Fellowships after Emergency Medicine

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Birdstrike said:
CC is the best if you want to do an EM fellowship and still have to work nights, weekends and holidays the next 30 years.
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Giant -- GIANT GIANT -- caveat and anecdote(s) are ahead. WARNING.

Next caveat: I haven't read this thread. Only the first three threads. Feel free to dismiss my comments for any of the above reasons .

That clarified nakedly, I propose the field of CCM for the interested, intellectual, and procedurally skilled (esp ballsy) EM doc is by far the best.

Yes, you will "waste" two years of ?300K income.

Yet, afterwards, you will command far more than $300K. And you will be more skilled, more respected, and more flexible.

Do not underestimate the power of flexibility. I could tomorrow get an EM job in my hospital or elsewhere. Don't want to pay my "bump"? No problem: I'll drop the unit and join my friends in the ED (please note: you should maintain friendships with your EM colleagues).

Again anecdotes: I am currently in one of the most competitive markets and I gave up an academic position in arguably the most competitive EM markets...yet I am secure because of my CCM fellowship. I command my salary and my standing in the hospital (if I was political at all, I would be in a way better spot).

My view:

CCM docs make more for years after "wasting" two years. We are better docs when it comes to the critically ill adult. We command out domain (EM never really will). We have the respect of admin and nursing. We have the respect of the hospitalists. Even admin, mostly. Even anesthesiolosgitsts, when the patient is super sick in the community.

Side note: I write notes no more than two paragraphs. No ROS. No PE. No nonsense. I acknowledge my need at the bedside -- then I check out to bill more than any specialty.

Well, that's enough. Choose wisely.

HH
 
Unpopular opinion...I like being the pit doc. I think (as a younger attending) the worst part of our job is the lack of freedom due to student loans and more recently job security.

But let's not lie why we all initially wanted to do EM...120 hours a month and once I leave, I am never thinking about work when I walk through the doors is hard to beat. Scribes to do 90% of notes so when I'm at work, even better. >95% of the time leaving work on time. Midlevels doing the time consuming lacs and splint placements. Interesting pathology to keep you on your toes with some procedures mixed in.

Obviously this is very job dependent, and I'm sure maybe after more time my opinions will change, but outside of working only 9-5 M-F and no holidays, I wouldn't really change much else.
 
I don't comment much but totally agree with @Hamhock on critical care. In my second year of ACCM fellowship. It is a beautiful escape from the ED. Sure you lose 2 years of EM salary upfront but I'll make that up in the back end because I will be able to have a much longer career. I don't think I would last more than 10 years straight EM.

Higher quantity of hours but quality is way better. I can go on coffee runs, eat lunch, empty my bladder, chat with nurses. Then when I go home I'm tired but don't have a raging headache and AKI like after my ED shifts.

The respect level is sooo much higher. I still moonlight in the ED and a lot of times I'll get the typical FU attitude on the phone from consultants. Yet when I work with them in the ICU, we have normal human interactions with basic decency. As I start looking for jobs, I'm learning that if you have specialized ICU skills, like comfort with ECMO cannulation and management, the respect level is even higher. Going in to residency, I didn't think this would matter to me. But it really makes such a difference to be truly needed by the hospital.

The knowledge and skills you pick up are awesome too. It really has revealed the things I did not know that I did not know as an EM doc and I have become a much more well rounded physician. If you are passionate about critical care, don't let rational reasons dissuade you from doing a fellowship.
 
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I appreciate these comments that are being made by the CCM folks. There are definitely perks, I'm sure. I definitely agree with the comments regarding respects level, especially from consultant. To an extent.

Where I trained, again, very heavy EM/CCM presence, the intensivists especially in surgical units were at the mercy of the surgeons. The surgeons communicated their plans when it came to big picture issues. The intensivists sort of stayed with the basic daily maintenance of the patient (i.e. "how many days has this central line been in? Ok, sure, lets replace it."). Honestly I personally felt like as a proceduralist the EM trained residents were far superior to anesthesia/surgery residents. But I am likely biased from that regard.

I thought medical units were far better in terms of how the intensivist ran the show since they were truly "closed" units.

