Left clinical EM and realized it doesn't have to be this way

[UrbanEM2]

Fellow EM doc that left the clinical game a while back. Made a 180 and have a totally unrelated job now. This post isn't meant to be prescriptive or to tell anyone to do the same thing I did since what I did is not for everyone. My goal is to point out observations I have from the other side. Particularly where I see the rot and burnout coming from.

One of the things that never ceases to strike me is how actually happy and well adjusted people in other professions are. Not everyone, but the vast majority of people I interact with daily seem happy and fulfilled. In EM, not a single shift went by that I didn't have a negative interaction with a colleague, whether a doctor, nurse, tech, or admin. I never expected anything out of patients since they weren't at work and held to any standard of professionalism. Rather it's the aggression from colleagues I found to really beat me down. It doesn't have to be this way. In my current line of work, I find people to be generally professional, kind, collegial, and not displaying overt or passive signs of aggression. It's not like my job now isn't stressful. It's arguably more stressful, but people handle themselves with much more grace. No aspect of medical training ever held anyone to any standard of professional collegiality amongst colleagues. For all the standardized patient sessions we did on how to properly show empathy to a patient, we probably should have had a few sessions on how to treat colleagues with respect.

I think med school admissions largely selects for traits that are contradictory to what makes for a good physician and colleague. You take a bunch of pre-meds, make them fight to the death to get into med school, then compete incessantly for four years, then all of a sudden in residency tell them they're playing a team sport and need to play nice and get along to work towards a shared goal. That just doesn't work.

Another root of burnout is what I saw as the stagnant nature of an EM career. Unless you're in the gerbil wheel trying to move up the CMG ladder, you pretty much plateau in terms of responsibility and compensation after residency. We find ourselves at 55 doing the same day to day work we did at 31. Maybe less shifts or less nights, but it's the same job. All while our friends outside medicine have enjoyed career progression, professional growth, promotions, increasing responsibility, and increased compensation as they get older. By becoming corporate cogs, we have given up the opportunity for this kind of growth that our forbearers enjoyed more of. Not saying everyone wants this, but I think it leads to many mid-career EM docs feeling stagnant in their jobs.

I really don't think there's a remedy for all these problems and the momentum causing macro level changes in EM are too great to slow down, but I think we can do something about burnout by teaching med students and trainees about professional conduct, collegiality, and kindness.

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[deleted6669]

I think we can do something about burnout by teaching med students and trainees about professional conduct, collegiality, and kindness.

I agree and thank you for this. I think this has been improving slowly but surely over the last 20 years. It used to be common for me to get yelled at by a surgeon just for having the nerve to call them about a patient of theirs with an acute surgical emergency, now more often than not the surgeons are downright pleasant on the phone. The culture of medicine is changing. More women are getting into medicine and it seems like a lot of them are just nicer human beings than the typical crusty 63 yr old male surgeons they are replacing. I have precepted medical students and residents in FP and EM for almost 25 years and I think programs are starting to do a better job of selecting well-wounded applicants and looking beyond straight gpa/mcat #s. The boat is turning around slowly. The old curmudgeons of medicine are dying or retiring, both physicians and battle ax nurses. Some of this may be due to political correctness and rules to play nice in the sandbox at work. Whatever the reason, I am a fan. One of the big reasons that I moved from working at busy urban trauma ctrs to rural critical access hospitals is that rural folks are just more chill. The volume is lower. They can deal with problems more easily and the coping skills are much better. Not being asked to see 3-5 pts/hr likely contributes to this. Move the meat is not a way to be happy at work.

 

[namethatsmell]

@UrbanEM2 Congrats on finding a gig that makes you happy! And thanks very much for writing about it.

Ain’t it great to show up for work without
the expectation that you’ll likely have to persuade (or flat out fight with) a wide variety of folks —techs, nurses, radiology , the lab, hospitalists, specialists, patients, admin, etc— to simply do their job and move the ball forward?

It’s important to work at a place where you feel like you’re valued and treated fairly. EM training really does lend itself well to MANY non-EM jobs. I’m sure people on here are going to ask you lots of questions and I look forward to reading more about your journey

 

[Rekt]

I agree and thank you for this. I think this has been improving slowly but surely over the last 20 years. It used to be common for me to get yelled at by a surgeon just for having the nerve to call them about a patient of theirs with an acute surgical emergency, now more often than not the surgeons are downright pleasant on the phone. The culture of medicine is changing. More women are getting into medicine and it seems like a lot of them are just nicer human beings than the typical crusty 63 yr old male surgeons they are replacing. I have precepted medical students and residents in FP and EM for almost 25 years and I think programs are starting to do a better job of selecting well-wounded applicants and looking beyond straight gpa/mcat #s. The boat is turning around slowly. The old curmudgeons of medicine are dying or retiring, both physicians and battle ax nurses. Some of this may be due to political correctness and rules to play nice in the sandbox at work. Whatever the reason, I am a fan. One of the big reasons that I moved from working at busy urban trauma ctrs to rural critical access hospitals is that rural folks are just more chill. The volume is lower. They can deal with problems more easily and the coping skills are much better. Not being asked to see 3-5 pts/hr likely contributes to this. Move the meat is not a way to be happy at work.

While I agree, it has gone too far in the other direction. Physician's can't say a single negative thing without severe punishment. It's the reason medicine is dead and lost to the admins, mid-levels, and CMGs

 

[cyanide12345678]

It’s important to work at a place where you feel like you’re valued and treated fairly. EM training really does lend itself well to MANY non-EM jobs. I’m sure people on here are going to ask you lots of questions and I look forward to reading more about your journey

Non EM jobs? Like what?

 

[cyanide12345678]

Fellow EM doc that left the clinical game a while back. Made a 180 and have a totally unrelated job now. This post isn't meant to be prescriptive or to tell anyone to do the same thing I did since what I did is not for everyone. My goal is to point out observations I have from the other side. Particularly where I see the rot and burnout coming from.

