If you no longer recommend EM to medical students, what alternative fields would you suggest?

[odyssey2]

If someone's a competitive medical student who entered thinking about EM but is worried about the future, which specialties do you think would be better? Or would you still recommend EM to students passionate about the field?

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[Birdstrike]

The specialties where you don't have to work nights, weekends, holidays, or take call, are the good ones. The others are more likely to give more burnout, than reward.

 

[miacomet]

I would add, and I'm sure Birdstrike agrees, the ones where you don't have to deal with CMS- outpatient specialities, or ones where you don't have to admit patients.

 

[Birdstrike]

The only valid reason to do EM, is if you absolutely need to work in an Emergency Department, to live. Otherwise, there's zero chance the rewards will outweigh the overwhelming burden of emotional exhaustion, disillusionment and circadian rhythm dysphoria you'll feel, in less than 5 years.

 

[odyssey2]

The specialties where you don't have to work nights, weekends, holidays, or take call, are the good ones. The others are more likely to give more burnout, than reward.

Any specific fields in mind?

 

[Tipsy McStagger]

In this thread, the perfect specialty is one that has:
- no nights, holidays, weekends
- no mornings or nights
- no patient interaction
- no insurance interaction
- no outpatient
- no inpatient
- no stress

I'll just add one that pays >500k annually with annual 200k retention bonus and 52 weeks paid vacation annually.

In all seriousness I think it's hard to pick a specialty for someone, but know that the things that interest you initially will likely fade over time. The things that will start to wear on you are things like working nights, becoming beholden to metrics, and being vulnerable to the vicissitudes of the hospital. I don't think there is a perfect specialty, just don't know how to pick a job for someone else.

 

[Rekt]

All of medicine is pretty awful honestly. I'd personally pick DR/IR. Patients are the worst part of the job. Just pick something you can tolerate until you can retire that will actually have job prospects unlike EM. (And path/radonc)

 

[Brigade4Radiant]

The one that you can control your practice and fire patients IM/FM. Every US medical student can do it there are several job openings being a good PCP is hard.

Life is about people. Figure out which is most important to you Money, Free time, Location.

For many its Location>Money>Free time

FM can practice anywhere you can graduate in Mississippi and then go get a job with Kaiser in LA making 275 with no nights and no weekends.

EM you lose half of your weekends and that is where most events occur. You can alter your FM practice to be inpatient or outpatient. You can do more OB or Derm, ENT, or psych

When you leave patient's may not stay with the Hospital group

It doesn't have prestigde and how residency is practiced people prefer more inpatient.

 

[Fecal_Occult]

Radiology, Anesthesiology, Psychiatry seem to be very popular now and relatively accessible compared to other desirable fields like Derm, Optho, surgical subspecialties. Of course there is also, IM which is extremely flexible given the fellowship options. You can do GI, cards if love procedures or pulm/crit if you love the adrenaline rush of participating in resuscitations and taking care of very sick pts. But the downside is that you'd have to do more years of training. 3 years of residency + 3 years of fellowship.

If you plan on working in saturated cities (NYC, LA, SF, etc.), don't do EM. No matter how passionate you are about the field, it's not worth it if you can't find a job. If you're fine with working in a rural setting, go for it. There is actually still a need for more EM physicians in that setting.

I see most people who were initially interested in EM switching to IM and anesthesiology so those are probably good fields to start looking at but everyone is different in terms of what they value in a future career. I also see a few switching to gen surg but the surgery lifestyle isn't for everyone. Hope this helps.

 

[brycew85]

Doctors used to be independent and run their own practices, but increasingly they're powerless cogs in the Global Capitalist Machine (GCM).

The past explains their prestige among laity, and the present their relative disrepute among the elite.

From New Order of Barbarians (1989):

The image of the doctor would change. No longer would he be seen as an individual professional in service to individual patients. But the doctor would be gradually recognized as a highly skilled technician... The image of the doctor being a powerful, independent person would have to be changed. The solo practitioner would become a thing of the past. A few die-hards might try to hold out, but most doctors would be employed by an institution of one kind or another. Group practice would be encouraged, corporations would be encouraged, and then once the corporate image of medical care... as this gradually became more and more acceptable, doctors would more and more become employees rather than independent contractors. And along with that, of course, unstated but necessary, is the employee serves his employer, not his patient. So that's -- we've already seen quite a lot of that in the last 20 years. And apparently more on the horizon.

So what fields would I tell medical students to go into? A field where they are able to be free of the GCM and be their own boss. Those fields are sprinkled across both competitive and non-competitive specialties and include:

Private Practice Psychiatry (cash only) tailoring to the rich and “worried well.” You really need the educational pedigree, marketing skills, and a certain look to pull this off though (white, conventionally attractive, not fat, smooth voice with great cadence). Not saying you can’t succeed without these qualities but it will be harder.

