Making a Career Out of Coomunity EM - The Early Years

[Arcan57]

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There are a lot of senior residents that are starting or in the middle of their job search right now. We've had a lot of threads inquiring about the existence of extraordinarily non-typical schedules or payment structures. They exist, but most of you aren't going to be in them. Given the job market today, it's likely your first employer is going to be a CMG and most of you are going to be full-time (which will vary by around 40hrs/mo depending on who's defining it). You've heard the people that are 10+ years out and you're worried about burn-out, so you're trying to come up with some strategy that's differerent from those old-timers so you don't have the same happen. But at least early on, the answer isn't to only work 4 shifts per month or to work 28 shifts/mo and pay off your loans in the first 6 months. Below are some of the things that help make clinical EM a career in the early stages (I'm 5 yrs out currently so have no qualifications to speak about long-term):

1) Invest your time and interest into the job - no matter which residency you're coming out of, there are things you're going to learn as an attending that you weren't taught. Keep learning and keep trying to be a better doctor. This helps maintain a sense of personal satisfaction in what you do, which helps fight the burnout from depersonalization and emotional exhaustion.

2) Don't act like you're burned out before you even start - that strategies that are adaptive for a mid-career doc whose been dealing with the burn for a decade are mal-adaptive for someone just starting out. If you're not working enough shifts in a busy enough environment then you're never going to be able to be successful in a high-acuity environment later in your career. As a corollary, no one with a choice wants a part-time new grad.

3) Don't accept a job where the scheduler doesn't make an attempt at a Circadian schedule. Your quality of life working 14 shifts per month can be great with a good scheduler or absolutely miserable (working lots of Saturday overnights, multiple DOMAs per month, flipping from swing back to am next day, etc). At the same time, don't have so many schedule requests that the only way to cram a FT schedule in is to have a horrible schedule.

4) Go in to your shift fresh - this makes a huge difference in your satisfaction during the shift but it's also the hardest to pull of consistently. If you're going to make a career out of EM, accept that the shifts are hard and that you need time for rest before and (to a lesser extent) after. Have an honest talk with your spouse regarding what is and isn't reasonable to expect on days you're working. Nobody but you is going to know what it feels like to short yourself on sleep continuously. And when you're tired and cranky this job sucks.

5) Get involved - get on a committee and actually go to it. Have a passable understanding of hospital politics. Develop relationships with your consultants. Just like you learned in residency, you get no points for just identifying the problem. If you're willing to help be part of the solution than you'd be suprised what can improve in the ED (even staying budget neutral).

 

[The White Coat Investor]

Great post! Couldn't agree more (7 years out, 4 with the military, 2 as a pre-partner and 1 as a partner in a small democratic group.)

Whether or not you work for a CMG is highly dependent on location.

 

[Arcan57]

Great post! Couldn't agree more (7 years out, 4 with the military, 2 as a pre-partner and 1 as a partner in a small democratic group.)

Whether or not you work for a CMG is highly dependent on location.

Agreed. Although I think the figure I heard quoted was that TH alone scooped up about 25% of the graduating residents from 2012.

Can you speak about what it was like going through the partnership track and what your current level of involvement in the operations of the group is? Did your mindset change when you became a partner? All the places I've worked have either been dominated by CMGs or had one guy that held the contract.

 

[Hercules]

1) Invest your time and interest into the job - no matter which residency you're coming out of, there are things you're going to learn as an attending that you weren't taught. Keep learning and keep trying to be a better doctor. This helps maintain a sense of personal satisfaction in what you do, which helps fight the burnout from depersonalization and emotional exhaustion.

2) Don't act like you're burned out before you even start - that strategies that are adaptive for a mid-career doc whose been dealing with the burn for a decade are mal-adaptive for someone just starting out. If you're not working enough shifts in a busy enough environment then you're never going to be able to be successful in a high-acuity environment later in your career. As a corollary, no one with a choice wants a part-time new grad.

3) Don't accept a job where the scheduler doesn't make an attempt at a Circadian schedule. Your quality of life working 14 shifts per month can be great with a good scheduler or absolutely miserable (working lots of Saturday overnights, multiple DOMAs per month, flipping from swing back to am next day, etc). At the same time, don't have so many schedule requests that the only way to cram a FT schedule in is to have a horrible schedule.

