Leave the USA??

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I think there should be a time limit on how long someone can work in an American ER. Kinda like how pilots have mandatory retirement age with full benefits. It seems the current system is designed to turn us into sociopaths. It's brutal, demanding and unforgiving ( lawsuits). The longer you stay working in system , the more at risk you become. I feel like somewhere around that 10yr mark is a good time to exit with some soul/empathy left.

I think ER physicians should be given the option to exit in 10yrs with full benefits. That will help the current job market and greatly improve mental health.
 
GeneralVeers said:
Yes the kid was a son of one of the daytime lab techs, so of course. Most expensive non-urgent COVID test ever!
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The test will most likely not be accepted by the Hawaii state department of health anyways, the test must come from a pre-approved lab (and that is not usually a random ER).
 
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Kryptocoin said:
I think there should be a time limit on how long someone can work in an American ER. Kinda like how pilots have mandatory retirement age with full benefits. It seems the current system is designed to turn us into sociopaths. It's brutal, demanding and unforgiving ( lawsuits). The longer you stay working in system , the more at risk you become. I feel like somewhere around that 10yr mark is a good time to exit with some soul/empathy left.

I think ER physicians should be given the option to exit in 10yrs with full benefits. That will help the current job market and greatly improve mental health.
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Lovely, but our same government couldn't even throw us a bone with regards to partial loan forgiveness during peak COVID. They literally give no F's.
 
GeneralVeers said:
To the OP

I've travelled extensively around the world, and typically go to Dubai several times a year. Your exit from the U.S. would depend on if you still want to practice clinically or not. Right now there are only two regions in the world where it's financially worth it to practice EM:

Middle East - Salary of 300-400K USD. As has been stated no taxes on the first 103K of income. Companies usually pay a housing stipend, medical/dental, as well as schooling for the children in private schools. Can negotiate other perks like a car as well. Right now only Abu Dhabi/Dubai and Oman are realistic as they offer most Western amenities without draconian laws against Westerners. You can still go to a nightclub, drink and party in the places. Would avoid Saudi given it's 11th century attitudes and general intolerance of modernity. The downside to Dubai is that it's unbearably hot between June and September to the point you can't go outside. Think Las Vegas/Phoenix temperatures but with 80% humidity. Religious Holidays like Ramadan also impose extra restrictions and you need to understand when these are. Mosts expat leave the country if they can during Ramadan. Being the hub for Emirates means you are an 8-hour flight to 2/3 of the world's destinations on the best airline in the world.

Australia - Salary of 300-450 AUD. I'd definitely move here long term if things in the U.S. continue to decay. Downside is much higher taxes (currently about 10% higher than U.S. at our salary level) and high cost of living in the big cities. Jobs are definitely available near Sydney, Brisbane, and Melbourne. There's a better overall quality of life than pretty much anywhere in the world, especially for outdoor activities. Unfortunately most jobs require 6 years or more of experience to come in as "Consultant" level or higher to earn the top salaries. Doctors are still respected here, and patients are generally more intelligent and respectful.

You mentioned South America. Brazil/Argentina/Chile are all great if you have decent nest egg. If you work clinically you are essentially volunteering your time. Great if you want to semi-retire and just do outdoors stuff or live near the beach.
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Logistically how does practice in AUS actually work? Like will they accept a US medical license and board certification? Do you have to re-board or re-train? Is it easy or difficult to get a work visa as a physician? Is there a demand for foreign physicians, or not really?
 
Fox800 said:
Lovely, but our same government couldn't even throw us a bone with regards to partial loan forgiveness during peak COVID. They literally give no F's.
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That's why we need a UNION like yesterday. This is something that pilots, police, and teachers know very well. No one gives a damn about you except those that are paid to fight for you. It's damn near hard to fire a pilot even those with alcohol or drug problems. Because they have a powerful union fighting for them. They get designated sleep time during long haul flights. And get to retire with excellent benefits.
 
The only way I would leave the USA right now would be if it involved a house on a secluded tropical beach somewhere, and me not working very hard, or at all.
 
