Leaving EM

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I have the utmost respect for nocturnists. I tried it for 3 months (with kids) and it just about killed me. I would have quit EM if I was forced to do nights.
Nights destroy me in a way that would shock my past self in medical school/residency. I have a rare month next month where I’m doing 3 in a row and I’m already dreading it. The circadian switching is NOTHING to me compared to how bad night shifts make me feel.
 
Nights destroy me in a way that would shock my past self in medical school/residency. I have a rare month next month where I’m doing 3 in a row and I’m already dreading it. The circadian switching is NOTHING to me compared to how bad night shifts make me feel.

Nights are terrible.

There's nothing like that pre-night shift dread that starts kicking in 5 hours before a shift.
 
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You're already coast fire.

You already did the hard part by becoming an SDG partner. Don't listen to the advice telling you to be some hospital employed cog doing this or that.

Buckle in, grind for another 4 years, put everything into VTI, become true fire and walk away completely.
It’ll take more than 4 years to get to completely financially independent with his current lifestyle and net worth. He needs $4million to be FI if he is 60 years old. Generally you want to give yourself a bit more of a buffer if you’re retiring at 45 instead. $6million would be my minimum target if my annual spend rate was $200k/yr and I was trying to retire under 50.

With a current net worth of $1.2 million and assuming the upper end of spend rate, and we’ll assume $450k pre-tax annual take home and the entirety of the remainder of his take home after taxes and living expenses is placed into VTI with an average real annual return of around 7%, it’ll take him 10 years to get to $4 million and 14 years to get to $6million in 2026 dollars.

At the end of 4 years, he’d still only be at $2.2 million. Hes not getting to FI in 4 years unless he’s making over a $million pre-tax/yr and saving $500k of his take home annually and that’d still only get him to the $4million mark, which ain’t happening.
 
I've not done a night shift in 6 years – consultants don't work overnight in most AUS/NZ hospitals. Considering how ruined my next day becomes with a 4p-12a shift, I don't even want to think about an overnight or string of overnights ....

are all US residency trained docs essentially starting at the level of a consultant or do you have to climb up the ladder all over again?

Also…. Why is someone not better off working 4-5 shifts in the US and then making 150k vs working a full schedule in Nz and then making 150k?
 
It’ll take more than 4 years to get to completely financially independent with his current lifestyle and net worth. He needs $4million to be FI if he is 60 years old. Generally you want to give yourself a bit more of a buffer if you’re retiring at 45 instead. $6million would be my minimum target if my annual spend rate was $200k/yr and I was trying to retire under 50.

With a current net worth of $1.2 million and assuming the upper end of spend rate, and we’ll assume $450k pre-tax annual take home and the entirety of the remainder of his take home after taxes and living expenses is placed into VTI with an average real annual return of around 7%, it’ll take him 10 years to get to $4 million and 14 years to get to $6million in 2026 dollars.

At the end of 4 years, he’d still only be at $2.2 million. Hes not getting to FI in 4 years unless he’s making over a $million pre-tax/yr and saving $500k of his take home annually and that’d still only get him to the $4million mark, which ain’t happening.

Annual spend of 200k is insane. Especially without kids. Decrease spending.
 
Do you find the chronic pain patients exhausting or do you just do procedures?
Some of the patients can be challenging but that challenge is on balance much less than the challenges of EM. I don't only do procedures, but procedures are half of my time. I have gotten to the point where I'm busy enough at my current job that I no longer accept new medication management patients. All new patients are procedure only, which is great. Of the patients I have on oral opiates, they're low dose and heavily screened by me before accepting. They are compliant and have been my patients for a long time.

Like any job there are pros and cons, but the pros greatly outweigh the cons (at least for me) compared to Emergency Medicine. If I could have done EM 9-5 Mon - Friday with no interference from Administrators I never would have left. But that job doesn't exist. Pain has worked out for me and I'm very happy with my current situation.
 
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are all US residency trained docs essentially starting at the level of a consultant or do you have to climb up the ladder all over again?

Also…. Why is someone not better off working 4-5 shifts in the US and then making 150k vs working a full schedule in Nz and then making 150k?

We have a couple expats that fly in do 7 shifts, fly home and have 20 days off.

Great way to make 300k.

Why work for sub 300/hr?
 
are all US residency trained docs essentially starting at the level of a consultant or do you have to climb up the ladder all over again?