Direct Primary Care (via FM or IM). Similar to above. Rich elite types will pay for their own concierge doc

Ophthalmology: out of all of the the surgical sub specialties this is the one best built for private practice. The $$ ceiling is the highest in medicine. You don’t need the above skills (other than marketing/business) as much for this either since it’s your technical skill that’s important not your persona.

Plastics, focusing on aesthetics: goes without saying. Patients will pay cash to have a better butt or stronger looking jawline to get more Instagram likes and court more conventionally attractive partners.

Avoid anything where you are hospital employed.

Avoid anything where you are forced to be part of a mega group where boomer leaders can sell you out before they ride off into the sunset.

Avoid anything that is super dependent on the whims of CMS payments.

So I would actually avoid some of the surgical sub specialties like ortho and neuro spine where you are dependent on the whims of CMS and where the data surrounding some of their procedures are lacking strong evidence making it prime for being on the chopping block.

 

[i-doctor]

Interesting take on ophtho. Boomers are selling their practices in droves to Private Equity for the big upfront cash. Some of these will fail. Don’t know how the field of ophthalmology will pay out on the future…

 

[Frazier]

Interesting take on ophtho. Boomers are selling their practices in droves to Private Equity for the big upfront cash. Some of these will fail. Don’t know how the field of ophthalmology will pay out on the future…

Relative of mine is a CPA and just changed jobs after 8 years. He is now working for a private equity group where apparently the firms ENTIRE purpose and model is just accumulating ophtho practices.

Very unfortunate. I was the least enthusiastic relative in response to hearing about this.

 

[WilcoWorld]

Doctors used to be independent and run their own practices, but increasingly they're powerless cogs in the Global Capitalist Machine (GCM).

The past explains their prestige among laity, and the present their relative disrepute among the elite.

From New Order of Barbarians (1989):

The image of the doctor would change. No longer would he be seen as an individual professional in service to individual patients. But the doctor would be gradually recognized as a highly skilled technician... The image of the doctor being a powerful, independent person would have to be changed. The solo practitioner would become a thing of the past. A few die-hards might try to hold out, but most doctors would be employed by an institution of one kind or another. Group practice would be encouraged, corporations would be encouraged, and then once the corporate image of medical care... as this gradually became more and more acceptable, doctors would more and more become employees rather than independent contractors. And along with that, of course, unstated but necessary, is the employee serves his employer, not his patient. So that's -- we've already seen quite a lot of that in the last 20 years. And apparently more on the horizon.

So what fields would I tell medical students to go into? A field where they are able to be free of the GCM and be their own boss. Those fields are sprinkled across both competitive and non-competitive specialties and include:

Private Practice Psychiatry (cash only) tailoring to the rich and “worried well.” You really need the educational pedigree, marketing skills, and a certain look to pull this off though (white, conventionally attractive, not fat, smooth voice with great cadence). Not saying you can’t succeed without these qualities but it will be harder.

Direct Primary Care (via FM or IM). Similar to above. Rich elite types will pay for their own concierge doc

Ophthalmology: out of all of the the surgical sub specialties this is the one best built for private practice. The $$ ceiling is the highest in medicine. You don’t need the above skills (other than marketing/business) as much for this either since it’s your technical skill that’s important not your persona.

Plastics, focusing on aesthetics: goes without saying. Patients will pay cash to have a better butt or stronger looking jawline to get more Instagram likes and court more conventionally attractive partners.

Avoid anything where you are hospital employed.

Avoid anything where you are forced to be part of a mega group where boomer leaders can sell you out before they ride off into the sunset.

Avoid anything that is super dependent on the whims of CMS payments.

So I would actually avoid some of the surgical sub specialties like ortho and neuro spine where you are dependent on the whims of CMS and where the data surrounding some of their procedures are lacking strong evidence making it prime for being on the chopping block.

I appreciate your clear-eyed and articulately-presented assessment of the near-to-mid term future of medicine.

I also want to point out that there is something absent from it: non-financial values. I know that to most on this forum I seem like a naiive pre-med when I say this stuff, but I went into medicine because I enjoy using my scientific reasoning skills to help people and I feel passionately about "doing the right thing" (even if my assessment of what that is changes over time). Your post (and most others I see on this issue) does not address these goals.

This is not to criticize your post or others, but rather to make a point: The proper response to the OP's question "What field do you recommend?" is perhaps not an answer (Psych/ophtho/IR) but a question, "What is it that you want out of your life?"

 

[DoctwoB]

There are causes for burnout in all fields, just different ones.

Rads: Good pay/hours, but Work is a grind, there is no spoon, there is only the next study. There is a reason radiology groups seem to choose to take more vacation then make more money. They need it.

Gas: Taking call, early OR starts, dealing with both surgeons and admin/nursing/CRNAs

IM/Hospitalist/PCP: PCP has great hours but a lot of burnout from being the dumping ground for specialties, unpaid care coordination, dealing with being the gatekeeper for work excuses, handicap parking, disability, narcotics, etc puts you in a crappy situation with many patients. Hospitalist is like lower paid EM, lot of BS and shift hours.

