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

[Franzd'Epinay]

Wasn't easy; but it happened.

Are you still doing the non-EM thing you were doing before? Can you share with the rest of the class yet?

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[RustedFox]

Are you still doing the non-EM thing you were doing before? Can you share with the rest of the class yet?

I am.
I'm not sharing. Yet.

 

[Ho0v-man]

So find what you like.

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

This pretty much sums up career advice to any med student at this point. Everyone’s burnt out.

 

[EctopicFetus]

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.

Sort of true however dont underestimate the pill mill online folks creeping into this field for online counseling, online psych meds and of course the psych NPs are rolling in there. I have spoken to PE and their main 4 fields to conquer, EM, Derm, Ophtho and psych. The guy I spoke with essentially said they can have 1 doc and then a bunch of NPs and they can coorindate care and counseling something a doc cant do.

Also lets be honest, plenty of primary care docs manage the standard depression, anxiety etc which is a lot of psych. The hardcore shizo etc often cant cash pay. Im not saying psych isn't good but there are no unturned stones anywhere when it comes to rent seekers and those who seek to siphon off as much money as possible.

 

[EctopicFetus]

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.

The techs do a lot of the work. When they see you they have all the answers and simply just need to chat with you for a few mins. Obviously this isn't true for surgeries but they crank those out as well.

 

[Kryptocoin]

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?

Easy question. Plastics. Cash based, no weekends or holidays, fairly healthy pts and hard to come under PE control. They can't commoditize your skills. One dermatologist can open 5 offices and have PAs/NPs run the clinics( tacky but I've seen it) . Can't do that with Plastics. PE are attracted to things they can scale.

 

[bronx43]

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.

A lot of my friends and residency classmates who didn’t specialize are doing outpatient GIM in our large Midwest metro. Many are partners in the huge primary care group in town, and they are definitely not beaten down. Not any more than the other clinicians. At the very least they call the shots and no one tells them what to do. The local hospitals don’t dare step on their toes since they are a huge referring source and there are multiple health systems vying for that business.

And most GIs I know are outright giddy about their specialty choice. Sure, chronic abdominal sucks but I think they are well comforted by the $800k they make doing scopes M-F during banker hours.

 

[treatem-and-streetem]

If I didn't do EM I would have done IM and subspecialized

 

[VA Hopeful Dr]

A lot of my friends and residency classmates who didn’t specialize are doing outpatient GIM in our large Midwest metro. Many are partners in the huge primary care group in town, and they are definitely not beaten down. Not any more than the other clinicians. At the very least they call the shots and no one tells them what to do. The local hospitals don’t dare step on their toes since they are a huge referring source and there are multiple health systems vying for that business.

And most GIs I know are outright giddy about their specialty choice. Sure, chronic abdominal sucks but I think they are well comforted by the $800k they make doing scopes M-F during banker hours.

None of the FPs I personally know in my area are burned out. I was starting to get that way so I cut my schedule down from 32 patients/day to 27 and I'm quite content these days.

 

[Angry Birds]

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.

Yeah I just wonder if this is grass is greener on the other side…
In any case, I have zero tolerance for psych stuff. The second they talk I start squirming.

Anyways, I couldn’t stand an 8-5 job 5 days a week…

 

[Trousseau]

I hate Psych ****shows…when I’d get them in residency clinic I would fix anything glaring, but otherwise leave it alone and refer to Psych…but they were all booked for months.

If you can do it, Psych has an acute shortage and probably will for a while. Good money/hour too.

 

[GatorCHOMPions]

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.

I used to feel this way before kids, guess you still feel that way with them around. I always said if I could work 3-4 day shifts per week making EM money I could do EM until I was 65. Heck I’d even take shifts ending by 9 pm. Once you start introducing shifts ending at 11 pm, 2 am, 7 am overnights, etc. the perk of those weekdays off lose their their luster for me. Especially without proper downtime switching back and forth. Add in 50% weekends worked and it’s a clear net negative for me.

To each their own I suppose, which is my piece of advice to OP. It’s hard, but try to know yourself both in the present and then project 10-15 years and beyond from now. If you think hard about it the two time periods are likely to be very different. Assuming you’re typical med student age, we change a lot in our 20s through early 30s. Choose what is right for you now and in the future. It’s a tough task but if you’re successful at this you’ll save a lot of headaches later.