Lunch breaks, bathroom breaks etc are fantastic. Agree with that, 100%.

But I didn't find the work less stressful. I found myself more tired after a month in the ICU than I did after a month in the ED. It takes a special type of person to have that degree of attention to detail. The family conversations, the goals of care, the patients who were in the unit for a month, getting trached because they can't wean off the ventilator etc was just a grind that wasn't for me.

I think ICU docs are fantastic, and clearly have a broader practice of medicine compared to EM docs. That being said, when it came to acute resuscitation, I did not find that they outperformed EM docs. And that was always the most interesting part to me.
 
TheComebacKid said:
I appreciate these comments that are being made by the CCM folks. There are definitely perks, I'm sure. I definitely agree with the comments regarding respects level, especially from consultant. To an extent.

Where I trained, again, very heavy EM/CCM presence, the intensivists especially in surgical units were at the mercy of the surgeons. The surgeons communicated their plans when it came to big picture issues. The intensivists sort of stayed with the basic daily maintenance of the patient (i.e. "how many days has this central line been in? Ok, sure, lets replace it."). Honestly I personally felt like as a proceduralist the EM trained residents were far superior to anesthesia/surgery residents. But I am likely biased from that regard.

I thought medical units were far better in terms of how the intensivist ran the show since they were truly "closed" units.

Lunch breaks, bathroom breaks etc are fantastic. Agree with that, 100%.

But I didn't find the work less stressful. I found myself more tired after a month in the ICU than I did after a month in the ED. It takes a special type of person to have that degree of attention to detail. The family conversations, the goals of care, the patients who were in the unit for a month, getting trached because they can't wean off the ventilator etc was just a grind that wasn't for me.

I think ICU docs are fantastic, and clearly have a broader practice of medicine compared to EM docs. That being said, when it came to acute resuscitation, I did not find that they outperformed EM docs. And that was always the most interesting part to me.
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First, this is a great post.

Second, I agree with lots of it.

Third, I would propose there is a great difference in training programs where CCM is the primary service (still few...Pitt, some Stanford, etc) and those where CCM is the consultant service. This is especially important to those EM applicants who will apply for surgical-CCM (eyeroll) or anesthesiology-CCM. I suggest -- just an opinion - that applicants apply for CCM programs where the CCM department (rare) is primary or IM-CCM programs where CCM is dominant and typically controls closed units.

HH
 
namethatsmell said:
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.
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Do you think taking a mid career break would quash the possibility of fellowship? I'd like a year off....
 
Fascinating read. Most CCM docs I know make in the low 400s. I am sure this varies all around the country. I feel for the younger EM docs hamstrung by their student loans. One of the great things about SDN is getting perspective and seeing where others are in an honest and anonymous sort of way.

In EM some jobs are better than others. $300/hr is out there. Working fewer nights is out there, in the right setting im sure working fewer weekends is as well.

I am no expert in CCM jobs but what I have seen is a number of spots not wanting the EM folks since they dont do pulm or sleep. As more and more people do CCM jobs will be tougher to find. I just spoke with a soon to be graduate of a CCM program looking for a job locally and they had to take a job 2 hours away because no “good” jobs were available.

One of the common issues is like EM docs most CCM jobs for EM docs are those employed by a hospital and not a private EM group. With that and a glut of fellows and a growth in that similar pressures will come and they will also get screwed.

I fully agree re more respect but the degree and amount matter based on the EM group and CCM situation. There is no doubt EM is the red headed step child in the hospital. I say that believing my group gets a fair bit of respect. More so than any ED group I have ever been associated with. Even with that and a good to great relationship with the hospital its not the same as the shiny big money money making specialities. Luckily I truly dont care About that but do care about how it impacts the department and patient care.
 