One of the things that never ceases to strike me is how actually happy and well adjusted people in other professions are. Not everyone, but the vast majority of people I interact with daily seem happy and fulfilled. In EM, not a single shift went by that I didn't have a negative interaction with a colleague, whether a doctor, nurse, tech, or admin. I never expected anything out of patients since they weren't at work and held to any standard of professionalism. Rather it's the aggression from colleagues I found to really beat me down. It doesn't have to be this way. In my current line of work, I find people to be generally professional, kind, collegial, and not displaying overt or passive signs of aggression. It's not like my job now isn't stressful. It's arguably more stressful, but people handle themselves with much more grace. No aspect of medical training ever held anyone to any standard of professional collegiality amongst colleagues. For all the standardized patient sessions we did on how to properly show empathy to a patient, we probably should have had a few sessions on how to treat colleagues with respect.

I think med school admissions largely selects for traits that are contradictory to what makes for a good physician and colleague. You take a bunch of pre-meds, make them fight to the death to get into med school, then compete incessantly for four years, then all of a sudden in residency tell them they're playing a team sport and need to play nice and get along to work towards a shared goal. That just doesn't work.

Another root of burnout is what I saw as the stagnant nature of an EM career. Unless you're in the gerbil wheel trying to move up the CMG ladder, you pretty much plateau in terms of responsibility and compensation after residency. We find ourselves at 55 doing the same day to day work we did at 31. Maybe less shifts or less nights, but it's the same job. All while our friends outside medicine have enjoyed career progression, professional growth, promotions, increasing responsibility, and increased compensation as they get older. By becoming corporate cogs, we have given up the opportunity for this kind of growth that our forbearers enjoyed more of. Not saying everyone wants this, but I think it leads to many mid-career EM docs feeling stagnant in their jobs.

I really don't think there's a remedy for all these problems and the momentum causing macro level changes in EM are too great to slow down, but I think we can do something about burnout by teaching med students and trainees about professional conduct, collegiality, and kindness.

If you don't mind sharing, what kind of a job did you find contentment?

 

[deleted547339]

I’m still pretty young (5 years of training and 3 years as faculty), but I feel like I’ve already noticed physicians are getting nicer and nurses are getting more proud.

 

[lp430]

I agree with a lot of what you're saying. I spent my entire 20s working towards the next step up the ladder, from pre-med to med student etc. Now, I'm an attending in the ER and have no interest in being admin so what's the next step? I think not having career progression can lead to dissatisfaction/burn out for sure.
One thing I've noticed in my short career is that congeniality seems to vary regionally. Working in NY was a much different experience than being in the midwest. I feel less burnt out even though I work my hours with my locums job just be being surrounded by colleagues that aren't always pissed off and complaining.

 

[thegenius]

Fellow EM doc that left the clinical game a while back. Made a 180 and have a totally unrelated job now. This post isn't meant to be prescriptive or to tell anyone to do the same thing I did since what I did is not for everyone. My goal is to point out observations I have from the other side. Particularly where I see the rot and burnout coming from.

One of the things that never ceases to strike me is how actually happy and well adjusted people in other professions are. Not everyone, but the vast majority of people I interact with daily seem happy and fulfilled. In EM, not a single shift went by that I didn't have a negative interaction with a colleague, whether a doctor, nurse, tech, or admin. I never expected anything out of patients since they weren't at work and held to any standard of professionalism. Rather it's the aggression from colleagues I found to really beat me down. It doesn't have to be this way. In my current line of work, I find people to be generally professional, kind, collegial, and not displaying overt or passive signs of aggression. It's not like my job now isn't stressful. It's arguably more stressful, but people handle themselves with much more grace. No aspect of medical training ever held anyone to any standard of professional collegiality amongst colleagues. For all the standardized patient sessions we did on how to properly show empathy to a patient, we probably should have had a few sessions on how to treat colleagues with respect.

I think med school admissions largely selects for traits that are contradictory to what makes for a good physician and colleague. You take a bunch of pre-meds, make them fight to the death to get into med school, then compete incessantly for four years, then all of a sudden in residency tell them they're playing a team sport and need to play nice and get along to work towards a shared goal. That just doesn't work.

Another root of burnout is what I saw as the stagnant nature of an EM career. Unless you're in the gerbil wheel trying to move up the CMG ladder, you pretty much plateau in terms of responsibility and compensation after residency. We find ourselves at 55 doing the same day to day work we did at 31. Maybe less shifts or less nights, but it's the same job. All while our friends outside medicine have enjoyed career progression, professional growth, promotions, increasing responsibility, and increased compensation as they get older. By becoming corporate cogs, we have given up the opportunity for this kind of growth that our forbearers enjoyed more of. Not saying everyone wants this, but I think it leads to many mid-career EM docs feeling stagnant in their jobs.

I really don't think there's a remedy for all these problems and the momentum causing macro level changes in EM are too great to slow down, but I think we can do something about burnout by teaching med students and trainees about professional conduct, collegiality, and kindness.

Insightful comments. We do treat each other like s&@tbags. I think we probably take our anger towards our patients out on our fellow colleagues.

 

[bartleby]

Not sure where you guys are working, but reading these comments makes me sad because a) most EDs aren’t like this and b) there are firm, non-confrontational to manage the jerks you deal with in EM and other specialties. There are toxic hospitals just like there are toxic offices. If the culture is so bad that bad behavior is rampant, do yourself a favor and find another place to practice this awesome specialty of ours.

 

[deleted6669]

Not sure where you guys are working, but reading these comments makes me sad because a) most EDs aren’t like this and b) there are firm, non-confrontational to manage the jerks you deal with in EM and other specialties. There are toxic hospitals just like there are toxic offices. If the culture is so bad that bad behavior is rampant, do yourself a favor and find another place to practice this awesome specialty of ours.

It is more common than not I am afraid. I have worked in more than a dozen EDs in six states and found the vast majority of them to have a malignant environment.

 

[sylvanthus]

Fellow EM doc that left the clinical game a while back. Made a 180 and have a totally unrelated job now. This post isn't meant to be prescriptive or to tell anyone to do the same thing I did since what I did is not for everyone. My goal is to point out observations I have from the other side. Particularly where I see the rot and burnout coming from.

