EM Pain Fellowship vs CC? Kind of want out of EM. Any advice?

[Angry Birds]

Anyone know of someone doing EM-->Palliative Care?

I have/am considering it.

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[Old_Mil]

Hey guys,

I'm reaching out for a little help and advice. I'm in a pretty rough place personally/emotionally and am not sure that I can do 20-30 years of EM.

You can't. Between the galley slave working conditions and violations of circadian rhythm I wouldn't count on it.

I really liked the chronic pain patients because many had very complex anatomic causes of their pain. I enjoyed the instant gratification of nerve blocks and injections and watching people walk out of the office.

My (ED) experience with chronic pain patients is that if there is any "cause" outside of outright addiction, it's psychiatric. For me, a chronic pain practice would be hell on earth...but I think Birdstrike is doing something along those lines so he's probably the guy to talk to.

 

[bravotwozero]

You can't. Between the galley slave working conditions and violations of circadian rhythm I wouldn't count on it.

Both of those factors are variables, not constants. I just switched jobs to another ED, where the payor mix is better so I make as much as my old gig, the volume lower, they don't have that stupid 6p-3a shift that everyone hates because it's a single coverage (with MLPs) shop, and we hired a nocturnist, so not many night shifts either. I can work here for 20 years without burning out. These jobs are out there.

 

[Birdstrike]

You can't. Between the galley slave working conditions and violations of circadian rhythm I wouldn't count on it.

My (ED) experience with chronic pain patients is that if there is any "cause" outside of outright addiction, it's psychiatric. For me, a chronic pain practice would be hell on earth...but I think Birdstrike is doing something along those lines so he's probably the guy to talk to.

My God. There is so much in this post here, it's amazing. And you don't even realize it.

For starters, 'chronic pain' isn't a disease, with a 'cause.' It's a symptom. There are many conditions and diseases that lead to Pain symptoms. They can't all be lumped in two diagnoses, such as your "addiction" and "crazy." Sure there can be overlying psychopathology (as there is in boatloads in ED patients).

But was the L1 fracture I posted above, that I cured within 24 hours with a kyphoplasty, caused by "addiction" or psych issues?

Are all the people I see for various injections, with pathology to match on imaging, and who aren't on opiates (and who will never be because I don't start opiate naive patients on opiates) "caused by addiction"?

When you see an L5/S1 foraminal stenosis on MRI, with pain radiating down the leg to the top of the foot, is that caused by mental illness? Does psychotherapy or addiction treatment help a hot L5 nerve root? Or does an epidural steroid injection do that?

Is the 91 year old with a bone on bone knee, who's too sick to get a TKR, and who needs synvisc shots in their knee every 6 months, seeing me because they're "addicted" to synvisc? Are they afflicted with schizophrenia in their knee?

But look again, up at your post, and look at it very carefully. Your specialty description was this, "Between the galley slave working conditions and violations of circadian rhythm I wouldn't count on it [lasting 20-30 years]." But this was your own description, of your own job, not mine. This was your description of working in EDs, not of working in my office. Furthermore, your next description, "My (ED) experience with chronic pain patients" is that they're all "addicts" and "crazy." But again, read again what you wrote. You were describing your job, your experience, and your patients, not mine. You were describing your job, Emergency Medicine. You weren't describing my job. You then said, "For me, a chronic pain practice would be hell on earth." And with this one, I'll take your word for it. It may be 'hell on Earth' for you. But you're basing it entirely on descriptions of your job, not mine. For me, 'galley slave working conditions' would be (and were) hell on Earth. But I, right now doing what I currently do, have great working conditions, not 'slave conditions.' I set the conditions. For me, constant circadian rhythm mood dysphoria, would be (and was) hell on Earth. But my sleep cycle right now, is the best it's ever been. Working a job I couldn't see myself surviving 20-30 years doing, would be (and was) Hell on Earth, but I don't have to any more.

Again, I am under no delusions that more than 1% of Emergency Physicians (maybe not even that many) would ever want to do what I do, and that's great! I don't need you all doing what I do, and setting up shop across the street as competition. Plus, we need as many of you to continue doing the heroes work of Emergency Medicine, as possible. But it's amazing how consistent, near robotically so, that EPs start to describe what they think my job is, and then they describe their job. They start describing all the (in their words) the "crazy patients they see" in the ED, and the "addicts" they see in the ED at three in the morning. But that's what they're doing, and their job. And it used to be what I did, and used to be my job. But it isn't anymore.

Over and over and over again, when people tell me they'd hate my job, and start describing why, they start describing their own job in the ED, while literally imagining, that it's my job they're describing. It amazes me how predictable and repetitive, like machinery, this example of cognitive dissonance presents itself, when I discuss what I do, with people in the ED. It's happened no less that 100 times now. Read this paragraph again.

Currently, I have great job. I go to sleep at the same time every night, within the first five minutes of getting tired. I wake up at the same time every day, feeling rested. I take my kid to school every day at the same time. I get to work every day at the same time. I either spend all day doing procedures (1/2) the time, which I enjoy doing and which involves no medication management at all. I take a 1 hour, relaxed, slow paced lunch every day. The other 1/2 of the time I do clinic. About 1/3 of those patients are on no opiates, will never be on opiates and have no interest in every doing so. I try to find the source of their pain and treat it if I can. That may involve an injection, a non-opiate med, physical therapy referral, referral to a surgeon or other. It never involves me starting them on an opiate. Another 1/3 of patients have clear pathology, are on low - moderate opiates, need to be on opiates, and have no signs of drug abuse or diversion. I also, concurrently pursue all the same non-opiate treatments I pursue with the others. Prescribing them opiates is no big deal: They need them, they're not on high doses (I don't do high dose [over 90 MME/day), they don't abuse them and the medicines help them (or at least don't seem to hurt). The other 1/3 of my patients need to be told, "No." For any number of reasons, I've determined they're not candidates for opiates (see long post above). And I tell them, "No" to the opiates and offer the non-opiate treatments. I don't argue. I don't get angry. I don't negotiate. I don't get emotionally involved. I just say no.

That whole big messy, intimidating ball of wax that so many EPs seem to fear, can be melted away, with a "No."

But it's never at 3 am. It's never on Christmas. It's never on New Years. It's never while I'm so frickin' exhausted or emotionally drained that I can't see doing what I do any longer. It's never, 24 hours after I cycled off a night shift. It's never 3 minutes after I just told a family their baby is dead. It's never during my kid's soccer game. It's never while an ambulance is crashing through my office doors with monitors beeping around my head like I'm living in a pinball machine. It's never before 7:30 am or after 4:30 pm. It's never between 12:00 noon and 1:00 pm. It's never on Sunday. It's never done with a worry of Press Ganey results. It's never done while simultaneously irritated that some jerk in a suit is going to say I didn't do it faster that I could have sanely done it. It's never done with a patient I'm forced by EMTALA law to see over, and over, and over and over again. It's never caused me to leave a neighborhood party early early because I had to go to work starting at 10 pm.

But again, it makes no difference to me if I convince anyone of this. I honestly couldn't care less. Because I'm much happier, much more content, much more rested, and much less irritable doing it. My family life is better. My wife likes me better. My kids like me better. My kids see me more as my days and hours off are the same as theirs. And for me, if none of this were true, I wouldn't be writing this, I'd be answering the recruiter call I just got for an ED begging for any board certified EP, even one who hasn't worked a shift in 5 years, to cover their department so they don't have to close their doors. But have absolutely no desire to make that call, because what I have now, is so much better, for me, for my mental health, my peace of mind and is perpetually sustainable as long as I need it to be. Now I have a normal life. When I worked your job, I was never able to. That means everything in the world to me. And I'm happy now.

