M4 Considering Specialty Switch (EM -> FM), Advice Please

[caskettcase94]

I’m an M4 in need of some advice about choosing a different specialty this late in the game (2 months before ERAS due :O). I don’t have a lot of great resources to go to at my school currently as I’d like to not damage my reputation with the department of the specialty I was planning to apply to. Here’s the scenario:

I worked as an ER scribe before med school which is where I first caught the EM bug. I love the variety and pace of EM – I can’t stand downtime while I’m at work. I love seeing a bunch of patients with different pathologies and hearing their crazy stories about how they ended up there, doing a few procedures here and there, and then going home and truly being done with responsibilities for the day (other than notes of course).

I just finished my home school sub-I in EM and am now having a lot of second thoughts. Nearly every resident or attending’s criticism for me was that I was doing a good job thinking through patients/DDx but was spending way too long trying to understand each patient’s case. The “just stabilize and disposition the patient” mentality really got to me after a while. A part of me does care what the actual diagnosis is, not just ruling out the life-threatening ones. It began to feel like every workup for each general ED chief complaint was the same without as much academic rigor as I would’ve liked. I like spending time educating patients, and I care what happens to them when they go upstairs or go home. I also started to find it exhausting to be meeting every single patient for the first time. Finally, I greatly underestimated the toll the shift work would take on my physical/mental wellbeing. Ultimately, I’m becoming highly concerned that I just don’t “fit” with the EM mentality.

I’m now having last-minute thoughts about jumping ship to family medicine as it seems to be a good balance of the pros and cons of EM for me. Breadth of medicine, some undifferentiated patients without it being every single encounter, opportunities for more focused patient education, continuity of care, and some flexibility in terms of shaping a practice to do a little more and less of what you like and don’t like as your interests evolve further in your career. I like seeing a little bit of MSK, peds, and OB and would primarily like to work in an outpatient setting if I were to do FM, which to me makes FM a better choice for me than IM. I’ve considered EM/FM programs, but everyone seems to state that it is very difficult to truly practice both (in terms of both working in a level 1 trauma center and having an outpatient clinic) and just adds extra years of training. I know FM docs can do EM at rural centers, but this is not really something I’m interested in.

The problem now is that it’s almost July of my M4 year, and my entire application has been prepped for EM. I’ve got 2 EM away rotations scheduled at “good” programs, and had been planning on getting SLOEs for EM and not really having to worry about individual physicians writing LORs. In order to apply to EM, I need one more SLOE at least. I have this slight hope that maybe just doing EM somewhere else will help me “fall back in love” so to speak, and then I would ensure I have the 2 SLOEs I need and the rest of this mess would go away. However, another part of me says I’m already 75% convinced against EM, so am I just wasting time verifying what I already know, and do I need to just get back to my home school and do a sub-I in FM earlier? I currently only have 1 potential FM LOR writer and would like to have a second plus one letter from an EM provider if I apply FM.

Thanks for reading this incredibly long post. I know the internet can’t tell me what to do, but I really value hearing others opinions - Maybe someone who was in a similar situation or can offer a different perspective. I never expected to be this conflicted this late in the game. It probably doesn’t matter for this scenario, but for what it’s worth: Step 1: 26X, honors on M3 rotations (not trolling here).

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[mistafab]

Hey - both EM and FM are great fields. I think it is perfect that you are really thinking about this now - better now than 2 years into your residency, or 5 years into your career!

I would set up a meeting with an FM advisor at your school ASAP and discuss this. If you’re not physically there, maybe a phone or skype meeting. Best of luck!

 

[Drrrrrr. Celty]

Get a LOR from some FM faculty at your school or hospital. Dual apply FM. Decide in February whether you still have second thoughts or like one more than the other. Even with a couple FM interviews you'll probably find yourself likely to match, otherwise soaping into FM isn't difficult.

My personal experience is that I wish I had dual applied last year because by the time I was in late November and realizing just how much I was in the wrong field, there wasn't really much I could do anymore about it.

It still worked out for me and I'm pretty blessed with just how well it did.

 

[caskettcase94]

Hey - both EM and FM are great fields. I think it is perfect that you are really thinking about this now - better now than 2 years into your residency, or 5 years into your career!

I would set up a meeting with an FM advisor at your school ASAP and discuss this. If you’re not physically there, maybe a phone or skype meeting. Best of luck!

I am definitely working on setting up meetings with advisors. Thank you!

 

[libertyyne]

I would seriously consider IM instead of FM. It seems like you appreciate the cerebral nature of working up a case, and IM would keep doors open for inpatient as well as outpatient practice through out the country. The only downside would be ob aspect.