One of the things that never ceases to strike me is how actually happy and well adjusted people in other professions are. Not everyone, but the vast majority of people I interact with daily seem happy and fulfilled. In EM, not a single shift went by that I didn't have a negative interaction with a colleague, whether a doctor, nurse, tech, or admin. I never expected anything out of patients since they weren't at work and held to any standard of professionalism. Rather it's the aggression from colleagues I found to really beat me down. It doesn't have to be this way. In my current line of work, I find people to be generally professional, kind, collegial, and not displaying overt or passive signs of aggression. It's not like my job now isn't stressful. It's arguably more stressful, but people handle themselves with much more grace. No aspect of medical training ever held anyone to any standard of professional collegiality amongst colleagues. For all the standardized patient sessions we did on how to properly show empathy to a patient, we probably should have had a few sessions on how to treat colleagues with respect.

I think med school admissions largely selects for traits that are contradictory to what makes for a good physician and colleague. You take a bunch of pre-meds, make them fight to the death to get into med school, then compete incessantly for four years, then all of a sudden in residency tell them they're playing a team sport and need to play nice and get along to work towards a shared goal. That just doesn't work.

Another root of burnout is what I saw as the stagnant nature of an EM career. Unless you're in the gerbil wheel trying to move up the CMG ladder, you pretty much plateau in terms of responsibility and compensation after residency. We find ourselves at 55 doing the same day to day work we did at 31. Maybe less shifts or less nights, but it's the same job. All while our friends outside medicine have enjoyed career progression, professional growth, promotions, increasing responsibility, and increased compensation as they get older. By becoming corporate cogs, we have given up the opportunity for this kind of growth that our forbearers enjoyed more of. Not saying everyone wants this, but I think it leads to many mid-career EM docs feeling stagnant in their jobs.

I really don't think there's a remedy for all these problems and the momentum causing macro level changes in EM are too great to slow down, but I think we can do something about burnout by teaching med students and trainees about professional conduct, collegiality, and kindness.

Im already being hit by the above and I graduate 1 1/2 years ago. Wondering if "this is it?" all the time now. Is this what I worked so hard for? Gonna be doing this for the next 20 years, no room to move up unless I sell my soul? Disheartening.

 

[Angry Birds]

OP -- don't leave us hanging. Let us know what you switched to, so that we can all live vicariously through you.
I am on my second shift in my stretch and I am just so tired. This sucks.

 

[sylvanthus]

We just switched hospitals, im in the ICU atm, RN staff are melting down, everyones calling out sick all the time, rules keep changing on where patients go (covid, noncovid), total cluster F atm and were not even really overrun. Can only imagine how bad this is gonna get mid jan.

 

[jw3600]

Yes @thegenius. Yes they did.

This goes for all docs. I'd argue EM folks are more reasonable and normal, but I'm clearly biased. My colleagues just all got a good laugh out of this thread. As much as we all hate on the MBAs, imagine what would happen if we let the people who desecrated this thread run a major healthcare company or even a single board meeting. It would be mayhem.

I hate to say it, but we did this to ourselves. If doctors want to have control and run healthcare, we need to act like we deserve and can handle that responsibility. All I see from the other side are doctors acting like petulant children slinging poop at each other. All specialties. All practice settings. All over the country.

While you guys were off topic arguing about psych admissions, some private equity or hedge fund investor probably just took over another healthcare company and controls the jobs of thousands more doctors.

Eh disagree. The MBAs created an environment where this behavior manifests out of self survival.

 

[Apollyon]

Yes @thegenius. Yes they did.

This goes for all docs. I'd argue EM folks are more reasonable and normal, but I'm clearly biased. My colleagues just all got a good laugh out of this thread. As much as we all hate on the MBAs, imagine what would happen if we let the people who desecrated this thread run a major healthcare company or even a single board meeting. It would be mayhem.

I hate to say it, but we did this to ourselves. If doctors want to have control and run healthcare, we need to act like we deserve and can handle that responsibility. All I see from the other side are doctors acting like petulant children slinging poop at each other. All specialties. All practice settings. All over the country.

While you guys were off topic arguing about psych admissions, some private equity or hedge fund investor probably just took over another healthcare company and controls the jobs of thousands more doctors.

Into which general area of work did you move?

 

[sylvanthus]

Yes @thegenius. Yes they did.

This goes for all docs. I'd argue EM folks are more reasonable and normal, but I'm clearly biased. My colleagues just all got a good laugh out of this thread. As much as we all hate on the MBAs, imagine what would happen if we let the people who desecrated this thread run a major healthcare company or even a single board meeting. It would be mayhem.

I hate to say it, but we did this to ourselves. If doctors want to have control and run healthcare, we need to act like we deserve and can handle that responsibility. All I see from the other side are doctors acting like petulant children slinging poop at each other. All specialties. All practice settings. All over the country.

While you guys were off topic arguing about psych admissions, some private equity or hedge fund investor probably just took over another healthcare company and controls the jobs of thousands more doctors.

Also, you are naive and oversimplifying things if you cannot see or are unwilling to see all the crap that EM physicians have going on currently. As you said, you no longer work clinically. We have midlevel enroachment, decreasing pay, increased liability, increased need for documentation to the point where we hire an extra person to follow us around and write everything down, pushback from consultants and for admissions, etc etc etc and you place blame on us being “petulant children?”.

Your blaming the victim, you are part of the problem.

 

[Hercules]

THIS IS AMAZING.

This thread literally proves my point PERFECTLY. I check back 24 hours later and it somehow devolved into a totally off topic mud wrestling match. Somehow we're talking about psych admissions, BALs, and throwing smack at each other.

THIS IS LITERALLY IT RIGHT HERE.

There's a reason why doctors have lost control of clinical medicine. We have proven ourselves incapable of behaving well and playing nicely in the sandbox with literally anyone. As a reason we lost our spot at the table. We're just a bunch of kids that the management has to "deal" with.

It's the ego-driven nature of physicians. We always think we have a good point and that we're the smartest in the room. That's actually often times not true.

I sent this thread to a few colleagues of mine and they all got a good laugh out of it. It was just a good reminder why people try to avoid bringing doctors into any serious business or management conversations. Just can't have nice things.

Can’t agree more for the majority of us physicians. I wound up serving on a finance committee for a non-medical organization a few years ago. At the first meeting, the chair introduced me as a doctor but asked (only half kidding) the others not to hold that against me, and said that despite being a doctor I was actually qualified to discuss finance and strategic business planning.