IM subs: honestly the lower paying ones like Endo, rheum, etc seem like a good gig from a lifestyle standpoint, but it’s a lot of training to make a pcp salary. Cards/GI, you’ve got plenty of call. GI screening colonoscopies also seems like a grind.

Psychsych patients. You’ve gotta love what you do, but if you do like psych probably the best gig from a lifestyle/burnout standpoint.

Surgical subs: Brutal residency, call, hours not as bad as advertised but will have early OR starts and sometimes middle of the night cases on call.

So find what you like.

Go now and burnout in what way seems best to you.

 

[Rekt]

I appreciate your clear-eyed and articulately-presented assessment of the near-to-mid term future of medicine.

I also want to point out that there is something absent from it: non-financial values. I know that to most on this forum I seem like a naiive pre-med when I say this stuff, but I went into medicine because I enjoy using my scientific reasoning skills to help people and I feel passionately about "doing the right thing" (even if my assessment of what that is changes over time). Your post (and most others I see on this issue) does not address these goals.

This is not to criticize your post or others, but rather to make a point: The proper response to the OP's question "What field do you recommend?" is perhaps not an answer (Psych/ophtho/IR) but a question, "What is it that you want out of your life?"

I still feel EM is wrong in regards to "helping people, using scientific reasoning, doing the right thing". It's actually probably the worst out of the specialities that deal with patients directly. We have no relationship with them. We rarely fix anything. Anybody sick enough will never remember you. Half the patients still ask what kind of doctor you're going to be. Patients only remember the ER if they have a bad experience. Never a good one. How many times have you genuinely been thanked? We actually probably have a net harm on patients rather than good or neutral at best. How many x-rays/Cts do you order that you know will be a complete waste? How many prescriptions? Labs? Swabs? Sure you can talk about Centor criteria or about how there's really no utility in the flu swab or the >2m rsv, but it's extremely more painful to sit there and discuss with the patient and fight them over something so silly when you have 30 other people that aren't sick either waiting to be seen. All in the name of satisfaction. Scientific reasoning? We delve into the depths of ACS, PE, risk algorithms all the time, but in reality it's all very shallow. Etc etc etc.

You go into EM for the money and least amount of time at work and maybe to do a fun procedure or have a neat story. But it's all rapidly disappearing as PE continues its takeover and residencies expand.

 

[odyssey2]

There are causes for burnout in all fields, just different ones.

Rads: Good pay/hours, but Work is a grind, there is no spoon, there is only the next study. There is a reason radiology groups seem to choose to take more vacation then make more money. They need it.

Gas: Taking call, early OR starts, dealing with both surgeons and admin/nursing/CRNAs

IM/Hospitalist/PCP: PCP has great hours but a lot of burnout from being the dumping ground for specialties, unpaid care coordination, dealing with being the gatekeeper for work excuses, handicap parking, disability, narcotics, etc puts you in a crappy situation with many patients. Hospitalist is like lower paid EM, lot of BS and shift hours.

IM subs: honestly the lower paying ones like Endo, rheum, etc seem like a good gig from a lifestyle standpoint, but it’s a lot of training to make a pcp salary. Cards/GI, you’ve got plenty of call. GI screening colonoscopies also seems like a grind.

Psychsych patients. You’ve gotta love what you do, but if you do like psych probably the best gig from a lifestyle/burnout standpoint.

Surgical subs: Brutal residency, call, hours not as bad as advertised but will have early OR starts and sometimes middle of the night cases on call.

So find what you like.

Go now and burnout in what way seems best to you.

what about derm/ophtho?

 

[bravotwozero]

Being a kicker on an NFL team. Can have career longevity with decent pay and less chance Of serious injuries - I.e concussions etc

 

[turkeyjerky]

I still feel EM is wrong in regards to "helping people, using scientific reasoning, doing the right thing". It's actually probably the worst out of the specialities that deal with patients directly. We have no relationship with them. We rarely fix anything. Anybody sick enough will never remember you. Half the patients still ask what kind of doctor you're going to be. Patients only remember the ER if they have a bad experience. Never a good one. How many times have you genuinely been thanked? We actually probably have a net harm on patients rather than good or neutral at best. How many x-rays/Cts do you order that you know will be a complete waste? How many prescriptions? Labs? Swabs? Sure you can talk about Centor criteria or about how there's really no utility in the flu swab or the >2m rsv, but it's extremely more painful to sit there and discuss with the patient and fight them over something so silly when you have 30 other people that aren't sick either waiting to be seen. All in the name of satisfaction. Scientific reasoning? We delve into the depths of ACS, PE, risk algorithms all the time, but in reality it's all very shallow. Etc etc etc.

You go into EM for the money and least amount of time at work and maybe to do a fun procedure or have a neat story. But it's all rapidly disappearing as PE continues its takeover and residencies expand.

Oof...way too much truth in this.

 

[Birdstrike]

Any specific fields in mind?