 

[sanfran256]

I second considering IM. Have you considered Pulm/Crit or rotated in an ICU? It seems perfect for you- fast paced but also has the cerebral aspect since it is your patient you also have time to figure out exactly what is going on .

 

[caskettcase94]

I would seriously consider IM instead of FM. It seems like you appreciate the cerebral nature of working up a case, and IM would keep doors open for inpatient as well as outpatient practice through out the country. The only downside would be ob aspect.

I agree with what you're saying, but as weird as it sounds I mostly disliked my hospital ward months. I seem to like both the ED and the clinic much more than the inpatient setting. I like thinking through cases, but I also like the instant gratification of finding a problem and working on a plan in a limited visit (either in ED or office setting) as my attention span is pretty short. I just think I like the additional breadth of treating a patient's disease over a longer scope than just in the ED. I've thought about EM/IM or EM/FM combined training in order to be able to practice outpatient clinical medicine WITH ED shifts, but it sounds like this is nearly impossible to do - clinic patients expect you to be working most days and administratively you'd have to have 2 different positions and would likely be unable to get benefits if you were doing part-time of both. I know if you do rural FM you can possibly do both, but you'd be limited to rural EDs. This would not be what I'd want unfortunately.

 

[AMEHigh]

Well you could soap into family med, so I wouldn't worry about not matching. But I wouldn't let attending/resident criticism deter you from EM. When you're a resident you can do whatever you want as long as you do your job well.

The bolded isn’t necessarily true, especially when it comes to the ED.
The OP said they enjoy getting to know people, a full work up and the diagnosis. You won’t have an ED job for long if you’re keeping every patient in the ED for hours upon hours and spending 30 minutes on discharge education. The ED is about triage and who is sick and who isn’t.

OP I was never 100% interested in ED but thought I’d like it more than I did. Similar to the reasons you mention. I also didn’t like my first FM rotation because that doctor seemed to refer most of his patients to specialists.

But I ended up seeing the beauty of FM for all the reasons you mention and I’m so glad I chose this specialty. I’m ultimately not going to do just "normal" outpatient work. However that’s also the beauty of FM in that the job opportunities are endless to fit your interests. I just finished residency and all 6 of us that just finished are doing completely different things.

Even with the pressures of corporate medicine you really do get to know your patients, build relationships with them and help shape their lives/health.

I would definitely try to do another FM rotation (2 week rotations are ok too) and then apply. Of course you can soap in to a FM program but you want to try to go somewhere you think you’d enjoy and give you the experience you’re looking to have. Good luck!

 

[zero0]

FM may be the most underrated specialty in medicine right now. EM is quite possibly the most overrated. As someone personally waffling between anesthesiology and FM I fully support the switch.

I also heavily considered EM at one point. In the end, I just couldn't justify dealing with all the crap they deal with for the extra 100 an hour. Also, those EM salaries are beginning to stagnate and may very well start to drop soon as EM residencies pump out more and more grads each year. Locums isn't as lucrative as it once was and EDs are starting to see more midlevel presence. The high salaries are all EM had for a while and pretty soon they may not even have that. This is just my opinion, but I had my finger on the pulse of that field for a while and just did not like what I saw. I just can't recommend it.

 

[caskettcase94]

FM may be the most underrated specialty in medicine right now. EM is quite possibly the most overrated. As someone personally waffling between anesthesiology and FM I fully support the switch.

I also heavily considered EM at one point. In the end, I just couldn't justify dealing with all the crap they deal with for the extra 100 an hour. Also, those EM salaries are beginning to stagnate and may very well start to drop soon as EM residencies pump out more and more grads each year. Locums isn't as lucrative as it once was and EDs are starting to see more midlevel presence. The high salaries are all EM had for a while and pretty soon they may not even have that. This is just my opinion, but I had my finger on the pulse of that field for a while and just did not like what I saw. I just can't recommend it.

Do you think you'll end up dual applying? Can I ask what your general thought process has been for FM that makes it so "underrated?" I'm just not sure I can make a decision within the next 2 months. I'm now planning to do one away for EM and do 1 home rotation in FM.

 

[InternistDO]

Do you think you'll end up dual applying? Can I ask what your general thought process has been for FM that makes it so "underrated?" I'm just not sure I can make a decision within the next 2 months. I'm now planning to do one away for EM and do 1 home rotation in FM.

FM has been the shat-on specialty (especially online) for years. The idea that if you do poorly on Step 1 you'll be forced to do FM, where you'll make no money, working bad hours, and all you do is insurance bullcrap and refer patients to specialists so they can do the Real Medicine.