Also…. Why is someone not better off working 4-5 shifts in the US and then making 150k vs working a full schedule in Nz and then making 150k?
This is what I don’t get about the N.z setup. It’s done more for the purpose of living in NZ. You could do locums in the us and work 4 12 hour shifts. Month and make 150. There are jobs doing rural medicine in the us making 275/ hr. You could do like 2 24s a month and also make that money almost and in your 48 hours see like 24 patients.
 
Annual spend of 200k is insane. Especially without kids. Decrease spending.
Some of that is home renovations, which is wrapping up. But, I also like to travel and take several trips including international a year. I also have a relatively expensive hobby. But these are the things that bring joy and make life worth living, you know? I have no intention of stopping working (mid 30s, plan on partial retirement at 55). Maybe I just need to buckle down and invest more but you never know the future and I just want to enjoy living my life while I’m (relatively) young and able instead of waiting for some golden retirement that may never materialize.
 
Some of that is home renovations, which is wrapping up. But, I also like to travel and take several trips including international a year. I also have a relatively expensive hobby. But these are the things that bring joy and make life worth living, you know? I have no intention of stopping working (mid 30s, plan on partial retirement at 55). Maybe I just need to buckle down and invest more but you never know the future and I just want to enjoy living my life while I’m (relatively) young and able instead of waiting for some golden retirement that may never materialize.

Hear that.

Just can't imagine giving up partnership to work another grunt job in medicine.
 
are all US residency trained docs essentially starting at the level of a consultant or do you have to climb up the ladder all over again?

Also…. Why is someone not better off working 4-5 shifts in the US and then making 150k vs working a full schedule in Nz and then making 150k?

FWIW, my salary is up to USD ~$240k for 6-7 shifts per month – but yea, that shift number comes from doing half-time admin and half-time clinical. But I'm about to start a 3 month sabbatical at full salary ... and, again, haven't even started to adjust that salary for my ~10 weeks of leave accrued each year, or CME or retirement contribution ....

No reason to sugar coat the pay cut, but it's not as bad as discussed in this thread – not if you're 10+ years post-ABEM. The published salary scale doesn't account for some of the other allowances EM gets. Or that the NZD will inevitably re-strengthen someday from ~0.6 back to the usual ~0.7+. Or you're FIRE, but still want to do EM as a sort of hobby, and your kids get to grow up somewhere interesting, collect a new passport after five years (one that lets you live and work in Australia, as well), etc.

You do get straight to consultant if you've been practicing sufficiently long to match the length of their training scheme – but it's not an early career move (make your $$$ in the U.S. + you'll be higher on the salary scale when you arrive).

Not perfect, but, if we're talking about leaving EM because of general unhappiness with various U.S.-specific factors, it's an option.
 
Our partners make more than that.

We also have access to lots of tax shelters that you do not.

Oh and we don't live out of a suitcase.

It has been awhile since I was part of a SDG but I do not feel the macro environment/revenue has changed much unless you are participating in IDR. I am not sure any SDG can bill for IDR if they are under a hospital roof/rules.

Short of IDR, I do not see how any SDG can make $575/hr. Our SDG was lean, well functioning, above avg payer mix. I was a upper management/partner and saw all of the numbers down to what % of payers we had/how much they paid per pt. Our Biller was exceptional also from everything I could gather compared to other SDG groups.

Unless it is some unicorn payer mix or recent IDR billing, there is no way the bottom 90% of SDGs are paying more than $575/hr. I know IDR well and even with IDR, the numbers just do not wash with $575/hr. Maybe there are a small group of partners and most everyone are "pre-partners" or some other non SDG structure.

I am sure your SDG is doing this well but it has to be a unicorn. Others SDGs can chime in but I would be shocked if many SDGs are paying their docs $350+/hr.
What's IDR?
 
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Independent Dispute Resolution - a process where disputes between hospitals/physicians and insurers goes to a third party arbitrator for resolution
 
Independent Dispute Resolution - a process where disputes between hospitals/physicians and insurers goes to a third party arbitrator for resolution
It’s been such a boon for physician staffing groups. We win about 95% of our cases and third party batches them and takes them to arbitration for us. Our collections have never been higher. It also gives better bargaining chips for contracts with insurance companies. Don’t want to contract fairly with us? No problem, we’ll see you in arbitration for all of your OON reimbursements.
 
