EM part time

[petomed]

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Thanks everyone for the continued input!

it seems like I'm beating on you a little bit

Definitely but no big, I have thick skin and appreciate the insights. I agree with most of what you've said. I just know from a prior career that going down the road of increasingly more hours tends to have diminishing returns. Quality over quantity is what everyone strives for but more often than not, as medical school teaches--it's the reps that count. For me, I've found the best way to work hard and manage to still get a good night's sleep is to lean on the licensing bodies. If I can't pass those exams then I didn't do enough work in med school, residency, etc. If those exams aren't representative of actual required performance, the buck stops at the board that wrote those exams and the state that granted me the license. If I did everything in-line with standards and CYA'd, etc. If I make a mistake, that's absolutely my fault and that mistake needs to be owned. But for me personally, going down the road of "I should've put in more during A and B etc..." is just endless. I'm sure I'll put in more work at times just like everyone else because, this is medicine and it's people's lives that are held in our hands. But when it's a bottomless pit, you need to find a way to feel good at work and outside of work.

Physicians in general are very naive

Nah it's not a doc thing. Priorities change over time. If I was 23 like my peers I'd probably be feeling burnt out in MS2 like they are right now. But I've done the alternate career thing already and I know it's a long uphill grind no matter what you do if you want to sit pretty after 10 years as a manager, director, etc. I'll do the work but I already have a life outside of medicine that I'm not willing to let crumble. That's what keeps bringing me back here. To crush those disillusionments and constantly make sure my expectations are aligned with reality.

 

[Arcan57]

Thanks everyone for the continued input!


Definitely but no big, I have thick skin and appreciate the insights. I agree with most of what you've said. I just know from a prior career that going down the road of increasingly more hours tends to have diminishing returns. Quality over quantity is what everyone strives for but more often than not, as medical school teaches--it's the reps that count. For me, I've found the best way to work hard and manage to still get a good night's sleep is to lean on the licensing bodies. If I can't pass those exams then I didn't do enough work in med school, residency, etc. If those exams aren't representative of actual required performance, the buck stops at the board that wrote those exams and the state that granted me the license. If I did everything in-line with standards and CYA'd, etc. If I make a mistake, that's absolutely my fault and that mistake needs to be owned. But for me personally, going down the road of "I should've put in more during A and B etc..." is just endless. I'm sure I'll put in more work at times just like everyone else because, this is medicine and it's people's lives that are held in our hands. But when it's a bottomless pit, you need to find a way to feel good at work and outside of work.

Just as a heads up, none of the tests that you have to take to become a licensed, board-certified physician ensure you are a competent medical practitioner. Medical licensing is based on a pillar of taking very bright, very motivated learners and forcing them through an arduous path that forces them to care deeply about the quality of care they provide. The idea is that a physician that can't provide quality care couldn't:
1) get into medical school
2) pass medical school and the first 2 USMLE exams
3) successfully match into a residency
4) complete 3-7 years of training and finish residency

State licensing and board certification is pretty much a participation trophy after that and mostly weeds out people who don't test well or developed crippling substance use/mental health problems somewhere between starting residency and finishing their specialty boards. The theory was that residency programs wouldn't allow doctors that were unsafe to graduate. Therefore, the type of extensive testing that would be required to prove clinical competence independently of having finished residency isn't necessary. The boards are designed to have enough specialized information that one specialty can't easily poach into another's specialty's domain without redoing training, not to ensure that the board certified practitioner is actually a competent doctor. EM's boards do an absolutely atrocious job of simulating the actual cognitive tasks needed to be a successful EM doc.

Since medicine isn't your first rodeo, you've probably picked out that relying on residencies to weed out/fail incompetent trainees is a point of vulnerability in the system. And you'd be correct. Much like other venerable institutions currently under threat, the house of medicine relies on adherence to strong norms that were so fundamental to it's founding that they're not actually written anywhere. This is best demonstrated in EM by the rise of CMG residencies. At the time the rules were created, the RRC made a list of experiences and procedures that were thought to be necessary for becoming a good emergency physician. The unwritten part was that these experiences and procedures would be obtained in large teaching facilities which offered full institutional support for the mission of education. The founding RRC never could have imagined small community hospitals cobbling together Frankencurriculums where the more onerous requirements are foisted off as away rotations at institutions that are happy to take the month of funding that comes with hosting these residents. And thus you have EM in 2023.