Kryptocoin said:
...the current system is designed to turn us into sociopaths. It's brutal, demanding and unforgiving...The longer you stay working in system , the more at risk you become.
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They care as much about our burnout as a zit on a titmouse. The industry's response to the problem of EM destroying it's doctors is to just make more. It's the most smash-mouth, in-your-face response they could ever have. Burnout? Bwahaha! Not my problem. (Hurry up team, flood the job market with thousands of replacement bodies!)

"Burn 'em to the core, we'll just make more." That's their attitude.

Until we adopt their own tactics to use against them, we'll never be a match for these people.
 
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Fox800 said:
This thread has made me have an epiphany. I enjoy emergency medicine. I don’t enjoy taking care of most Americans with their “emergencies“.

I’m using that term lightly because 90% of what we see in the ER could have gone home without any kind of treatment and been fine, in exactly the same condition as when they started their day...
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Yup...and this entire thread is the reason why we are going to get paid less going forward...because no insurer will want to pay for these outrageous bills. They will either not pay or demand that a PA see someone with a scab.
 
RoyBasch said:
Logistically how does practice in AUS actually work? Like will they accept a US medical license and board certification? Do you have to re-board or re-train? Is it easy or difficult to get a work visa as a physician? Is there a demand for foreign physicians, or not really?
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They accept U.S. medical training as substantially comparable. You can become board-certified as a FACEM after a short period of supervision and possible upskilling, all of which depends on your years in practice and clinical experience. Australia may be dealing with a bit of an oversupply, as well, with predominantly rural positions the ones being advertised.

I'm hardly an expert in the market down here in NZ, let alone in Oz; I'm sure it has its own nuances, complexities, and challenges for which I'm not aware.
 
xaelia said:
They accept U.S. medical training as substantially comparable. You can become board-certified as a FACEM after a short period of supervision and possible upskilling, all of which depends on your years in practice and clinical experience. Australia may be dealing with a bit of an oversupply, as well, with predominantly rural positions the ones being advertised.

I'm hardly an expert in the market down here in NZ, let alone in Oz; I'm sure it has its own nuances, complexities, and challenges for which I'm not aware.
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The job market is completely saturated in the capital cities with locally trained FACEMs scrambling for shifts. Lots of locum work available in more rural/regional places, and the bigger locum companies sponsor visas (which can be a bigger hurdle than getting your training recognised)

I can put OP or anybody in touch with people who've made the leap across if they're seriously considering it.
 
xaelia said:
They accept U.S. medical training as substantially comparable. You can become board-certified as a FACEM after a short period of supervision and possible upskilling, all of which depends on your years in practice and clinical experience. Australia may be dealing with a bit of an oversupply, as well, with predominantly rural positions the ones being advertised.

I'm hardly an expert in the market down here in NZ, let alone in Oz; I'm sure it has its own nuances, complexities, and challenges for which I'm not aware.
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When did you start practicing in NZ? What do you think of it?
 
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RustedFox said:
sNqNi9E.png
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Omg I MUST steal this
 
haven't read the thread, but might be useful info that if the country you're moving to has reciprocal tax credit agreement with each other, you only need to pay the higher tax from one country.
 
GeneralVeers said:
I hate most of the patients. Even the normal-ish ones seem crazy to me. What is possibly going on in the lives of these average people that they have such anxiety that they have to come into the ED at 3AM for mild somatic complaints? This is not normal human behavior. When I tell my European and Aussie friends about this they are astonished. They would never think of going in for that, and would wait till morning to call their GP. Americans are crazy, and beyond hope.
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I agree with the first sentence.
 
RoyBasch said:
When did you start practicing in NZ? What do you think of it?
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10 months ago.

It's quite pleasant, as long as I don't think about the USD conversion of my salary. Oh, and if you hate Epic, just wait until the blast from the past of doing paper orders ....

I do work at one of the largest hospitals in NZ, though, so the experience is different in the rural centers scattered throughout – but, again, good and bad in different ways.
 
xaelia said:
10 months ago.

It's quite pleasant, as long as I don't think about the USD conversion of my salary. Oh, and if you hate Epic, just wait until the blast from the past of doing paper orders ....

I do work at one of the largest hospitals in NZ, though, so the experience is different in the rural centers scattered throughout – but, again, good and bad in different ways.
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You planning on staying there long term, or just a year or so?
 
xaelia said:
10 months ago.