 

[miacomet]

I've managed to do EM for (!) 15 years since residency. Started out with locums, then found a unicorn job through sheer luck. There are many, many problems with my current job and with EM. Here is what worked for me:
1. I have many obligations that involve traveling overseas, so the chunks of time off were absolutely necessary.
2. I saved like crazy and could moderate-FIRE now; I live in a crazy HCOL area (as high as SF or NYC, real estate-wise) which keeps me plugging away.
3. After 10 years I cut down to 80-90 hours a month and tried to lump my shifts.

I'd still like to quit and I dread going to work- like can't sleep and anxiety. But I haven't found anything, hour for hour that works with my lifestyle.

I doubt if this path would be accessible to today's grads. If you want such a life, I'd pick IM and do hospitalist, or anesthesia or rads.

 

[namethatsmell]

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.

So this is true and I do miss this. A massive perk of EM.

Now that our family is growing, I put a decent value of having evenings/weekends/holidays free. And I get them all off to be with the fam...for better or worse lol. Also get ~2.5 months PTO per year.

But man I miss being able to go to Costco at 11am on a Wednesday and revel in the absence of the people crush.

 

[namethatsmell]

Sort of true however dont underestimate the pill mill online folks creeping into this field for online counseling, online psych meds and of course the psych NPs are rolling in there. I have spoken to PE and their main 4 fields to conquer, EM, Derm, Ophtho and psych. The guy I spoke with essentially said they can have 1 doc and then a bunch of NPs and they can coorindate care and counseling something a doc cant do.

Also lets be honest, plenty of primary care docs manage the standard depression, anxiety etc which is a lot of psych. The hardcore shizo etc often cant cash pay. Im not saying psych isn't good but there are no unturned stones anywhere when it comes to rent seekers and those who seek to siphon off as much money as possible.

The PE people I know want to conquer...ANY field where they think they can pump EBITDA before they dump the practice. I'm not surprised psych is on that list...it's a field that isn't proving easy to conquer so they see "opportunity." The PE footprint there (and in all fields) may continue to grow. But there are some major road-block for PE taking over psych.

Perhaps the biggest is that the majority of the bread and butter semi-well-to-do MDD / anxiety patients want to see a "doctor" for those issues. Why? Because psych is a fairly cerebral, nuanced field and most midlevels flying solo will not have great outcomes...and patient's who can pay cash (or have BCBS, United, etc) will vote with their feet (something patients don't really think they can do in an ED).

The other issue PE has w/psych is that luring a decent shrink to work for PE to basically just "supervise" an army of midlevels...is incredibly difficult. Why would a psychiatrist give away control of how they practice, incur a much larger swath of liability, and have to kiss the clipboard ring...when they can captain their own ship, suffer no admin fools, and make a comfortable living?

Have many med schools friends and extended family who are shrinks. They value control and being left the hell alone to do their thing...kinda the opposite of what PE offers. I only know one psych who seems solely focused on making $, and that guy does indeed supervise a posse of midlevels. But he employs them himself and makes 1-2mil most years.

The non-compliant 'caid patient with bipolar d/o? Sure a PE group can lure those patients...but is that juice worth the squeeze? PE may not likey.

 

[TheComebacKid]

The other issue PE has w/psych is that luring a decent shrink to work for PE to basically just "supervise" an army of midlevels...is incredibly difficult. Why would a psychiatrist give away control of how they practice, incur a much larger swath of liability, and have to kiss the clipboard ring...when they can captain their own ship, suffer no admin fools, and make a comfortable living?

Why would an EM doc do it? Why would an anesthesiologist do it? Why would any physician in their right mind in medicine do it? Do we all not want to limit liability, and maintain control of how we practice?

The question is moot, because it's already happened, and PE will come for everyone. The formula is simple: pay some shrinks crazy high salaries as you buy up every psych practice in the market over the course of several years. Have them supervise the midlevel army. Create a residency program to flood the market with more shrinks. Once you own every shop in town and supply exceeds demand, start cutting wages and bathe in the glory of it all for yourself and your investors. It's worked very well for the CMGs in EM.