 

[The Knife & Gun Club]

Correct, the main point of residency IS to do almost nothing but work and study. This is my problem: People seem to come to emergency medicine not expecting this. I appreciate that with most other residencies they do not tolerate this kind of weak sauce and it doesn't seem to be expected by the applicants/residents. People seem to have the misunderstanding that emergency medicine is a kind of medicine on easy-mode or half-ass kinda thing.

I think you over-estimate yourself. You think you can get equal results with less work than everyone else in training and in practice. You aren't talking about tending to your mental-health and balancing your life-work, you are talking about training and working less than HALF of most physicians. I am telling you, you will not be good if you do this. You don't have some special gift or knack for this, you need the reps like everyone else.

You use the term "Elitist Standard" in a pejorative way, but you are correct, I am elitist. We physicians are the elite. That's why we as physicians are at the top of the health care clinical hierarchy. This isn't a position that we have a divine right to. We EARN this position by taking the smartest students and giving them the most rigorous training. They are then the individuals who have the best knowledge and skills, which other people do not have. That is why people look to us for leadership and guidance.

The idea of wanting to be a clinical leader but not wanting to put in the work to actually deserve that responsibility is a mid-level provider mindset.
In other words, bodybuilder Ronnie Coleman put it best when he said "Er'yone wanna be a bodybuilder, but nobody wanna lift no heavy goddam weights."

Correct. This is how you get good. And you need to be good on day 1 solo. Practice has no training wheels, you are expected to come out that gate fully-formed and ready to provide excellent standard of care to your patients.


You are correct, being slow and inefficient will probably limit how much revenue you can generate for yourself and your practice, which may be a risk to your job security in any specialty. I think you are starting to see why they are very few part-time early career physicians across specialties. That being said, what is unique to emergency medicine is being slow and inefficient are actually patient safety and personal liability issues in this specialty. You ARE responsible for the patient in the waiting room who dies waiting to be seen because you couldn't get to them fast enough.


All in all, I know it seems like I'm beating on you a little bit, and I apologize for that. Ultimately I think you are actually doing something very wise, which is asking the right questions and being introspective about what you want out of your career and how to get that. I genuinely do applaud that. I think you are coming to the realization EM may not be right for you, and that's great. There are a lot of other specialties out there.

I would push back on this a little - I worked by butt off in residency but definitely didn’t only work and study. With a little bit of hustle you can absolutely not feel completely robbed of those 3-4 years (maybe only partially robbed).

I took a couple trips per year, got married, made it to happy hour or a concert maybe once every week or two with friends. Certainly not a blossoming social life but if you never do anything but work and study you’ll probably go insane.

And I didn’t come out a fully terrible doctor…I think 🤷‍♂️

 

[Arcan57]

I would push back on this a little - I worked by butt off in residency but definitely didn’t only work and study. With a little bit of hustle you can absolutely not feel completely robbed of those 3-4 years (maybe only partially robbed).

I took a couple trips per year, got married, made it to happy hour or a concert maybe once every week or two with friends. Certainly not a blossoming social life but if you never do anything but work and study you’ll probably go insane.

And I didn’t come out a fully terrible doctor…I think 🤷‍♂️

I definitely agree that residency isn't all misery, but what I think the OP was getting at wasn't so much an "I'm going hard in both work and play and I'm willing to deal with the consequences to my body" that a lot of us were expecting during residency. I think it's more along the lines of "I want a residency where medical training isn't the main focus of my life". And that feels a lot tougher to pull off and still graduate as a good physician. The people in residency that I saw try that were either 4-5 sigmas above the curve on efficiency/talent or were crappy residents that everyone hated and became trash doctors.