It's quite pleasant, as long as I don't think about the USD conversion of my salary. Oh, and if you hate Epic, just wait until the blast from the past of doing paper orders ....

I do work at one of the largest hospitals in NZ, though, so the experience is different in the rural centers scattered throughout – but, again, good and bad in different ways.
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I agree with you, I know people who have gone to NZ and love it. Unbeatable country to live in if you like outdoorsy stuff. Unfortunately for me, I'd rather not work at all for that kind of salary, unless it was very limited number of days with mainly resident supervision.
 
turkeyjerky said:
You planning on staying there long term, or just a year or so?
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Earliest return 2023. Not really up to me – up to the rest of the family. Personally, I take a bit of the long view – that getting citizenship down here (5+ years) would allow us and our children (especially our children, with 70+ years ahead of them) access to USA, NZ, and Australia at their discretion, as the winds shift around the world.

GeneralVeers said:
I agree with you, I know people who have gone to NZ and love it. Unbeatable country to live in if you like outdoorsy stuff. Unfortunately for me, I'd rather not work at all for that kind of salary, unless it was very limited number of days with mainly resident supervision.
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It's nice. I'm from Oregon, and it's kind of like living in Oregon ... if Oregon were its own country out on an island. I tell people Christchurch is sort of as if Victoria BC and Bend OR had a baby.

Each workplace has its own unique set-up, shift schedule, compensation scheme etc. So far, I've pretty much worked an average of 8 shifts per month with 2 of those being a weekend. The core clinical commitment is higher than that, but I chip away a couple shifts each month with a day of leave here and there. I also have about *7 weeks* of annual, holiday, and CME leave I've not even yet touched.

On shift, the typical staffing is as part of a team of 3 consultants supervising about ~10 house staff, fellows and CNSs (basically, NPs) covering about 330 visits a day. I cherry-pick 4 to 6 interesting or quick cases during a shift, work with the senior nurses on flow, and try to keep the juniors from getting derailed. There are three consultant shifts: 8a-5p, 4p-12a, and 12:30p-9:30p "front of house". I take "call" from home about once a month, and I've been called to come in once (GSW chest). In addition, we're expected to work ~9 hours per week on "non-clinical" duties, meaning meetings, committees, etc. + your own professional development time. Everyone has their unique niche; I do a little resource stewardship oversight, some IT work, and liaise with a couple different specialties, plus consider my academic work (podcasts, journals, social media) as part of those hours.

I take home about NZD$5500 fortnightly after taxes and retirement contributions. There's usually opportunities to snipe extra hours for time+0.5 or time+0.9 for extra money, but my kids are young and high-maintenance, and my wife is also working full-time, so we don't need to do that. I think of it like a low-stress academic job from the U.S., and it feels not unfairly compensated.
 
Anyone know anything about working EM in Ireland? I have a EU member nation passport (not Irish) in addition to my US citizenship (if that makes things easier).

When I save up enough money and the kids are out of high school, it might be fun to phase out of medicine by spending a few years in Ireland. I don’t speak any other languages so I figure I’d be limited to English speaking countries if taking advantage of my EU citizenship. AUS/ NZ would be awesome, but they’re just so far away.
 
xaelia said:
I take home about NZD$5500 fortnightly after taxes and retirement contributions. There's usually opportunities to snipe extra hours for time+0.5 or time+0.9 for extra money, but my kids are young and high-maintenance, and my wife is also working full-time, so we don't need to do that. I think of it like a low-stress academic job from the U.S., and it feels not unfairly compensated.
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In case anyone else was wondering about the conversion:
$5500 NZD fortnightly after tax and retirement = 143k NZD = 99.1K USD annually

99.1k USD post tax is the same as ~135k pretax, assuming you live in a state without income tax. It's 145k-155k in states w/ income tax depending on the state.

8 shifts/mo @9 hrs a shift --> 72 hrs a month, + ~36 hrs of academic time = 108hrs/mo = 1296 hrs/yr

I don't know how the 7 weeks of "leave" works with shift work. Does that mean you have banked 49 days that you get paid for? Does it only mean if you're scheduled for 2 shifts in a week and you take that week off, just those 2 shifts are covered? Lots of possibilities.