 

[Apollyon]

Ha! We're going to get along great

Again, I'll ask. In what general area did you go to work? Health care related? Something you did before med school? Family business/connections? Private equity? Writer? Home Depot/Lowe's?

 

[thegenius]

Follow your own advice and practice kindness, not come on the EM forum and state were petulant children.

I didn't feel like the original post was a slam against ER docs, I interpreted it more as an indictment of health care overall. It's not like all specialties are collegial EXCEPT with emergency medicine.

The problem we have in the ER is we are charged in offering mostly free care whenever someone wants it. And we have not figured out a way to combat that abuse. Because it's abused ALL THE TIME. EMTALA is ABUSED ALL THE TIME.

 

[bronx43]

Again, I'll ask. In what general area did you go to work? Health care related? Something you did before med school? Family business/connections? Private equity? Writer? Home Depot/Lowe's?

Totally not fishy that OP just came by, flashed success in leaving clinical medicine, dropped blame on physicians, then dodge every question about what he/she actually does now...

 

[sloh]

It’s unfortunate the environment many of us practice in unwittingly turns us on each other. The entitled and exasperating patients. The system. Avoiding it completely or finding a niche where you are exposed the least is the best solution. Wish the OP could come back and respond!

 

[UrbanEM2]

OP's first post was reasonable, but then he lost all credibility when he essentially went "physicians are at fault for being taken advantage of by admins and mid-levels".

Extra bull**** points for forwarding this to his buddies and going "look at these idiots; good thing i'M nOt LiKe ThE oThEr DoCtOrS. tee hee"

I never said anything about mid-levels. Mid-level encroachment is a product of having been taken advantage of by admin. I do stick by that we let that admin encroachment happen over the last 30 years. Not saying it's all our fault, but we didn't do much to alleviate the burden. There are of course many other macro level forces that affected and hastened this process. Rise of managed care, increasing IT requirements, and many others.

To answer the question of what I do now, a little over a decade ago I cut down clinical hours and took a job as an investor, mostly in the public markets. It's not for everyone, certainly EM doctors. It's a pretty standard desk job and doesn't provide the kind of constant adrenaline that working in a busy ER does, but I enjoy the process of figuring out mispriced equities. I continued working some urgent care shifts on weekends for a few years, but that ended up being too much time dedicated to work.

I feel fulfilled. I sometimes even get to make meaningful change for companies and help them serve employees, patients, and the public better, which is a nice perk. Not saying it's as meaningful or provides the kind of public service as being an ER doctor does, but I find myself happy and able to be a pleasant person around my family.

 

[Porfirio]

I honestly love what I do. Is it stressful? Yes. But all the things the OP stated in original post happen everywhere else working any job. People are people. Digging ditches, crunching numbers, tracking stocks or seeing patients is all the same.

I know plenty of hedge fund managers who are unhappy people. And just as rude.

 

[UrbanEM2]

@Porfirio That is wonderful! If you love what you do, stress is something easily overlooked.

I would say all jobs have these stressors, absolutely. I just feel like the burnout is much higher in EM.

 

[Angry Birds]

I never said anything about mid-levels. Mid-level encroachment is a product of having been taken advantage of by admin. I do stick by that we let that admin encroachment happen over the last 30 years. Not saying it's all our fault, but we didn't do much to alleviate the burden. There are of course many other macro level forces that affected and hastened this process. Rise of managed care, increasing IT requirements, and many others.

To answer the question of what I do now, a little over a decade ago I cut down clinical hours and took a job as an investor, mostly in the public markets. It's not for everyone, certainly EM doctors. It's a pretty standard desk job and doesn't provide the kind of constant adrenaline that working in a busy ER does, but I enjoy the process of figuring out mispriced equities. I continued working some urgent care shifts on weekends for a few years, but that ended up being too much time dedicated to work.

I feel fulfilled. I sometimes even get to make meaningful change for companies and help them serve employees, patients, and the public better, which is a nice perk. Not saying it's as meaningful or provides the kind of public service as being an ER doctor does, but I find myself happy and able to be a pleasant person around my family.

Congrats on getting out of the game.
I have dreams of the same ...

 

[Birdstrike]

I also left clinical EM 9 years ago. Still, I'm frequently reminded how many things that I had to deal with in the ED, that I had no idea the rest of the working world didn't have to deal with. There's a whole different set of rules, working conditions, living conditions, emotional impacts and norms of human interaction. You don't notice how staggering the difference is, until you're out.

ED = Mars. Everywhere else = Venus.

 

[southerndoc]

I have spent a significant amount of time to move the off-topic posts to the Off-Topic Threads Forum. If you think a post should've been moved (or if you thought a post should not have been moved), then please contact me via private messaging.

I agree with the OP. It's frustrating how things turned off-topic, but hopefully this will get us back to the original topic.

Thanks for your understanding.

 

[UrbanEM2]

Thank you @southerndoc.

It would be wonderful to have a discussion on how EM physicians can foster collegiality, band together, and help decrease the burden of burnout.

 

[southerndoc]

Thank you @southerndoc.

It would be wonderful to have a discussion on how EM physicians can foster collegiality, band together, and help decrease the burden of burnout.

That was my purpose in bringing the topic back into the EM forum. I thought it wasn't fair to move the whole thread. I spent a lot of time moving the posts, but hopefully we can keep this thread on topic and let the other thread have all the mudslinging.

 

[namethatsmell]

Precisely comments like this that ensure doctors will never have any real seat at the table. This kind of poop slinging behavior is pervasive in medicine .

I stick by my petulant children comment. If this isn't a bunch of petulant children, I'm not sure what is.

People just handle themselves more graciously outside clinical medicine.

I'm glad you're sharing your experience about succeeding in finance. It sounds like it's been a great move for you and I think it's important people hear it.

It's a bit curious that you took the time to share your message (which I think does have some truth) while at the same time choosing to belittle us. Was your intent to help show other EM docs how to find happiness at work? Or to simply offer an editorial of the field now that you've moved on?

Some other observations:

It makes sense (at least to an outsider like myself) that in the finance world people tend to get along. The purpose is to make money, so I'd guess everybody who takes finance jobs share the same overall goal. As long as people are pulling their weight and the trajectory is in the right direction, I could see things being pretty copacetic. Perhaps I'm wrong though?