How about this physician wellness fellowship 😄

Physician Wellness

The Stanford Department of Emergency Medicine advances healthcare through innovation, scientific discovery, and precision emergency care. We offer career-defining education and cutting-edge research to transform the future of emergency medicine.
emed.stanford.edu emed.stanford.edu
 
Bea5T said:
How about this physician wellness fellowship 😄

Physician Wellness

The Stanford Department of Emergency Medicine advances healthcare through innovation, scientific discovery, and precision emergency care. We offer career-defining education and cutting-edge research to transform the future of emergency medicine.
emed.stanford.edu emed.stanford.edu
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For it to truly be a wellness fellowship, it needs to pay me more money than what I would earn in the community for a lot less work. That would be make me feel extremely well.
 
Birdstrike said:
You work in an anti-vax health system? lol

Seriously, that's a thing?

Is it HCA?
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Not HCA, although they are anti-vax, too, but quieter about it. Cleveland Clinic is also anti-vax.
We were told we would never have a vaccine mandate and that the system does not believe in mandates. We have a flu vaccine mandate so I'm confused. System also refuses to follow OSHA PPE standards.
 
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miacomet said:
Not HCA, although they are anti-vax, too, but quieter about it. Cleveland Clinic is also anti-vax.
We were told we would never have a vaccine mandate and that the system does not believe in mandates. We have a flu vaccine mandate so I'm confused. System also refuses to follow OSHA PPE standards.
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Oh reaaaallllyyyy$$$$$$....

Whistle Blower Netflix GIF by Stranger Things
 
Yep. "Our state has not adopted these and we don't find them necessary in our system."

Also, I was not kidding about the year on a beach in Mexico followed by a fellowship application.
 
Birdstrike said:
How about working 1 day a week, while in Mexico laying on the beach the other 6 days? Still a vacation (almost) but no gap in work to explain.H
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Flying to work one day a week sounds not so relaxing.
There is no real need for locums right now. Too many EM docs for now and forever.
 
miacomet said:
Flying to work one day a week sounds not so relaxing.
There is no real need for locums right now. Too many EM docs for now and forever.
Click to expand...

Right now there actually is. Locums market has opened up, seeing offers from $250-$300/hr. I get that this might be just a post covid bump or whatever and will not last, but if anyone wanted to do locums right now, there are lots of opportunities.
 
bravotwozero said:
Right now there actually is. Locums market has opened up, seeing offers from $250-$300/hr. I get that this might be just a post covid bump or whatever and will not last, but if anyone wanted to do locums right now, there are lots of opportunities.
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Oh, cool! Which companies are recruiting?
 
During residency is when I realized that I couldn't do EM for the rest of my life. More often than not I left shifts feeling drained, dreading going back, and realized I probably wouldn't make it to 50 in the ED and stay married and happy and close with kids and . That's when I started looking at pain, rotated through as a resident, and applied during 2nd year.

I'm currently in fellowship, and for me the decision was right. Calculate out however much money you want in the opportunity cost, the reduction of stress alone is enough that I'd gladly pay a few million over my life to be where I am now. People argue over the cost of using scribes in the ED and the benefit that has psychologically for docs. For me, 100x that and that's where I feel I am currently. About a month ago I realized that since starting fellowship and being out of the ED, my daily cursing rate has dropped by about 1,000...🤔

It's easy to look at salary and income and make comparisons, but not nearly as easy to measure satisfaction and happiness, and sooo hard to make comparisons between jobs when you factor in personality differences, practice type, setting, patient base, partners, and colleagues. But please, don't rule it out solely on a financial opportunity cost. Your health and sanity is worth more than that.
 
redchyvak said:
During residency is when I realized that I couldn't do EM for the rest of my life. More often than not I left shifts feeling drained, dreading going back, and realized I probably wouldn't make it to 50 in the ED and stay married and happy and close with kids and . That's when I started looking at pain, rotated through as a resident, and applied during 2nd year.