Except in reality you can work 4 days a week (normal weekdays during the day), make a perfectly reasonable to very good physician salary--lots of jobs in NYC start at above 200k, which means everywhere else in the country they make more than that (and of course there's always private practice). You can work up your patients as much as you want before sending them off to the subspecialist, and you can do inpatient or outpatient or both, depending on your level of craziness. And you can get a job literally anywhere in the US with almost no effort, with minimal risks of market saturation or things like that.


I agree with what @zero0 says about EM, though I'm applying EM anyway because I'm a crazy person. I think the big salaries are going to drop but the schedules and workload are going to stay the same, though I think EM is too punishing of a job for it to ever get really saturated like path or rad onc--people will quit the field or drop their hours real low if it gets that bad.

 

[hallowmann]

I agree with what you're saying, but as weird as it sounds I mostly disliked my hospital ward months. I seem to like both the ED and the clinic much more than the inpatient setting. I like thinking through cases, but I also like the instant gratification of finding a problem and working on a plan in a limited visit (either in ED or office setting) as my attention span is pretty short. I just think I like the additional breadth of treating a patient's disease over a longer scope than just in the ED. I've thought about EM/IM or EM/FM combined training in order to be able to practice outpatient clinical medicine WITH ED shifts, but it sounds like this is nearly impossible to do - clinic patients expect you to be working most days and administratively you'd have to have 2 different positions and would likely be unable to get benefits if you were doing part-time of both. I know if you do rural FM you can possibly do both, but you'd be limited to rural EDs. This would not be what I'd want unfortunately.

Don't do EM. It just doesn't sound like what you want. FM is good, just make sure you like OB and Peds. If you don't like OB, then aim for a program that doesn't do a lot of OB. Some programs have a bigger emphasis on inpatient, others outpatient, some emphasize the ED, some don't. There's a lot of option when it comes to FM and FM programs with varied strengths and weaknesses.

EM is a great specialty if you love it, but despite considering it, I found myself hating it for the reasons you described, and after actually experiencing it as a resident and not a student, I can assuredly say that I am relieved I'm not doing it.

 

[zero0]

Do you think you'll end up dual applying? Can I ask what your general thought process has been for FM that makes it so "underrated?" I'm just not sure I can make a decision within the next 2 months. I'm now planning to do one away for EM and do 1 home rotation in FM.

I'm not sure exactly what I'll do. I'm still waiting on Step 2 scores. Assuming that's on par with both fields, I have 3 gas rotations lined up back to back July-September since I needed letters (already have 1 for FM). Once I do those, I'll have a better idea of if I even want to do anesthesiology. My exposure so far has been pretty limited.

The decision to specialize is a personal one in every case, there's no universal rule of this specialty is better than this one so you should do it, so I'll tell you what I like about FM. In my neck of the woods, there's just not that many gas residencies. I just got married and my wife and I want to stay close to family. There's 20 FM residencies within a stone's throw of where we are. We sat down and got to talking about it and decided that the extra 100k from working gas just won't really change our lives that much. I'd rather have a better work/life balance during residency and after to spend time with family. Or I can choose to work more and still make a ton. What I like most is the versatility of FM. It's a specialty where you can still be your own boss. You can do inpatient, pick up EM shifts, do nursing home, hell you can open a hair loss clinic and do exclusively cosmetics. Point is, you can build the kind of practice that you want and between all of the options that are out there a setup exists to make everybody happy. You just don't get that kind of versatility in most other fields where you're contracted by a hospital and have very little control of where and how much you work. And if you lose your job or a contract with the hospital, that can be it for you in that area and you have to move. It's just a more stable field than many things out there right now. Midlevels will always be a thing but every FM doc in town I know has a 3 month wait. No one wants to see a PA/NP if they can help it and everyone still prefers a doctor when insurance charges them the same. You don't get to choose who you see at the ED and most people think anesthesiologists are nurses anyway. Those are just a few reasons off the top of my head.

 

[nimbus]

We sat down and got to talking about it and decided that the extra 100k from working gas just won't really change our lives that much.

FYI on average at this time the difference is over 200k. They are completely different jobs. Do what fits best. No amount of money is worth doing something you don’t enjoy.

 

[Splenda88]

FYI on average at this time it’s more like 200k. But do what fits best. No amount of money is worth doing something you don’t enjoy.

200k/year is a lot of money, to be honest... But I agree that people should do what they enjoy...

If you can see yourself enjoying another specialty where you can make substantially more, go for the $$$.

 

[backpackpalsy]

I had the same problem recently and ended up picking FM. I was initially set on EM but as I slogged through 2 months of EM rotations, I realized the cover your ass mentality and ****ty shift work weren't worth the extra money for me. A lot of my EM attendings were pretty jaded and talked openly about their burnout and exit strategy to work in pain clinics or urgent care once they hit mid 40s. For what it's worth, I have similar stats to you on step and rotations so don't let people tell you you're wasting your talents or a good board score or some BS.

