Government Opportunity

[HoosierdaddyO]

So there’s been so much talk recently about the Job Market, and salaries and influx of new residencies saturating the market in 10 years and the chaos of and Unsustainability of EM and grinding in the pit each and every shift.

So what are people’s thoughts of working for the government as a civilian if an opportunity presented itself, ie either DoD, or IHS or VA?! I mean yes I get that there will be some that hate the thought off the Govt immediately. But the deeper you look in to it the better those jobs sound??

For example: stable pay on par with the rest of the EM world. Annual leave and sick leave accrued every pay period. A pension?? Like woah where else in medicine does someone offer a pension (except for Kaiser perhaps… but not on the same levels as the government). Amazing healthcare benefits, TSP/401 with great match. Patient population is usually by in large much nicer (at least on the DoD side of things perhaps.

The obvious concern is skill atrophy and stagnation at jobs like these… but with the future erosion of EM… curious on people’s thoughts as to if you can land a solid DoD or VA or IHS job… are these gold mine situations (solid pay, solid benefits, job security, etc), or am I missing something here ?!

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[Fox800]

It's a decent gig. You might work more shift days per month but benefits are nice. Volumes tend to be lower. Less trauma, no pediatrics, basically no OB.

It can be worth it to get out of the dumpster fire of overrun, low-paying community EM jobs.

 

[HoosierdaddyO]

I guess it really is a hedge on the future potential of just how big that dumpster fire can grow to in the coming years?!

Any thoughts on reasons not to take a position like this?! Hire-ability back into the real world after working at a job like this for 5 or 10 years etc?!

I mean the thought of sitting in a stable job with guaranteed step increases in pay and COLA while the rest of the EM world is burning… seems quite attractive lol!!!

 

[JAFERD_MD]

Skill atrophy is real but there are no restrictions on external moonlighting. You can move up depending on your interests and abilities. The benefits, stability, low stress are unmatched. Don’t forget that the Tort Claims Act means you are never directly sued for malpractice (there are still internal quality reviews).

My friends complain of cut hours resulting in having to see more patients (pay is hourly based), increasing forced midlevel supervision, and being required to follow up with patients on their off days (unpaid). I have experienced none of that.

YMMV between facilities but I am happy with my choice. PM me if you have questions.

 

[BoardingDoc]

From: Physician (Emergency Medicine)/Supervisory Physician (Emergency Medicine)
"A salary quote will not be provided to you at the time of the initial job offer. The salary determination process begins after the initial job offer is accepted. This consists of the Activity Compensation Panel adding base pay and market pay to determine your starting salary and this will be provided to you once approved. Salary for physician positions is based on a tier scale, determined by the position specialty, grade, and location.

This announcement may be used to fill positions at any of the tier's listed below:
Tier 1: $108,645 - $348,000
Tier 2: $120,000 - $365,000
Tier 3: $135,000 - $385,000"

Depending on how easy the gig is, it could be a good fit. When I read the above though, all I see is "The salary determination process begins after the initial job offer is accepted" as well as the pay ranges where the absolute most that you can get paid (presumably after years of promotions/however the heck this works) is significantly less than I currently make.

 

[namethatsmell]

From: Physician (Emergency Medicine)/Supervisory Physician (Emergency Medicine)
"A salary quote will not be provided to you at the time of the initial job offer. The salary determination process begins after the initial job offer is accepted. This consists of the Activity Compensation Panel adding base pay and market pay to determine your starting salary and this will be provided to you once approved. Salary for physician positions is based on a tier scale, determined by the position specialty, grade, and location.

This announcement may be used to fill positions at any of the tier's listed below:
Tier 1: $108,645 - $348,000
Tier 2: $120,000 - $365,000
Tier 3: $135,000 - $385,000"

Depending on how easy the gig is, it could be a good fit. When I read the above though, all I see is "The salary determination process begins after the initial job offer is accepted" as well as the pay ranges where the absolute most that you can get paid (presumably after years of promotions/however the heck this works) is significantly less than I currently make.

Helpful to do an apples to apples comparison. If you ask around the fed shop you're interested in, you'll get a sense for the ballpark of what the offer will be. At some places you can negotiate for more, at others not so much.