In medicine, as I'm sure you remember, the goals of each specialty are not always aligned. The needs of the patient come first, but in the crappy way our system is structured, there also has to be some level of profit to keep it functional. These goals can be difficult to reconcile. Then, while hopefully everybody wants what's best for the patient (or at least what they think is best), there isn't always a clear path on how to get there. Take the 60 yo femur Fx. While ortho will usually be happy to operate, they'd love nothing more than for the hospitalist to admit. And what's in it for the hospitalist? Well, either the hospitalist has already been beaten down by admin long ago telling them to admit for ortho...or it's your job to try to battle it out with ortho and the hospitalist to find a home for the patient. Same thing goes for psych, GI, borderline surgical patients...etc. The lines of responsibility in medicine these days are unfortunately so distorted and blurred that it's not really surprising that there are routinely squabbles between docs. And with docs having less and less ownership and control of medicine with each year, the fighting inevitably becomes more and more petty.

I completely agree with you that docs fighting with each other only opens the doors for admin and private equity to control us even more. At the same time, hand-cuffs on docs in the form of the stark laws probably caused docs to lose the seat at the table more than any unenviable human qualities.

 

[DeadCactus]

Great post, thank you for sharing. I think there are some great lessons in here even for people that want to stay in medicine.

1. Chasing the highest reimbursement while ignoring the quality of the work environment is short-sighted. We come out of training damaged enough, I have to wonder how many people do permanent damage to their career satisfaction and personal life working high-paying trash jobs for even a few years. I get the pressure to pay-off debts but I'd steer most people to a fiscal strategy of reduced spending and a longer career than powering through to save a few percentage points of interest.

2. I think the comment about stagnant nature is a critical point but would argue the issue is not necessarily stagnation but a lack of career planning. Physicians spend over a decade hyper-focused on the next clearly defined goal sometimes not even aware of the next goal (i.e. medical students learning about residency and the match in medical school) let alone paying any thought to more abstract goals after the training pipeline stops. You can't map out your whole life and things change along the way but the complete lack of long-term goal setting leaves so many people adrift in their own career and then surprised they aren't happy. For all the asinine interview questions about 10-year plans, I don't feel like actually having long-term career and life plans is at all emphasized in medicine. We spend to much of our time anxious about the next exam or application cycle. I don't think a stagnant career is bad for all people. Plenty are happy to have a stable consistent work life and pursue advancement and new goals outside of work. Other people want to continue to face new challenges and responsibilities at work. Either is fine. I think the problem is when you don't define what you want and find yourself just adrift with no real purposeful development in either your personal or professional life.

As a tie-back to point 1, I worry paying off debt has become sort of a surrogate hyper-focused career goal after residency? It's like we've carved out this pathologic pipeline where people work their ass off for 10 years to become emergency physicians and then immediately start working their ass off for another 10 years to get out of medicine without every really defining what it is they are trying to get out of life.

 

[lp430]

Great post, thank you for sharing. I think there are some great lessons in here even for people that want to stay in medicine.

1. Chasing the highest reimbursement while ignoring the quality of the work environment is short-sighted. We come out of training damaged enough, I have to wonder how many people do permanent damage to their career satisfaction and personal life working high-paying trash jobs for even a few years. I get the pressure to pay-off debts but I'd steer most people to a fiscal strategy of reduced spending and a longer career than powering through to save a few percentage points of interest.

2. I think the comment about stagnant nature is a critical point but would argue the issue is not necessarily stagnation but a lack of career planning. Physicians spend over a decade hyper-focused on the next clearly defined goal sometimes not even aware of the next goal (i.e. medical students learning about residency and the match in medical school) let alone paying any thought to more abstract goals after the training pipeline stops. You can't map out your whole life and things change along the way but the complete lack of long-term goal setting leaves so many people adrift in their own career and then surprised they aren't happy. For all the asinine interview questions about 10-year plans, I don't feel like actually having long-term career and life plans is at all emphasized in medicine. We spend to much of our time anxious about the next exam or application cycle. I don't think a stagnant career is bad for all people. Plenty are happy to have a stable consistent work life and pursue advancement and new goals outside of work. Other people want to continue to face new challenges and responsibilities at work. Either is fine. I think the problem is when you don't define what you want and find yourself just adrift with no real purposeful development in either your personal or professional life.

As a tie-back to point 1, I worry paying off debt has become sort of a surrogate hyper-focused career goal after residency? It's like we've carved out this pathologic pipeline where people work their ass off for 10 years to become emergency physicians and then immediately start working their ass off for another 10 years to get out of medicine without every really defining what it is they are trying to get out of life.

I am glad you brought this back up because I think you're hitting the nail on the head. Most of us, as physicians, have become great at setting short term goals to get us to the next step. There isn't much upward mobility after that unless you want to be involved in hospital admin. Definitely not something I thought about as a medical student.
Now, it's one of my biggest dissatisfactions with my job and why I'll probably leave full time clinical medicine. I enjoy working hard, taking on the next challenge but I feel like I am running on a treadmill. This may not be true for every ER doc, but it is for me.

 

[UrbanEM2]

I'm glad you're sharing your experience about succeeding in finance. It sounds like it's been a great move for you and I think it's important people hear it.

It's a bit curious that you took the time to share your message (which I think does have some truth) while at the same time choosing to belittle us. Was your intent to help show other EM docs how to find happiness at work? Or to simply offer an editorial of the field now that you've moved on?

Some other observations:

It makes sense (at least to an outsider like myself) that in the finance world people tend to get along. The purpose is to make money, so I'd guess everybody who takes finance jobs share the same overall goal. As long as people are pulling their weight and the trajectory is in the right direction, I could see things being pretty copacetic. Perhaps I'm wrong though?