Assuming it means 49 full paid days of work off, that drops the annual hours down to 1296 - (9*49) = 826 hrs/yr

So on the high end, with some very favorable assumptions, this job is equivalent to 155k pretax USD / 826 hrs = $187 USD/hr + benefits.
 
BoardingDoc said:
In case anyone else was wondering about the conversion:
$5500 NZD fortnightly after tax and retirement = 143k NZD = 99.1K USD annually

99.1k USD post tax is the same as ~135k pretax, assuming you live in a state without income tax. It's 145k-155k in states w/ income tax depending on the state.

8 shifts/mo @9 hrs a shift --> 72 hrs a month, + ~36 hrs of academic time = 108hrs/mo = 1296 hrs/yr

I don't know how the 7 weeks of "leave" works with shift work. Does that mean you have banked 49 days that you get paid for? Does it only mean if you're scheduled for 2 shifts in a week and you take that week off, just those 2 shifts are covered? Lots of possibilities.

Assuming it means 49 full paid days of work off, that drops the annual hours down to 1296 - (9*49) = 826 hrs/yr

So on the high end, with some very favorable assumptions, this job is equivalent to 155k pretax USD / 826 hrs = $187 USD/hr + benefits.
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Not bad for never working overnight (past midnight or so) and having a fairly leisurely shift. You can make $187/hr in the US in Southern California/Chicago/etc getting killed with corporate metrics, CMG nonsense, and being stressed as all hell.
 
BoardingDoc said:
I don't know how the 7 weeks of "leave" works with shift work. Does that mean you have banked 49 days that you get paid for? Does it only mean if you're scheduled for 2 shifts in a week and you take that week off, just those 2 shifts are covered? Lots of possibilities.
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Leave is ... complex ....

I started trying to explain how it worked, but it's 1) too messy 2) probably not generalizable. The short version is: if you take a big chunk, you also have to apply leave to the non-clinical hours of your FTE, as well as some other fractions of shifts. Accumulated leave can also be cashed out, yet another complexity.

In all, it's definitely not a bad short-term gig, and long-term depends on many other factors.
 
GeneralVeers said:
Mainly salary. Right now I'm in a job that pays fantastically at $300+ per hour. Should that decrease to national norms, which I expect to happen soon, then I either retire from medicine, or jump ship to another country. I may move anyway even if retired due to the unstable tax/political environment in the U.S.
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How did you pull off a >$300/hr job? Are partnered in a SDG? Pumping through patients and getting tons of RVUs with a CMG? Or do you have a pill mill on the side?
 
Sushirolls said:
I've had consults where I spent 90 minutes of my time digging for any pathology and finally the patient states they just want an ESA letter so they can take take their pet into hotels while they vacation (no mental health diagnosis, and no letter provided).
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Just go to Certapet.com for an ESA (but an ESA still won't get you into a hotel on vacation, you're need a legit service dog... which certapet can also handle).

Don't ask me how I know.
 
MechEDoc said:
How did you pull off a >$300/hr job? Are partnered in a SDG? Pumping through patients and getting tons of RVUs with a CMG? Or do you have a pill mill on the side?
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It's a Dinosaur job. A long time ago an SDG partnered with a CMG to do HR and billing. As a result they still get most of the collections under the agreement. Unfortunately as time has gone on the CMG has gotten more and more control over the contract, including forcing a residency on us. It's only a matter of time until the CMG Asteroid hits and the Dinosaur is wiped out. I'm prepping my spaceship to escape the planet before the calamity.
 
GeneralVeers said:
It's a Dinosaur job. A long time ago an SDG partnered with a CMG to do HR and billing. As a result they still get most of the collections under the agreement. Unfortunately as time has gone on the CMG has gotten more and more control over the contract, including forcing a residency on us. It's only a matter of time until the CMG Asteroid hits and the Dinosaur is wiped out. I'm prepping my spaceship to escape the planet before the calamity.
Click to expand...

Abilene?
 
xaelia said:
Earliest return 2023. Not really up to me – up to the rest of the family. Personally, I take a bit of the long view – that getting citizenship down here (5+ years) would allow us and our children (especially our children, with 70+ years ahead of them) access to USA, NZ, and Australia at their discretion, as the winds shift around the world.