You can make your own list. But to start, Derm, Pain, PM&R, Psych, Rad Onc, Pathology and all the other specialties you never called during your EM rotations. Those are the ones worth doing.

 

[DoctwoB]

what about derm/ophtho?

Both have a lot of private equity groups, can feel like a cog in the machine. Both tend to have extremely busy clinics, 50 patients or more a day is not uncommon which can be a grind. Ditto for procedures. To make money in cataracts you need to really Crank them out and/or upsell on lenses, which can give some ophtos the car salesman vibe. Ophtho especially tends to have very low starting salaries for partnership tract jobs though partners can make $$$.

Note I’m playing devils advocate. They’re both great fields, but there are plenty of factors in any field that can contribute to burnout.

 

[WilcoWorld]

I still feel EM is wrong in regards to "helping people, using scientific reasoning, doing the right thing". It's actually probably the worst out of the specialities that deal with patients directly. We have no relationship with them. We rarely fix anything. Anybody sick enough will never remember you. Half the patients still ask what kind of doctor you're going to be. Patients only remember the ER if they have a bad experience. Never a good one. How many times have you genuinely been thanked? We actually probably have a net harm on patients rather than good or neutral at best. How many x-rays/Cts do you order that you know will be a complete waste? How many prescriptions? Labs? Swabs? Sure you can talk about Centor criteria or about how there's really no utility in the flu swab or the >2m rsv, but it's extremely more painful to sit there and discuss with the patient and fight them over something so silly when you have 30 other people that aren't sick either waiting to be seen. All in the name of satisfaction. Scientific reasoning? We delve into the depths of ACS, PE, risk algorithms all the time, but in reality it's all very shallow. Etc etc etc.

You go into EM for the money and least amount of time at work and maybe to do a fun procedure or have a neat story. But it's all rapidly disappearing as PE continues its takeover and residencies expand.

I know that many EM Docs feel cornered into the type of practice you describe. I did at one point as well. I decided it wasn't worth doing that to keep my job, so I stopped doing it. That was around five years ago - I haven't been fired.

You have your experience, I have mine. That's OK.

 

[RustedFox]

I still feel EM is wrong in regards to "helping people, using scientific reasoning, doing the right thing". It's actually probably the worst out of the specialities that deal with patients directly. We have no relationship with them. We rarely fix anything. Anybody sick enough will never remember you. Half the patients still ask what kind of doctor you're going to be. Patients only remember the ER if they have a bad experience. Never a good one. How many times have you genuinely been thanked? We actually probably have a net harm on patients rather than good or neutral at best. How many x-rays/Cts do you order that you know will be a complete waste? How many prescriptions? Labs? Swabs? Sure you can talk about Centor criteria or about how there's really no utility in the flu swab or the >2m rsv, but it's extremely more painful to sit there and discuss with the patient and fight them over something so silly when you have 30 other people that aren't sick either waiting to be seen. All in the name of satisfaction. Scientific reasoning? We delve into the depths of ACS, PE, risk algorithms all the time, but in reality it's all very shallow. Etc etc etc.

You go into EM for the money and least amount of time at work and maybe to do a fun procedure or have a neat story. But it's all rapidly disappearing as PE continues its takeover and residencies expand.

I decided awhile back that the only reason that I came back to do EM after one calendar year away was because I liked the critical care aspect of it. That was it.

I do my absolute bare minimum hours now. I never, ever "pick up a shift".

 

[bronx43]

I feel bad for med students in this day and age... they're basically going to be the first generation of doctors who will never experience the fleeting positives (security, income) but have to endure all the negatives (length of training, cost of education, high expectations from both the system and the public).

The highest yield specialty right now is rads given their high income, lack of pt interaction, and relatively stable hours. However, they're probably the least resilient to any big changes in the system since they aren't able to create their own demand and essentially rely on us clinicians to feed them. Clinicians can easily cut half of the imaging we order without sacrificing much outcome.

The buy-low specialty is primary care. They're by far the most resilient, as they are the front line. Incomes are creeping up and market is wide open.

 

[Angry Birds]

 

[alpinism]

People love to say radiology but in reality its working a corporate desk job writing reports all day.

 

[BoardingDoc]

People love to say radiology but in reality its working a corporate desk job writing reports all day.

Yeah. The quality of life in terms of hours and money is definitely nice. The work itself is not for everyone. I would go utterly insane doing that job.

 

[Taurus]

Radiology is like taking a test. If you don’t mind taking tests, you’ll be fine in rads. We also do procedures and can even have patient interactions. After a while, you realize that both are a pain and you would rather sit at your workstation drinking your coffee and eating your yogurt while looking at that chest x-ray. No regrets. It’s a great field. The pay for hours worked and the vacation time aren't too bad either. 😉

 

[Mbekweni]

Relative of mine is a CPA and just changed jobs after 8 years. He is now working for a private equity group where apparently the firms ENTIRE purpose and model is just accumulating ophtho practices.

