Fellowships after Emergency Medicine

[RustedFox]

Whichever one lets you avoid antidepressants and therapy.

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[chillaxbro]

All Pain.

Lifestyle = Derm

-Stress reduction, 90%

-Hours: Mon -Thurs, 8-12, 1 hour lunch break, then 1pm to 3:30/4:30ish (depending on day). Friday, 8am - 12pm
No nights, no weekends, no holidays, no call. Ever.

-2 days, all procedures. 2.5 days, clinic, mostly pre-/post-procedural stuff, very minimal [but some] opiates)

How's the pay?

 

[ethosuximideme]

CCM is a tremendous field and one that lends itself well to people who trained in EM, but I think people who are going into it as a way out from EM are making a terrible mistake. CCM is just as prone to the corporate takeover as EM is. The hours are long, and exhausting, and the additional training is no joke. Sometimes I wonder if the love for CCM in this forum is a product of "grass is always greener" mentality.

I did an EMS fellowship. I don't think its a bail out from EM per se, and I will probably make less money over the course of my career. Jobs in the field aren't easy to come by, especially not the classic big city medical director positions, but there are definitely other opportunities in the field and exciting things going on. My biggest hope is that I can do more EMS stuff which is primarily administrative, and as a result, buy down clinical time in the ED as get older.

I have a handful of friends who I went to residency with that did US fellowships. Unless you are creating an US program at a site, doing QA/QI, billing for POCUS studies, etc, there's no utility to doing an ultrasound fellowship IMO. Most of my friends in clinical practice who are US trained don't use the additional year of training in their practice.

Toxicology is a phenomenal fellowship, one that is very niche, highly academic and desirable but still with opportunities to get out and go into industry. Probably has less utility in the community world, but still a great gig.

Why anyone would do wilderness/hyperbarics etc is beyond me.

What kind of other job opportunities are there with EMS? I'm heavily considering a fellowship in EMS, but I'm deciding whether it would be worth it in the long term and if it would allow for other job offerings outside of the ED. No other fellowships in EM really interest me at the moment, so if I don't do the EMS route, I won't be doing a fellowship. But, with the current job market, I would ideally like to complete a fellowship if it would open more doors for me.

 

[cyanide12345678]

How's the pay?

Probably around 400k for pain.

It's one of the few fellowships that improves lifestyle and maintains the EM income.

I sometimes toy with the idea of doing a palliative care or addiction medicine fellowship, but the massive paycut isn't worth it. I think I'm just better off working 7-8 monthly 12 hour shifts in the ER and make the same as a palliative doc and just enjoy my time off.

One of the things that i feel EM docs should consider prior to fellowship is a change in practice setting. I've worked an ER where i used to see 8 patients in 24 hours, would sleep 6-7 hours, it paid $135/hr but i always felt so refreshed after such a shift. 6 x 24 hour shifts per month still can get you over 200k.

After thinking long and hard about my career and future, i personally opted to work 80% at a place seeing 0.8 patients per hour while making $192/hr plus amazing benefits. Starting in November, so will see how i like it. I think it's the perfect balance between income, and the volume stresses of EM. I truly really enjoy my work when im not thinking of how many patients i still haven't seen and how long that lac or Central line will take and that the waiting room would blow up while I'm doing so.

We work too much. We balance too many things. 1 pph and i think most of us will suddenly find ourselves happy and stress free.

 

[southerndoc]

What kind of other job opportunities are there with EMS? I'm heavily considering a fellowship in EMS, but I'm deciding whether it would be worth it in the long term and if it would allow for other job offerings outside of the ED. No other fellowships in EM really interest me at the moment, so if I don't do the EMS route, I won't be doing a fellowship. But, with the current job market, I would ideally like to complete a fellowship if it would open more doors for me.

Lots of opportunities, but mainly in a big city. I've turned down several >$250k+ full-time EMS medical director gigs. If I start getting burned out or older, I may consider it. Full-time office gig. Would be a pay cut from general EM though.

 

[DeadCactus]

I truly really enjoy my work when im not thinking of how many patients i still haven't seen and how long that lac or Central line will take and that the waiting room would blow up while I'm doing so.

The idea that it's our fault the waiting room is backing up when we take the time to provide high-quality emergency medicine to patients rather than being clear evidence of ****ty staffing decisions has been one of the most effective poisons against our job satisfaction and autonomy.

 

[Birdstrike]

How's the pay?

Good. It tends to track similar to anesthesia and the other procedure based, non-surgery, Subspecialties. Check out a recent MGMA survey. The last one I looked at (3-4 yes ago?) it was in the high 4’s.

 

[cyanide12345678]

The idea that it's our fault the waiting room is backing up when we take the time to provide high-quality emergency medicine to patients rather than being clear evidence of ****ty staffing decisions has been one of the most effective poisons against our job satisfaction and autonomy.

It's not our fault but we're the ones who have to deal with it unfortunately.

 

[Birdstrike]

The idea that it's our fault the waiting room is backing up when we take the time to provide high-quality emergency medicine to patients rather than being clear evidence of ****ty staffing decisions has been one of the most effective poisons against our job satisfaction and autonomy.