And the only reason I'm even posting any of this, is not to convince anyone of anything, because I know that's a losing proposition. This is religion for a lot of people. The purpose is to inform those interested and asking questions, such as the OP. Because what works for one, may not work for another. And that's what makes the world go 'round.

 

[deleted547339]

My God. There is so much in this post here, it's amazing. And you don't even realize it.

For starters, 'chronic pain' isn't a disease, with a 'cause.' It's a symptom. There are many conditions and diseases that lead to Pain symptoms. They can't all be lumped in two diagnoses, such as your "addiction" and "crazy." Sure there can be overlying psychopathology (as there is in boatloads in ED patients).

But was the L1 fracture I posted above, that I cured within 24 hours with a kyphoplasty, caused by "addiction" or psych issues?

Are all the people I see for various injections, with pathology to match on imaging, and who aren't on opiates (and who will never be because I don't start opiate naive patients on opiates) "caused by addiction"?

When you see an L5/S1 foraminal stenosis on MRI, with pain radiating down the leg to the top of the foot, is that caused by mental illness? Does psychotherapy or addiction treatment help a hot L5 nerve root? Or does an epidural steroid injection do that?

Is the 91 year old with a bone on bone knee, who's too sick to get a TKR, and who needs synvisc shots in their knee every 6 months, seeing me because they're "addicted" to synvisc? Are they afflicted with schizophrenia in their knee?

But look again, up at your post, and look at it very carefully. Your specialty description was this, "Between the galley slave working conditions and violations of circadian rhythm I wouldn't count on it [lasting 20-30 years]." But this was your own description, of your own job, not mine. This was your description of working in EDs, not of working in my office. Furthermore, your next description, "My (ED) experience with chronic pain patients" is that they're all "addicts" and "crazy." But again, read again what you wrote. You were describing your job, your experience, and your patients, not mine. You were describing your job, Emergency Medicine. You weren't describing my job. You then said, "For me, a chronic pain practice would be hell on earth." And with this one, I'll take your word for it. It may be 'hell on Earth' for you. But you're basing it entirely on descriptions of your job, not mine. For me, 'galley slave working conditions' would be (and were) hell on Earth. But I, right now doing what I currently do, have great working conditions, not 'slave conditions.' I set the conditions. For me, constant circadian rhythm mood dysphoria, would be (and was) hell on Earth. But my sleep cycle right now, is the best it's ever been. Working a job I couldn't see myself surviving 20-30 years doing, would be (and was) Hell on Earth, but I don't have to any more.

Again, I am under no delusions that more than 1% of Emergency Physicians (maybe not even that many) would ever want to do what I do, and that's great! I don't need you all doing what I do, and setting up shop across the street as competition. Plus, we need as many of you to continue doing the heroes work of Emergency Medicine, as possible. But it's amazing how consistent, near robotically so, that EPs start to describe what they think my job is, and then they describe their job. They start describing all the (in their words) the "crazy patients they see" in the ED, and the "addicts" they see in the ED at three in the morning. But that's what they're doing, and their job. And it used to be what I did, and used to be my job. But it isn't anymore.

Over and over and over again, when people tell me they'd hate my job, and start describing why, they start describing their own job in the ED, while literally imagining, that it's my job they're describing. It amazes me how predictable and repetitive, like machinery, this example of cognitive dissonance presents itself, when I discuss what I do, with people in the ED. It's happened no less that 100 times now. Read this paragraph again.

Currently, I have great job. I go to sleep at the same time every night, within the first five minutes of getting tired. I wake up at the same time every day, feeling rested. I take my kid to school every day at the same time. I get to work every day at the same time. I either spend all day doing procedures (1/2) the time, which I enjoy doing and which involves no medication management at all. I take a 1 hour, relaxed, slow paced lunch every day. The other 1/2 of the time I do clinic. About 1/3 of those patients are on no opiates, will never be on opiates and have no interest in every doing so. I try to find the source of their pain and treat it if I can. That may involve an injection, a non-opiate med, physical therapy referral, referral to a surgeon or other. It never involves me starting them on an opiate. Another 1/3 of patients have clear pathology, are on low - moderate opiates, need to be on opiates, and have no signs of drug abuse or diversion. I also, concurrently pursue all the same non-opiate treatments I pursue with the others. Prescribing them opiates is no big deal: They need them, they're not on high doses (I don't do high dose [over 90 MME/day), they don't abuse them and the medicines help them (or at least don't seem to hurt). The other 1/3 of my patients need to be told, "No." For any number of reasons, I've determined they're not candidates for opiates (see long post above). And I tell them, "No" to the opiates and offer the non-opiate treatments. I don't argue. I don't get angry. I don't negotiate. I don't get emotionally involved. I just say no.

That whole big messy, intimidating ball of wax that so many EPs seem to fear, can be melted away, with a "No."

But it's never at 3 am. It's never on Christmas. It's never on New Years. It's never while I'm so frickin' exhausted or emotionally drained that I can't see doing what I do any longer. It's never, 24 hours after I cycled off a night shift. It's never 3 minutes after I just told a family their baby is dead. It's never during my kid's soccer game. It's never while an ambulance is crashing through my office doors with monitors beeping around my head like I'm living in a pinball machine. It's never before 7:30 am or after 4:30 pm. It's never between 12:00 noon and 1:00 pm. It's never on Sunday. It's never done with a worry of Press Ganey results. It's never done while simultaneously irritated that some jerk in a suit is going to say I didn't do it faster that I could have sanely done it. It's never done with a patient I'm forced by EMTALA law to see over, and over, and over and over again. It's never caused me to leave a neighborhood party early early because I had to go to work starting at 10 pm.

But again, it makes no difference to me if I convince anyone of this. I honestly couldn't care less. Because I'm much happier, much more content, much more rested, and much less irritable doing it. My family life is better. My wife likes me better. My kids like me better. My kids see me more as my days and hours off are the same as theirs. And for me, if none of this were true, I wouldn't be writing this, I'd be answering the recruiter call I just got for an ED begging for any board certified EP, even one who hasn't worked a shift in 5 years, to cover their department so they don't have to close their doors. But have absolutely no desire to make that call, because what I have now, is so much better, for me, for my mental health, my peace of mind and is perpetually sustainable as long as I need it to be. Now I have a normal life. When I worked your job, I was never able to. That means everything in the world to me. And I'm happy now.

And the only reason I'm even posting any of this, is not to convince anyone of anything, because I know that's a losing proposition. This is religion for a lot of people. The purpose is to inform those interested and asking questions, such as the OP. Because what works for one, may not work for another. And that's what makes the world go 'round.

I feel like this thread has made you post more in the past month than you have in the past 2 years.

 

[Birdstrike]

I feel like this thread has made you post more in the past month than you have in the past 2 years.

You are correct. It's something new & positive I have to offer, regarding Emergency Medicine, at least in relation to one of it's subspecialties. My earlier SDN posts were mostly ventings and rants about working ED shifts (2010-2013) and some clinical cases. I don't think that's useful anymore, for anyone, except maybe the clinical cases, if any interesting ones come up. My new focus is to post about how things got better for me, and to offer something unique, that most others can't.

 

[WilcoWorld]

...And the only reason I'm even posting any of this, is not to convince anyone of anything...

You know, it does sound a little bit like you're trying to convince yourself.