I'm currently in fellowship, and for me the decision was right. Calculate out however much money you want in the opportunity cost, the reduction of stress alone is enough that I'd gladly pay a few million over my life to be where I am now. People argue over the cost of using scribes in the ED and the benefit that has psychologically for docs. For me, 100x that and that's where I feel I am currently. About a month ago I realized that since starting fellowship and being out of the ED, my daily cursing rate has dropped by about 1,000...🤔

It's easy to look at salary and income and make comparisons, but not nearly as easy to measure satisfaction and happiness, and sooo hard to make comparisons between jobs when you factor in personality differences, practice type, setting, patient base, partners, and colleagues. But please, don't rule it out solely on a financial opportunity cost. Your health and sanity is worth more than that.
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Agreed here. You have to enjoy it. Its also why I think CCM is a good option. its a different world than EM. If it floats your boat go for it. I think it is wise to admit you made a mistake doing EM so the rest of your life you will be happy. Perhaps it is spending my career in unicorn groups making a decent wage but I still like what I do but i freely admit that going into admin has helped. I still work 3 days a week clinically and am not bored outside of clinical work but I truly look forward to my shifts. Of course I just did 8 shifts in 9 days almost all evenings and that was terrible but the payoff is coming with some trips and a bunch of time off. So no complaints.
 
EctopicFetus said:
Agreed here. You have to enjoy it. Its also why I think CCM is a good option. its a different world than EM. If it floats your boat go for it. I think it is wise to admit you made a mistake doing EM so the rest of your life you will be happy. Perhaps it is spending my career in unicorn groups making a decent wage but I still like what I do but i freely admit that going into admin has helped. I still work 3 days a week clinically and am not bored outside of clinical work but I truly look forward to my shifts. Of course I just did 8 shifts in 9 days almost all evenings and that was terrible but the payoff is coming with some trips and a bunch of time off. So no complaints.
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As far as feeling bored - my dad said he had to "reinvent" his career every 10 years or so to keep from getting bored. Fellowship or not, there's a lot about feeling bored in work or outside of it. I think admin could be interesting - negotiating, strategy, feedback and discipline. And totally agree that for most people, more than 10-12 shifts is too many. A lot of my coresidents agreed to 16 shifts/mo, then perpetually get 1-2 shifts added on each month. At that point, you're essentially still working like you did in residency.
 
namethatsmell said:
Have you ever had to interview applicants for a job? If somebody has attributes like those--and are not a sociopath or chronically late for work-- they will stand out from much of the job-seeking pack.

Maybe you will have to take an entry level job someplace to start. Such is life. Many will still pay 6 figures and some can have a high ceiling over time. If you're intelligent and at all motivated (which the vast majority of docs are) you'll likely excel up the foodchain over time. I don't expect anybody to hand me an upper management gig at Facebook, Deloitte et al because I'm a physician. Did you expect to be handed the ET tube and a blade the first time you set foot in the ED as a medical student?
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I don’t think many mid life career changing doctors are motivated to work resident-esqe hours in a brand new field. Most midlife career changers are likely seeking a job that would offer better quality of life.
 
NRAI2001 said:
I don’t think many mid life career changing doctors are motivated to work resident-esqe hours in a brand new field. Most midlife career changers are likely seeking a job that would offer better quality of life.
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I mean....you're right.

That may be why most doctors don't change fields. Anybody's who's happy in EM and thinks the future in their given setting looks good has no need to consider something else.

But I'll challenge the assumption that going back to fellowship/residency = no life whatsoever during that training. Of all the docs I know who've changed fields, almost all (except those going to CC) are changing to more of a "lifestyle" field or at least a less intense decision-making/hour mental load relative to EM while at work.

I also found the return to training to be much easier as I already knew how to doctor and take care of patients. It was so much less mentally taxing than residency when everything about being actually responsible for patient care was brand new and everything was a challenge. I knew I was just back in training to expand my skillset. I probably worked 50hrs / wk max and had 4 weeks/yr off + holidays. So while I certainly had less time and control over my schedule as an EM attending, I still had somewhat of a life during fellowship. My friends who've done cc definitely had tougher lives in fellowship but all but 1 is very happy with the cc lifestyle now post-fellowship.

But in the end, you're right. There ain't no free lunch. Taking the time to undertake legitimate training to better take care of people is what separates us from noctors.
 
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southerndoc said:
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.
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Do you feel that doing an EMS fellowship may open more doors to work as a faculty member at a residency or an academic center? I'm very early in residency now, but I like the thought that I can end my career more in an office/administration type role. What is your monthly schedule like? Do you split time in the ED and time doing EMS admin type work? Do you also work in a place with a residency program?
 