It's not a matter of "why would a psychiatrist do it" because quite frankly they won't have a choice. Most of us in EM didn't either. Inpatient psychiatry in particular is ripe for takeover by midlevels. Outpatient as well IMO. Pay for psych midlevels is extremely competitive, hospitals are clamoring for them, not enough to go around. If I was in psych I would be really worried about the pay that psych midlevels are demanding, because it will just attract more midlevels to the field. The writing is on the wall.

 

[bravotwozero]

I've managed to do EM for (!) 15 years since residency. Started out with locums, then found a unicorn job through sheer luck. There are many, many problems with my current job and with EM. Here is what worked for me:
1. I have many obligations that involve traveling overseas, so the chunks of time off were absolutely necessary.
2. I saved like crazy and could moderate-FIRE now; I live in a crazy HCOL area (as high as SF or NYC, real estate-wise) which keeps me plugging away.
3. After 10 years I cut down to 80-90 hours a month and tried to lump my shifts.

I'd still like to quit and I dread going to work- like can't sleep and anxiety. But I haven't found anything, hour for hour that works with my lifestyle.

I doubt if this path would be accessible to today's grads. If you want such a life, I'd pick IM and do hospitalist, or anesthesia or rads.

15 years in EM is honestly plenty. I’m planning my exit in that timeframe. If someone is doing EM past their 60s, something has gone horribly wrong lol.

 

[bronx43]

Why would an EM doc do it? Why would an anesthesiologist do it? Why would any physician in their right mind in medicine do it? Do we all not want to limit liability, and maintain control of how we practice?

The question is moot, because it's already happened, and PE will come for everyone. The formula is simple: pay some shrinks crazy high salaries as you buy up every psych practice in the market over the course of several years. Have them supervise the midlevel army. Create a residency program to flood the market with more shrinks. Once you own every shop in town and supply exceeds demand, start cutting wages and bathe in the glory of it all for yourself and your investors. It's worked very well for the CMGs in EM.

It's not a matter of "why would a psychiatrist do it" because quite frankly they won't have a choice. Most of us in EM didn't either. Inpatient psychiatry in particular is ripe for takeover by midlevels. Outpatient as well IMO. Pay for psych midlevels is extremely competitive, hospitals are clamoring for them, not enough to go around. If I was in psych I would be really worried about the pay that psych midlevels are demanding, because it will just attract more midlevels to the field. The writing is on the wall.

Except psych can always just hang a shingle with minimum overhead and be full within months. It’s not really even the same as derm, which has substantially more overhead and startup cost to deter many young grads. Outpatient psych can literally be one room in a medical building and a cheap EMR (if any at all). What’s the point of even buying up psych practices? You get literally nothing for your money but a searchable google entity with 1.6/5 stars, a rented room, and some illegible scribble on paper charts.

Specialties that live by the mercy of hospitals don’t have the same luxury.

 

[Brigade4Radiant]

Psych NPs don’t practice psych that well same with PCP.

PCP issues tend to be from insurance and the smart ones dump the insurance that requires to much paper work

PCP you make your own practice you don’t have to deal with kids or OBGYN if you don’t want to

 

[RustedFox]

Psych NPs don’t practice psych that well same with PCP.

PCP issues tend to be from insurance and the smart ones dump the insurance that requires to much paper work

PCP you make your own practice you don’t have to deal with kids or OBGYN if you don’t want to

I would never deal with OBGYN.
Especially OB.
That's like, the Mecca of white magic nonsense.

 

[GassYous]

Why would an EM doc do it? Why would an anesthesiologist do it? Why would any physician in their right mind in medicine do it? Do we all not want to limit liability, and maintain control of how we practice?

The question is moot, because it's already happened, and PE will come for everyone. The formula is simple: pay some shrinks crazy high salaries as you buy up every psych practice in the market over the course of several years. Have them supervise the midlevel army. Create a residency program to flood the market with more shrinks. Once you own every shop in town and supply exceeds demand, start cutting wages and bathe in the glory of it all for yourself and your investors. It's worked very well for the CMGs in EM.

It's not a matter of "why would a psychiatrist do it" because quite frankly they won't have a choice. Most of us in EM didn't either. Inpatient psychiatry in particular is ripe for takeover by midlevels. Outpatient as well IMO. Pay for psych midlevels is extremely competitive, hospitals are clamoring for them, not enough to go around. If I was in psych I would be really worried about the pay that psych midlevels are demanding, because it will just attract more midlevels to the field. The writing is on the wall.