I'm really glad that you're happy. We should all be so happy. Why the hell spend so long working so hard to hate one's job?
For some, happiness will require a change of shop, for others it may require a change in specialty. But I think that for most, what is needed is something else you described in your post. It's a much simpler, but more fundamental change than the above. It's a change in the way we approach suffering and difficulties, "I don't argue. I don't get angry. I don't negotiate. I don't get emotionally involved."

My life and job satisfaction have become immensely better since I've decided that there's no need for (and no benefit from) me getting angry at work.

 

[Birdstrike]

You know, it does sound a little bit like you're trying to convince yourself.

When I left my EM position for my Pain fellowship, I did it with the plan that if at any point I realized it was a mistake and if any significant doubt crept into my mind, and that immediately quitting & going back to general EM shifts was best, I’d do it, in a heartbeat. Unlike someone leaving a specialty mid-residency where there’s something to lose, years of training down the drain, I had no such thing to worry about. I could have left after 2 weeks, 2 months or at any point, with virtually little downside. I left my EM job on good terms with an open ended offer to come back at any time, not to mention the multiple recruiting emails & calls I get weekly. I could have and still could, quit at anytime and go back. And I haven’t.

And you’ll notice I didn’t post here on SDN about this, for a long, long time. I specifically waited until I was 100% sure it was the right move and that I could recommend it to others interested. Also, if it turned out to be a big mistake, I’d gladly have come here and waved the red flag, saying, “Don’t do what I did,” as I have about many other things on this forum.

So, the “convincing myself” stage has long since come, and gone. I made the conscious decision to do that in private, and in my head, and not publicly on SDN. Many of you asked for years, “Birdstrike, what do you do now?” And for a long time, I gave no answer, for a reason. Either I was going to reveal what I did, and why it worked out. Or, reveal what I did, and why others shouldn’t make the same mistake. So I waited until I was ready to do one of those things, with certainty. If my outlook changes, I’ll gladly come on here and give an update, if I think it’s something that would be useful to someone.




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[Old_Mil]

Birdstrike is right, since I haven't been in a clinic based pain management practice, I can't really speak authoritatively on that issue. It is what I imagine it to be from my ED experience. One of the major advantages of a clinic based practice that you don't have in a hospital or ED is that you can fire problem patients...or not see them to begin with. In our current system that is a huge advantage, one that I didn't really appreciate in training (where you don't really get to fire patients). If you're interested, he is the man to talk to.

 

[dchristismi]

Bumping because... deep breath... I'm starting at a local hospice tomorrow.

Been out in the community for 10 years, faced a lot of burnout, cut my hours back, paid my debts and did a lot of soul searching. At the end of October, my current main gig director called me to say that the CMG didn't want "part timers" (I've been giving them 9 shifts a month for 2 years) and I could stay on PRN if I wanted but they wouldn't guarantee me shifts. I had already been on the brink of jumping ship, at least at this place. I've got 2 backup EDs, so not terribly worried. Also, there is always work and I have a substantial financial cushion, so to quote Cartman, I'm very close to a "screw you guys, I'm going home" situation. Hell, maybe I'm already there. There are other issues too, but the timing seemed fortuitous...

One night last month, as I was talking to a family who was amenable to hospice for (demented septic) grandpa, and the (outside) hospice nurse casually joked: "We've been trying to recruit her for years..." FWIW, I have a great relationship with this particular hospice, and they know me quite well from our many interactions.

So I pulled her aside, mentioned that no one had ever asked me about it, and asked how one would go about learning more.
Later that week, the medical director met with me and I start my orientation/computer/stuff tomorrow.
It's just part time for now (like 10 hours a week part time) and will involve rounding at the 12 bed hospice house in the next town over. It'll be mostly weekends to start, but it's the first time I've been excited about rounding since, oh, my 3rd year of medical school.

I dug up this thread to PM Birdstrike as he's successfully made the leap, but since others had asked about hospice/palliative med, I figured I'd just post. I'm not giving up my day job just yet, and there are many things I love about EM, but after a series of really painful shifts AKA flu-mageddon, it's sounding better and better.

Now, I don't know that I'm terribly interested in palliative care, but I think I've always known that when I burned out of EM for good, I'd go do hospice. I mentioned right off the bat that I'm obviously not fellowship trained, and the director basically said that she wasn't worried and that I'd learn from their other docs.

So yeah. Feels a little surreal, but it's happening.

 

[Angry Birds]

Bumping because... deep breath... I'm starting at a local hospice tomorrow.

Been out in the community for 10 years, faced a lot of burnout, cut my hours back, paid my debts and did a lot of soul searching. At the end of October, my current main gig director called me to say that the CMG didn't want "part timers" (I've been giving them 9 shifts a month for 2 years) and I could stay on PRN if I wanted but they wouldn't guarantee me shifts. I had already been on the brink of jumping ship, at least at this place. I've got 2 backup EDs, so not terribly worried. Also, there is always work and I have a substantial financial cushion, so to quote Cartman, I'm very close to a "screw you guys, I'm going home" situation. Hell, maybe I'm already there. There are other issues too, but the timing seemed fortuitous...

One night last month, as I was talking to a family who was amenable to hospice for (demented septic) grandpa, and the (outside) hospice nurse casually joked: "We've been trying to recruit her for years..." FWIW, I have a great relationship with this particular hospice, and they know me quite well from our many interactions.

So I pulled her aside, mentioned that no one had ever asked me about it, and asked how one would go about learning more.
Later that week, the medical director met with me and I start my orientation/computer/stuff tomorrow.
It's just part time for now (like 10 hours a week part time) and will involve rounding at the 12 bed hospice house in the next town over. It'll be mostly weekends to start, but it's the first time I've been excited about rounding since, oh, my 3rd year of medical school.

I dug up this thread to PM Birdstrike as he's successfully made the leap, but since others had asked about hospice/palliative med, I figured I'd just post. I'm not giving up my day job just yet, and there are many things I love about EM, but after a series of really painful shifts AKA flu-mageddon, it's sounding better and better.

Now, I don't know that I'm terribly interested in palliative care, but I think I've always known that when I burned out of EM for good, I'd go do hospice. I mentioned right off the bat that I'm obviously not fellowship trained, and the director basically said that she wasn't worried and that I'd learn from their other docs.

So yeah. Feels a little surreal, but it's happening.

That's great that you are trying something new. Good luck, and hope you succeed.

I guess the main question I have is: does this hospice-route offer you comparable compensation as clinical EM? Or at least sustainable compensation if not comparable?

 

[unnumzaan]

Now, I don't know that I'm terribly interested in palliative care, but I think I've always known that when I burned out of EM for good, I'd go do hospice. I mentioned right off the bat that I'm obviously not fellowship trained, and the director basically said that she wasn't worried and that I'd learn from their other docs.

What do you enjoy about hospice care/what kind of self-reflection lead you there? It's always good to have options, and fortunate the the EM job market currently allows for this kind of exploration.

 

[enalli]

Bumping because... deep breath... I'm starting at a local hospice tomorrow.

...

If you enjoy it, do you think you'll try to get into a fellowship and become board certified, or would that not be worth it financially for you?

 

[dchristismi]

To answer what I can:

Pay is, from what I can tell, nowhere near comparable. It may indeed be the lowest paying specialty - however it does happen to have very high physician satisfaction, and I think that's going to be more important for me. I love EM, I really do. I just don't love the feeling of dread when I *know* there are 30 in the lobby, there are 15 admit holds and god only knows what the midlevels are putting my name on. (mostly at my main shop, which I am scheduled for exactly 6 more shifts in the next 3 months. And I don't think there will be any more after that.