For what it's worth, the tiers above are guidelines...not hard rules (it's possible to be paid above them). One shop may start at 300k, another 240k, and another 330k. Your salary is essentially guaranteed to go up regularly over time.

Then you add in the 10-15k annual bonus most docs get, the 5% 401k match, the federal contribution to the pension, the built-in admin time, the insane amount of PTO, the value of the health/insurance bene's, and then estimate the financial/mental health value of sovereign immunity...and you generally arrive at total package that adds on an extra 25-30% in cash+bene value above the "salary" number. If you land loan repayment, that's up to an additional 200k.

Not saying that working for the fed will make you rich. It won't. But depending on the mechanics of the specific shop in question, it can be a great gig and you may be treated/paid far better than the average EM job.

 

[TheComebacKid]

People talk a lot about skill atrophy. Yes, it's a real thing. But the only solution to prevent total and complete skill atrophy is to work a good number of shifts in a high acuity shop, with no residents, minimal consultant backup. That's obviously an extreme example, but preventing skill atrophy equates to more stressful work in my eyes.

I think I'm willing to tolerate some skill atrophy if it means preventing some soul atrophy.

I'd highly recommend taking a job at the VA. Get paid, be protected, take that taxpayer money straight to the bank and enjoy your life. When you're done with this career, you aren't going to look back and feel amazing about all the surgical airways you did.

 

[alpinism]

So here's my thoughts as someone who's spent time working in government healthcare prior to med school.

Its definitely be a solid option for some people however I'd caution against thinking its some kind of hidden secret.

Most facilities are basically glorified all hours primary care clinics with very little true emergency medicine. I've known people who've gone literally multiple years without performing even a single intubation or central line. Its common to go months without seeing even a single critical patient. There comes a point when the acuity is so low that its debatable to even call the job emergency medicine.

 

[southerndoc]

Can always go to work in the intelligence community. They actively recruit ED docs.

 

[Pudortu]

Can always go to work in the intelligence community. They actively recruit ED docs.

Fascinating. Can you please elaborate?

 

[Apollyon]

Can always go to work in the intelligence community. They actively recruit ED docs.

I wish I would have known that a few years ago. When I looked at CIA, they were paying about $90k per year. This was about 5 years ago.

 

[WilcoWorld]

I wish I would have known that a few years ago. When I looked at CIA, they were paying about $90k per year. This was about 5 years ago.

90k/y to do what?

 

[Apollyon]

90k/y to do what?

To be an overt agent for covert agents. It looked like non op minor ortho stuff in case officers when they returned stateside, and urgent care level care. It required moving to metro DC. These folks are, generally, really healthy, so, no obese, no diabetics, no seizures, and, if addicts, are EXPERT at hiding it.

At ACEP a few years ago, though, I asked one of the docs if they went to "the farm" to train (that's what they call it). She demurred, but, I also asked about covert missions, and she couldn't answer that one, either. That was mildly shocking to me.

 

[Franzd'Epinay]

90k/y to do what?

He could tell you, but then he'd have to kill you.

 

[namethatsmell]

I wish I would have known that a few years ago. When I looked at CIA, they were paying about $90k per year. This was about 5 years ago.

I recall seeing an ad for this a few years ago. Just checked and they're still advertising...listed pay is upper 100s...I wonder why

 

[alpinism]

The Central Intelligence Agency does still actively recruit doctors for its Office of Medical Services.

Not surprisingly the exact job specifics are classified but generally speaking there are multiple different clinical roles that range from providing routine primary care services for employees and dependents to on call emergency assistance for employees who've been injured and need secure treatment overseas in the field. There are non clinical roles as well the most common being providing medical training for paramilitaries fighting overseas in agency sponsored operations such as the ones that are ongoing in Ukraine these days.

 

[southerndoc]

In addition to clinical opportunities, there is also foreign medical intelligence (FMI). They are analysts within DI who assess the health of foreign leaders and provide analysis reports. Although DI is involved in this, the DOD (through the DIA) is more commonly the source for most FMI. Countries may suffer instability from unexpected deaths or transitions of power, and if someone has a life-threatening diagnosis, then it needs to be considered. Many FMI analysts have a paragraph or two that make it into the PDB. I'm sure there is intense focus on Putin's mental stability currently and FMIAs ranging from physicians to psychologists are assessing his status. Not all of this work involves full-time work. There are physicians who do this on a contract basis particularly those with knowledge of particular countries through prior international work. As long as you can pass an SF86/TS-SCI screening, then anyone is game for a 1099 position if you have a particular area of expertise with certain countries.