Eh there are a few anesthesiology practices that I know of that were taken over by pe and then somehow broke out. There's one in san jose (cep/vituity) and one in reno (napa). There was also westchester a few years back but they were academic (napa).

 

[namethatsmell]

Except psych can always just hang a shingle with minimum overhead and be full within months. It’s not really even the same as derm, which has substantially more overhead and startup cost to deter many young grads. Outpatient psych can literally be one room in a medical building and a cheap EMR (if any at all). What’s the point of even buying up psych practices? You get literally nothing for your money but a searchable google entity with 1.6/5 stars, a rented room, and some illegible scribble on paper charts.

Specialties that live by the mercy of hospitals don’t have the same luxury.

Precisely.

Why would an EM doc do it? Why would an anesthesiologist do it? Why would any physician in their right mind in medicine do it? Do we all not want to limit liability, and maintain control of how we practice?

The question is moot, because it's already happened, and PE will come for everyone. The formula is simple: pay some shrinks crazy high salaries as you buy up every psych practice in the market over the course of several years. Have them supervise the midlevel army. Create a residency program to flood the market with more shrinks. Once you own every shop in town and supply exceeds demand, start cutting wages and bathe in the glory of it all for yourself and your investors. It's worked very well for the CMGs in EM.

It's not a matter of "why would a psychiatrist do it" because quite frankly they won't have a choice. Most of us in EM didn't either. Inpatient psychiatry in particular is ripe for takeover by midlevels. Outpatient as well IMO. Pay for psych midlevels is extremely competitive, hospitals are clamoring for them, not enough to go around. If I was in psych I would be really worried about the pay that psych midlevels are demanding, because it will just attract more midlevels to the field. The writing is on the wall.

I get the sentiment as intuitively it makes sense.

If you field is dependent on the hospital, then you're correct: escaping PE can be difficult.

But with psych, the checks and balances are strongly in their favor. Barring legislative changes, there is a near 0 chance of supply exceeding demand.

And in the larger outpatient world, even if it's only PE shops all around you, you can beat them. It does take work and some years to build up a practice, but if you can offer a better product than the PE shops (no hard to do) and are willing to commit to the risk you can thrive. In the elective setting patients have options and will vote with their feet.

 

[namethatsmell]

Eh there are a few anesthesiology practices that I know of that were taken over by pe and then somehow broke out. There's one in san jose (cep/vituity) and one in reno (napa). There was also westchester a few years back but they were academic (napa).

I met a pain doc who sold his practices to PE about 9 years ago. 4 years ago he bought them back at a 25% discount.

Every time a PE healthcare acquisition goes south, an angel gets his wings.

 

[EctopicFetus]

The PE people I know want to conquer...ANY field where they think they can pump EBITDA before they dump the practice. I'm not surprised psych is on that list...it's a field that isn't proving easy to conquer so they see "opportunity." The PE footprint there (and in all fields) may continue to grow. But there are some major road-block for PE taking over psych.

Perhaps the biggest is that the majority of the bread and butter semi-well-to-do MDD / anxiety patients want to see a "doctor" for those issues. Why? Because psych is a fairly cerebral, nuanced field and most midlevels flying solo will not have great outcomes...and patient's who can pay cash (or have BCBS, United, etc) will vote with their feet (something patients don't really think they can do in an ED).

The other issue PE has w/psych is that luring a decent shrink to work for PE to basically just "supervise" an army of midlevels...is incredibly difficult. Why would a psychiatrist give away control of how they practice, incur a much larger swath of liability, and have to kiss the clipboard ring...when they can captain their own ship, suffer no admin fools, and make a comfortable living?

Have many med schools friends and extended family who are shrinks. They value control and being left the hell alone to do their thing...kinda the opposite of what PE offers. I only know one psych who seems solely focused on making $, and that guy does indeed supervise a posse of midlevels. But he employs them himself and makes 1-2mil most years.

The non-compliant 'caid patient with bipolar d/o? Sure a PE group can lure those patients...but is that juice worth the squeeze? PE may not likey.

I mean this sounds all fine and dandy but reality is there are a ton of well capitalized online psych platforms.

