Is this realistic?
Started by InnocentMedicalStudent
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Implementing this wouldn't be up to me or you. It would be up to the younger generation to save EM, if they think it's savable and worth saving. I made my decision that it was best for me and my family to leave EM, rather than to be a martyr in the cause of fixing EM. It may not be fixable. But if it is, it requires a greater man than I.
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From an admin standpoint I worry that will happen
but when it's rebuilt, I warn you all of the hubris that congress, TeamHealth, and even the common patient will care if they see a doctor or an NP
the almighty dollar decides all
and doctors are expensive
I think this thread touches on multiple issues with EM-
*PTSD / Trauma
*Circadian flips
*Being held responsible with little power to fix issues
*Increased movement towards widget economics and attention on moving meat / operations with only a fake word spoken about “quality” (the quality that affect reimbursement).
*Focus on patient satisfaction regardless of root causes
*lack of ownership
*weekends and holidays
*flight of on-call specialists from many hospitals
*hospitals purposeful operating at 98% capacity with expected downstream
Boarding issues.
*adrenaline fatigue / “always on” can’t turn off Stress.
With a population of ED MDs who (I postulate) are more likely than average to have anxiety, ADHD, cynical tendencies, and even possibly underdiagnosed depression / substance use issues.
Are we shocked there is a burnout epidemic? 😆
My own theory is than many people are rather immune to some of the above stimuli. And conversely many people are more sensitive to certain ones. So in some cases fixing out of work issues (depression? Divorce?) and modifying work (avoid nights, avoid toxic satisfaction culture) make a reasonable length career in EM something that can be achieved…
I also think it starts to systemically select for people willing to punch a clock, not actually give a **** about patient care, and robot their way through some clicks to get a reward (cash). The en****ification of EM, just click the sepsis button when 2 SIRS criteria are met, and discharge that ankle sprain with #10 perce and a work note.
*PTSD / Trauma
*Circadian flips
*Being held responsible with little power to fix issues
*Increased movement towards widget economics and attention on moving meat / operations with only a fake word spoken about “quality” (the quality that affect reimbursement).
*Focus on patient satisfaction regardless of root causes
*lack of ownership
*weekends and holidays
*flight of on-call specialists from many hospitals
*hospitals purposeful operating at 98% capacity with expected downstream
Boarding issues.
*adrenaline fatigue / “always on” can’t turn off Stress.
With a population of ED MDs who (I postulate) are more likely than average to have anxiety, ADHD, cynical tendencies, and even possibly underdiagnosed depression / substance use issues.
Are we shocked there is a burnout epidemic? 😆
My own theory is than many people are rather immune to some of the above stimuli. And conversely many people are more sensitive to certain ones. So in some cases fixing out of work issues (depression? Divorce?) and modifying work (avoid nights, avoid toxic satisfaction culture) make a reasonable length career in EM something that can be achieved…
I also think it starts to systemically select for people willing to punch a clock, not actually give a **** about patient care, and robot their way through some clicks to get a reward (cash). The en****ification of EM, just click the sepsis button when 2 SIRS criteria are met, and discharge that ankle sprain with #10 perce and a work note.
I know that's a cush schedule. Like...I KNOW it.
...but I can't keep looking at that part. You also said those CD words which give me PTSD.
I got into... early retirement! Went backpacking in Costa Rica, then got a puppy and started dedicating my (daytime only) waking hours to doing things I enjoy with people whose company I enjoy -- or with my (now two) dogs, or just alone. People often ask if I'm bored, what I do with all my time, etc. It's been almost 7 years now, and I'm never bored.
Dude that's awesome. You're my hero. Do you mind giving any more details about where you were at with FIRE ballpark when you pulled the trigger? How have you been invested since then and are you happy with retirement position? Flat, growth, decrease? Do you mind telling us how you are invested and do you let someone else manage that or do you manage it yourself? Any future plans for work? Any back up plan? (I.E. telemedicine if you need some extra cash, etc..)
Is this something you decided near your retirement, or did you plan for it all along?
If you've answered all this stuff before, just link me to the post. I'm completely fascinated and in awe.