I agree 100%. Being continuously held accountable and blamed for factors out of my control was a morale killer.

 

[Franzd'Epinay]

Lots of opportunities, but mainly in a big city. I've turned down several >$250k+ full-time EMS medical director gigs. If I start getting burned out or older, I may consider it. Full-time office gig. Would be a pay cut from general EM though.

What level of big city are we talking? NYC/LA metropolis, Chicago/Houston big city, or more St. Louis/Cincinnati? I always assumed these full-time jobs were rare to non-existent.

 

[southerndoc]

What level of big city are we talking? NYC/LA metropolis, Chicago/Houston big city, or more St. Louis/Cincinnati? I always assumed these full-time jobs were rare to non-existent.

I'm in a suburb of Atlanta. I know of one other who is full-time in a suburb of South Atlanta. There are a lot of places that have full-time medical directors. It's growing. There was an ad recently for Salem, Oregon recruiting a full-time medical director. It's not just major cities that are recruiting these days. A lot of the mid-size cities/counties are looking for full-time medical directors, and almost all of them require you to be subspecialty certified in EMS.

 

[RustedFox]

I'm in a suburb of Atlanta. I know of one other who is full-time in a suburb of South Atlanta. There are a lot of places that have full-time medical directors. It's growing. There was an ad recently for Salem, Oregon recruiting a full-time medical director. It's not just major cities that are recruiting these days. A lot of the mid-size cities/counties are looking for full-time medical directors, and almost all of them require you to be subspecialty certified in EMS.

How is "South Atlanta" different than "Atlanta"?
I'm asking, not telling.
I'm not being nitpicky in an attempt to disqualify your statement; I know very little about Atlanta other than the food is outta sight good.
Seems like South Atlanta has its own definition.

 

[southerndoc]

How is "South Atlanta" different than "Atlanta"?
I'm asking, not telling.
I'm not being nitpicky in an attempt to disqualify your statement; I know very little about Atlanta other than the food is outta sight good.
Seems like South Atlanta has its own definition.

I'm speaking of the South Metro area. It's not the city limits of Atlanta. "Atlanta" that we refer to is metro Atlanta, which sprawls out about 45-70 miles in each direction from downtown Atlanta. It's the reason traffic is such a problem. Although I really do like the skyway tollercoaster (an elevated bypass that you can pay to drive on and beat the traffic in the north corridor/North Atlanta).

 

[RustedFox]

I'm speaking of the South Metro area. It's not the city limits of Atlanta. "Atlanta" that we refer to is metro Atlanta, which sprawls out about 45-70 miles in each direction from downtown Atlanta. It's the reason traffic is such a problem. Although I really do like the skyway tollercoaster (an elevated bypass that you can pay to drive on and beat the traffic in the north corridor/North Atlanta).

I gotcha.
I've driven around the city a few times and stopped here and there. Never really got to know it.
That tollercoaster is something. Scary.

 

[bravotwozero]

Whichever one lets you avoid antidepressants and therapy.

And wake up in the morning, and go to sleep at night, in your bed at home.

 

[RustedFox]

And wake up in the morning, and go to sleep at night, in your bed at home.

See, I wouldn't mind the nights and such if it weren't for the absolutely bat**** insane patients.

A strange game. The. Only. Winning. Move. Is. Not. To. Play.

 

[southerndoc]

I gotcha.
I've driven around the city a few times and stopped here and there. Never really got to know it.
That tollercoaster is something. Scary.

Skip to the 11:40 mark and you can see how high up it gets. I was trying to Google exactly how many feet high it is. I think it's probably 100 feet in the air when it goes over Canton Rd in Marietta. "Spaghetti Junction" in Atlanta I think is 90 feet high.

 

[TheComebacKid]

What kind of other job opportunities are there with EMS? I'm heavily considering a fellowship in EMS, but I'm deciding whether it would be worth it in the long term and if it would allow for other job offerings outside of the ED. No other fellowships in EM really interest me at the moment, so if I don't do the EMS route, I won't be doing a fellowship. But, with the current job market, I would ideally like to complete a fellowship if it would open more doors for me.

EMS is an administrative subspecialty of EM. If you want to do operational medicine i.e. "doc in the field", with extremely rare exceptions, the US system is not set up for that. Most of the jobs involve meetings, protocol development, QA/QI, research, continuing education etc.

So there's the big city medical directors... highly political jobs, I guess you could say somewhat prestigious. Lots of red tape. But very hard to come by. Most medical directors will stay in those roles for years/decades. Meetings with the fire chief, the city manager, mayor etc all day everyday.

You can be an EMS medical director for a smaller agency, either municipal service, volunteer fire department, rural service, flight service etc. The degree of clinical buy down you get for this will likely be much less, and in many cases there are rural FM docs who have provided this service to their town for free, in which case you may not get paid at all. I would argue if you are a fellowship trained graduate, you should negotiate some sort of salary.