Online Mental Health Care That Caters to You | Cerebral

Cerebral experts can treat anxiety, depression, insomnia, and more. Learn about the care you can get today.

cerebral.com

SoftBank leads mental health startup Cerebral's $300M round, propelling valuation to $4.8B

Launched just two years ago, online mental health startup Ce | Launched just two years ago, startup Cerebral is growing rapidly, propelled by increased demand for behavioral health care services during the COVID-19 pandemic. The company banked $300 million in a series C round led by the SoftBank...

www.fiercehealthcare.com

They have raised almost $500m dollars and have a market cap similar to many cmgs (when they were public).

I don’t see psych salaries being all that impressive. Just as there are em practices that are unicorns I am sure there are similar psych practices.

ADHD Drugs Are Convenient To Get Online. Maybe Too Convenient

Backed by SoftBank and promoted by Simone Biles, Cerebral has built the fastest-growing online mental health business. Former employees say the rapid expansion comes at the expense of patient care.

www.bloomberg.com

200k paying subscribers. Keep in mind these online places are typically subscription based and np heavy.

PE pumping into cerebral and others is an example. Fwiw cerebral is worth 10x the capital they have raised.

 

[EctopicFetus]

Precisely.




I get the sentiment as intuitively it makes sense.

If you field is dependent on the hospital, then you're correct: escaping PE can be difficult.

But with psych, the checks and balances are strongly in their favor. Barring legislative changes, there is a near 0 chance of supply exceeding demand.

And in the larger outpatient world, even if it's only PE shops all around you, you can beat them. It does take work and some years to build up a practice, but if you can offer a better product than the PE shops (no hard to do) and are willing to commit to the risk you can thrive. In the elective setting patients have options and will vote with their feet.

Unless the pe shops go to the insurers and limit the panels. Sure it is cash pay but the flip side is it is ripe for telemedicine. See my prior post. I’m not gloom and doom on psych as I know very little about the true specifics but it’s not exactly sunshine and daisies over there.

 

[namethatsmell]

I mean this sounds all fine and dandy but reality is there are a ton of well capitalized online psych platforms.

Online Mental Health Care That Caters to You | Cerebral

Cerebral experts can treat anxiety, depression, insomnia, and more. Learn about the care you can get today.

cerebral.com

SoftBank leads mental health startup Cerebral's $300M round, propelling valuation to $4.8B

Launched just two years ago, online mental health startup Ce | Launched just two years ago, startup Cerebral is growing rapidly, propelled by increased demand for behavioral health care services during the COVID-19 pandemic. The company banked $300 million in a series C round led by the SoftBank...

www.fiercehealthcare.com

They have raised almost $500m dollars and have a market cap similar to many cmgs (when they were public).

I don’t see psych salaries being all that impressive. Just as there are em practices that are unicorns I am sure there are similar psych practices.

ADHD Drugs Are Convenient To Get Online. Maybe Too Convenient

Backed by SoftBank and promoted by Simone Biles, Cerebral has built the fastest-growing online mental health business. Former employees say the rapid expansion comes at the expense of patient care.

www.bloomberg.com

200k paying subscribers. Keep in mind these online places are typically subscription based and np heavy.

PE pumping into cerebral and others is an example. Fwiw cerebral is worth 10x the capital they have raised.

I think we're each getting at slightly different points which are actually compatible.

You: PE will continue to increase market share in psych.

Me: Psych has a massive supply : demand mismatch, increadibly low start-up costs, and hoards of anxious educated+high SES cash / PPO pts who won't accept a substitute for a psychiatrist. Shrinks are well positioned to control their own professional destiny.

 

[Birdstrike]

Not everyone is like you!

Yet.

 

[namethatsmell]

Unless the pe shops go to the insurers and limit the panels. Sure it is cash pay but the flip side is it is ripe for telemedicine. See my prior post. I’m not gloom and doom on psych as I know very little about the true specifics but it’s not exactly sunshine and daisies over there.

You're right, psych ain't sunshine and rainbows though I'm not sure any field is. From my n=7 of psychiatrists who I have # for (and I don't think are lying), 2 of them make more (far more) than I do in pain, another 2 make around what I make, 2 make around the average CMG EM doc in their cities but they only work ~30 hrs/wk. The last one just retired just before the pandemic at the ripe age of 52 and splits his time between his city house and his water house.

Also, unless the PE shops find a way to truly match demand (unlikely) I can't imagine an insurer would ever limit the panel when there's been an ongoing pysch insurance desert for the last few decades.