Very unfortunate. I was the least enthusiastic relative in response to hearing about this.

A friend of mine just sold Optho practice to PE for 20 million. Yes 20. He was making 1-2MM a year before that but saw 70-80 patients a day in clinic and had super busy OR days too. No free lunch and with Optho and insurance big money comes from big volume.

 

[miacomet]

I decided awhile back that the only reason that I came back to do EM after one calendar year away was because I liked the critical care aspect of it. That was it.

I do my absolute bare minimum hours now. I never, ever "pick up a shift".

Wow, how did you manage to find a job after being out of the ER for a year?

 

[TysonCook]

I still feel EM is wrong in regards to "helping people, using scientific reasoning, doing the right thing". It's actually probably the worst out of the specialities that deal with patients directly. We have no relationship with them. We rarely fix anything. Anybody sick enough will never remember you. Half the patients still ask what kind of doctor you're going to be. Patients only remember the ER if they have a bad experience. Never a good one. How many times have you genuinely been thanked? We actually probably have a net harm on patients rather than good or neutral at best. How many x-rays/Cts do you order that you know will be a complete waste? How many prescriptions? Labs? Swabs? Sure you can talk about Centor criteria or about how there's really no utility in the flu swab or the >2m rsv, but it's extremely more painful to sit there and discuss with the patient and fight them over something so silly when you have 30 other people that aren't sick either waiting to be seen. All in the name of satisfaction. Scientific reasoning? We delve into the depths of ACS, PE, risk algorithms all the time, but in reality it's all very shallow. Etc etc etc.

This. You may be able to modify it to some extent (see other quotes), but in the end you work for a company (either CMG or SDG or hospital) and they will expect productivity, quality and satisfaction. While productivity and good clinical medicine are not always mutually exclusive, you are constantly trying to do what is medically best, professionally best, and have excellent "customer service" all at the same time - which unfortunately are constantly in conflict.

There are not a lot of "exits" from EM and from what I've seen, you can plan on decreasing reimbursements (i.e. salary), for increasing professional demands (huge ED workups, clerical hoops, and professional hoops) and less job opportunities (10k new grads, MLP encroachment).

I was lucky getting in when I did, but I would not recommend it as a career path to a new student. Look for careers where you have some autonomy if you want to swap jobs, locale, etc. Also look for careers where you aren't 100% dependent on what you can negotiate with insurance companies (i.e. ability to directly bill patients).

 

[Janders]

I still wouldn’t tell people very interested in EM that they MUST RUN AND HIDE… but I would tell them to read this thread and see that the vast majority of current advice is to look at other fields.

If they are hell bent on EM, I would explain for their longevity and health, they should assume in the future they will work 12-14 shifts a month and not sniff any more money than a PCP in clinic, and they will work 1/3 overnights and 1/2 the weekends and thats best case scenario. They WILL need to answer to clipboards and metrics and satisfaction. If they prefer this set of circumstances to the SAME MONEY working 4 clinic days a week, then so be it.

As far as alternatives?
There has always been a historic overlap between Anesthesia and EM personalities it seems, though I can imagine in the future many of the same negative aspects of EM could rear their heads in Anesthesia.

If you have an entrepreneurial spirit, I can imagine it rewarding to start your own PCP practice with a group of like-minded people, perhaps doing it via direct patient care and obtaining ownership that way.

Otherwise, there is a reason Derm is competitive

Personally I think IR is very neat, probably would be my choice to explore if I did everything over again. Or other niche procedure-heavy things… ERCP is cool as hell IMHO, though a lot of slog to become an advanced endoscopist.

 

[RustedFox]

Wow, how did you manage to find a job after being out of the ER for a year?

Wasn't easy; but it happened.

 

[IRattending2021]

I feel bad for med students in this day and age... they're basically going to be the first generation of doctors who will never experience the fleeting positives (security, income) but have to endure all the negatives (length of training, cost of education, high expectations from both the system and the public).

The highest yield specialty right now is rads given their high income, lack of pt interaction, and relatively stable hours. However, they're probably the least resilient to any big changes in the system since they aren't able to create their own demand and essentially rely on us clinicians to feed them. Clinicians can easily cut half of the imaging we order without sacrificing much outcome.

The buy-low specialty is primary care. They're by far the most resilient, as they are the front line. Incomes are creeping up and market is wide open.

Right now the “high income” of rad lands you squarely middle class in places like the bay area where coders get paid way more for doing less.

 

[bravotwozero]

Right now the “high income” of rad lands you squarely middle class in places like the bay area where coders get paid way more for doing less.