In medicine, as I'm sure you remember, the goals of each specialty are not always aligned. The needs of the patient come first, but in the crappy way our system is structured, there also has to be some level of profit to keep it functional. These goals can be difficult to reconcile. Then, while hopefully everybody wants what's best for the patient (or at least what they think is best), there isn't always a clear path on how to get there. Take the 60 yo femur Fx. While ortho will usually be happy to operate, they'd love nothing more than for the hospitalist to admit. And what's in it for the hospitalist? Well, either the hospitalist has already been beaten down by admin long ago telling them to admit for ortho...or it's your job to try to battle it out with ortho and the hospitalist to find a home for the patient. Same thing goes for psych, GI, borderline surgical patients...etc. The lines of responsibility in medicine these days are unfortunately so distorted and blurred that it's not really surprising that there are routinely squabbles between docs. And with docs having less and less ownership and control of medicine with each year, the fighting inevitably becomes more and more petty.

I completely agree with you that docs fighting with each other only opens the doors for admin and private equity to control us even more. At the same time, hand-cuffs on docs in the form of the stark laws probably caused docs to lose the seat at the table more than any unenviable human qualities.

I apologize if I came across as belittling. I'm generally a dramatic and blunt person so that's just my personality. My goal was to offer commentary and am genuinely curious others' perspectives. I'm still very close with the EM world and feel the burnout in my generation and younger ones to be an epidemic. It took me a while out of the game to realize that in addition to the constant butt kissing that I was terrible at, it's really dealing with colleagues that personally beat me down. Less so EM colleagues, but just about everyone else. I can still probably count on 2 hands the number of doctors I met that always did the right thing by the patient no matter how late it was, how tired they were, or how annoying the patient was. People outside medicine generally think doctors are always acting in the patients' best interest, but I rarely found that to be the case. Instead of spending years spinning in the wheel and eventually cracking, I found a good opportunity to get out.

 

[UrbanEM2]

Great post, thank you for sharing. I think there are some great lessons in here even for people that want to stay in medicine.

1. Chasing the highest reimbursement while ignoring the quality of the work environment is short-sighted. We come out of training damaged enough, I have to wonder how many people do permanent damage to their career satisfaction and personal life working high-paying trash jobs for even a few years. I get the pressure to pay-off debts but I'd steer most people to a fiscal strategy of reduced spending and a longer career than powering through to save a few percentage points of interest.

2. I think the comment about stagnant nature is a critical point but would argue the issue is not necessarily stagnation but a lack of career planning. Physicians spend over a decade hyper-focused on the next clearly defined goal sometimes not even aware of the next goal (i.e. medical students learning about residency and the match in medical school) let alone paying any thought to more abstract goals after the training pipeline stops. You can't map out your whole life and things change along the way but the complete lack of long-term goal setting leaves so many people adrift in their own career and then surprised they aren't happy. For all the asinine interview questions about 10-year plans, I don't feel like actually having long-term career and life plans is at all emphasized in medicine. We spend to much of our time anxious about the next exam or application cycle. I don't think a stagnant career is bad for all people. Plenty are happy to have a stable consistent work life and pursue advancement and new goals outside of work. Other people want to continue to face new challenges and responsibilities at work. Either is fine. I think the problem is when you don't define what you want and find yourself just adrift with no real purposeful development in either your personal or professional life.

As a tie-back to point 1, I worry paying off debt has become sort of a surrogate hyper-focused career goal after residency? It's like we've carved out this pathologic pipeline where people work their ass off for 10 years to become emergency physicians and then immediately start working their ass off for another 10 years to get out of medicine without every really defining what it is they are trying to get out of life.

This is a great point. You're absolutely right. Most people that become doctors, especially EM docs have always had a goal in mind and a challenge to conquer. When this stops being the case, then what? I'm not sure what the answer to this is.

Is it more a matter of level setting expectations for the next generation?

 

[cyanide12345678]

This is a great point. You're absolutely right. Most people that become doctors, especially EM docs have always had a goal in mind and a challenge to conquer. When this stops being the case, then what? I'm not sure what the answer to this is.

Is it more a matter of level setting expectations for the next generation?

I felt this exact same thing after becoming attending.

I worked for a decade to get to that point. My life revolved around becoming a doctor for so long, and all of a sudden it was gone and over. I truly felt some emptiness for a little while. I found myself asking "now what?"

Maybe that's why i went down the entrepreneurial route after becoming an attending. It was my way of satisfying my intellectual curiosities.

Also, did you start working for a finance based company? Or just do trading/investments at home and make money doing so. Are you day trading/swing trading/option trading etc? How big of a portfolio did you need before you felt comfortable quitting medicine?

 

[UrbanEM2]

I went to a company. I wanted to be sure I'd be able to at least make as much as I was as an attending and would be able to build a full career. I used to trade stocks on my own, but didn't think it provided stable enough income. Maybe I was just too risk averse with my own money.

What are your entrepreneurial endeavors?

 

[deleted547339]

I went to a company. I wanted to be sure I'd be able to at least make as much as I was as an attending and would be able to build a full career. I used to trade stocks on my own, but didn't think it provided stable enough income. Maybe I was just too risk averse with my own money.

What are your entrepreneurial endeavors?

That will end well....everyone knows how to day trade in a bull market.

 

[Apollyon]

That will end well....everyone knows how to day trade in a bull market.

That sounds unduly harsh, and, actually, only tangential to the OP's point. Nothing that he wrote strikes me as "day trading". I mean, if you work for a company, you have to show success, or you're out of a job - and nothing succeeds like success. If this guy has been doing it for years, it doesn't sound like some kind of bubble, just waiting to burst.

 

[UrbanEM2]

That will end well....everyone knows how to day trade in a bull market.

What do you mean? I don't day trade and I've been doing this for over a decade. In fact what we do is as far from day trading as you can get. I would go as far as to say day traders are a bunch of amateurs and fools.

We do well in bull and bear markets around the world. The key is identifying misprices assets, whether too high or too low. But you are right, there is inherent risk in this job and most people do well in bull markets. Hedge funds go bust all the time so longevity is an indicator of consistent success in varying market conditions.

 

[deleted547339]

What do you mean? I don't day trade and I've been doing this for over a decade. In fact what we do is as far from day trading as you can get. I would go as far as to say day traders are a bunch of amateurs and fools.

We do well in bull and bear markets around the world. The key is identifying misprices assets, whether too high or too low. But you are right, there is inherent risk in this job and most people do well in bull markets. Hedge funds go bust all the time so longevity is an indicator of consistent success in varying market conditions.

“I used to trade stocks but it wasn’t stable enough.” Not “the expected return relative to an index was negative”.