Anyway, I'll get off my soapbox about psych. It's good field, but hardly the only one.

 

[Waterlover]

People can still do EM but have a fellowship option that allows you to branch out, such as ICU, Sports, or Pain. Addiction and Palliative are other options too, however I'm not sure about pay for those two.

 

[Groove]

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?

I would most definitely NOT recommend EM and that's the honest truth. We are saturated, pay is decreasing, job security is decreasing, and the specialty is being overtaken by private equity firms. Although I have the respect of my consultants in the hospital, EM without a doubt is one of the LEAST respected specialties. Nobody views us as experts in anything, just the red headed step children that got relegated to work in the pits of the ED, where nobody else wants to work. We were en vogue for a good decade with supply/demand market forces bolstering our salary but those days are over.

If I were smart, and a bit clairvoyant?... I'd have picked psychiatry. Laugh all you want, but these guys have it made. It's also not totally uninteresting work, low stress, great longevity, relatively small foot print of pathophysiology and pharmacology to master. Outpt/inpt variety, etc.. Psych has never been viewed as a sexy specialty and is unpopular which drives up demand and keeps salary high for these peeps.

Realistically...what would I have picked? Probably gas. I almost picked gas but was scared off by the CRNA encroachment though these guys have proved to be incredibly resilient...and have adapted and thrived in spite of the current nursing blitzkrieg. Also...they've got some pretty cool and varied fellowship options for future proofing. That's my view from outside looking in but I'm sure anesthesia might see things differently. I'm also not sure I could put up with prima donna surgeons all day long. I'd probably snap a few times and get fired for unprofessional behavior.

Most similar alternate specialty? Critical Care. I doubt these guys are any more immune to burnout than we are though. Most ICU docs that I know are pretty frazzled and I get a keen sense of "burnout kinship" when I'm dealing with them.

Best practical specialty? FM without a doubt. Huge demand and much better pay than I anticipated, at least here in the SE. Probably the single specialty with the greatest variety potential. So many fellowships and so many different ways to practice. I doubt I'd get bored in FM. You could literally mix it up every 5-10 years until you retired.

 

[Franzd'Epinay]

I'm not sure how many people are in the same boat as me, but as a medical student I couldn't see myself doing anything other than EM. If I am completely honest with myself, even with the knowledge of the incoming doom, I really couldn't see myself going through 3+ years of another field's residency training.

If I had to advise someone like myself, I would tell them to still go into EM, but to have a hard look at the fellowships. Specifically, I would tell them to do elective rotations (ideally during residency) in pain, sports med, tox, addiction, and clinical informatics, as these are the main fellowships that can get them out of the ED.

On that note, I think EM as a field needs to become a lot more like IM and really emphasize the possibility of subspecializing (real subspecialties, not EM niches like ultrasound and wilderness). This will not only lead to improved satisfaction for those who leave for the subspecialties, but can also alleviate some of the oncoming surplus issues for those who stay.

 

[Drägerman]

Eh there are a few anesthesiology practices that I know of that were taken over by pe and then somehow broke out. There's one in san jose (cep/vituity) and one in reno (napa). There was also westchester a few years back but they were academic (napa).

And Minneapolis (Mednax)

 

[bronx43]

On that note, I think EM as a field needs to become a lot more like IM and really emphasize the possibility of subspecializing (real subspecialties, not EM niches like ultrasound and wilderness). This will not only lead to improved satisfaction for those who leave for the subspecialties, but can also alleviate some of the oncoming surplus issues for those who stay.

Like what fellowships? Everything is already spoken for. Not sure what sorts of services you think EM can take over.

 

[Franzd'Epinay]

Like what fellowships? Everything is already spoken for. Not sure what sorts of services you think EM can take over.

Some of them are listed in the paragraph above the one you quoted: pain, sports med, tox, addiction, and clinical informatics. The other one I didn't originally mention was crit care (only because I was speaking in the context of electives to learn about new fields, and everyone in EM already has significant ICU exposure).

I don't think EM can or will take over any of these fields, but they still may be great options for a lot of EM physicians. The point I was making is that, other than crit care, we are terribly underexposed to all the (real) subspecialties we have access to. At least in the case of sports med and pain, a real case could be made that they should be present in all EM curricula.