You could be the medical director for a initial education paramedic program at a local college. Basically the law states that these programs need oversight from a physician medical director. A lot of this is just signing off on the content they are receiving, although you could do some educational stuff, cadaver labs etc.

You could be a state EMS medical director. This involves more regulatory oversight on your state as a whole, as opposed to a single agency. Lots of this deals with credentialing, licensure of medics etc. You would potentially be involved with regional trauma committees, etc. When a medic has an issue often times it may be state mandated reportable problem that you would potentially investigate.

You could be the medical director of a dispatch center, help develop protocols for 911 dispatchers, perform QA/QI for your local 911 system.

You could be involved in disaster management, either on the hospital level or state/regional level. This is usually less pulling bodies out of rubble, and more making sure a team of operators is healthy. Lots of drills/planning, and people not wanting to pay to prepared for the inevitable disaster despite your pleas.

You could be involve in SWAT as a tactical doc. Seems sexy, but honestly you probably will never get paid for it, and will just terrify your spouse everyday you get a callout. If you have a tactical medic team as part of SWAT, you are pretty much on call at the time. Whenever some bum wants to hold his girlfriend at gun point, you will be expected to be there, at all hours of the night.

On the hospital side you can be in charge of a base station that provides online medical direction to crews who call in for orders. You could also be involve with the credentialing/designation of subspecialty centers such as trauma centers, STEMI centers, comprehensive stroke centers, etc.


There are lots of other areas to get involved, and areas that haven't been thought of yet. But the truth of the matter is, with the exception of a big city medical director, the vast majority of EMS doesn't pay that great. I would argue you would likely take a significant pay cut. It's also not that easy of a lifestyle. Often times, I'm on call for a week at a time for an EMS agency and get phone calls 24/7 from crews for online medical direction i.e. "yes you should terminate this arrest, or yes you can give an additional 100mcg of fentanyl for pain outside of protocol". EMS is also fairly high liability.

In my opinion, the work is amazing and I love it, but I wouldn't say its easier or less stressful than EM, and it's a different type of stress, and one I think I will tolerate a little better as I age.

Just don't make the mistake of going into it because you think you are going to be doing thoracotomies on the side of the road. That's just now how this subspecialty works.

 

[southerndoc]

EMS definitely doesn't pay more than EM that's for sure. Usually about $125-150/hr seems to be the going rate. As @TheComebacKid said, lots of administrative work. This is why I don't see myself doing it full-time until I'm ready to retire from clinical shifts. I enjoy EM too much to give it up. I could work PRN, but 5 days/week plus extra days clinically doesn't sound like fun.

 

[hector10]

What’s everyone’s opinion on palliative care???

I’m in between palliative and cc right now. I’m jaded and burnt out from the EI just started my pgy2.

if I could go back I would do a medicine sub. I don’t see myself going back.

Cc attracts me for “ status” salary, more interesting and a little better lifestyle than EM.

palliative attracts me cause of lifestyle. One year fellowship, and being a consultant.

I’m torn, and I’ll be applying next summer. Would love to hear what you guys think!

 

[Franzd'Epinay]

What’s everyone’s opinion on palliative care???

I’m in between palliative and cc right now. I’m jaded and burnt out from the EI just started my pgy2.

if I could go back I would do a medicine sub. I don’t see myself going back.

Cc attracts me for “ status” salary, more interesting and a little better lifestyle than EM.

palliative attracts me cause of lifestyle. One year fellowship, and being a consultant.

I’m torn, and I’ll be applying next summer. Would love to hear what you guys think!

Depends on the reasons for your burnout. I could see CC being great for some burned-out folks, but terrible for others

 

[alpinism]

EMS is an administrative subspecialty of EM. If you want to do operational medicine i.e. "doc in the field", with extremely rare exceptions, the US system is not set up for that. Most of the jobs involve meetings, protocol development, QA/QI, research, continuing education etc.

So there's the big city medical directors... highly political jobs, I guess you could say somewhat prestigious. Lots of red tape. But very hard to come by. Most medical directors will stay in those roles for years/decades. Meetings with the fire chief, the city manager, mayor etc all day everyday.

You can be an EMS medical director for a smaller agency, either municipal service, volunteer fire department, rural service, flight service etc. The degree of clinical buy down you get for this will likely be much less, and in many cases there are rural FM docs who have provided this service to their town for free, in which case you may not get paid at all. I would argue if you are a fellowship trained graduate, you should negotiate some sort of salary.

You could be the medical director for a initial education paramedic program at a local college. Basically the law states that these programs need oversight from a physician medical director. A lot of this is just signing off on the content they are receiving, although you could do some educational stuff, cadaver labs etc.

You could be a state EMS medical director. This involves more regulatory oversight on your state as a whole, as opposed to a single agency. Lots of this deals with credentialing, licensure of medics etc. You would potentially be involved with regional trauma committees, etc. When a medic has an issue often times it may be state mandated reportable problem that you would potentially investigate.

You could be the medical director of a dispatch center, help develop protocols for 911 dispatchers, perform QA/QI for your local 911 system.