It’s been such a boon for physician staffing groups. We win about 95% of our cases and third party batches them and takes them to arbitration for us. Our collections have never been higher. It also gives better bargaining chips for contracts with insurance companies. Don’t want to contract fairly with us? No problem, we’ll see you in arbitration for all of your OON reimbursements.
Right now is the golden age of EM for private groups. Best to print now b/c everything is cyclical and can not last forever. Hospitals owned EM staffing must be making some serious coin b/c they can bill facility on top of professional. I actually feel bad for these EM docs who are salaried or part of a CMG. The are getting fleeced and will not partake in the golden age of EM.
 
This goes with most specialties. I know Rad/Anesthesiology are doing it. I have no idea about others b/c they have a much lower volume of pts and may not be worth the investment.
 
Polly Pockets- I'm PGY20 (also a nocturnist) and also very much feeling the burnout, so your post resonated a lot with me.
I've been doing a lot of soul-searching myself. For myself, I've decided to stay on for a bit longer. My FIRE date is in about 5.5 yrs, so I feel like it's worth holding onto it unless I really find something better.

Here are some insights I have which may be useful to you:
1) Dropping 10-15% of your shifts will give you an asymmetrical amount of joy relative to the income you are giving up. I went from 14 shifts/month to 12, and the difference has been life-changing. I'm more present with my family and kids, have more time to work out and take care of my health, have more time to travel, and have more time to recover. Highly recommend doing a trial of 10-20% less and seeing how it feels.
- The above effect is temporary. It all comes back, but it buys some time.

2) I've looked at non-EM jobs. Everything from investment firms (I'm probably not even qualified, honestly) to Tech to Urgent Care to UM. This made me realize that:
a) I like working nights when nobody else is working, and I like having the day off when everybody else is working.
b) Only working 12-14 days/month for 400k+ is amazing, and I'm not willing to give it up.
c) My current job situation gives me a lot of time with my kids
d) Very few jobs out there allow you to titrate the amount of work you do to the amount of income you need/the amount of time you want to spend at work
The point is that when we're burned out, we focus on the negatives. There are a few truly awesome things about being an ED doc, and a ED Noturnist especially.

3) It really helps to be specific about what is causing the burnout and to try to solve for that problem. There were two issues for me:
a) Patients- specifically the ratio of (nice patients having a rough day that I can help + patients with interesting pathology) to (dinguses + entitled people + TikTok fibromyalgia specialists + violent patients). Haven't solved it, but better by spending more time with nice folks and minimizing the time I spend with jerks as much as I can.
(Side note- the return of droperidol has added like 2 yrs to my career)
b) "The system"- specifically that the ED is the dumping ground for drunks, domestic violence without physical injury but with social needs, old folks who can't live at home anymore, etc etc. (New twist: my local police department is now bringing us every person they catch committing an act of violence that has a psych history.... "he tried to set fire to the school....must be his bipolar flaring up..." This cancels out all the gains from droperidol mentioned above.) We recently got a night social worker- which honestly has been amazing. As far as the "Social Admits"- my leadership team and that of the hospital have worked out a pathway of who and when patients get admitted for social reasons. It helps because it's not a new problem you have to solve every time it happens. Everyone is on the same page, and we just steer the workflow down the algorithm.
c) Malpractice risk- I was recently named to a malpractice suit about 2 yrs ago. I was just dropped, though they are still suing the Hospital. I really feel I did nothing wrong. The resulting injury to the patient is suspect. When I was first named, the stress was unbelievable (my only suit in 16 yrs as an attending). It changed my practice style in ways I didn't like. I've dialed back a lot of those changes. The stress slowly decreased, but never really went away. I work in a bad malpractice state, though the specific area of my state makes it somewhat better. I have contemplated moving or getting a job on the other side of the state line. If I ever get named again, it will probably be enough to push me over to the bordering state, even if it would be at least a 90-minute commute. For now, my "solution" is acceptance that this is always a risk and just a part of the job.

Ultimately, the upside of continuing my EM career was greater than the downside.... at least for now.

For you, my best advice is to name what is bothering you about your job/EM, see if you can work to minimize that pain, then decide if the pros outweight the cons.
 
Fellow nocturnist here that was so burned out in 2020 for all the reasons in (3) listed by the above poster that I almost walked into the forest and didn't walk out.

Now I'm better than ever. I'm 44. Will probably cut down to part time in my late 50s the way I feel now.