 

[UrbanEM2]

“I used to trade stocks but it wasn’t stable enough.” Not “the expected return relative to an index was negative”.

Not really sure what you're getting at.

I may have misspoken. I meant I wasn't willing to trade enough of my own money to generate returns to feel comfortable. Also, the kind of investing I do now is very different than what a lay investor can do just given the scale and size of our funds. We take large positions is companies. which sometimes gives us the opportunity to be active vs passive investors.

The hedge fund world is a different beast. Not the same as investing your own money, though I'd argue a good investor is a good investor. The work we do as active investors is a totally different skillset, more in line with typical private equity investors.

 

[deleted547339]

Not really sure what you're getting at.

I may have misspoken. I meant I wasn't willing to trade enough of my own money to generate returns to feel comfortable. Also, the kind of investing I do now is very different than what a lay investor can do just given the scale and size of our funds. We take large positions is companies. which sometimes gives us the opportunity to be active vs passive investors.

The hedge fund world is a different beast. Not the same as investing your own money, though I'd argue a good investor is a good investor. The work we do as active investors is a totally different skillset, more in line with typical private equity investors.

We have fundamentally different world views that won’t be reconciled on this forum, so I don’t see the need to continue. I acknowledge that there are sectors where money can be made in PE, but suffice it to say that I don’t think there are “good investors.” I believe all the data supports me that over a long period of time an indexed approach will win out.

 

[UrbanEM2]

We have fundamentally different world views that won’t be reconciled on this forum, so I don’t see the need to continue. I acknowledge that there are sectors where money can be made in PE, but suffice it to say that I don’t think there are “good investors.” I believe all the data supports me that over a long period of time an indexed approach will win out.

We're actually on the same page on this. Most investors don't return more than a standard index.

Job is still a lot of fun though. Keeps my happy.

 

[HankTheTank910]

It's been said a couple times in this thread, but one of the things I struggled with after graduating residency was that notion of "no goals left to achieve." The day-to-day becomes just a job, and I discovered that this lack of something to be ambitious about caused a lot of of my emptiness that I felt with my professional life.

I don't think there's any easy remedy for this, but what's helped me immensely is looking for things outside of medicine to chase professionally. Over the last couple years I've really gotten into real estate- managing my properties, chasing deals, improving my properties, etc. It's not just a money thing- I do find enjoyment in these things. I hope in the future to own some apartment complexes and it's the building toward these things that exciting and fulfilling (professionally as well as financially). My wife and I are also talking about a couple business ideas that we think would be both fun and fulfilling.

You may not like real estate, and you may not want to start a business- that's fine! Find something professionally that interests you and pursue it. As high income earners that don't work 80 hours a week we have both the time and capital to give us the freedom to pursue other ventures. I still enjoy EM and don't envision myself leaving clinical work anytime soon, but I now use all that extra income to help fund my other professional life, and it's helped improve my quality of life immensely.

Just my $0.02.

 

[sloh]

It's been said a couple times in this thread, but one of the things I struggled with after graduating residency was that notion of "no goals left to achieve." The day-to-day becomes just a job, and I discovered that this lack of something to be ambitious about caused a lot of of my emptiness that I felt with my professional life.

I don't think there's any easy remedy for this, but what's helped me immensely is looking for things outside of medicine to chase professionally. Over the last couple years I've really gotten into real estate- managing my properties, chasing deals, improving my properties, etc. It's not just a money thing- I do find enjoyment in these things. I hope in the future to own some apartment complexes and it's the building toward these things that exciting and fulfilling (professionally as well as financially). My wife and I are also talking about a couple business ideas that we think would be both fun and fulfilling.

You may not like real estate, and you may not want to start a business- that's fine! Find something professionally that interests you and pursue it. As high income earners that don't work 80 hours a week we have both the time and capital to give us the freedom to pursue other ventures. I still enjoy EM and don't envision myself leaving clinical work anytime soon, but I now use all that extra income to help fund my other professional life, and it's helped improve my quality of life immensely.

Just my $0.02.

“Most of the positive emotion that people feel is not associated with the accomplishment of a goal. It is associated with the pursuit of a goal. That means: no goal, no positive emotion. This also implies that the higher and more elevated the goal, the more emotional power there is in the realization that you’re moving towards it. So, one of the things you want to do is to formulate, a, what I would say, profound metaphysical vision that is practical.

Your vision is about your career path, friendships, intimate relationships, your family, activities outside work, your mental and physical health, your character. You need to think about all those things and you need to integrate them into a vision of who you could be.

Then it has to be a vision that speaks to you. The vision says something like ‘if I could be this and have this then that would fully justify my conditions of existence’. Your vision has to be sufficiently compelling. You have to be able to believe in it. That lends to all of your endeavors the power of that vision. It also makes you less anxious. Because one of the reasons that people get anxious is because they’re uncertain, and one of the ways out of uncertainty is to define your pathway forwards." —Jordan Peterson

At 32, most of my peak experiences occur when I find myself returning to flow states. We have all experienced these states as children, and I argue that one of the greatest challenges of adulthood are rediscovering these pursuits (usually will be different from the ones we had as children but nonetheless are there for the taking) as we get older to fight off tedium, ennui, entropy, and nihilism. I won’t deny the appeal of hedonism and acceptance, but they pale in comparison to what Waitzkin expounds on here:

“Before first-round play began I was seated at my board, deep in thought about my opening preparation, when the public address system announced that the subject of Searching for Bobby Fischer was at the event. A tournament director placed a poster of the movie next to my table, and immediately a sea of fans surged around the ropes separating the top boards from the audience. As the games progressed, when I rose to clear my mind young girls gave me their phone numbers and asked me to autograph their stomachs or legs.

This might sound like a dream for a seventeen-year-old boy, and I won’t deny enjoying the attention, but professionally it was a nightmare. My game began to unravel. I caught myself thinking about how I looked thinking instead of losing myself in thought. The Grandmasters, my elders, were ignored and scowled at me. Some of them treated me like a pariah. I had won eight national championships and had more fans, public support and recognition than I could dream of, but none of this was helping my search for excellence, let alone for happiness.