 

[Apollyon]

PDB - President's Daily Briefing

SF86/TS-SCI - security clearance, "Top Secret- Sensitive Compartmented Information"

 

[HoosierdaddyO]

Everyone is talking about atrophy of skills, which is a valid concern… but I’m willing to bet that in most of these academic places, most attendings haven’t even touched a tube or a central line in years either. Granted they are supervising and handing them off to interns or residents but rarely do I see an academic attending (except during conference days) actually do the procedure. So with all this skill atrophy talk… I’m sure it’s more widespread than people think.

 

[Kryptocoin]

VA can be a decent gig to consider, maybe, after ten years of working in the community and honing your skills. Trauma, peds, critical resuscitation, and women's health are significant components of EM that you'll rarely see at the VA.
I see a lot of VA patients in my ER, and if the patient is even remotely sick, the VA will decline the transfer. So we end up just admitting a ton of them.

 

[HoosierdaddyO]

VA can be a decent gig to consider, maybe, after ten years of working in the community and honing your skills. Trauma, peds, critical resuscitation, and women's health are significant components of EM that you'll rarely see at the VA.
I see a lot of VA patients in my ER, and if the patient is even remotely sick, the VA will decline the transfer. So we end up just admitting a ton of them.

Thats a very valid concern for the VA system… but what about if you can get locked in to one of these DoD large Medical centers. In theory you’ll be taking care of active duty (while mostly healthy there are a fair % of men and women these days)… you take care of their dependents and children and also the retiree/veterans population and their spouses as well. Not necessarily a homogenized patient population if you ask me?!

 

[Kryptocoin]

Thats a very valid concern for the VA system… but what about if you can get locked in to one of these DoD large Medical centers. In theory you’ll be taking care of active duty (while mostly healthy there are a fair % of men and women these days)… you take care of their dependents and children and also the retiree/veterans population and their spouses as well. Not necessarily a homogenized patient population if you ask me?!

No firsthand knowledge of those facilities but it sounds like they'd be more geared towards more PMR and primary care.

 

[HoosierdaddyO]

I can see how you get the perception that it’s more PCP or PMR.. but these are 40k visit per year emergency Depts with ct scans and us and mri. And with my understanding do emergency medicine.

A female soldier has torsion they are going to the Military medical center, the retired veteran has acute CHF they are going to the the military treatment facilities ER. Etc etc etc. I was making the comparison that because you just aren’t seeing old Vietnam vets and mostly men in their 50s and above. That these DoD jobs might actually be more comparable to civilian Emergency Dept then that of the VA system? Thoughts lol?!

 

[BoardingDoc]

I can see how you get the perception that it’s more PCP or PMR.. but these are 40k visit per year emergency Depts with ct scans and us and mri. And with my understanding do emergency medicine.

A female soldier has torsion they are going to the Military medical center, the retired veteran has acute CHF they are going to the the military treatment facilities ER. Etc etc etc. I was making the comparison that because you just aren’t seeing old Vietnam vets and mostly men in their 50s and above. That these DoD jobs might actually be more comparable to civilian Emergency Dept then that of the VA system? Thoughts lol?!

I have two friends who worked in military EDs as part of their service requirement straight out of residency. One was air force, one navy fwiw. Both said that they essentially ran an urgent care that skewed towards treating STDs. Neither of them felt that it was remotely like practicing actual emergency medicine.

Granted, this is an N of 2 and these guys were both active duty as part of their military payback which may imply a different job than the one being discussed, though I'm not sure how it would be different.

 

[HoosierdaddyO]

I have two friends who worked in military EDs as part of their service requirement straight out of residency. One was air force, one navy fwiw. Both said that they essentially ran an urgent care that skewed towards treating STDs. Neither of them felt that it was remotely like practicing actual emergency medicine.

Granted, this is an N of 2 and these guys were both active duty as part of their military payback which may imply a different job than the one being discussed, though I'm not sure how it would be different.