That’s your problem right there, you want to work in the Bay Area where everyone makes less money than the entire country combined

 

[larpleston]

I still feel EM is wrong in regards to "helping people, using scientific reasoning, doing the right thing". It's actually probably the worst out of the specialities that deal with patients directly. We have no relationship with them. We rarely fix anything. Anybody sick enough will never remember you. Half the patients still ask what kind of doctor you're going to be. Patients only remember the ER if they have a bad experience. Never a good one. How many times have you genuinely been thanked? We actually probably have a net harm on patients rather than good or neutral at best. How many x-rays/Cts do you order that you know will be a complete waste? How many prescriptions? Labs? Swabs? Sure you can talk about Centor criteria or about how there's really no utility in the flu swab or the >2m rsv, but it's extremely more painful to sit there and discuss with the patient and fight them over something so silly when you have 30 other people that aren't sick either waiting to be seen. All in the name of satisfaction. Scientific reasoning? We delve into the depths of ACS, PE, risk algorithms all the time, but in reality it's all very shallow. Etc etc etc.

You go into EM for the money and least amount of time at work and maybe to do a fun procedure or have a neat story. But it's all rapidly disappearing as PE continues its takeover and residencies expand.

I’m as down on the future of EM as the next guy but this is a stretch. First off, does ANYONE in medicine really make a difference? I think a lot of dissatisfaction comes from our idealized notions of “helping people” come up against the reality that care is so fragmented and most sick people don’t have quick fixes and a single person can’t really make a difference. You really want to make an impactful long lasting impact in someone’s life? Become a teacher or a politician. Otherwise your role is to do your small part and take comfort in knowing you fixed 0.5% of their problems. Is the neurosurgeon doing the 10th shunt revision of some developmentally delayed kid changing the world? Is an ortho doc doing arthroscopies of dubious efficacy making a difference? Nah, but they convince themselves they are because patients, hospital systems, and other docs kiss their a$&. The reality is we play our small part. Saying that we do nothing for patients is so detached that it’s not worth even arguing over. Even lame stuff like giving someone a dose of antibiotics for pyelo has a benefit to patients. Yeah it’s easy to convince ourselves “anyone could do that, my part is irrelevant”. In reality much of what we do could not be done by another person, or they would do our jobs competently but it would be so slowly and inefficiently that people would suffer. Now, does that mean EM is a good career choice. HELL NO. Do rads or anesthesia. But what we do makes a ‘difference’ in the sense that anyone in the universe can make a difference, which is a whole other discussion on our pointlessness and irrelevance in the universe.

 

[WilcoWorld]

I think a lot of dissatisfaction comes from our idealized notions of “helping people” come up against the reality...The reality is we play our small part...anyone in the universe can make a difference, which is a whole other discussion on our pointlessness and irrelevance in the universe.

Yes!

It's not that we don't or can't make a difference, it's that we fail to appreciate the small differences we can make. Nobody, not even the POTUS gets to "change the world" every day. On the other hand, our job is overflowing with opportunities to make little impacts. When I take the hand of a sick, scared patient and say "we're going to work on making you feel better" I can and do change THEIR world.

 

[EctopicFetus]

The only valid reason to do EM, is if you absolutely need to work in an Emergency Department, to live. Otherwise, there's zero chance the rewards will outweigh the overwhelming burden of emotional exhaustion, disillusionment and circadian rhythm dysphoria you'll feel, in less than 5 years.

I disagree here. Few specialties make what we do per hour and there are a few on here with their unicorn jobs making $400/hr+. Yes nights yes weekends yes holidays though all can be minimized. At $400/hr you can work very little and make a lot. The key is financial discipline. In my group people “sell” their nights. Essentially a night differential from one person to the other.

In general I agree but there are exceptions like all rules.

 

[IRattending2021]

That’s your problem right there, you want to work in the Bay Area where everyone makes less money than the entire country combined

That’s your problem right there, you want to work in the Bay Area where everyone makes less money than the entire country combined

Actually everyone mostly make more money in the bay, trashman, plumbers, NPs, I do think PCP make decent income there. Just that everyone else make way more proportionally than docs.

I know people who work there, their salary in employed gig are better than partnership salary in other part of the country. It’s just that tech company just pays so much more.

 

[Angry Birds]

I disagree here. Few specialties make what we do per hour and there are a few on here with their unicorn jobs making $400/hr+. Yes nights yes weekends yes holidays though all can be minimized. At $400/hr you can work very little and make a lot. The key is financial discipline. In my group people “sell” their nights. Essentially a night differential from one person to the other.

In general I agree but there are exceptions like all rules.

You're only making $400/hr? Here on SDN we all make at least $750/hr... it correlates with our exceptionally high board scores.

 

[Trousseau]

Honestly if you're worried about employment I would do FP...those guys will never be out of a job, and if they are, it means all of medicine is over anyways and we all need to bounce.

General Internists used to be a thing, but IM is increasingly positioning itself as an inpatient field, so odds are if you do IM, your clinic will be taught by someone who hates clinic. Unsurprisingly, residents in those programs rarely do general internal medicine.

 

[bronx43]

Right now the “high income” of rad lands you squarely middle class in places like the bay area where coders get paid way more for doing less.

Sure, but what about your clinician colleagues? They’re probably sharing a studio apartment with four other clinicians.