It can open more doors. About 25% of my time is administrative (associate medical director of the ED, EMS medical director). We have a residency program, but I stepped down from core faculty status when I took the associate medical director position. Just not enough time to devote to it, the residency (interviews, weekly didactics, etc.), and EMS. We recruited another EMS person to take my spot.
 
What's the word on toxicology fellowships? I feel that not that many people pursue this fellowship as it is 2 years and highly niche. But, I feel that it can possibly open more doors in the future for academic EM positions. Additionally, it allows an EM doc to become more specialized in a subject manner and actually become a consultant if that's desired. Would love to hear more about the field though as my program does not have a fellowship.
 
pillowsnice said:
What's the word on toxicology fellowships? I feel that not that many people pursue this fellowship as it is 2 years and highly niche. But, I feel that it can possibly open more doors in the future for academic EM positions. Additionally, it allows an EM doc to become more specialized in a subject manner and actually become a consultant if that's desired. Would love to hear more about the field though as my program does not have a fellowship.
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No money and little need. Generally working for a government entity as many tox centers are means no money. You can run a consult service or become a consultant to some product i guess. At my old spot we had an EM guy do tox consults. Great guy super helpful but he was still pulling a normal number of shifts and I know he still works FT as an EM doc so makes me think he either loves EM or more likely he uses tox as a side gig to make some extra money doing something he likes.
 
pillowsnice said:
What's the word on toxicology fellowships? I feel that not that many people pursue this fellowship as it is 2 years and highly niche. But, I feel that it can possibly open more doors in the future for academic EM positions. Additionally, it allows an EM doc to become more specialized in a subject manner and actually become a consultant if that's desired. Would love to hear more about the field though as my program does not have a fellowship.
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It's very academic. If you can find a way to do research with it, I think academic EM departments would hire you in a heartbeat. There's also a lot of toxicology folks really branching into addiction medicine and starting an additional consult service. It's a hot area right now and I think some departments are looking for it.

You can be the medical director for a poison control center, provide support at a zoo etc. I think one of the best aspects of tox is that you can use it as a very easy out from clinical medicine all together and go into private industry or do consulting. Lots of pharmaceutical companies, chemical/industrial companies would pay you a pretty penny for minimal work.

Certain departments really value tox more than others but I would say for academic medicine is arguably one of the most marketable EM fellowships currently.
 
TheComebacKid said:
It's very academic. If you can find a way to do research with it, I think academic EM departments would hire you in a heartbeat. There's also a lot of toxicology folks really branching into addiction medicine and starting an additional consult service. It's a hot area right now and I think some departments are looking for it.

You can be the medical director for a poison control center, provide support at a zoo etc. I think one of the best aspects of tox is that you can use it as a very easy out from clinical medicine all together and go into private industry or do consulting. Lots of pharmaceutical companies, chemical/industrial companies would pay you a pretty penny for minimal work.

Certain departments really value tox more than others but I would say for academic medicine is arguably one of the most marketable EM fellowships currently.
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I saw you posted earlier that you pursued the EMS route and gave a very detailed explanation of that subspecialty. I am actually torn between both EMS and tox fellowship. I have a strong background in EMS prior to and during medical school, so pursuing an EMS fellowship could be a natural transition, but I'm not really sure I would truly enjoy the administrative side of EMS. It would be cool to have a physician response vehicle, but I understand those opportunities are rare. Plus, correct me if I'm wrong, I'm not sure if EMS could provide me "a way out" if I wanted it down the line, whereas you state that tox it may be possible. I recently became interested in tox so I'm trying to learn more about the fellowship, but I like that you can become an expert/consultant in a subject for the ED, and be involved with teaching/academics. My residency has neither EMS or a tox fellowship, so it is very difficult to determine which lifestyle I would like more.
 
EM-fellowship seekers, here's what you have to decide:

Do you want an EM fellowship that focuses you more tightly, and keeps you boxed in, to a future dependent on working in an ED environment?