You could be involved in disaster management, either on the hospital level or state/regional level. This is usually less pulling bodies out of rubble, and more making sure a team of operators is healthy. Lots of drills/planning, and people not wanting to pay to prepared for the inevitable disaster despite your pleas.

You could be involve in SWAT as a tactical doc. Seems sexy, but honestly you probably will never get paid for it, and will just terrify your spouse everyday you get a callout. If you have a tactical medic team as part of SWAT, you are pretty much on call at the time. Whenever some bum wants to hold his girlfriend at gun point, you will be expected to be there, at all hours of the night.

On the hospital side you can be in charge of a base station that provides online medical direction to crews who call in for orders. You could also be involve with the credentialing/designation of subspecialty centers such as trauma centers, STEMI centers, comprehensive stroke centers, etc.


There are lots of other areas to get involved, and areas that haven't been thought of yet. But the truth of the matter is, with the exception of a big city medical director, the vast majority of EMS doesn't pay that great. I would argue you would likely take a significant pay cut. It's also not that easy of a lifestyle. Often times, I'm on call for a week at a time for an EMS agency and get phone calls 24/7 from crews for online medical direction i.e. "yes you should terminate this arrest, or yes you can give an additional 100mcg of fentanyl for pain outside of protocol". EMS is also fairly high liability.

In my opinion, the work is amazing and I love it, but I wouldn't say its easier or less stressful than EM, and it's a different type of stress, and one I think I will tolerate a little better as I age.

Just don't make the mistake of going into it because you think you are going to be doing thoracotomies on the side of the road. That's just now how this subspecialty works.

Great Post.

I'll add that its much the same with Disaster Medicine. Its also largely an administrative specialty where you spend most of your time in meetings and writing protocols for the first responders. I've been on a handful of deployments with DMATs and you spend very little time caring for actual patients.
Not only that but all the actual emergencies are sent to hospitals and you end up caring for primary care patients and handing out medication refills.
The big problem with EM subspecialties is that most are nonclinical and don't offer a path to practice medicine outside the emergency department.

 

[The Knife & Gun Club]

Great Post.

I'll add that its much the same with Disaster Medicine. Its also largely an administrative specialty where you spend most of your time in meetings and writing protocols for the first responders. I've been on a handful of deployments with DMATs and you spend very little time caring for actual patients.
Not only that but all the actual emergencies are sent to hospitals and you end up caring for primary care patients and handing out medication refills.
The big problem with EM subspecialties is that most are nonclinical and don't offer a path to practice medicine outside the emergency department.

But disaster medicine is just such a cool thing to add to your title!

 

[Birdstrike]

Most EM fellowships pigeonhole you even more narrowly into EM. A better fellowship is to expand your skill set outside of the focus, and work setting, of EM. Pain Medicine does that. It essentially gives you a second specialty, a second type of practice setting and second type of lifestyle, with only a one year commitment.

Want to work in an ortho or neurosurgery group and have ownership in a surgery center?

Pain allows that.

Want to have the option to have your income completely independent of hospital based practice in an Emergency Department?

Pain allows that.

Want the option to have a normal life, work no nights, holidays, weekends or call, ever again?

Pain allows that.

Want to be able to pick and choose your patients, have control over your patient flow, practice focus and the conditions you treat?

Pain allows that.

Want to still be able to work shifts in the ED, if you want to?

Pain also allows that.

 

[Birdstrike]

My morning so far:


L5/S1 epidural steroid injection

Right L4/5, L5/S1 facet joint (medial branch) nerve ablation

Cervical epidural steroid injection, C7/T1

Right knee steroid injection

L4/5 epidural steroid injection


Opiates prescribed: zero

Number of militant patients trying to gaslight me into giving them inappropriate meds while I make live and death decisions: zero.

Circadian-rhythm dysphoria meter (0-10 scale): zero

Half-day, tomorrow (every Friday).


It's not for everyone.

 

[Waterlover]

Most EM fellowships pigeonhole you even more narrowly into EM. A better fellowship is to expand your skill set outside of the focus, and work setting, of EM. Pain Medicine does that. It essentially gives you a second specialty, a second type of practice setting and second type of lifestyle, with only a one year commitment.

Want to work in an ortho or neurosurgery group and have ownership in a surgery center?

Pain allows that.

Want to have the option to have your income completely independent of hospital based practice in an Emergency Department?

Pain allows that.

Want the option to have a normal life, work no nights, holidays, weekends or call, ever again?

Pain allows that.

Want to be able to pick and choose your patients, have control over your patient flow, practice focus and the conditions you treat?

Pain allows that.

Want to still be able to work shifts in the ED, if you want to?

Pain also allows that.

Sports Med is another one EM can do but most people never talk about it or bring it up

 

[Birdstrike]

Sports Med is another one EM can do but most people never talk about it or bring it up

Yes. True. I think I would have liked Sports Med, too. In Interventional Pain, I do a lot of what you might call non-operative Ortho type stuff, that Sports Med docs also do: Hip, knee, elbow, ankle, shoulder and other joint injections, for example.

 

[Fox800]

I've thought about many of the fellowships.