 

[bronx43]

Some of them are listed in the paragraph above the one you quoted: pain, sports med, tox, addiction, and clinical informatics. The other one I didn't originally mention was crit care (only because I was speaking in the context of electives to learn about new fields, and everyone in EM already has significant ICU exposure).

I don't think EM can or will take over any of these fields, but they still may be great options for a lot of EM physicians. The point I was making is that, other than crit care, we are terribly underexposed to all the (real) subspecialties we have access to. At least in the case of sports med and pain, a real case could be made that they should be present in all EM curricula.

Sure they can add it to EM curricula, but the bottle neck is the fellowship spots themselves. Pain and sports med are already competitive and have established pipelines from other specialties. So even if they added it to all EM curricula, it doesn't offer any true outlet for EM grads. The best you can do is displace a few other applicants, but even that is unlikely.

 

[Franzd'Epinay]

Sure they can add it to EM curricula, but the bottle neck is the fellowship spots themselves. Pain and sports med are already competitive and have established pipelines from other specialties. So even if they added it to all EM curricula, it doesn't offer any true outlet for EM grads. The best you can do is displace a few other applicants, but even that is unlikely.

There certainly is anti-EM (or pro-traditional-pipeline) bias in these fields. However, I do think they may be similar to crit care, where the specialties (and programs themselves) lack exposure to EM trainees; once that exposure happens, they may be more amenable to getting people in from our side. A rotation in these fields would serve to not only to expose residents to programs (and vice-versa), but to jump start networking and mentoring relationships that can certainly help with the application process.

Again, I'm not saying EM is going to take over these fields, but I do think EM residencies should show that these are viable options for trainees and help them get there.

 

[bronx43]

There certainly is anti-EM (or pro-traditional-pipeline) bias in these fields. However, I do think they may be similar to crit care, where the specialties (and programs themselves) lack exposure to EM trainees; once that exposure happens, they may be more amenable to getting people in from our side. A rotation in these fields would serve to not only to expose residents to programs (and vice-versa), but to jump start networking and mentoring relationships that can certainly help with the application process.

Again, I'm not saying EM is going to take over these fields, but I do think EM residencies should show that these are viable options for trainees and help them get there.

How many EM residents are there and how many realistic spots do you think EM will displace from other specialties' applicants for pain and sports med? Seems like a negligible percentage to be frank. And if anyone has desire to pursue pain or sports med, they should probably not do EM. This approach for EM seems to be just trying hard to fit a square peg into a round hole.
If someone is going into EM thinking about specializing in a non-EM related niche, then they haven't really thought their situation through that well.

 

[RustedFox]

Like what fellowships? Everything is already spoken for. Not sure what sorts of services you think EM can take over.

FM fellowship.

 

[VA Hopeful Dr]

FM fellowship.

I think that could work, but I doubt you'd want to do it in a way that the ABFM would want.

 

[RustedFox]

I think that could work, but I doubt you'd want to do it in a way that the ABFM would want.

Yeah, I realize it would have some wrinkles to smooth out; but the skill set would carry over in such a good fashion.

Like a, "this does not need to go to the ER, I can handle this right here and now" fashion.

Everyone wins then.

 

[Franzd'Epinay]

I think that could work, but I doubt you'd want to do it in a way that the ABFM would want.

Yeah, I realize it would have some wrinkles to smooth out; but the skill set would carry over in such a good fashion.

Like a, "this does not need to go to the ER, I can handle this right here and now" fashion.

Everyone wins then.

I wonder if people here would take the following deal from the ABFM:

"Your one-year EM-to-FM fellows can get board certified, but in return our one-year FM-to-EM fellows can too."

 

[VA Hopeful Dr]

I wonder if people here would take the following deal from the ABFM:

"Your one-year EM-to-FM fellows can get board certified, but in return our one-year FM-to-EM fellows can too."

I wouldn't. I've said before that I don't think a 1 year fellowship is enough to train FPs to be good EPs. The converse is also likely true since you can't really learn chronic disease management in a year. Not that the information is too much but 1 year doesn't give you any true chronic disease management.

 

[RustedFox]

I wouldn't. I've said before that I don't think a 1 year fellowship is enough to train FPs to be good EPs. The converse is also likely true since you can't really learn chronic disease management in a year. Not that the information is too much but 1 year doesn't give you any true chronic disease management.

Agree with this statement.
I'd be down for 1.5 years of fellowship.