Or, do you want a fellowship that allows you to expand your focus, expand your horizons, adds a second specialty to your skill-stack and breaks the shackles that chain you to working only in an ED?
 
pillowsnice said:
I saw you posted earlier that you pursued the EMS route and gave a very detailed explanation of that subspecialty. I am actually torn between both EMS and tox fellowship. I have a strong background in EMS prior to and during medical school, so pursuing an EMS fellowship could be a natural transition, but I'm not really sure I would truly enjoy the administrative side of EMS. It would be cool to have a physician response vehicle, but I understand those opportunities are rare. Plus, correct me if I'm wrong, I'm not sure if EMS could provide me "a way out" if I wanted it down the line, whereas you state that tox it may be possible. I recently became interested in tox so I'm trying to learn more about the fellowship, but I like that you can become an expert/consultant in a subject for the ED, and be involved with teaching/academics. My residency has neither EMS or a tox fellowship, so it is very difficult to determine which lifestyle I would like more.
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Great question.

Personally, as an EMS doc I can tell you that it seems like my career options are more narrow as compared to toxicology. While I suppose your out from clinical medicine in EMS is doing more administrative work, research, QA/QI, education etc, you are still within earshot of the specialty of EM. Tox on the other hand... you could really branch out into private industry if you wanted to, or even practice addiction medicine which is a whole different specialty.

Depending on the system you work for, an EMS medical director may have to take lots of call, often times annoying ones. Medic calls you at 3AM for orders on termination of resuscitation for a 98 year old cardiac arrest patient in systole for 30 minutes. Or you have to deal with aggravated ED directors calling you to say, "YOUR MEDIC DID XYZ TO A PATIENT DO THEY EVEN GET ANY TRAINING?" type of stuff. For tox, you will get the 3am call from the peds ER "a 5 year old sniffed his grandmothers metoprolol WHAT DO WE DO". There are downsides to the lifestyle of both.

That being said, I think toxicology is more in line with what academic departments and chairs value. EMS, at least to a lot of people, comes off as "doctor wants to play on the ambulance" which couldn't be farther from the truth, but I don't feel like it jives as well with the academic mission as toxicology does. Now to use a phrase that SDN adores, there are definitely some academic EMS powerhouses like Pitt, New Mexico, UW, etc but toxicology from my perspective is more traditional and more marketable.

To Birdstrike's point, I think both EMS and tox allow you to add a secondary skillset outside of straight clinical EM, but I personally feel like toxicology can take you much farther. One of my tox attendings in residency just left and took a job with a chemicals manufacturer and never set foot in the ED ever again and loves every minute of their 9-4 Monday through Friday gig. EMS doesn't usually afford you that same degree of flexibility, or at least I can't appreciate it in my current set up.

You should do EMS if you love EMS/prehospital medicine, which includes the vast majority of non sexy stuff including the calls with the fire chiefs and the city manager and reviewing hundreds of run sheets and doing quality assurance for all your cardiac arrests etc. It may not afford you the same degree of flexibility as other fellowships, and some people find it boring as hell, but I think it's a really awesome gig and I can't imagine doing anything else.
 
Also, side note... if you want to take a break from clinical medicine in academics, it doesn't matter how great or unique of a fellowship you do, that could by tox, EMS, US, whatever... unless you get someone to pay you for your fellowship skills, nobody will care. Buy down is the name of the game, and that unfortunately equates to $$$$$

There are plenty of tox/EMS faculty that are great at what they do, but they can't get anyone to pay for what they do, and so still work a butt load of clinical shifts, AND try to do their other stuff. It's a recipe for total burnout if you can't find a way to get bought down. Academics can really destroy you mentally when you realize your days off are all gone doing research and other endeavors and you are getting paid less money than your community counterparts for sometimes little to zero buy down.

Academic departments are also notorious for skimming lots of money of the top from the money you bring in. Maybe for 1 shift you work you get paid $1200 bucks by your department. But if you want to get bought down for one shift, you may have to bring in close to $20,000 (varies depending on the institution) because the university skims a huge chunk of change off the top. It's really a racket and source of immense frustration for many academic attendings. Something to keep in mind.
 
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