EMS sounds cool (that's my background) but I worry about the job market. There just can't be that many full-time EMS medical director positions open at any one time, and I don't want to be forced to live and work somewhere I don't want to be just because that's where jobs are.

Pain sounds cool. So does sports med. Unfortunately, neither fellowship exists in at my local academic medical center.
One thing no one is talking about: with EM pay rates falling, you can do pain or sports medicine and make the same pay/benefits as EM. The days of $300+/hr EM jobs are over. At $200-250/hr working nights and weekends, you'd make the same doing pain or sports medicine but work regular hours and have benefits.

Have also considered CCM.
Pros: mentally stimulating/fascinating. Can do full-time tele ICU.
Cons: Still a slave to hospital pay and metrics, no way to branch out and open up your own practice. Shift work disorder, though not as bad as EM.

HPM sounds interesting but big pay cut.

 

[Birdstrike]

Pain sounds cool. So does sports med. Unfortunately, neither fellowship exists in at my local academic medical center.

Neither did mine.

 

[bravotwozero]

My morning so far:


L5/S1 epidural steroid injection

Right L4/5, L5/S1 facet joint (medial branch) nerve ablation

Cervical epidural steroid injection, C7/T1

Right knee steroid injection

L4/5 epidural steroid injection


Opiates prescribed: zero

Number of militant patients trying to gaslight me into giving them inappropriate meds while I make live and death decisions: zero.

Circadian-rhythm dysphoria meter (0-10 scale): zero

Half-day, tomorrow (every Friday).


It's not for everyone.

Daily pop tarts eaten on the go: 0
Average number of Panera bread lunches per week: 5

 

[deuist]

The only way an EM doc becomes "trapped" in the ED is if he/she won't take a leap to make a change.

These "The only thing stopping you is YOU" kinds of posts are unhelpful. I simply make far too much money doing my current job to do just about anything else. Sure, I can find a new hospital, fellowship, or career, but I would have such a substantial financial hit that my wife would look at me like a crazy person for even suggesting it.

 

[Birdstrike]

The only way an EM doc becomes "trapped" in the ED is if he/she won't take a leap to make a change.

These "The only thing stopping you is YOU" kinds of posts are unhelpful. I simply make far too much money doing my current job to do just about anything else. Sure, I can find a new hospital, fellowship, or career, but I would have such a substantial financial hit that my wife would look at me like a crazy person for even suggesting it.

If you're happy doing what you're doing, then you wouldn’t fit the definition of feeling "trapped."

 

[namethatsmell]

These "The only thing stopping you is YOU" kinds of posts are unhelpful. I simply make far too much money doing my current job to do just about anything else. Sure, I can find a new hospital, fellowship, or career, but I would have such a substantial financial hit that my wife would look at me like a crazy person for even suggesting it.

I'm sorry you simply make far too much money.

Ever wondered if self-fulfilling prophecies are a thing?

 

[dadaddadaBATMAN]

These "The only thing stopping you is YOU" kinds of posts are unhelpful. I simply make far too much money doing my current job to do just about anything else. Sure, I can find a new hospital, fellowship, or career, but I would have such a substantial financial hit that my wife would look at me like a crazy person for even suggesting it.

And yet you are literally what they are describing. What do you want, a step by step guide on how to leave the specialty without losing a cent? It doesn’t exist.

I opened one of these conversations with my spouse, and it basically went “I’m really unhappy and it’s all about the job.”

I am going to lose money leaving. Hundreds of thousands of dollars, and after that I will probably make less money than I would have as an em doc. By the time I retire, the cumulative loss will probably be in the millions.

But honestly, we live on a fraction of my salary much less our combined salary and it doesn’t matter. And frankly, to me it’s worth it. It might not be to you. People are made differently.

It does help for me that my spouse is also pretty unhappy with my job.

 

[Mount Asclepius]

I think it’s a scale with your financial independence and value of further net worth on one side, and on the other side your satisfaction with work and how it affects your personal life. You decide it’s time to make a change once one side of the scale hits the ground. For most though, the scale doesn’t become unbalanced enough to make a change. For some it does. There are also probably a few who try to ignore their reality and hope the wind changes. Unfortunately, each side of the scale is heavy and they would probably be better off tipping the scale in the right direction if it becomes unbalanced, rather than waiting on external forces outside their control.

 

[Birdstrike]

And yet you are literally what they are describing. What do you want, a step by step guide on how to leave the specialty without losing a cent? It doesn’t exist.

I opened one of these conversations with my spouse, and it basically went “I’m really unhappy and it’s all about the job.”

...

It does help for me that my spouse is also pretty unhappy with my job.

Yep. Fortunately I have a spouse that was supportive of my desire to institute plan Get Out Before Ya Stroke Out. When I was talking about transitioning out of EM someday when I was near semi-retirement, she clapped back, "Don't wait until then. Do it now!" She knew how hard EM was on me and how much it was dragging me down. The absurd hours and demands on the family were also making my wife unhappy, too.