I'd also trade things like OB/Peds for more intensive chronic disease mgmt.

 

[alpinism]

Yeah fellowships need to be at least be a couple years.

 

[GatorCHOMPions]

I wouldn't. I've said before that I don't think a 1 year fellowship is enough to train FPs to be good EPs. The converse is also likely true since you can't really learn chronic disease management in a year. Not that the information is too much but 1 year doesn't give you any true chronic disease management.

I’m finishing up my pain fellowship now and can confidently say 1 year is “not enough”, but nevertheless I will be set free to do as I wish this July. Most people who do the fellowship feel the same way and there are many who think that it should be its own residency. Quotes for emphasis because I bet most trainees do not feel 100% competent in their skills upon graduation no matter the residency. Medicine is so vast and each specialty is vast in its own right.

A 1 year EM to FM or FM to EM pathway would surely have its shortcomings but people would figure it out just fine.

 

[HemorrhagicShock]

I’m finishing up my pain fellowship now and can confidently say 1 year is “not enough”, but nevertheless I will be set free to do as I wish this July. Most people who do the fellowship feel the same way and there are many who think that it should be its own residency. Quotes for emphasis because I bet most trainees do not feel 100% competent in their skills upon graduation no matter the residency. Medicine is so vast and each specialty is vast in its own right.

A 1 year EM to FM or FM to EM pathway would surely have its shortcomings but people would figure it out just fine.

How is the job market looking for pain? I have a friend who recently quit pain medicine (anesthesiology as his base training) to focus on his real estate portfolio. He kept talking about how pain medicine is dead, all taken over by private equity, and the small/solo practitioner is getting destroyed by private equity and conglomeration.

When asked if it was a reasonable specialty to consider in order for me to transition out of EM, he nearly begged me to not "ruin my life" by doing so! I would be interested in your thoughts...

 

[GatorCHOMPions]

How is the job market looking for pain? I have a friend who recently quit pain medicine (anesthesiology as his base training) to focus on his real estate portfolio. He kept talking about how pain medicine is dead, all taken over by private equity, and the small/solo practitioner is getting destroyed by private equity and conglomeration.

When asked if it was a reasonable specialty to consider in order for me to transition out of EM, he nearly begged me to not "ruin my life" by doing so! I would be interested in your thoughts...

If you are geographically restricted to a major metro area it will be difficult to find a good job. I am in this situation and while I have had a few offers most of them are kind of crappy. However the EM jobs in these regions are just as bad or worse, if any exist at all. All my co-fellows have found pretty good jobs in smaller cities. Private equity doesn’t seem near the threat to Pain, at least right now, as it does to EM. The reason for Pain jobs being crappy in my experience looking in 2-3 major metro areas is because some private practice owners are greedy and know they can make a lot of profit off their employee doctors’ backs because the local market is saturated. There are also a few opioid heavy practices that offer decent money but the headaches of such a practice are not worth it to me.

 

[sloh]

How is the job market looking for pain? I have a friend who recently quit pain medicine (anesthesiology as his base training) to focus on his real estate portfolio. He kept talking about how pain medicine is dead, all taken over by private equity, and the small/solo practitioner is getting destroyed by private equity and conglomeration.

When asked if it was a reasonable specialty to consider in order for me to transition out of EM, he nearly begged me to not "ruin my life" by doing so! I would be interested in your thoughts...

Should venture over to the pain forums and read a couple threads. Job market doesn’t look too hot for pain

 

[BoardingDoc]

Should venture over to the pain forums and read a couple threads. Job market doesn’t look too hot for pain

Yeah, I follow along over there as well as I had seriously considered going into pain for a while. Many of the frequent posters are making buckets of money. The vast majority of them are in small cities or relatively rural areas. Everyone who is posting about a job in any major metro area is talking about how it's either impossible or they're getting paid crap wages. Sound familiar?

 

[sloh]

Yeah, I follow along over there as well as I had seriously considered going into pain for a while. Many of the frequent posters are making buckets of money. The vast majority of them are in small cities or relatively rural areas. Everyone who is posting about a job in any major metro area is talking about how it's either impossible or they're getting paid crap wages. Sound familiar?

Yeah I live in SoCal and know many new pain attendings getting pretty bad job offers. It's so bad that the fellowship is essentially a waste. But because of sunk cost fallacy, they still take the jobs.