I'm trying to remember that I'm really not in it for the money. Of course, being used to BIG attending paychecks is one thing. Mentally grasping that I've saved a ton and don't *need* to make that much is harder to wrap your brain around. I'm getting better at it... in fact, I am looking at this whole gig as a "well, that can be my charitable donation fund," so that I'm not fixating on the money. But I am still pulling ED shifts for now as well at one lower acuity shop that I enjoy, and going to work a few at a lower volume freestanding for a change of pace and to help out a friend.

I don't really think a fellowship is in the cards. We have roots here now, and husband's dad is getting up there in years... for now, we're staying. I think if I was going to pack up and move, I'd have done it by now. Also, I'm not as young as I used to be, and I really I doubt it would be financially worth it. Ok, no. I KNOW it wouldn't be worth it. I'll be 41 in a few months, and I'll be financially independent soon enough.

Is it wrong that I'm wondering how few shifts I can work and still keep up my skills? Or that I might *gasp* not recert when my boards expire? So many things to contemplate.

 

[enalli]

If after a year in (or 2, 3 etc) you're really enjoying palliative care, will you just leave EM altogether, or will you always try to keep that option open by moonlighting to keep up your skills?

 

[dchristismi]

Damned if I know.

 

[gman33]

OP.

You have no idea if you like EM now.
You are a resident.
That has almost nothing to do with practicing as an attending.

I had very similar feelings during training.
A lot of that comes from working too much and really having no control on your environment.

You may learn that you hate EM and want to do something else, but I'd finish out and get a community job for a couple years.
Most fellowships are not that competitive, so you should not have much problem finding one if you want it later on.

 

[Birdstrike]

To answer what I can:

Pay is, from what I can tell, nowhere near comparable. It may indeed be the lowest paying specialty - however it does happen to have very high physician satisfaction, and I think that's going to be more important for me. I love EM, I really do. I just don't love the feeling of dread when I *know* there are 30 in the lobby, there are 15 admit holds and god only knows what the midlevels are putting my name on. (mostly at my main shop, which I am scheduled for exactly 6 more shifts in the next 3 months. And I don't think there will be any more after that.

I'm trying to remember that I'm really not in it for the money. Of course, being used to BIG attending paychecks is one thing. Mentally grasping that I've saved a ton and don't *need* to make that much is harder to wrap your brain around. I'm getting better at it... in fact, I am looking at this whole gig as a "well, that can be my charitable donation fund," so that I'm not fixating on the money. But I am still pulling ED shifts for now as well at one lower acuity shop that I enjoy, and going to work a few at a lower volume freestanding for a change of pace and to help out a friend.

I don't really think a fellowship is in the cards. We have roots here now, and husband's dad is getting up there in years... for now, we're staying. I think if I was going to pack up and move, I'd have done it by now. Also, I'm not as young as I used to be, and I really I doubt it would be financially worth it. Ok, no. I KNOW it wouldn't be worth it. I'll be 41 in a few months, and I'll be financially independent soon enough.

Is it wrong that I'm wondering how few shifts I can work and still keep up my skills? Or that I might *gasp* not recert when my boards expire? So many things to contemplate.

As part of my Pain fellowship we did one month of Hospice and Palliative care. I actually liked it a lot. It can be very sad at times (so can the ED) but with the focus on easing suffering, it can be very positive, too. In fact, I thought about taking the boards the last year one was able to grandfather-in without a fellowship, but I decided not to, since I already had one fellowship board to study for, already.

 

[sonofva]

Birdstrike is it hard to do part time pain if im intersted in mixed practive?

 

[Birdstrike]

Birdstrike is it hard to do part time pain if im intersted in mixed practive?

I think in private practice, part time would be much harder to find than full time, but it does exist. In an academic job or other job with a huge group with multiple specialties, it would be much easier, since you could get dual credentials with both, at the same site.

 

[briarby]

I did a pain medicine rotation while in EM residency, but I still love the ER as a PGY II, it can definitely be tough but everyone I talk to says it gets better. I'm still on the fence about applying to pain even though applications are already due. I would only apply to the program I rotated at. Birdstrike is right the majority of patients are not pain seekers I worked at an interventional only department. I guess what's holding me back from applying is that I feel like I would have to give up ER to do pain. It will be hard to find a part time pain job and I'm realistically not going to give up my weekends to work in the ER as a pain doctor. I can't do the fellowship then go back to the ER and then expect to go back to pain when I'm older, no one is going to hire a guy who hasn't been in the fluoroscopy suite for a few years. Pain procedures are interesting, but clinic days are so boring. The saddest part are when you see patients coming back saying the procedure didn't help, which is extremely depressing when they just got a 100k spinal cord stimulator. So honestly for the original poster there will be days when you feel like you make no difference in any specialty you go into. I would love to practice EM for a few years then go back to pain, but the program director at the place I rotated at basically told me my chances later would be slim to none coming from EM unless I went for it now. It worked for birdstrike but he was willing to go anywhere, hard to do when you have a wife and kids.

 

[Birdstrike]

...was willing to go anywhere, hard to do when you have a wife and kids.

It is hard. I also had a wife and kids, but my kids were very young and therefore very adaptable and moveable, and my wife was fully on board with moving for 1 year (but only 1 year). So I have her to thank for that, being very supportive and a trooper, like that. But it certainly was hard. Very hard.

 

[katmandu]

Bumping because... deep breath... I'm starting at a local hospice tomorrow.

Been out in the community for 10 years, faced a lot of burnout, cut my hours back, paid my debts and did a lot of soul searching. At the end of October, my current main gig director called me to say that the CMG didn't want "part timers" (I've been giving them 9 shifts a month for 2 years) and I could stay on PRN if I wanted but they wouldn't guarantee me shifts. I had already been on the brink of jumping ship, at least at this place. I've got 2 backup EDs, so not terribly worried. Also, there is always work and I have a substantial financial cushion, so to quote Cartman, I'm very close to a "screw you guys, I'm going home" situation. Hell, maybe I'm already there. There are other issues too, but the timing seemed fortuitous...

One night last month, as I was talking to a family who was amenable to hospice for (demented septic) grandpa, and the (outside) hospice nurse casually joked: "We've been trying to recruit her for years..." FWIW, I have a great relationship with this particular hospice, and they know me quite well from our many interactions.

So I pulled her aside, mentioned that no one had ever asked me about it, and asked how one would go about learning more.
Later that week, the medical director met with me and I start my orientation/computer/stuff tomorrow.
It's just part time for now (like 10 hours a week part time) and will involve rounding at the 12 bed hospice house in the next town over. It'll be mostly weekends to start, but it's the first time I've been excited about rounding since, oh, my 3rd year of medical school.

I dug up this thread to PM Birdstrike as he's successfully made the leap, but since others had asked about hospice/palliative med, I figured I'd just post. I'm not giving up my day job just yet, and there are many things I love about EM, but after a series of really painful shifts AKA flu-mageddon, it's sounding better and better.

Now, I don't know that I'm terribly interested in palliative care, but I think I've always known that when I burned out of EM for good, I'd go do hospice. I mentioned right off the bat that I'm obviously not fellowship trained, and the director basically said that she wasn't worried and that I'd learn from their other docs.

So yeah. Feels a little surreal, but it's happening.