Dudette here. 🙂 Thanks, but it's not as impressive as it might seem. Note I said "backpacking in Costa Rica," not "flying first class to New Zealand." (But I'm not living in a van down by the river. Just living like most people, who can "afford anything (within reason), but not everything.")
I might have answered this before, but I don't remember, and I can't be bothered to do a search for it! I don't think I ever loved the job once I learned what it really involved. Some aspects of it, yes, but there were enough negatives that overall it was a negative. But I figured very few people love their job anyway, and at least this one paid well. Then I learned about FIRE in 2015 (5 years post-residency), had some hope for a new path, and started seriously trimming down my budget. Got married in 2017 but kept our finances separate, reached LeanFIRE in 2019 (without factoring in spouse's $) and quit working, combined finances with husband a year or two later and have considered us CoastFIRE together since then. He'll probably retire in about 5 years (non-medical career, decent income but nothing crazy).
I had a financial advisor years ago, but I quickly realized he wasn't doing anything I couldn't do myself, plus he was costing me a lot. I had an accountant when I was working, but now I just do it all myself. Investments are all at Vanguard, emergency fund is at Ally, and taxes are easy since our only income is a W2. Dr. Jim Dahle of the White Coat Investor hasn't steered me wrong yet! The market has done really well since I retired, but fortunately we haven't needed to touch our investments. We keep a healthy emergency fund and a handful of "sinking funds" for things like home repair, vehicle replacement, etc. I'm pretty financially conservative, but even I don't feel like I need more of a backup plan. I can't imagine anyone hiring me after being out for this long anyway!
Badass! Thanks for sharing. That will no doubt be a very useful post for other docs considering the same path so thanks for taking the time to share the details. I can imagine how petrifying that would be making a decision with that magnitude at a young age, early in your medical career. Petrifying but probably equally liberating. Congrats!
I’ve said this here before as well. Going down to 6-8 shifts didn’t help with my dread. And for all intents and purposes, that should be an amazing schedule to anyone looking from the outside in. But it wasn’t.
InnocentMedicalStudent
Full Member
what do you think is the minimum amount of shifts that most places would still give you benifits?
Every employer can be different. A lot of retirement plans have a set minimum number of hours to participate but they have some more leeway in other benefits. I don’t think too many employers would be offering full benefits for part timers. Many part timers are likely to be 1099 and not W2.
I've seen plenty of shops, including the one I left, offer benefits as low as 0.5 FTE. Things like insurance/etc necessarily cost MORE, but they are still at least offered. I worked 0.75 FTE nights my last year of attending with a moderate bump in cost of benefits but still had all offerings of 1.0. It was also offered at 0.5 for a price increase.
If you find a good SDG it can be very little. it would be about 60 clinical hours a month for my group for a partner.
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My guess is that somebody asking what the absolute minimum they can work to get benefits at this point likely doesn’t have a partner mindset. Now, if it were someone that had already been a partner for 15-20 years then I get that.
Bittersteel
Full Member
The problem with EM is that the work and everything surrounding it, sucks azz. You can do everything right and still catch shyt because some divorced nurse had a bad tinder date last night or some druggy didnt get their narcs or some validation seeker didnt get their dollar menu requests. Its trash. The only upside is a possible gateway to early retirement.
InnocentMedicalStudent
Full Member
what about urgent care telemed?
Personally, I’d go crazy just sitting at a computer prescribing z-packs and medrol dose packs all day.
Bittersteel
Full Member
I'd rather work at Walmart.
Ugh. Target, at least!
InnocentMedicalStudent
Full Member
can you atleast set up your own hours reliably working an ethical job? I heard that UC telemed is kinda shady in the sense that you're just prescribing whatever to whomever which is not something I will ever do. But if you are doing clinically relevant work that improves society then its something that I could consider
Yeah...that's not how UC works if you want to keep the patients coming.
There are a lot of expectations in medicine to do what the patient wants and you just act like a middle man. Urgent cares are prime examples of this. Emergency medicine has this component to it as well.
Bittersteel
Full Member
I'd rather the patient just pick what they want from an iPad in the room and ill sign the orders and write the chart. At least we could skip the part where j have to talk to them.