So, we dove in, took a pay cut for a year and an adventure in a big new city. The whole family has been much better off ever since. I eventually made the money back that I lost during the fellowship year. But if I hadn't, having done the fellowship has extended the amount of clinical years I could work, probably 5-15 years. That allows another avenue to recoup the short term loses of a fellowship year. But some things are worth more than money. Having a job that doesn't make you miserable, or shower your free time with circadian-rhythm dysphoria, is one of those things.

 

[GatorCHOMPions]

And yet you are literally what they are describing. What do you want, a step by step guide on how to leave the specialty without losing a cent? It doesn’t exist.

I opened one of these conversations with my spouse, and it basically went “I’m really unhappy and it’s all about the job.”

I am going to lose money leaving. Hundreds of thousands of dollars, and after that I will probably make less money than I would have as an em doc. By the time I retire, the cumulative loss will probably be in the millions.

But honestly, we live on a fraction of my salary much less our combined salary and it doesn’t matter. And frankly, to me it’s worth it. It might not be to you. People are made differently.

It does help for me that my spouse is also pretty unhappy with my job.

Yep. Fortunately I have a spouse that was supportive of my desire to institute plan Get Out Before Ya Stroke Out. When I was talking about transitioning out of EM someday when I was near semi-retirement, she clapped back, "Don't wait until then. Do it now!" She knew how hard EM was on me and how much it was dragging me down. The absurd hours and demands on the family were also making my wife unhappy, too.

So, we dove in, took a pay cut for a year and an adventure in a big new city. The whole family has been much better off ever since. I eventually made the money back that I lost during the fellowship year. But if I hadn't, having done the fellowship has extended the amount of clinical years I could work, probably 5-15 years. That allows another avenue to recoup the short term loses of a fellowship year. But some things are worth more than money. Having a job that doesn't make you miserable, or shower your free time with circadian-rhythm dysphoria, is one of those things.

Same here, my wife was all in with my switch and temporary pay cut. We had to move areas but in the end it’s just a year. In the grand scheme of ideally working into your late 50s-early 60s it is a blip on the radar. With EM I know I couldn’t have lasted in a healthy capacity past age 45. Now in Pain I’m hopeful to retire whenever I want, if I want.

I don’t peruse the other forums outside of EM and Pain, but there is a clear difference in the topics which dominate the boards between the two. In the former there are at least a couple active threads all the time about FIRE, getting out, or general doom and gloom. In the latter it is mostly about the practice and/or business of medicine. It is truly eye opening. Are other fields as vocally discontent as EM? It is a shame, but a testament to how many of us naively fell for the field.

 

[Febreeze]

Can y'all tell me what FIRE stands for? I get it with context clues but wondering what it stands for haha

 

[Mount Asclepius]

Can y'all tell me what FIRE stands for? I get it with context clues but wondering what it stands for haha

A dumpster fire was historically an ED you could go work in as a locums physician that was absolutely awful, but paid incredibly well as a result.

Now days most of EM is on fire due to unreasonably entitled patients that you can’t turn away (went from taking care of anyone with an emergency regardless of ability to pay, to taking care of everyone’s ability to not adult without paying), residency over-expansion, midlevel encroachment, lack of support with inadequate tech and nurse staffing, and the overall capitalization and rape of medicine by corporate entities.

Hence everyone is scrambling for FIRE (Financial Independence Retire Early). This is a phenomena not unique to EM as the gap between rich and poor grows, and the pandemic made people realize life is too short.

 

[sylvanthus]

But disaster medicine is just such a cool thing to add to your title!

Theres a masters in disaster management. Could be the master of disaster. Coolest title ever.

 

[namethatsmell]

OK I've gotten PMs re:taking a leap so thought I'd just post this here:

I made moves to pursue fellowship well before the abrupt change in the EM market and the pandemic. The shops I staffed were overall really good places to work (and still are from what I hear). Deciding to leave these places behind to do fellowship was scary and I had to ask myself more than once if I was crazy.

Overall the decision probably cost me ~375k.

But when I look at the larger picture, it's basically a down-payment on the rest of my career. My income potential is now far higher than before. And I now see several viable options to keep working for the next 1-3 decades (if I want)...not sure I can say that for EM. One thing I didn't anticipate was feeling so much better now that I don't constantly flip sleep schedules. It's maybe not as significant as what Birdstrike has often written about, but I definitely feel healthier and am less snippy with people. And I cannot overstate how refreshing it feels to not be beholden to EMTALA.

So yes, making a big change to return to training can be stressful and does carry some potential financial risk. Only you can decide if the tradeoffs are worth it. And if you decide you want to keep doing EM, that's awesome. We need excellent EM docs.

 

[EctopicFetus]

I’ll be the outlier here. So much of this depends on your setup. I make good money doing EM. I work under 100 hours a month clinically and I could work 0 nights if I wanted. I work under 3 8s a week. It’s great. We have docs work past 65.
not every setup sucks. Most do. Without ownership and control you are probably screwed. The more u rely on money the more you are beholden to the contract holder. Earn a lot and save it. The rest of your career will be so much better. I’m 10+ years out. I’m planning on another 15-20. It will be my choice though.