Dchristismi, I can identify with so much of your post. I am also currently working part time, like the job but the growing challenges outside of a physician's control (admin, metrics, leaner and leaner staffing ratios removing surge capacity, medicolegal climate, etc) are increasingly frustrating. I'm also concerned about losing my part time options.
I've considered a fellowship to expand my options, but this seems less than ideal, being fewer than 10 years out from financial independence. But, maybe if I had a position that I really enjoyed and was less draining, I wouldn't be in the same rush to secure my financial independence and ride off into the sunset.
I hope this option works for you. Keep us posted.

 

[Birdstrike]

But, maybe if I had a position that I really enjoyed and was less draining, I wouldn't be in the same rush to secure my financial independence and ride off into the sunset.

This explains perfectly how I felt when I worked EM, full time. I felt that the clock was ticking faster and faster everyday, and never did I think I could continue on the same course, until 'retirement age.' Now that I'm in a position where I get to have a normal life and normal sleep schedule, I feel I could continue doing what I'm currently doing, as long as I need to.

 

[RandomChaos]

Hey guys,

I'm reaching out for a little help and advice. I'm in a pretty rough place personally/emotionally and am not sure that I can do 20-30 years of EM.

A little about me:

I'm a pgy2 at a very good 3 year EM program. I had great board scores (245+ step 1/2), grades (3.6 H/HP/P), and was top 1/4 of my class. I'm a US MD from the standard state school. My medical school interests included orthopedics and pain management. I initially felt emergency medicine was a great crossroads field and would allow me to do a little of everything I enjoyed. In ortho, I enjoyed the reductions and non-operative management of acute fractures. I liked, but didn't love the OR. My personal hell was a day in the OR doing 4 TKA's. I really liked the chronic pain patients because many had very complex anatomic causes of their pain. I enjoyed the instant gratification of nerve blocks and injections and watching people walk out of the office.

I really loved EM at first. I loved the crashing patient and doing procedures (dropping lines, chest tubes, and so on). In reflection, I found that I was "protected" from the "bad learning" BS cases that we see day-to-day, so my patient population and acuity expectations may have been incorrect.

After 1.5 years I've grown to find EM very fatiguing. I'm struggling with our breath of knowledge and having the patience to deal with our patient population. I also wish I was doing more procedures. I often drive home from a shift wondering If I've done anything to help anyone that day. I really enjoy managing the crashing patient, but am less interested in the non-sick patient (and despise ped's).

If I could have done it over, I probably would have just done ortho. But its probably not realistic to do another residency and have lost of my contacts and recommendations from med school.

Long story short: I love crashing sick patients and dislike the primary care stuff. I love procedures, but often feel too busy to do them in the ED. I feel like I'm not having an impact on people. I'm struggling with the breath of our field and wish to narrow the knowledge that I'm responsible for. I'm also not dealing well with the constant distractions on shift. Looking for a way out.

Is it viable to view critical care and pain management as a possible road out? I've been reading a lot about neuro-CC and think It could be a very fulfilling career. I've currently trying to gear up my application to be competitive for either. Still doing some personal exploration prior to committing to either.

So far, everyone that I have talked to about this has been less than understanding and have brought up the "your not gonna quit are you?" line. Trying to have a better plan before meeting with the PD to discuss.

My questions for you guys:

1) Has anyone completed the CC or Pain management fellowship and transitioned their careers into predominantly CC/Pain?

I know I'll probably make less $$ and lose a lot on opportunity cost, but I think i'll personally feel more fulfilled.

I was advised to consider working in the community for a few years to see if my mind changes, but am wondering if it will just hinder my application and would lose out of LOR's. I also think it would be hard to turn down 300+K to go back to fellow salary.

Bringing back to life an old question. But, I recently matched into a Pain fellowship after doing EM/CC. I think it offers a significant amount of variety and there is a good amount of overlap with the 3. I think we might be on to something and PM me with any questions about it. I think it has a bright future though.

 

[Groove]

Bringing back to life an old question. But, I recently matched into a Pain fellowship after doing EM/CC. I think it offers a significant amount of variety and there is a good amount of overlap with the 3. I think we might be on to something and PM me with any questions about it. I think it has a bright future though.

So, you did an EM residency, then 2 years of CC and NOW are jumping to a second fellowship in pain to get away from BOTH EM & CC? Care to elaborate on your personal story? I'm always curious and a bit suspicious when I hear people jump ship from multiple practice environments. It reminds me of my PD who was anesthesia boarded, pain boarded, EM boarded and 3/4 through my residency he jumped to a CC fellowship in his 50s and last I checked was back doing anesthesia in an academic hospital. In his case, I always suspected that it had more to do with personal demons than actual unhappiness with the work. What's your story?

 

[dchristismi]

Wow.

Yeah, so as of last month, I retired from general EM.

One of my groups landed a contract to staff the "urgent care" at an ivory tower cancer center. It's not EMTALA bound, it technically isn't even a hospital, but these folks are SICK and on weird-ass immunotherapies, so it's very different from general EM. Lots of neutropenic fever, cord compressions, crazy stuff. Rarely, something EMish. I pull a couple overnights there a month for now as it pays quite well, and can be chill as hell or... just hell.

I am making my very last mortgage payment next month, and while I technically could be FIRE, I really, really, really love my hospice.

I'm working a lot closer with the coders/billers now, and with all the doom and gloom in the other threads, I'm making more (hourly) than I apparently would in NYC. It's still part time, usually 4-6 hours a day once I've made my own schedule and did I mention that I really love it? I've also militantly guarded what I'll do for them (no overnight call, no certifications, etc) which is mostly about me having control, unlike 5 years ago as med director working my ass off and always being asked to do more more more with less less less.

I'm torn on the other place. They are overnights, but the place dies down big time at midnight, or at least for now, so I usually get some semblance of a nap. Once I've been mortgage-free for awhile, I'll reassess. I've been throwing a lot of dough at it to pay it off (it's the principle of the thing), so I may be able to live quite comfortably *and travel* on my hospice gig alone. Time will tell. (If I was working full time, the salary is around $200/$225K, but I'm not ever planning to work full time again.)

 

[Frazier]

Wow.

Yeah, so as of last month, I retired from general EM.

One of my groups landed a contract to staff the "urgent care" at an ivory tower cancer center. It's not EMTALA bound, it technically isn't even a hospital, but these folks are SICK and on weird-ass immunotherapies, so it's very different from general EM. Lots of neutropenic fever, cord compressions, crazy stuff. Rarely, something EMish. I pull a couple overnights there a month for now as it pays quite well, and can be chill as hell or... just hell.

I am making my very last mortgage payment next month, and while I technically could be FIRE, I really, really, really love my hospice.

I'm working a lot closer with the coders/billers now, and with all the doom and gloom in the other threads, I'm making more (hourly) than I apparently would in NYC. It's still part time, usually 4-6 hours a day once I've made my own schedule and did I mention that I really love it? I've also militantly guarded what I'll do for them (no overnight call, no certifications, etc) which is mostly about me having control, unlike 5 years ago as med director working my ass off and always being asked to do more more more with less less less.

I'm torn on the other place. They are overnights, but the place dies down big time at midnight, or at least for now, so I usually get some semblance of a nap. Once I've been mortgage-free for awhile, I'll reassess. I've been throwing a lot of dough at it to pay it off (it's the principle of the thing), so I may be able to live quite comfortably *and travel* on my hospice gig alone. Time will tell. (If I was working full time, the salary is around $200/$225K, but I'm not ever planning to work full time again.)

HPM is a fantastic field. You function in the quintessential spirit of "physician". There is something like a 98% high satisfaction rate among graduated fellows. Hard (impossible?) to replicate in other fields.