I had to change everything. The jobsite. The mindset. The expectations for myself. The expectations for society. EVERY.THING.

There's light, bro.
 
Fellow nocturnist here that was so burned out in 2020 for all the reasons in (3) listed by the above poster that I almost walked into the forest and didn't walk out.

Now I'm better than ever. I'm 44. Will probably cut down to part time in my late 50s the way I feel now.

I had to change everything. The jobsite. The mindset. The expectations for myself. The expectations for society. EVERY.THING.

There's light, bro.

Can you give us a fox guide?
 
@RustedFox One more vote for you telling us about your secret sauce.
Can you give us a fox guide?

I made mention of this about a month or so back as well. Several people contacted me via PM about it and we've talked via text and such. Nice to make new friends.

I'll tell y'all what: I'll give the people what they want, but it's gonna take me some time and keystrokes to do it. For starters, go read this:

 
I made mention of this about a month or so back as well. Several people contacted me via PM about it and we've talked via text and such. Nice to make new friends.

I'll tell y'all what: I'll give the people what they want, but it's gonna take me some time and keystrokes to do it. For starters, go read this:

Somehow I missed this the first time. It’s a sorta amazing combination of two of my lawsuits.

Glad you got to the other side.
 
It’ll take more than 4 years to get to completely financially independent with his current lifestyle and net worth. He needs $4million to be FI if he is 60 years old. Generally you want to give yourself a bit more of a buffer if you’re retiring at 45 instead. $6million would be my minimum target if my annual spend rate was $200k/yr and I was trying to retire under 50.

With a current net worth of $1.2 million and assuming the upper end of spend rate, and we’ll assume $450k pre-tax annual take home and the entirety of the remainder of his take home after taxes and living expenses is placed into VTI with an average real annual return of around 7%, it’ll take him 10 years to get to $4 million and 14 years to get to $6million in 2026 dollars.

At the end of 4 years, he’d still only be at $2.2 million. Hes not getting to FI in 4 years unless he’s making over a $million pre-tax/yr and saving $500k of his take home annually and that’d still only get him to the $4million mark, which ain’t happening.
I think physicians overestimate how much one needs to be FIRE.

I think in 4 years, his net worth might get to 2.5M. He might not retire completely but 4 days EM work per month should sustain OP lifestyle without touching his nest egg.
 
I think physicians overestimate how much one needs to be FIRE.

I think in 4 years, his net worth might get to 2.5M. He might not retire completely but 4 days EM work per month should sustain OP lifestyle without touching his nest egg.
Not overestimating anything, the numbers you quoted are the basic calculations utilized to determine when someone is safe to retire financially. What you are stating wouldn’t be FIRE, that’s what we call coastFIRE which still requires someone to work. The individual I was replying to was talking about outright retirement in 4 years which is not possible for the OP.
 
Not overestimating anything, the numbers you quoted are the basic calculations utilized to determine when someone is safe to retire financially. What you are stating wouldn’t be FIRE, that’s what we call coastFIRE which still requires someone to work. The individual I was replying to was talking about outright retirement in 4 years which is not possible for the OP.
I live in small city in the south and I can retire here easily with 2.5M net worth.
 
I live in small city in the south and I can retire here easily with 2.5M net worth.
Concur. That’s my target for “f you” money and a base retirement. Will still probably coast after that, but $2.5 is plenty. You will never want for food/housing/transportation/basic pleasantries.

It’s only on SDN where we all got a 280 Step 1 where $2.5m isn’t enough.
 
Concur. That’s my target for “f you” money and a base retirement. Will still probably coast after that, but $2.5 is plenty. You will never want for food/housing/transportation/basic pleasantries.

It’s only on SDN where we all got a 280 Step 1 where $2.5m isn’t enough.
Most Americans would be ecstatic to retire with 2.5M net worth.

It seems like most physicians are out of touch with the struggle of middle class families.

Probably < 5% of US household retire with 2.5M+ net worth.
 
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Most Americans would be ecstatic to retire with 2.5M net worth.

It seems like most physicians are out of touch with the struggle of middle class families.

Probably < 5% of US household retire with 2.5M+ net worth.
It’s a disease. I have partners in my own practice that are well out of residency and still moonlighting at other shops to supplement income for a lifestyle that has gotten completely out of hand.

They can’t imagine living a lower, but still better, lifestyle than the average American, so they’ve put themselves into a position NO BETTER than the average American by turning themselves into indentured servants of the system.