Bittersteel
Full Member
Agree. I chose the short sighted path of easy residency instead of having grit and going into a field where you can actually do something. And now like most here I'm in a race for the exit.
Waffle House. I want tips.
You gotta be a fighter for that
I'd rather go back to pushing carts at Meijers
Kids these days have machines that push carts for them
lazy
I figure if I’m the line cook I’m not a front line fighter. Plus I feel well trained for it!
I'll put it behind a spoiler tag.
When I was working in South Carolina, there was a patient that was all cluster B. There was one doc that had to see her with a nurse chaperone, and, even so, one day, as my colleague exited the room, along with the nurse, the patient called 911 from the ED, saying the doc had sexually assaulted her. Anyways, when this pt was working at a Waffle House, she threw up on the flat top, and her puke cooked on it like it was made to be there!
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lol.
I’ve had 4 patients call 9-1-1 on me in my career.
Oddly all 4 times THEY ended up arrested 🤷♂️
IM nocturnist x10 years here.
Honestly the most naive part of your plan nobody seemed to touch upon is the plan to save 85% of your money. I hope you meant net not gross- because surely you understand that even in the most tax friendly states your best case take home is 60-70% of your gross.
10-15% saving is average. 20% is very good. 25-30% is aggressive. 50% is something even the leanest of FIREers usually can't sustain for long.
Even if you truly live like a resident on 60k a year, that's another 20% of your gross. Financial forums will cerebrally masturbate about lifestyle creep, but so much of isn't boats and sports cars. It's normal adulting things you just deferred for a decade. It's a decent home, a safe car, seeing the world a little bit, a nice restaurant every week, high quality groceries. If you're lucky, you're blessed with more mouths to feed, a daycare bill, 529s to fund. Unless youre planning on being a bachelor sharing an apartment and eating ramen-saving over 50% is incredibly challenging.
That's without even considering any student loans.
I started my career working 1.2-1.4 FTEs and moonlighting on top of that closer to 1.75 FTEs. With bonuses, I was making significantly more than 90% of EM docs. 5-7 years ago, I was definitely the one adamantly screaming i can work nights forever. Now with toddlers and pushing 40, I'm actively looking for a way out. I started looking at switching to swing shifts in the afternoon, but those jobs don't seem to open until someone dies. At my hospital, 0.5 fte is the minimum for benefits and so that's probably where I'm heading in 2-3 years when my primary home is paid off and kids are out of daycare.
It took me 10 years of jumping on every extra shift to get to a point where I can seriously consider cutting down or even retiring early in next 5 years. Your early years are for hustling and learning your craft, not for thinking about how to work the least possible before you've even started.
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Do you find nights much less tolerable now? Can you expand on that? I think your perspective would be very helpful because hospitalist night shifts tend to be less chaotic than EM shifts, and if it's taking a significant toll on you, that's something to be said for nights in general.
Not to be pedantic, but it’s the other way around. Say you make $1M gross, pay $350k taxes, and save $500k. You saved 50% gross and 77% net. But yes, basically impossible to hit 85% gross, but maybe possible net. Living on $60k at 85% savings would take $400k net, so maybe a little over $600k in a median tax state for gross.
I do eyes so as to not work nights, so I’ll let you folks keep cooking.
Yes thank you-i'm on 4 hours of sleep today and was juggling keeping my toddlers alive at the beach and typing as you beat me to editing it!
But yes I can see alot of med students think "if I can make 500k, live off of 75k, and save 425k then I can have 1.3M invested by mid 30s and then coast to retirement.
That's just about as naive as it gets. Even grossing 500k (which the average specialist is far from) and net 300-350k- almost nobody can actually sustain saving say 250k. Honestly 100k saved would be commendable. With compounding means one's realistically 5-7 years away from being a millionaire and 10-15 from coasting/realistic thoughts of early retirement. Again that's assuming base case scenario with no wet blankets weighing you down like hundreds of thousands in student loans, private schools, medical bills, divorce etc.
For sure.