The pay is excellent by general public standards, but mediocre to poor by specialist doc standards. But one doesnt choose the field for the dollars, rather the essence. I tell my medical buddies ("but you could make more doing straight EM") I could have been a neurosurgeon if I HAD to have a huge paycheck. It is not the best field for everyone, but for a real proportion, it sure is exactly that.

Thanks for sharing. You should start a thread in the future.

 

[AlvinKamara]

HPM is a fantastic field. You function in the quintessential spirit of "physician". There is something like a 98% high satisfaction rate among graduated fellows. Hard (impossible?) to replicate in other fields.

The pay is excellent by general public standards, but mediocre to poor by specialist doc standards. But one doesnt choose the field for the dollars, rather the essence. I tell my medical buddies ("but you could make more doing straight EM") I could have been a neurosurgeon if I HAD to have a huge paycheck. It is not the best field for everyone, but for a real proportion, it sure is exactly that.

Thanks for sharing. You should start a thread in the future.

Any idea of salary range?


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[Frazier]

Any idea of salary range?


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Full-time tends to range 190k-250k. There are outliers in both directions. Also depends on practice setting and region (similar to most specialties).

Typically M-F, ~9 to ~5

The hourly comes out to much less than EM. However, it is also a very different pace, liability load, and circadian influence than EM.

Be sure to check it out more if interested!

 

[namethatsmell]

Full-time tends to range 190k-250k. There are outliers in both directions. Also depends on practice setting and region (similar to most specialties).

Typically M-F, ~9 to ~5

The hourly comes out to much less than EM. However, it is also a very different pace, liability load, and circadian influence than EM.

Be sure to check it out more if interested!

HPM is great. You get to actually talk with patients and families, focus on their goals, and take care of them.

What’s your take on the future of employment opportunities in the field? Is there a decent risk of corporatization? One shop I used to work at actually had a few HPM groups (unicorn, eh?) and one appeared to be a big regional corporation which was heavily staffed by NPs. Is the field at risk of devolving into the HPM doc “supervising” a bunch of midlevels in the typical venture capital-backed for-profit model?

Sorry if I seem like a Debbie Downer, but I’m truly curious.


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[dchristismi]

In my particular situation, having been really burned out, I knew basically what I wanted to do, and what I didn't. I wanted the sickest of the sick and the dying, to be at the bedside, and let families cry on my shoulder. And I found a unicorn gig.

Because of this, I only work in an inpatient level hospice house, which is where pretty much most of the MDs in this group are based due to billing - my NPs can't bill at the hospice houses. I have asked repeatedly how to fix this since everyone else in the house of medicine does it, but I've been told that Hospice is different. Anyway, I have an army of NPs who do all the home visits. I didn't want to do them, and I'm happy not to. I get calls occasionally asking for help when it comes to tough medical situations, but those are often fun and challenging. (For example, I had a call last week about a lady with severe abdominal pain. But the thing is, she had lung cancer and no good explanation for this pain. Long story short, I had them send her to me, I laid hands on, rapidly had a discussion about her surgical abdomen, and she ended up going to the ER and then the OR. She was new to hospice and wasn't ready to die. And that's fine.)

So I basically round on my inpatients, and manage the crises and symptoms that could not be handled at home. This is where my EM training comes in beautifully, as sometimes you have to get creative when standard therapies fail. Also, I didn't want to commit to a full time job, so I fully acknowledge that I don't make near as much as I used to, but that is by choice. I do a few administrative things, but mostly have steered clear by choice. This is, after all, my retirement gig.

My particular hospice talks about billing and money far less than any place I've ever worked, and that has been a big change. (It has been like pulling teeth to get the billers to actually tell me how to increase my revenue.) We function a great deal on donations and a surprising number of the NP visits don't get paid. It's a very different world. I suspect my hospice is an outlier, but it's all I know, and I specifically chose them due to my experience with them in the ED.

As far as employment, the field is desperate for docs. My hospice is currently searching for physicians. Burnout is common partly because of the stress and partly because most docs are overworked as there aren't enough bodies to go around. It's fulfilling work, but it isn't easy. It's not the physical challenge of running your ass off in an ED - it's different. But it's still hard.

 

[Frazier]

HPM is great. You get to actually talk with patients and families, focus on their goals, and take care of them.

What’s your take on the future of employment opportunities in the field? Is there a decent risk of corporatization? One shop I used to work at actually had a few HPM groups (unicorn, eh?) and one appeared to be a big regional corporation which was heavily staffed by NPs. Is the field at risk of devolving into the HPM doc “supervising” a bunch of midlevels in the typical venture capital-backed for-profit model?

Sorry if I seem like a Debbie Downer, but I’m truly curious.


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Excellent talking points. The future is excellent for opportunities. As noted above, there is a major shortage. Most people get chronic or life limiting diseases. Everyone dies. Every one of those cases sans sudden unexpected death could benefit from having a specialist offer you and your family services dedicated to your QoL, wishes, and dignity. The patient pool is endless and essentially only limited by cultural and ideological constraints.

Corporations have already infiltrated hospice decades ago when a corporation named Roto-Rooter diversified from the drain cleaning business and created VITAS (you likely heard of them). It isnt necessarily a bad thing. They do great service for countless patients. But, for-profit hospices are nothing new. They achieve their investors' needs through economy of scales, popping up across the country-- because the margins are extremely thin. It's fine the services are needed coast to coast.

Unlike ortho, GI, or even EM --- palliative/hospice doesnt bring in patients, RVU's, or significant profits ( at least not like those fields). The field is more of a "cost saver" for Medicare and hospitals -- it just so happens that the cost-saving services offered are immense for improving patient QoL.

So while you might do some therapeutic paracentesis or thoracentesis every now and then for comfort -- it is a vastly different world and mindset than other fields of medicine (as alluded to in post above).

For hospice, Medicare pays a fixed amount per day. And that's it essentially. It is very regulated and closely monitored. There was a lot of fraud going on in the past. Medicare has tightened down the screws. Most of the largest palliative services run out of academic hospitals. Hospices are typically community based, however some hospitals have inpatient hospice floors.

NP's are extremely common. They are part of the IDT (interdisciplinary team)... along with social workers, pharmacy, chaplains, attendings, etc. There isnt really an issue of them "stealing business" or "missing a diagnosis" like you might hear derm or EM lament over -- as essentially all patients get discussed every day or so in roundtable discussions. Similar to the docs, they arent there for the money (can make more elsewhere) so they tend to be passionate about HPM... good for you and good for the patient.

As the doc you supervise similar to how fellows might be supervised. There are only about 300 fellows entering the workforce each year. There is a significant number of docs in their 60's. Huge need. Small margins. The 10 person team of say 3 docs and 7 NP's wouldnt financially survive if it was instead 10 docs all commanding attending-level salaries. The model would crumble.

Long story short: great job prospects coast to coast. Corporations have long been involved with hospice. I doubt the hedge funds/ VC are super interested given the super tight margins and close federal regulations. NP's are very common as part of the team model. Their role and "threat" (lackthereof) is very different than in other fields.

disclaimer I am just a guy 1 month out from fellowship match. But have been pretty involved with the field last few years. Not an expert. YMMV.

 

[dchristismi]

Nah, I think you hit the nail on the head.
And as I learned at last years AAHPM, I'm too cynical for palliative. (But too touchy-feeley to last in EM much more than a decade.)

 

[Frazier]

On a lighthearted note, here are two pictures I feel capture the essence of practicing in the ED versus in HPM...