At a young age I came to know that there is something profoundly hollow about the nature of fame. I had spent my life devoted to artistic growth and was used to the sweaty-palmed sense of contentment one gets after many hours of intense reflection. This peaceful feeling had nothing to do with external adulation, and I yearned for a return to that innocent, fertile time. I missed just being a student of the game, but there was no escaping the spotlight. I found myself dreading chess, miserable before leaving for tournaments. I played without inspiration and was invited to appear on television shows. I smiled.

Then when I was eighteen years old I stumbled upon a little book called the Tao Te Ching, and my life took a turn. I was moved by the book’s natural wisdom and I started delving into other Buddhist and Taoist philosophical texts. I recognized that being at the pinnacle in other people’s eyes had nothing to do with quality of life, and I was drawn to the potential for inner tranquility.”

 

[UrbanEM2]

“Most of the positive emotion that people feel is not associated with the accomplishment of a goal. It is associated with the pursuit of a goal. That means: no goal, no positive emotion. This also implies that the higher and more elevated the goal, the more emotional power there is in the realization that you’re moving towards it. So, one of the things you want to do is to formulate, a, what I would say, profound metaphysical vision that is practical.

Your vision is about your career path, friendships, intimate relationships, your family, activities outside work, your mental and physical health, your character. You need to think about all those things and you need to integrate them into a vision of who you could be.

Then it has to be a vision that speaks to you. The vision says something like ‘if I could be this and have this then that would fully justify my conditions of existence’. Your vision has to be sufficiently compelling. You have to be able to believe in it. That lends to all of your endeavors the power of that vision. It also makes you less anxious. Because one of the reasons that people get anxious is because they’re uncertain, and one of the ways out of uncertainty is to define your pathway forwards." —Jordan Peterson

At 32, most of my peak experiences occur when I find myself returning to flow states. We have all experienced these states as children, and I argue that one of the greatest challenges of adulthood are rediscovering these pursuits (usually will be different from the ones we had as children but nonetheless are there for the taking) as we get older to fight off tedium, ennui, entropy, and nihilism. I won’t deny the appeal of hedonism and acceptance, but they pale in comparison to what Waitzkin expounds on here:

“Before first-round play began I was seated at my board, deep in thought about my opening preparation, when the public address system announced that the subject of Searching for Bobby Fischer was at the event. A tournament director placed a poster of the movie next to my table, and immediately a sea of fans surged around the ropes separating the top boards from the audience. As the games progressed, when I rose to clear my mind young girls gave me their phone numbers and asked me to autograph their stomachs or legs.

This might sound like a dream for a seventeen-year-old boy, and I won’t deny enjoying the attention, but professionally it was a nightmare. My game began to unravel. I caught myself thinking about how I looked thinking instead of losing myself in thought. The Grandmasters, my elders, were ignored and scowled at me. Some of them treated me like a pariah. I had won eight national championships and had more fans, public support and recognition than I could dream of, but none of this was helping my search for excellence, let alone for happiness.

At a young age I came to know that there is something profoundly hollow about the nature of fame. I had spent my life devoted to artistic growth and was used to the sweaty-palmed sense of contentment one gets after many hours of intense reflection. This peaceful feeling had nothing to do with external adulation, and I yearned for a return to that innocent, fertile time. I missed just being a student of the game, but there was no escaping the spotlight. I found myself dreading chess, miserable before leaving for tournaments. I played without inspiration and was invited to appear on television shows. I smiled.

Then when I was eighteen years old I stumbled upon a little book called the Tao Te Ching, and my life took a turn. I was moved by the book’s natural wisdom and I started delving into other Buddhist and Taoist philosophical texts. I recognized that being at the pinnacle in other people’s eyes had nothing to do with quality of life, and I was drawn to the potential for inner tranquility.”

You're in the wrong profession. You should be a writer or something. All this went way over my head.

Whatever it is, sounds like you've figured things out at a young age. Kudos!

 

[Angry Birds]

UrbanEM2, I am jealous of you.
I am still planning my exit and watch this video every six months to motivate me:

 

[doctalaughs]

We're actually on the same page on this. Most investors don't return more than a standard index.

Job is still a lot of fun though. Keeps my happy.

Have a bunch of friends that either do PE or work at hedge funds.

Seems like (for some) they can make a stupid amount of money, but whenever I get into a conversation with them I can’t help but think they are basically operating a legal Ponzi scheme- moving around money, taking from suckers and creating zero actual value for society.

For example, PE companies on the medical side seem to basically artificially pump up values in companies while squeezing money out of consumers (patient premiums) and doctors (producers of the goods) and then sell before everything collapses.

Am I wrong? Do PE and hedge funds actually do something redeeming for our economy or serve any long term purpose (other than enriching the owners)? Can a efficient capitalist economy function without these vehicles (or replace them with something else)?

Not saying I wouldn’t do the same if I could! It’s obviously the way things are right now, so kudos to those that can take advantage.

 

[beekle]

Have a bunch of friends that either do PE or work at hedge funds.

Seems like (for some) they can make a stupid amount of money, but whenever I get into a conversation with them I can’t help but think they are basically operating a legal Ponzi scheme- moving around money, taking from suckers and creating zero actual value for society.

For example, PE companies on the medical side seem to basically artificially pump up values in companies while squeezing money out of consumers (patient premiums) and doctors (producers of the goods) and then sell before everything collapses.

Am I wrong? Do PE and hedge funds actually do something redeeming for our economy or serve any long term purpose (other than enriching the owners)? Can a efficient capitalist economy function without these vehicles (or replace them with something else)?

Not saying I wouldn’t do the same if I could! It’s obviously the way things are right now, so kudos to those that can take advantage.

The owner of a company can make a big difference in its value. A PE firm can often bring in expertise to increase profits in ways that the current owners can’t, for example by increasing reimbursement, optimizing revenue cycle, or reducing expenses. Often other companies in the firms portfolio help augment this. These methods are not artificially pumping up value - they actually make the company more profitable and therefore more valuable. Sometimes they can be exploitative - like air medical transport companies that have used surprise medical billing to pump up revenue. Sometimes they just take advantage of underlying trends, like acquiring a CMG in anticipation of physician oversupply reducing labor costs. There are some shady tactics that give PE a bad name but in at least some cases, they genuinely improve companies after acquisition.