 

[Mount Asclepius]

I've thought a lot about doing a fellowship or switching fields over the years. I haven't made the leap. I'm lucky to have a pretty good setup which has probably tipped the scales towards inertia. I'm still not immune though to many of the criticisms of EM and concerned regarding the shifting landscape.

I think a key point that others have highlighted is that if you can see yourself practicing a longer career in something outside of EM, then from a financial standpoint a fellowship will pay for itself. It only takes 1-3 years of extra work to come out even or ahead. You have to have interest though in the field you are going into. Doing a fellowship just to do a fellowship and escape can easily result in errantly thinking the grass is greener when dissatisfaction can just follow you to the other side of the fence. Interests do change over time and it is worth continual self reflection to gage whether or not pain, sports, HPM, critical care, toxicology, or even an entirely new field now holds significantly increased interest compared to your younger self.

Some want to work in medicine into their 50s-60s or beyond. EM is very difficult to practice at that age unless you can scale back hours, limit nights and work in a position with decreased pph that is less physically taxing. If you can find that right setup, then EM may still work long term. If you saved well, you also don't need a high income later in your career. Otherwise it is probably worth exploring all options. I don't have a desire to do medicine past 50. I could be content with slow days filled with various hobbies. For those like me (and everyone else too), saving is incredibly important. If you hit 40-45 with at least $3M in net worth you will have a lot of flexibility and freedom.

 

[SeekerOfTheTree]

I’ll be the outlier here. So much of this depends on your setup. I make good money doing EM. I work under 100 hours a month clinically and I could work 0 nights if I wanted. I work under 3 8s a week. It’s great. We have docs work past 65.
not every setup sucks. Most do. Without ownership and control you are probably screwed. The more u rely on money the more you are beholden to the contract holder. Earn a lot and save it. The rest of your career will be so much better. I’m 10+ years out. I’m planning on another 15-20. It will be my choice though.

This I could do. This is a unicorn to find. It does increase longevity, The less time in the ED the better.

 

[EctopicFetus]

I've thought a lot about doing a fellowship or switching fields over the years. I haven't made the leap. I'm lucky to have a pretty good setup which has probably tipped the scales towards inertia. I'm still not immune though to many of the criticisms of EM and concerned regarding the shifting landscape.

I think a key point that others have highlighted is that if you can see yourself practicing a longer career in something outside of EM, then from a financial standpoint a fellowship will pay for itself. It only takes 1-3 years of extra work to come out even or ahead. You have to have interest though in the field you are going into. Doing a fellowship just to do a fellowship and escape can easily result in errantly thinking the grass is greener when dissatisfaction can just follow you to the other side of the fence. Interests do change over time and it is worth continual self reflection to gage whether or not pain, sports, HPM, critical care, toxicology, or even an entirely new field now holds significantly increased interest compared to your younger self.

Some want to work in medicine into their 50s-60s or beyond. EM is very difficult to practice at that age unless you can scale back hours, limit nights and work in a position with decreased pph that is less physically taxing. If you can find that right setup, then EM may still work long term. If you saved well, you also don't need a high income later in your career. Otherwise it is probably worth exploring all options. I don't have a desire to do medicine past 50. I could be content with slow days filled with various hobbies. For those like me (and everyone else too), saving is incredibly important. If you hit 40-45 with at least $3M in net worth you will have a lot of flexibility and freedom.

I think the cost of the fellowship depends on when you do it and if you would actually save the money. Lets say the fellowship pays 100k and a regular year in the ED pays 400k. If you do your fellowship after residency the 300k per year (lets break it down into 60k in retirement And 240k post tax (take that at 50%). That 180k growing in the market for 30 years is a lot of cheddar. It’s 8x that amount. Assuming returns of 7.2% your money doubles every decade. So 180k —> 360k —> 720k —> 1.44M

2/3 of that 1.44M is post tax. I think the key is save early and work as much or as little as you want. Find passive income real estate is the most obvious but there are tons of other options. I am super sad for the new resident grads and other docs being abused in their setup. EM was once a great career where docs I knew complained about stupid things. Now we as a specialty are incredibly marginalized and abused. The CMGs are profiting but hopefully the surprise billing ruling drops the hammer on them. The downward wage pressure is coming either way to EM. I haven’t seen the numbers but I hope applications are down a ton. Seems like a wasted career at this point. I wouldn’t enter EM today unless i was guaranteed some sort of decent job. I wouldn’t enter into the great unknown of HCA / envision employment, USACS openly flaunting they think their docs are idiots, and others seeing us as nothing more than laborers to be profited off of.

 

[Mount Asclepius]

I think the cost of the fellowship depends on when you do it and if you would actually save the money. Lets say the fellowship pays 100k and a regular year in the ED pays 400k. If you do your fellowship after residency the 300k per year (lets break it down into 60k in retirement And 240k post tax (take that at 50%). That 180k growing in the market for 30 years is a lot of cheddar. It’s 8x that amount. Assuming returns of 7.2% your money doubles every decade. So 180k —> 360k —> 720k —> 1.44M

That's a good financial point to consider when determine at what point in your career to complete a fellowship. From a financial standpoint, it might make more sense to do a fellowship mid to late career instead of right off the bat post residency given compounding return over time and the power of early saving.