HPM on Monday

... Meanwhile in the ED

Jokes aside, EM is a fantastic field. There is no other primary specialty I would have rather done on the journey to where I'm heading.

 

[GonnaBeADoc2222]

In my particular situation, having been really burned out, I knew basically what I wanted to do, and what I didn't. I wanted the sickest of the sick and the dying, to be at the bedside, and let families cry on my shoulder. And I found a unicorn gig.

Because of this, I only work in an inpatient level hospice house, which is where pretty much most of the MDs in this group are based due to billing - my NPs can't bill at the hospice houses. I have asked repeatedly how to fix this since everyone else in the house of medicine does it, but I've been told that Hospice is different. Anyway, I have an army of NPs who do all the home visits. I didn't want to do them, and I'm happy not to. I get calls occasionally asking for help when it comes to tough medical situations, but those are often fun and challenging. (For example, I had a call last week about a lady with severe abdominal pain. But the thing is, she had lung cancer and no good explanation for this pain. Long story short, I had them send her to me, I laid hands on, rapidly had a discussion about her surgical abdomen, and she ended up going to the ER and then the OR. She was new to hospice and wasn't ready to die. And that's fine.)

So I basically round on my inpatients, and manage the crises and symptoms that could not be handled at home. This is where my EM training comes in beautifully, as sometimes you have to get creative when standard therapies fail. Also, I didn't want to commit to a full time job, so I fully acknowledge that I don't make near as much as I used to, but that is by choice. I do a few administrative things, but mostly have steered clear by choice. This is, after all, my retirement gig.

My particular hospice talks about billing and money far less than any place I've ever worked, and that has been a big change. (It has been like pulling teeth to get the billers to actually tell me how to increase my revenue.) We function a great deal on donations and a surprising number of the NP visits don't get paid. It's a very different world. I suspect my hospice is an outlier, but it's all I know, and I specifically chose them due to my experience with them in the ED.

As far as employment, the field is desperate for docs. My hospice is currently searching for physicians. Burnout is common partly because of the stress and partly because most docs are overworked as there aren't enough bodies to go around. It's fulfilling work, but it isn't easy. It's not the physical challenge of running your ass off in an ED - it's different. But it's still hard.

Is a fellowship absolutely necessary?

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[slippery_when_wet]

Is a fellowship absolutely necessary?

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I imagine it'd be a difficult sell to potential employers without a HPM fellowship.

 

[dchristismi]

Depends on what you want to do.

I only do hospice, and for that, a fellowship is overkill. In fact, the med director point blank told me that the only reason I'd need to go back would be if I wanted to be a hospice medical director. Since there's no way in hell I'm ever doing that, I didn't. (I should add yet again, that this is my retirement gig which I do solely because I really enjoy it. I know several mid-to-late career EPs who went back and did fellowships. It really depends on what you want to do.)

If you wanted to focus on Palliative, the tools they use are a little more in-depth, and they also focus on goals of care and coordinating with other services. I mean, I had to learn the Palliative Performance Scale and the PAIN-AD scale. And that was really about it. I was already comfortable with pain management, and I had plenty of critical care experience. Oh, and methadone. That was new. But otherwise, I was quite familiar with the big opioids, sedatives, and antipsychotics, which are the mainstay of my hospice practice.

So it really comes down to what you want to do with it. Do you want to consult in hospitals? Do you want to work on symptoms to make the oncology patient's life better? Do you want to focus on trauma and ICU? Do you want to work outpatient? Inpatient? With people who are actively dying or who are just in a holding pattern for possibly years? Neurologic disease? Burns? Physican-Aid-in-Dying? Legislative issues? Regulatory issues? HPM can encompass all of this and more. You just have to figure out what you want your role to be.

My hospice started chomping at the bit when I mentioned I had some EM friends who were interested in learning more. FWIW, and I am totally biased, EM is the best specialty to transition from... we are masters at critical care, masters at rescus, and we also unfortunately know what often comes next. We know the revolving door of hospital-rehab-SNF. We aren't as optimistic as oncologists, but I often have families thank me for "telling it how it is."

Oh, and Frazier, you forgot to photoshop the dog into the fireplace photo. I have people bring their pets to my hospice house all the time. It's funny how a ball of fur changes the whole feel of a patient's room. It's good for the patient, the family, and also, the dog.

 

[Birdstrike]

FWIW, and I am totally biased, EM is the best specialty to transition from... we are masters at critical care, masters at rescus, and we also unfortunately know what often comes next. We know the revolving door of hospital-rehab-SNF. We aren't as optimistic as oncologists, but I often have families thank me for "telling it how it is."

 

[dchristismi]

Well, critical care might be the best *SUBspecialty* but still. It's been a very natural transition for me.

 

[deuist]

One thing I've never understood is the sheer rigidity and lack of fellowships in EM. For example, could toxicology be 5 years of part time work? That way, fellows could continue working in the ED and not take such as significant financial hit. Also, could fellowships involve more training away from the mothership? I could work with a Hospice group in my area, read on my own, and only occasionally travel to the primary training location. Again, the time to fellowship completion might have to be extended. At the end if the day, there's no way I can move to another city and give up my salary to switch medical specialties.

 

[miacomet]

Depends on what you want to do.

I only do hospice, and for that, a fellowship is overkill. In fact, the med director point blank told me that the only reason I'd need to go back would be if I wanted to be a hospice medical director. Since there's no way in hell I'm ever doing that, I didn't. (I should add yet again, that this is my retirement gig which I do solely because I really enjoy it. I know several mid-to-late career EPs who went back and did fellowships. It really depends on what you want to do.)

If you wanted to focus on Palliative, the tools they use are a little more in-depth, and they also focus on goals of care and coordinating with other services. I mean, I had to learn the Palliative Performance Scale and the PAIN-AD scale. And that was really about it. I was already comfortable with pain management, and I had plenty of critical care experience. Oh, and methadone. That was new. But otherwise, I was quite familiar with the big opioids, sedatives, and antipsychotics, which are the mainstay of my hospice practice.

So it really comes down to what you want to do with it. Do you want to consult in hospitals? Do you want to work on symptoms to make the oncology patient's life better? Do you want to focus on trauma and ICU? Do you want to work outpatient? Inpatient? With people who are actively dying or who are just in a holding pattern for possibly years? Neurologic disease? Burns? Physican-Aid-in-Dying? Legislative issues? Regulatory issues? HPM can encompass all of this and more. You just have to figure out what you want your role to be.

My hospice started chomping at the bit when I mentioned I had some EM friends who were interested in learning more. FWIW, and I am totally biased, EM is the best specialty to transition from... we are masters at critical care, masters at rescus, and we also unfortunately know what often comes next. We know the revolving door of hospital-rehab-SNF. We aren't as optimistic as oncologists, but I often have families thank me for "telling it how it is."

Oh, and Frazier, you forgot to photoshop the dog into the fireplace photo. I have people bring their pets to my hospice house all the time. It's funny how a ball of fur changes the whole feel of a patient's room. It's good for the patient, the family, and also, the dog.

Thanks for telling us about your experience- would you be able to tell us what other fellowships your colleagues completed mid-career?

 

[dchristismi]

Ah, those were docs at the AAHPM meeting in the EM subgroup, and several had gone back and done HPM after years in EM.
I personally only know one early/mid-career EM doc who retrained in something else, and she went and did tox... but she also had her heart in academics, so can't really speak to any others, sorry. Bird is the guy there, as apparently several of us have consulted him on the down low.