In my early 30s i would do 10-14 nights in a row and have the rest of the month off to travel abroad every month, still make my hospital's 990 as the top 5 highest paid employee, and i thought that was about as good as life gets. Some of those nights I was taking on extra work after my 12 hour shifts. I didn't care if I was working 15 or 18 hours; all I cared about was squeezing every last $ out of every day I had to be in the hospital.
Now I get really crusty after 3 in a row. More than 5 I would gets very unpleasant and 7 or more honestly gets unsafe.
Much of it has to do with having kids. When I was single I could mold the world to my lifestyle. I could sleep in, play with time zones to my advantage, work as many in a row as I could to minimize transition days. Now I can't just go to sleep as soon as I get home or wake up a half hour before my shift. Best case scenario I get home by 8, drop them off at daycare by 845 and get to bed by 930. Then I need to be up by 5p for pickup and get ready for my shift. Don't get me wrong, it's by all means awesome to be able to be there for every pick up, drop off, dinner, and some of bed time (which wouldn't be the case if I worked 7a-7p), and overnights can work well really well for alot of new parents. But now a days there's no way around being a square peg in a round hole.
Then comes the final realization that each night is really, honestly, equivalent to 2 days. I fought this concept mentally really hard until there was no denying it. My logic told me if I worked 10 nights a month, I get 20 whole days off. What a sick arrangement! Who else gets 20 days off a month?! That just completely ignores pre shift sleep and post shift recovery.
Say I want to take my kids to the zoo on Saturday. Every other person in the world could work a friday day and do that. Me? I need to request Friday AND Saturday off. If I work only Friday night I gotta sleep through Saturday. If I work Saturday night, I gotta nap by noon to get ready for my shift. As my scheduler has gotten more strict about time off requests through the years, I need to be much more thoughtful and careful about which days off I'm going to ask for to be there for my kids.
Lastly there's the undeniable physical manifestations. No matter how well I arrange my shifts or how good I sleep, when 3 or 4am rolls in I still get what my colleagues and I fondly refer to as the 4am brain-worms. You get nauseous, jetlagged, your processing and decision making get foggy. When i started 10 years ago i recall zero awareness or talk of the long term health impacts of night shift work. In the last 3-5 years the data has been mounting and awareness has really been raised. I sleep reasonably well, but I have to take sleeping pills many nights to achieve this. I try to exercise before every shift and eat as well as I can, but I recognize those take much more effort and will power to stay consistent with working nights.
I still don't necessarily regret it. To me the downsides still outweigh rounding, having to deal with clip board admins, satisfaction metrics, case managers, discharge planning. It still allowed me to become wealthier in my 30s than many docs ever will be.
But while I used to think i could do this forever (one colleague is pushing 60 and has done it for 25 years), now I understand it's a young man's game. It's a tool to significantly expedite wealth building while working on your exit plan. And it's certainly not for starting at 0.5 FTEs and thinking somehow you'll fire 3-5 years later.
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Have a couple friends that do some version of this via locums. One does 6 in a row followed by 6 weeks off but she’s an Olympian with a whole life seperate from EM.
I have another friend who will locums fly in, do 7 nights, have a day off, then do 7 more nights then take 2-4 weeks off. Idk how he does it but he seems genuinely happy up until around shift #11.
Im EM/CCM - with CCM I can easily do 14 in a row and my record is 21 in a row. For me with EM after night #5 I’m ready to drive off a cliff.
I have another friend who will locums fly in, do 7 nights, have a day off, then do 7 more nights then take 2-4 weeks off. Idk how he does it but he seems genuinely happy up until around shift #11.
Im EM/CCM - with CCM I can easily do 14 in a row and my record is 21 in a row. For me with EM after night #5 I’m ready to drive off a cliff.
Bittersteel
Full Member
Sustainability is possible in other fields Ike CCM because you can (usually) focus on one situation at a time and theres downtime where your neurons aren't constantly being fried. Unlike in EM where your attention is pulled in 17 directions at once, usually for nonsense, or to placate some nurse who can't figure it out herself.