However, I think the discussion more so was related to do you plow ahead dissatisfied mid career in EM trying to stick it out a few more years before FIRE, versus taking a temporary financial hit going back to fellowship, but potentially increasing your longevity with more money earning years.

It can be more difficult to go back and do a fellowship later on though for several other reasons compared to completing immediately after residency:

1) Transiently decreased pay of fellowship compared to attending EM salary.​

2) Supervised as a learner instead of autonomy of attending life.​

3) Decreased motivation to study harder and work longer hours again like a resident/fellow.​

4) Uprooting family and moving for 1-2 years when potentially developed stability in one location.​

5) Slightly more difficult to get applicable up to date LORs the further removed you are from training and an academic environment.​

 

[WilcoWorld]

I think the cost of the fellowship depends on when you do it and if you would actually save the money. Lets say the fellowship pays 100k and a regular year in the ED pays 400k. If you do your fellowship after residency the 300k per year (lets break it down into 60k in retirement And 240k post tax (take that at 50%). That 180k growing in the market for 30 years is a lot of cheddar. It’s 8x that amount. Assuming returns of 7.2% your money doubles every decade. So 180k —> 360k —> 720k —> 1.44M

2/3 of that 1.44M is post tax. I think the key is save early and work as much or as little as you want. Find passive income real estate is the most obvious but there are tons of other options. I am super sad for the new resident grads and other docs being abused in their setup. EM was once a great career where docs I knew complained about stupid things. Now we as a specialty are incredibly marginalized and abused. The CMGs are profiting but hopefully the surprise billing ruling drops the hammer on them. The downward wage pressure is coming either way to EM. I haven’t seen the numbers but I hope applications are down a ton. Seems like a wasted career at this point. I wouldn’t enter EM today unless i was guaranteed some sort of decent job. I wouldn’t enter into the great unknown of HCA / envision employment, USACS openly flaunting they think their docs are idiots, and others seeing us as nothing more than laborers to be profited off of.

That's a good financial point to consider when determine at what point in your career to complete a fellowship. From a financial standpoint, it might make more sense to do a fellowship mid to late career instead of right off the bat post residency given compounding return over time and the power of early saving.

However, I think the discussion more so was related to do you plow ahead dissatisfied mid career in EM trying to stick it out a few more years before FIRE, versus taking a temporary financial hit going back to fellowship, but potentially increasing your longevity with more money earning years.

It can be more difficult to go back and do a fellowship later on though for several other reasons compared to completing immediately after residency:

1) Transiently decreased pay of fellowship compared to attending EM salary.​

2) Supervised as a learner instead of autonomy of attending life.​

3) Decreased motivation to study harder and work longer hours again like a resident/fellow.​

4) Uprooting family and moving for 1-2 years when potentially developed stability in one location.​

5) Slightly more difficult to get applicable up to date LORs the further removed you are from training and an academic environment.​

I did fellowship the year after my 10 year ABEM recert exam. At that time my 1st year attending retirement savings had more than doubled, I had an affordable mortgage payment, and plenty in liquid assets to afford vacations during fellowship. I simply stepped off the gas on my extra, extra savings for the year and didn't have to change my lifestyle in the least.

Now that my passion for medicine has been reawakened, and I have a job I expect I'll want to keep working through my 50s and likely into my 60s...it's probably a good idea for me to save even LESS for retirement. I'm currently way over-shooting my target and who knows when death could come anyway?

 

[WilcoWorld]

Perhaps even more important than the financial rationale - if you get a few years of independent practice under your belt, you're more likely to actually know what kind of a fellowship you want to do. My subspecialty (an excellent fit) was not even on my radar when I was finishing residency.

 

[Fox800]

Perhaps even more important than the financial rationale - if you get a few years of independent practice under your belt, you're more likely to actually know what kind of a fellowship you want to do. My subspecialty (an excellent fit) was not even on my radar when I was finishing residency.

What fellowship did you do?

 

[namethatsmell]

I think the cost of the fellowship depends on when you do it and if you would actually save the money. Lets say the fellowship pays 100k and a regular year in the ED pays 400k. If you do your fellowship after residency the 300k per year (lets break it down into 60k in retirement And 240k post tax (take that at 50%). That 180k growing in the market for 30 years is a lot of cheddar. It’s 8x that amount. Assuming returns of 7.2% your money doubles every decade. So 180k —> 360k —> 720k —> 1.44M

Counterpoint: if your savings example is somebody's behavioral reality, that person can go back to training and still easily retire early and comfortably. Their discipline to save as you describe will make them rich regardless.

But it's really about an individuals goal.

If somebody is looking to hit FIRE so they can exit medicine in 5-10 years than going back to do a fellowship or 2nd residency doesn't make sense. Nothing wrong at all with that plan.

But if somebody is unhappy in EM and looking for a way to stay in medicine for awhile longer than 1-3 years of additional training is unlikely to matter financially in retirement if it happily lengthens their career by 10-30 years.