 

[RandomChaos]

So, you did an EM residency, then 2 years of CC and NOW are jumping to a second fellowship in pain to get away from BOTH EM & CC? Care to elaborate on your personal story? I'm always curious and a bit suspicious when I hear people jump ship from multiple practice environments. It reminds me of my PD who was anesthesia boarded, pain boarded, EM boarded and 3/4 through my residency he jumped to a CC fellowship in his 50s and last I checked was back doing anesthesia in an academic hospital. In his case, I always suspected that it had more to do with personal demons than actual unhappiness with the work. What's your story?

Wow that PD sounds motivated? I am not that crazy.

My plan was always to combine EM/CC with another specialty that would allow me to get involved with Post-ICU care. I would not say that I am trying to get away from EM/CC, but only trying to further enhance the specialties. The long term goal is to focus on Post-ICU care and I think that Pain is a way to do that. Many of these patients go on to develop Post-Intensive Care Syndrome and need further care after resolution of the acute illness. Most Pain clinics utilize pharmacists, psychologists, physical therapists, etc., which are resources that would also be useful for Post-ICU care.

 

[gro2001]

One thing I've never understood is the sheer rigidity and lack of fellowships in EM. For example, could toxicology be 5 years of part time work? That way, fellows could continue working in the ED and not take such as significant financial hit. Also, could fellowships involve more training away from the mothership? I could work with a Hospice group in my area, read on my own, and only occasionally travel to the primary training location. Again, the time to fellowship completion might have to be extended. At the end if the day, there's no way I can move to another city and give up my salary to switch medical specialties.

That's an interesting concept. Do you know of any other, non-EM, fellowships that can be structured this way? I was under the impression that graduate medical education in the US generally can't work that way, but would love to be proven wrong.

 

[deleted547339]

Wow that PD sounds motivated? I am not that crazy.

My plan was always to combine EM/CC with another specialty that would allow me to get involved with Post-ICU care. I would not say that I am trying to get away from EM/CC, but only trying to further enhance the specialties. The long term goal is to focus on Post-ICU care and I think that Pain is a way to do that. Many of these patients go on to develop Post-Intensive Care Syndrome and need further care after resolution of the acute illness. Most Pain clinics utilize pharmacists, psychologists, physical therapists, etc., which are resources that would also be useful for Post-ICU care.

The problem with this is compensation. Pulmonary seems to make the most sense as pulm follow up post-icu is easily justifiable.

 

[RandomChaos]

The problem with this is compensation. Pulmonary seems to make the most sense as pulm follow up post-icu is easily justifiable.

Yeah I have spoken to a few Pulmonologists about this and they seem to have the same issues with compensation. It seems that many of them seem to fail due to this. I think no matter which route you do it the reimbursement is always going to be an issue. But, again Pain clinics tend to use more of the same resources ie. pharmacist, psychologist, PT that would be needed for post-ICU patients, so the framework is already there. Where as I have never seen these resources in a normal pulmonary clinic.

 

[deuist]

That's an interesting concept. Do you know of any other, non-EM, fellowships that can be structured this way? I was under the impression that graduate medical education in the US generally can't work that way, but would love to be proven wrong.

As far as I know, all accredited fellowships in the United States require full-time work. I still think that moving in a part-time direction for some of the specialties makes sense.

 

[Groove]

Wow that PD sounds motivated? I am not that crazy.

My plan was always to combine EM/CC with another specialty that would allow me to get involved with Post-ICU care. I would not say that I am trying to get away from EM/CC, but only trying to further enhance the specialties. The long term goal is to focus on Post-ICU care and I think that Pain is a way to do that. Many of these patients go on to develop Post-Intensive Care Syndrome and need further care after resolution of the acute illness. Most Pain clinics utilize pharmacists, psychologists, physical therapists, etc., which are resources that would also be useful for Post-ICU care.

Dude, I don't doubt for a second that your plan sounds fantastic in your own mind, but I really fail to grasp your logic. For instance...."I would not say that I am trying to get away from EM/CC, but only trying to further enhance the specialties". Eh, what? As for "post intensive care syndrome", why on earth would you think a pain clinic would be the best place for ICU f/u post discharge? I mean, I get that you may have a segment of patients dealing with chronic post icu pain syndromes, but I would guess that to be the least utilized business model for a pain clinic. (What pain clinic gets most of their business from nearby ICU referrals?) Does that mean you want to work half your time in the ICU and see half of your discharged pt's in the pain clinic for f/u? Are you certain about the viability of that type of practice? Have you met anyone out there doing the same thing? If not, it's going to make job finding extremely difficult for you.

Just remember, you've sacrificed anywhere from $1million to $1.5million in lost revenue during your efforts to "enhance the specialties". I'm all for learning and expanding my skillset, but sooner or later you have to leave the academic nest, get your hands dirty outside the ivory tower and start earning some cold hard cash to sock away for retirement. All that extra training isn't going to mean much when all your fellow co-residents from EM residency are retired and sailing in the Caribbean at age 60 while you are slaving away for another 10-15 years. You may have "enhanced the specialties" but I doubt you will have enhanced your quality of life or your retirement savings account for that matter. Be that as it may, I hope it works out!

 

[RandomChaos]

Dude, I don't doubt for a second that your plan sounds fantastic in your own mind, but I really fail to grasp your logic. For instance...."I would not say that I am trying to get away from EM/CC, but only trying to further enhance the specialties". Eh, what? As for "post intensive care syndrome", why on earth would you think a pain clinic would be the best place for ICU f/u post discharge? I mean, I get that you may have a segment of patients dealing with chronic post icu pain syndromes, but I would guess that to be the least utilized business model for a pain clinic. (What pain clinic gets most of their business from nearby ICU referrals?) Does that mean you want to work half your time in the ICU and see half of your discharged pt's in the pain clinic for f/u? Are you certain about the viability of that type of practice? Have you met anyone out there doing the same thing? If not, it's going to make job finding extremely difficult for you.

Just remember, you've sacrificed anywhere from $1million to $1.5million in lost revenue during your efforts to "enhance the specialties". I'm all for learning and expanding my skillset, but sooner or later you have to leave the academic nest, get your hands dirty outside the ivory tower and start earning some cold hard cash to sock away for retirement. All that extra training isn't going to mean much when all your fellow co-residents from EM residency are retired and sailing in the Caribbean at age 60 while you are slaving away for another 10-15 years. You may have "enhanced the specialties" but I doubt you will have enhanced your quality of life or your retirement savings account for that matter. Be that as it may, I hope it works out!

You seem a bit angry about something and many of your questions seem rhetorical, but I’ll do my best to try and answer them

Yes, time will be split between ICU and clinic. There has be a slow move towards the development of Post-ICU care clinics, I have been in touch with a few hospitals that are very supportive of the idea. You are right that they have run into issues with funding over time. The clinic I envision will likely begin as a traditional pain clinic with a slow referral of post ICU patients. Once the clinic has been built up or reimbursements change in a away that makes post ICU care solely sustainable then will transition to a main focus of post ICU care.

Also, thank you for the advice. I understand the barriers and sacrifice necessary to make a novel idea no longer novel.

I realize that much of medicine nowadays is based off capitalism and profits. But unfortunately, some important aspects of patient care are non-profitable until you show the true importance of it.

You also seem to be very concerned about my quality of life and financial well being, and to have some distain towards academia or “ivory tower”. If it reassures you, I did work in the community for many years in order to pay off my loans and to invest a considerable amount of money to where I could be financially comfortable and allow my money to make money.

I hope this answers most of your questions, I’m sure that I may have overlooked some, as much was said. And finally, thanks for the words of encouragement