EMS Education, Disaster Prep, Homeland Security. FBI, SWAT

Wilderness &Travel Med... Think Cruise ships, Resorts, ski patrol, Search and Rescue, Forest Fire Service,

Mix and match those, throw in a liberal helping of Research, Acedemic EM, Administrative, Public Health, Industry, Pharmaceuticals, International relief Missions, and the ever popular Urgent Care Center, and youve got yourself a really diverse, flexible, and exciting career.

 

[zinjanthropus]

I just came across this thread

Way to jump down the OPs throat, people! Keep telling people about themselves, and how they are lazier and dumber than you are, It'll get you far.

Asking EM folks what they can do outside the ED with their training is like asking an Ortho resident how to carreer plan for part time work. They dont know much about it because theyve never thought of it in their wildest imaginations. EM docs think ED, like Ortho docs think Wokaholic.

To answer the OP, if I can, with EM, the sky's the limit.

Take the fellowships first:

Sports Med... use your imagination, Think NFL team physician. If anyone says thats for Ortho... The Redskins have a cardiologist on staff, anyone can do it.

Toxicology... think Poison control centers , Law enforcement, Pathology, academia, industry, Lab

EMS... think Medical Director, Paramedic backup in the field, Full-time online medical control MD for the FDNY, EMS Education, Disaster Prep, Homeland Security. FBI, SWAT

Wilderness &Travel Med... Think Cruise ships, Resorts, ski patrol, Search and Rescue, Forest Fire Service,

Mix and match those, throw in a liberal helping of Research, Acedemic EM, Administrative, Public Health, Industry, Pharmaceuticals, International relief Missions, and the ever popular Urgent Care Center, and youve got yourself a really diverse, flexible, and exciting career.

one of the ACEP talks in Seattle was titled the same as this thread....can anyone remember who gave that talk? i missed it for an EMRA event...but if anyone can remember it, we can link to it on the ACEP page (of course you would still have to pay for the video stream)