It's nice. I'm from Oregon, and it's kind of like living in Oregon ... if Oregon were its own country out on an island. I tell people Christchurch is sort of as if Victoria BC and Bend OR had a baby.

Each workplace has its own unique set-up, shift schedule, compensation scheme etc. So far, I've pretty much worked an average of 8 shifts per month with 2 of those being a weekend. The core clinical commitment is higher than that, but I chip away a couple shifts each month with a day of leave here and there. I also have about *7 weeks* of annual, holiday, and CME leave I've not even yet touched.

On shift, the typical staffing is as part of a team of 3 consultants supervising about ~10 house staff, fellows and CNSs (basically, NPs) covering about 330 visits a day. I cherry-pick 4 to 6 interesting or quick cases during a shift, work with the senior nurses on flow, and try to keep the juniors from getting derailed. There are three consultant shifts: 8a-5p, 4p-12a, and 12:30p-9:30p "front of house". I take "call" from home about once a month, and I've been called to come in once (GSW chest). In addition, we're expected to work ~9 hours per week on "non-clinical" duties, meaning meetings, committees, etc. + your own professional development time. Everyone has their unique niche; I do a little resource stewardship oversight, some IT work, and liaise with a couple different specialties, plus consider my academic work (podcasts, journals, social media) as part of those hours.

I take home about NZD$5500 fortnightly after taxes and retirement contributions. There's usually opportunities to snipe extra hours for time+0.5 or time+0.9 for extra money, but my kids are young and high-maintenance, and my wife is also working full-time, so we don't need to do that. I think of it like a low-stress academic job from the U.S., and it feels not unfairly compensated.
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Sounds pretty low key/nice.

Did you move to NZ specifically for better ER work environment, or was it your spouses job or some other pressure?

Anyways, sounds like it's working out well.
 
RoyBasch said:
Sounds pretty low key/nice.

Did you move to NZ specifically for better ER work environment, or was it your spouses job or some other pressure?

Anyways, sounds like it's working out well.
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My wife saw the writing on the wall re: interminable school closures etc. last March.

I was already looking for a new job.

Had talked about NZ before.

Just one of those confluences of events crystallising a potential path forward.
 
xaelia said:
Not typically. A team lead by a senior registrar (basically ... PGY-5? 6?) covers. One of the medical officers (FACEM, but doing a fellowship) is in the ED until 2am, as well.
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That’s great. If EM was like that here, I might still be doing it.
 
Birdstrike said:
That’s great. If EM was like that here, I might still be doing it.
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There is no question it's not *quite* the same as U.S. academic ED where there's always an ABEM physician on the floor providing direct supervision – let alone community ED.

But, for what unusual presentations or ideal management might be missed, I will say we probably do a lot less iatrogenic harm here from over-treatment (opioids, especially) ....
 
I wouldn't leave the US to *practice* elsewhere, but definitely plan to FIRE ASAP, put most in an index, some in high IV growth plays, then retire, sell options for play money and travel abroad and domestically with an airbnb-type home base since I love where I live now.. should happen worse case scenario about 11 years after I graduated residency, sooner if investments pay-off. I actually genuinely like EM for the interesting people you meet, ortho reductions, cardioverting as many pts as possible, etc and will probably have some ER withdrawal post retirement but ultimately it's just not a healthy lifestyle and while compensation is fair (at my shop at least) the job takes more than it gives. It's nice helping people but it's also nice being financially independent, doing whatever tf you want and focusing on something other than the miserable inevitability of mortality.

Life is short.
 
You're not alone in wanting to leave. The idea of FIRE is a great one, and setting a concrete goal and timeline to financial freedom can help you motivated.

But if you can't wait that long, there are actually a number of countries where you can practice with American credentials. EM is a bit of a newer specialty, and isn't recognized in all countries, but Australia, New Zealand, the UAE tend to be viable possibilities, and doing telemedicine from abroad for some of the companies that allow it is also possible. Might be worth looking through here -
www.hippocraticadventures.com

Where Can American Doctors Practice Abroad?

We are a community of American-trained physicians who dream of practicing medicine all over the world. See where your white coat can take you!
www.hippocraticadventures.com www.hippocraticadventures.com
 
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