As my rotations were scheduled with EM in mind, I ended up getting two 2-week FM rotations this month to show interest. For LORs, I will have an FM letter from my core rotation, a letter from an IM/Peds doc from my peds rotation, and a letter from one of my EM rotations explaining how I did a great job in EM but decided to pursue FM. That way programs don't think I'm just applying FM as an afterthought or backup. I'm also planning to attend the national AAFP conference at the end of this month to start looking at programs. The rotations I'm on now aren't really set up in a way to allow for another LOR in FM, but the department chair says he could write a letter based on our meetings and end of rotation comments to really bring home the point if needed.

I've already sat down with several EM and FM advisors to get advice on the topic so feel free to PM me if you want more info on any of the advice I've gotten so far.

 

[ACSurgeon]

As someone who is finally on the other side and done with training let me weigh in.

- you won’t truly know if a field is a good fit until you’re in it. Sometimes you’ll know for sure it’s a bad fit. Those who are happy in life are those who make the most out of what they have and don’t always look at the other side thinking the grass is greener.

- regarding money. There is good money in medicine. This can change at any moment. You’ll be bitter if money/lifestyle is the main driving force. I’ll tell you I’m making more money while have a much better lifestyle as a general surgeon/intensivist than I ever thought possible when I was a student or even resident. It’s a win-win for me because I get to do what I like and get paid well for it. I truly believe I would have still been happy if the money and lifestyle were as bad as I expected coming into surgery.

- family medicine doctors have to work really hard to make subspecialty type of money (large volume of patients per day). That said, it seems much easier to own your practice as a FM doctor. Some open multiple clinics and put APPs and make good money without having to work all that much. You have to be business savvy and I often wonder if these successful businessmen are also good doctors or if their clinics provide good care. Nonetheless, given how difficult it would be for me as a general surgeon to start my own practice in my city where 100% of surgeons are employed, it seems nice to have the option of being self employed.

Ultimately your main goal should be finding a field that you can enjoy for the next 30 years. Part of enjoying a field is having an acceptable work life balance and being paid well enough. That last part is different for different people. Some academic surgeons who spend 10 years in residency/fellowship/research before finally becoming an attending are taking jobs barely paying more than an internist who completed their training in a fraction of the time and with less rigor. Different strokes for different folks.

Disclaimer: not knocking internists. But the fact remains that if you wait an extra 5-7 years before you start making money, paying back loans, saving for retirement, well, then you’re really behind financially.

 

[Tenk]

OP, to give you a different perspective, you can make about $200,000 in EM working six 12 hour shifts a month. In other words, you can enjoy 24 days off in EM making about the same money as FM.

 

[Atlas Shrugged]

OP, to give you a different perspective, you can make about $200,000 in EM working six 12 hour shifts a month. In other words, you can enjoy 24 days off in EM making about the same money as FM.

And deal with increased liability (you WILL get sued vs you may get sued), circadian rhythm disruption, no weekends/holidays, and requiring a hospital to work (yes, there are free standing EDs but this is the minority).

Family medicine is one of the few specialties that you don’t actually need any ancillary staff. Check out direct primary care.

I really thought about emergency medicine, and really like working in the ED with emergent patients, but they are so few and far in between— at least in the military healthcare system. For some reason pharyngitis and other low acuity problems really piss me off in the ED when I’m happy to see it in clinic.

 

[Tenk]

And deal with increased liability (you WILL get sued vs you may get sued), circadian rhythm disruption, no weekends/holidays, and requiring a hospital to work (yes, there are free standing EDs but this is the minority).

Family medicine is one of the few specialties that you don’t actually need any ancillary staff. Check out direct primary care.

I really thought about emergency medicine, and really like working in the ED with emergent patients, but they are so few and far in between— at least in the military healthcare system. For some reason pharyngitis and other low acuity problems really piss me off in the ED when I’m happy to see it in clinic.

Part time workers really don’t have to work much holidays (if any) and usually don’t work much nights (if any) so no disruption. If you do locums for one week a month you can literally pick your schedule every month.

Can’t argue much about the low acuity bs though. I don’t think malpractice risk should dissuade anyone from a specialty though except for OB since their statute of limitations is so damn long.

 

[IntheClouds4ever]

Go FM.. You may end up liking a smaller ER in rural area that sees 30-40K patients/year, or you can do hospitalist work, urgent care, or clinic work as well as medical director work for nursing homes and other medical entities, or some combination thereof. Anyone who is making <200K in FM is doing so by choice or complete lack of any business acumen. .