 

[namethatsmell]

The specialties where you don't have to work nights, weekends, holidays, or take call, are the good ones. The others are more likely to give more burnout, than reward.

This is the way

When I look back to my full-time EM days, I'm fairly certain some of the schedulers used a Plinko-like randomizer to make my schedule. I had no idea how disruptive it really was until I came to work a bankers hours M-F job and the old shift flips slowly washed out of my system. While I do officially work more hours now, I am out of the office right on time or within 10 minutes with all notes done 98% of the time. When I compare that with my last FT EM gig-- official EM hours + unofficial uncompensated EM hours (staying late with a code, charting, uncompensated meetings, etc) +DOMAs....I think my actual usable hours outside of work have actually increased. It makes me a much happier person at work and at home.

 

[namethatsmell]

I tell lots of medical students to consider psychiatry.

Why?

IMHO much of the burnout in medicine comes from docs having a significant lack of control of their workplace, but still being expected to be "responsible" for things at the end of the day. It's an ultimate form of gaslighting. I have about 786% more control now and it's been soul-saving.

Psychiatry affords the opportunity to have more control over your work environment--and be serve nobody but the patient--probably more than any other field in medicine.

Demand for their services is huge and people pay cash. Psychs can open their own practice for peanuts: cheap med-mal policy+a doximity dialer account+paypal+notepad. And because of all this, onerous bureaucratic regulations, private equity, and insurance companies cannot mess with them.

 

[TheComebacKid]

While our specialty is really trending down at this point (tanking may be a more appropriate term), I really struggle to understand how we let our sensibilities get so out of control to the point that we come to highly emotional and irrational conclusions about every other specialty. Yes, I get it. You hate the state of our specialty right now, and things aren't looking up for EM anytime soon. I hate EM currently too. But to take the current state of our specialty and give advice to people that they should do Family medicine/primary care, or become hospitalist, or a cardiologist because it's "better" is delusional, irresponsible, and nothing more than you projecting your own regret instead of giving targeted/tailored advice to an individual.

I have, to this day, never met a PCP who isn't absolutely beat down. They have huge panels of patients, very demanding patients (chronic pain, uncontrolled diabetes, think of the most horrible complaints we see in the ED and then imagine having to see the same patients for years on end), pressures to see more patients with less time allotted, overbooked clinics, AND the threat of midlevel encroachment.

Inpatient hospital wards are a cesspool of demanding patients, nightmare social issues, drug seeking behavior, you name it. How many hospitalists do you call/talk to that love their work?

Cardiologists get absolutely brutalized by call, work very long hours on inpatient consult services. I know a handful of interventionalists, they all hate their lives. Every discussion with cardiology regarding taking someone to cath is draining, not because they are bad/dumb people, but because they are so overworked that often times the amount of extra money they make from billing for a procedure is not worth them getting some extra sleep and dealing with it in the morning. Yes they are handsomely compensated, perhaps better than we are, but they are still exhausted. In EM at least I feel that way 13-15 days a month, not 27.

GI? Are you kidding me? Scoping unstable UGI bleeds in the middle of the night, dealing with unbelievable amounts of functional abdominal pain in clinic, forget it, you couldn't pay me enough to do this.

Yes, the nights/holidays, CMGs/corporate pressure/metrics, challenging patients, midlevels etc in EM absolutely suck. But primary care, IM hospitalist etc have a whole different level of suck. Some students may handle the EM brand of suck better. Some may handle outpatient primary care better. Either way, nobody is escaping the suck of medicine in general.

 

[bravotwozero]

When I look back to my full-time EM days, I'm fairly certain some of the schedulers used a Plinko-like randomizer to make my schedule. I had no idea how disruptive it really was until I came to work a bankers hours M-F job and the old shift flips slowly washed out of my system. While I do officially work more hours now, I am out of the office right on time or within 10 minutes with all notes done 98% of the time. When I compare that with my last FT EM gig-- official EM hours + unofficial uncompensated EM hours (staying late with a code, charting, uncompensated meetings, etc) +DOMAs....I think my actual usable hours outside of work have actually increased. It makes me a much happier person at work and at home.

One thing I will say that is if I transitioned to a M-F 9-5 kind of job, I'm not sure i'd want to or be able to get used to it.

I know this sounds bizarre, almost to the point of perverse, but having off days to do things in off peak hours is a significant advantage.

Case in point - going to the gym. I get to work out on a random wednesday morning at 10am or thursday afternoon at 2pm, when the gym is completely dead. Anyone working a 40 hour 9-5 will then have to go at peak hours, stupid early, or late at night, that's not going to work when you also have kids and have to pick them up / drop off etc. Same goes for stuff like groceries, needing to go to the post office car appointments etc.

It also helps that my wife works PT 3 days a week. So frequently, both of us will have weekdays off together, and the kids are off to school and it's just bliss, like a weekend off during the weekday...

Definitely not a reason to consider EM, that would be insane, but it is a perk of sorts.