CCM is probably the ideal setup for 7-14 in a row. Most ICU patients are 🪨 s. I remember from my rotations it'd take me 2-3 days to feel comfortable with the list and then it was on cruise control rest of the week. It was a lot of babysitting with small incremental changes and a couple new admits a day. Little to no discharge planning- if they could cross their legs they can go to the floor. A code every couple days to keep things exciting but that's about it. Some of the most competent nurses in the world who can pretty much manage their own patients and only bother you for real stuff. Rounds took 30-40 minutes for 12 bed icu. If youre daytime, rest of the day was procedures or family updates. Night time was 100% Netflix or sleep between admits and codes. If I were CCM I would honestly not do any less than 7 in a row.
Bittersteel
Full Member
Working with competent nurses must be nice. Most of the useless ones I work with can't be bothered with independent thought or action and therefore run to the attending for everything.
This is why I advocate for CCM for anyone who’s a bit too overcooked with EM. Still get to do the fun resuscitating that is at the heart of EM. You still “move the meat” but in a much more linear way - balancing admits, downgrades, and hospices.
My usual day is busy from 7am-12pm. Then rounds are done, plans are made, notes are short and largely copied forward except for a brief blurb for what I did that day. I do any procedures that need done (in an ICU even intubation can sometimes be left until after lunch if it’s a slow fail).
It’s like playing medical chess. You make a move, set your day up, and then circle back in 6/12/24 hours to see if the move worked and decide what’s next.
My usual day is busy from 7am-12pm. Then rounds are done, plans are made, notes are short and largely copied forward except for a brief blurb for what I did that day. I do any procedures that need done (in an ICU even intubation can sometimes be left until after lunch if it’s a slow fail).
It’s like playing medical chess. You make a move, set your day up, and then circle back in 6/12/24 hours to see if the move worked and decide what’s next.
Bittersteel
Full Member
Practicing at the bottom of her license I see.
At least she isn't actively trying to kill your patients
A truly regarded nurse once gave a patient 4 mg of ativan IV for an invented CIWA score and I was called to the room for an unresponsive patient. totally apneic, sent to our tertiary care place for hepatology consult for elevated LFT's but absolutely not in withdrawal when I interviewed him earlier, no history of withdrawal, no ****ing reason at all to medicate him beyond whatever CIWA she came up with and nearly murdered him
Then when I wanted to give flumazenil (for second time ever) pharmcist was up my ass about seizure risk, despite no previous benzo use ever, no seizure history and not in withdrawal. I politely told everyone STFU and he immediately woke up breathing on his own, wondering why I was bagging his face
my hand sweats telling that story
I ****ing hated my time in the pit
A truly regarded nurse once gave a patient 4 mg of ativan IV for an invented CIWA score and I was called to the room for an unresponsive patient. totally apneic, sent to our tertiary care place for hepatology consult for elevated LFT's but absolutely not in withdrawal when I interviewed him earlier, no history of withdrawal, no ****ing reason at all to medicate him beyond whatever CIWA she came up with and nearly murdered him
Then when I wanted to give flumazenil (for second time ever) pharmcist was up my ass about seizure risk, despite no previous benzo use ever, no seizure history and not in withdrawal. I politely told everyone STFU and he immediately woke up breathing on his own, wondering why I was bagging his face
my hand sweats telling that story
I ****ing hated my time in the pit
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I've had this thought where I want a hologram version of me to go and entertain patients with their nonsense while I eff off and actually get important things done.
Bittersteel
Full Member
"Please state the nature of the medical emergency."
Bittersteel
Full Member
Highly regarded.
I mean it will help you succeed on the AHA get with the guidelines stroke rankings! Never will miss an nihss!
Also useless.
I dunno man. It seems like I hear code blues with extreme regularity in the ICU and on the med/surg floors that you guys respond to in my hospital. The one thing I've been jealous of is the increasing frequency of APC staffing at night. Most of the pulm/cc groups in my area work zero nights and have all the units staffed with MLPs who actually seem very well trained. I'm sure the pace is more regimented and slower than the ED of course but I doubt I'd want all those critical patients all day long and the daily vent weaning.
Plus, the phrase "fun resuscitation" meant completely different things to me early in my career vs now. Other day, I had barely gotten to work, sipping my coffee, at 6am before a 51 yo arrest was called in from the radio 5 mins out. Exciting 3-5 years out? Sure. Exciting now? Absolutely not.