Turn down the knob on the hedonic treadmill just 20% and gain control of your work life. That’s true happiness, while still easily achieving financial goals.
 
Concur. That’s my target for “f you” money and a base retirement. Will still probably coast after that, but $2.5 is plenty. You will never want for food/housing/transportation/basic pleasantries.

It’s only on SDN where we all got a 280 Step 1 where $2.5m isn’t enough.
It’s all relative. I’m well past that number but with two young children it doesn’t feel like enough to live the life *we* want. Could I retire now and be ok? Probably, but a 30-50% drop in the market would have me thinking otherwise. We’ve never been big spenders but have recently been loosening the purse strings in various ways.
 
It’s all relative. I’m well past that number but with two young children it doesn’t feel like enough to live the life *we* want. Could I retire now and be ok? Probably, but a 30-50% drop in the market would have me thinking otherwise. We’ve never been big spenders but have recently been loosening the purse strings in various ways.
Which is fine. I’m confident my wife and I will end up higher than that number (in 2026 dollars) by retirement.

I’m mostly speaking to those that are hitting that number and Can’t. Stop. Working.

I hope at this point, you are your spouse are feeling the “f you” and are truly working an amount that feels good (hard to imagine that’s anything more than 0.75 FTE in this biz, and likely more like 0.5 FTE). Because if no one else has said it yet, you made it.
 
It’s all relative. I’m well past that number but with two young children it doesn’t feel like enough to live the life *we* want. Could I retire now and be ok? Probably, but a 30-50% drop in the market would have me thinking otherwise. We’ve never been big spenders but have recently been loosening the purse strings in various ways.
The point I was making was if for whatever reason I am not able to work after reaching 2.5M net worth, I will be ok financially--better than 90% of my fellow American compatriots.
 
I live in small city in the south and I can retire here easily with 2.5M net worth.
You are confusing your calculation based on your lifestyle with the OP’s. Again, these are basic retirement number calculations. What you can retire off of has 0 bearing on the calculation I made.
 
You are confusing your calculation based on your lifestyle with the OP’s. Again, these are basic retirement number calculations. What you can retire off of has 0 bearing on the calculation I made.
'Sacrifices' have to be made if you HATE your job.
 
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Which is fine. I’m confident my wife and I will end up higher than that number (in 2026 dollars) by retirement.

I’m mostly speaking to those that are hitting that number and Can’t. Stop. Working.

I hope at this point, you are your spouse are feeling the “f you” and are truly working an amount that feels good (hard to imagine that’s anything more than 0.75 FTE in this biz, and likely more like 0.5 FTE). Because if no one else has said it yet, you made it.
I’ve cut my hours back a bit but I’m still trying to make some hay while the sun is shining while not missing family time. The stress on if something happens job wise has significantly lessened but I’d like the group to continue to do well for the newer physicians. Significant financial flexibility is still very important to us.
 
How much you need to retire all comes down to how much you're going to spend in retirement for how long.

Disagree. If I say I need 50M to retire in my mid 40s as a doc because I want to travel private, everyone would think I am unrealistic.

I think people should look at it in that lens IMO. If for whatever reason I am unable to bring an income and my net worth is 3M, will I have an average or even above middle class lifestyle? The answer is yes. This is when one crosses the FU money threshold. But that does not mean you should stop working.

Above a certain amount (eg., 5M), the extra money one accumulates is to help others because it won't improve your lifestyle substantially. 5M vs. 10M provide almost identical lifestyle IMO in most part of the US.
 
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better to have more than less don't know if a natural disaster may wipe out your home or you get really sick

Double-edged sword.

Should we save MORE for retirement in case we get really sick and need tons of cash? Or should we NOT work insanely for 25yr because we make get really sick and never have a true retirement?
 
Double-edged sword.

Should we save MORE for retirement in case we get really sick and need tons of cash? Or should we NOT work insanely for 25yr because we make get really sick and never have a true retirement?
“Meteor plans” are about anxiety, not reality. I plan for the likely, not the seriously unlikely. A meteor could strike the earth, but I’m not planning for it, I’m just gonna have to deal with that one as it comes.
 
“Meteor plans” are about anxiety, not reality. I plan for the likely, not the seriously unlikely. A meteor could strike the earth, but I’m not planning for it, I’m just gonna have to deal with that one as it comes.
Exactly. Plus my house has insurance for a reason 🙂
 
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