 

[thegenius]

A friend of mine just sold Optho practice to PE for 20 million. Yes 20. He was making 1-2MM a year before that but saw 70-80 patients a day in clinic and had super busy OR days too. No free lunch and with Optho and insurance big money comes from big volume.

How do you see 70-80 pt/day. That's absurd. Especially being an eye doctor where you probably can't just "fake" the physical exam.

 

[thegenius]

I’m as down on the future of EM as the next guy but this is a stretch. First off, does ANYONE in medicine really make a difference? I think a lot of dissatisfaction comes from our idealized notions of “helping people” come up against the reality that care is so fragmented and most sick people don’t have quick fixes and a single person can’t really make a difference. You really want to make an impactful long lasting impact in someone’s life? Become a teacher or a politician. Otherwise your role is to do your small part and take comfort in knowing you fixed 0.5% of their problems. Is the neurosurgeon doing the 10th shunt revision of some developmentally delayed kid changing the world? Is an ortho doc doing arthroscopies of dubious efficacy making a difference? Nah, but they convince themselves they are because patients, hospital systems, and other docs kiss their a$&. The reality is we play our small part. Saying that we do nothing for patients is so detached that it’s not worth even arguing over. Even lame stuff like giving someone a dose of antibiotics for pyelo has a benefit to patients. Yeah it’s easy to convince ourselves “anyone could do that, my part is irrelevant”. In reality much of what we do could not be done by another person, or they would do our jobs competently but it would be so slowly and inefficiently that people would suffer. Now, does that mean EM is a good career choice. HELL NO. Do rads or anesthesia. But what we do makes a ‘difference’ in the sense that anyone in the universe can make a difference, which is a whole other discussion on our pointlessness and irrelevance in the universe.

Yea man I agree. I still like being an ER doctor for the most part. Every year that goes by I get a tiny bit more crusty, but I'm on year 8 and I like going to work.

But I'll argue that giving abx for pyelo, if they truly have pyelo, should feel good!

 

[thegenius]

The only valid reason to do EM, is if you absolutely need to work in an Emergency Department, to live. Otherwise, there's zero chance the rewards will outweigh the overwhelming burden of emotional exhaustion, disillusionment and circadian rhythm dysphoria you'll feel, in less than 5 years.

Not everyone is like you!

 

[thegenius]

While our specialty is really trending down at this point (tanking may be a more appropriate term), I really struggle to understand how we let our sensibilities get so out of control to the point that we come to highly emotional and irrational conclusions about every other specialty. Yes, I get it. You hate the state of our specialty right now, and things aren't looking up for EM anytime soon. I hate EM currently too. But to take the current state of our specialty and give advice to people that they should do Family medicine/primary care, or become hospitalist, or a cardiologist because it's "better" is delusional, irresponsible, and nothing more than you projecting your own regret instead of giving targeted/tailored advice to an individual.

I have, to this day, never met a PCP who isn't absolutely beat down. They have huge panels of patients, very demanding patients (chronic pain, uncontrolled diabetes, think of the most horrible complaints we see in the ED and then imagine having to see the same patients for years on end), pressures to see more patients with less time allotted, overbooked clinics, AND the threat of midlevel encroachment.

Inpatient hospital wards are a cesspool of demanding patients, nightmare social issues, drug seeking behavior, you name it. How many hospitalists do you call/talk to that love their work?

Cardiologists get absolutely brutalized by call, work very long hours on inpatient consult services. I know a handful of interventionalists, they all hate their lives. Every discussion with cardiology regarding taking someone to cath is draining, not because they are bad/dumb people, but because they are so overworked that often times the amount of extra money they make from billing for a procedure is not worth them getting some extra sleep and dealing with it in the morning. Yes they are handsomely compensated, perhaps better than we are, but they are still exhausted. In EM at least I feel that way 13-15 days a month, not 27.

GI? Are you kidding me? Scoping unstable UGI bleeds in the middle of the night, dealing with unbelievable amounts of functional abdominal pain in clinic, forget it, you couldn't pay me enough to do this.

Yes, the nights/holidays, CMGs/corporate pressure/metrics, challenging patients, midlevels etc in EM absolutely suck. But primary care, IM hospitalist etc have a whole different level of suck. Some students may handle the EM brand of suck better. Some may handle outpatient primary care better. Either way, nobody is escaping the suck of medicine in general.

All true man. I think the cash pay only specialties are the way to go...but even then if you accept their cash you better be damn good as customer service and answer their phone call at 2:00 AM when they don't feel good with nausea 3 weeks post-op breast reduction. And you better NOT send them to the ER because we will RAIL ON YOU NON STOP!

 

[Franzd'Epinay]

GI? Are you kidding me? Scoping unstable UGI bleeds in the middle of the night, dealing with unbelievable amounts of functional abdominal pain in clinic, forget it, you couldn't pay me enough to do this.

In my experience, GI bleeds are always either too stable or too unstable to get scoped in the middle of the night. I strongly suspect endoscopes are actually solar powered.