Yea happy to explain… so the military has multiple urgent cares and “hospitals” all over the place… and who else to fill these roles then people who have to… ie active duty right out of residency military doctors. On the other hand you have large scope military medical centers (not many but like 10-12 nation wide) like trippler in Hawaii or Walter Reed, or Sam Houston that are large complex centers with more robust ERs bc the population and catchment area is larger and larger populations. So for example fort drum has an “ER” which is basically an urgent care” but Walter Reed or various large Mil Med Centers like trippler, while it’s not inner city Chicago… they do get sick and complex more then you’d think

 

[turkeyjerky]

Everyone is talking about atrophy of skills, which is a valid concern… but I’m willing to bet that in most of these academic places, most attendings haven’t even touched a tube or a central line in years either. Granted they are supervising and handing them off to interns or residents but rarely do I see an academic attending (except during conference days) actually do the procedure. So with all this skill atrophy talk… I’m sure it’s more widespread than people think.

Although the average academic attending likely isn't as slick at procedures as an experienced community doc or a strong graduating resident, I think there's a qualitative difference here, in that those in academics are nearly constantly refreshing the nature of the procedures in their minds while they teach or discuss procedures w/ residents. Moreover, they're intimately involved in the cognitive aspects of the resuscitation of ill patients. When academics venture into the community, my guess is it isn't the sick patients or procedures they struggle with, it's the volume, pace and lack of consultants. After a prolonged stint at the VA, you'd probably struggle w/ both.

I've spent a lot of time looking at EM jobs at the VA. One of these days I'll get to writing a whole post about it, but here's the good and the bad.

In terms of best to worst EM jobs, it seems like unicorn democratic jobs are the top (#1). Good CMG jobs are somewhere near the bottom (#3), just above malicious democratic groups (#4) and awful CMG gigs (#5). I would put VA jobs right around #2.

The two biggest issues for EM docs looking at VA jobs is the schedule and the pay. In the community, 120 hours/mo gives you full time. At the VA, it's 160 for everyone, EM included. But exact hours at different locations will vary. Some locations offer official admin time that lowers your clinical hours. Some want you full time clinical.

This sounds like a fair assessment. Also, regarding the schedule, my understanding is that the VA typically requires you to work 80 hours, minus any admin time, every two week block, negating the schedule flexibility that so many of us take for granted. Although, on the positive end, many utilize non-employed contractors as nocturnists, meaning this is only day and swing shifts.

I like your ranking system. I'm thinking good hospital employed gigs and academics go in #2 and typical hospital employed #3, is this correct? Also, by 'malicious' democratic groups, do you mean working as an employee of an exploitative group (single or just a few owners) that doesn't give you actual partnership, or as an actual full fininancial partner is a small group that just has godawful leadership or hospital admin to deal with?

 

[BoardingDoc]

Yea happy to explain… so the military has multiple urgent cares and “hospitals” all over the place… and who else to fill these roles then people who have to… ie active duty right out of residency military doctors. On the other hand you have large scope military medical centers (not many but like 10-12 nation wide) like trippler in Hawaii or Walter Reed, or Sam Houston that are large complex centers with more robust ERs bc the population and catchment area is larger and larger populations. So for example fort drum has an “ER” which is basically an urgent care” but Walter Reed or various large Mil Med Centers like trippler, while it’s not inner city Chicago… they do get sick and complex more then you’d think

Yeah, I'm sure there are some VA gigs that have some actual acuity, but as you yourself said, there are maybe 10-12 of those nationwide. I assume that those ones aren't hiring terribly often or aren't paying enough to make it worthwhile.

I'm not saying people shouldn't do military medicine. I just think that you're unlikely to practice what most of us would actually consider emergency medicine if you do so.

 

[HoosierdaddyO]

Haha there is a whole thread titled on how people want to escape the pit. When I hear that I think of docs who are tired of being over run with ungrateful patients, ungrateful bosses! The constant messing with the circadian rhythm, the daily grind of shift work, no PTO, no job security, and market forces essentially threatening to undercut and screw everyone over. Ohh and the constant fear of medmal.

It seems to me like the best of both worlds is possibly a solid DoD or VA or IHS job to mitigate a lot of these concerns all while making really good pay and still being able to do Emergency medicine… just my 2 cents!!!

Not saying this is the end all be all for everyone… but for some or even more than some, I can’t blame them for choosing that route lol!!!

 

[Backpack234]

Haha there is a whole thread titled on how people want to escape the pit. When I hear that I think of docs who are tired of being over run with ungrateful patients, ungrateful bosses! The constant messing with the circadian rhythm, the daily grind of shift work, no PTO, no job security, and market forces essentially threatening to undercut and screw everyone over. Ohh and the constant fear of medmal.

It seems to me like the best of both worlds is possibly a solid DoD or VA or IHS job to mitigate a lot of these concerns all while making really good pay and still being able to do Emergency medicine… just my 2 cents!!!

Not saying this is the end all be all for everyone… but for some or even more than some, I can’t blame them for choosing that route lol!!!

I started that escape the pit thread! You’re pretty spot on with the reasons, and actually I am going to take a job with the VA. I don’t know if that’s how I’ll actually escape the pit, but I hope it makes it more survivable.

 

[BoardingDoc]

I started that escape the pit thread! You’re pretty spot on with the reasons, and actually I am going to take a job with the VA. I don’t know if that’s how I’ll actually escape the pit, but I hope it makes it more survivable.

Any idea when you're making the jump? I'd be curious to hear your thoughts on it once you've been there a while and have a good lay of the land.

 

[alpinism]

Thats a very valid concern for the VA system… but what about if you can get locked in to one of these DoD large Medical centers. In theory you’ll be taking care of active duty (while mostly healthy there are a fair % of men and women these days)… you take care of their dependents and children and also the retiree/veterans population and their spouses as well. Not necessarily a homogenized patient population if you ask me?!

The main issue is that very few military dependents live on actual military bases and go to DOD medical centers. The vast majority live in the surrounding communities nearby civilian hospitals. They're all covered by Tricare which pays for ED care at civilian hospitals so most people literally just show up at the closest ED when there's a true medical emergency. The DOD medical centers are mainly designed to provide care that's focused on active duty members working on the military bases. The population of these bases consists of all young and healthy people who've been screened for any serious medical conditions prior to being allowed to join the military.

 

[alpinism]

Yea happy to explain… so the military has multiple urgent cares and “hospitals” all over the place… and who else to fill these roles then people who have to… ie active duty right out of residency military doctors. On the other hand you have large scope military medical centers (not many but like 10-12 nation wide) like trippler in Hawaii or Walter Reed, or Sam Houston that are large complex centers with more robust ERs bc the population and catchment area is larger and larger populations. So for example fort drum has an “ER” which is basically an urgent care” but Walter Reed or various large Mil Med Centers like trippler, while it’s not inner city Chicago… they do get sick and complex more then you’d think

This is true however remember that since these are the only military hospitals that see any real pathology they all have military residencies and basically you'll be working in academics teaching EM residents and non EM residents and mostly supervising them doing all the procedures.

 

[HoosierdaddyO]

This is true however remember that since these are the only military hospitals that see any real pathology they all have military residencies and basically you'll be working in academics teaching EM residents and non EM residents and mostly supervising them doing all the procedures.

Haha valid point with having residents at one of these main Medical Centers… even more of a reason I’d be ok with that kind of job… opportunities for growth and teaching and advancement

 

[thegenius]

I've spent a lot of time looking at EM jobs at the VA. One of these days I'll get to writing a whole post about it, but here's the good and the bad.

In terms of best to worst EM jobs, it seems like unicorn democratic jobs are the top (#1). Good CMG jobs are somewhere near the bottom (#3), just above malicious democratic groups (#4) and awful CMG gigs (#5). I would put VA jobs right around #2.

The two biggest issues for EM docs looking at VA jobs is the schedule and the pay. In the community, 120 hours/mo gives you full time. At the VA, it's 160 for everyone, EM included. But exact hours at different locations will vary. Some locations offer official admin time that lowers your clinical hours. Some want you full time clinical.


Maybe this is just because I’m seeing 2-4 critical patients every day now. But is this really a bad thing? In an rvu shop putting in a central line kills your times. So you end up doing peripheral pressors a ton. Intubations though, I’d hate to give up.

Would you rather do so much emergency medicine you don’t have the time to really do it right or so little emergency medicine you don’t do it often enough?

We should be incentivized/rewarded when we practice good medicine.
We should be penalized when we practice bad medicine, or medicine commensurate with how we are paid.

That's a putatively pithy statement, isn't it.