4) Go in to your shift fresh - this makes a huge difference in your satisfaction during the shift but it's also the hardest to pull of consistently. If you're going to make a career out of EM, accept that the shifts are hard and that you need time for rest before and (to a lesser extent) after. Have an honest talk with your spouse regarding what is and isn't reasonable to expect on days you're working. Nobody but you is going to know what it feels like to short yourself on sleep continuously. And when you're tired and cranky this job sucks.

5) Get involved - get on a committee and actually go to it. Have a passable understanding of hospital politics. Develop relationships with your consultants. Just like you learned in residency, you get no points for just identifying the problem. If you're willing to help be part of the solution than you'd be suprised what can improve in the ED (even staying budget neutral).

Great post, Arcan! I'm a little over 4 years out with all my time spent with a SDG. Partner for the past 3 years. Agree with almost everything.

I would add to #3 though that flexible scheduling may be even more important to you then circadian. My group's schedule really revolves around requests 1st and circadian 2nd. Some groups are so strict with their circadian scheduling that it can be very difficult to get off for the events you want (birthdays, school play, social events, trips, etc.). I have never been denies a request in 4 years.

I also think #5 is huge. It helps get you plugged into the hospital community and makes those 3AM calls to consultants go a lot smoother when they've spent time around you in nonclinical committee settings. It also helps for the admin of your hospital to see you putting effort into solving hospital problems. If you do ever have a concern to bring to them, they're less likely to write you off as a whiner.

On your partner question, I don't really have anything else to compare to other than my moonlighting experience, but it does give things more of a small business owner feel instead of an employee feel. This could be good or bad depending on your personality (it's good for me).

 

[Arcan57]

Great post, Arcan! I'm a little over 4 years out with all my time spent with a SDG. Partner for the past 3 years. Agree with almost everything.

I would add to #3 though that flexible scheduling may be even more important to you then circadian. My group's schedule really revolves around requests 1st and circadian 2nd. Some groups are so strict with their circadian scheduling that it can be very difficult to get off for the events you want (birthdays, school play, social events, trips, etc.). I have never been denies a request in 4 years.

I also think #5 is huge. It helps get you plugged into the hospital community and makes those 3AM calls to consultants go a lot smoother when they've spent time around you in nonclinical committee settings. It also helps for the admin of your hospital to see you putting effort into solving hospital problems. If you do ever have a concern to bring to them, they're less likely to write you off as a whiner.

On your partner question, I don't really have anything else to compare to other than my moonlighting experience, but it does give things more of a small business owner feel instead of an employee feel. This could be good or bad depending on your personality (it's good for me).

Having just had to put the requests vs. circadian to a vote during the summer, there's definitely pros and cons to each. The one thing you don't want to be is someone with almost no off requests in a groups that's prioritized them. This essentially guarantees you a crappy schedule (which everyone else is cool with because they asked for 10-15 days off that month) without the payoff.

Also, I don't think a schedule has to be a rolling day-swing-night-off block in order to be Circadian. I generally find the schedule tolerable if

1) I'm progressing forward in time (5a->9a, 1p->6p)
2) I have 4 or fewer shifts in a row
3) If working nights, I have at least 2 days before my next clinic shift or 3 days if working 4 nights in a row.
4) I don't do the swing or night shifts then try to attend admin meetings.

I've broken all of these rules while scheduling myself, but I find if I do that more than a couple of times a month that usually ends up with me getting sick or spending a week feeling like I'm being rubbed with sandpaper everytime I have to interact with someone.

Although it doesn't apply to everyone, I think there's a sixth pillar of happiness in community EM:

6) Don't get divorced - obviously some of us will choose our initial mates poorly, but unless you just completely f'ed up your choice of spouses, put in the time and effort to keep the partnership together. Nothing is as ubiquitous (not even the wanting to retire student loans early) as a cause for ignoring the first 5 rules as an early to mid-career divorce. Dealing with losing half your assets as well as the vagaries of visitation rights leads to a much higher risk of agreeing to situations that guarantee burn-out.

Just because EM gives you the flexibility to do a certain schedule doesn't mean it's advisable or that it's sustainable for a career.

 

[namethatsmell]

This is very helpful stuff, thanks for taking the time and initiative to post it.

How feasible is it to work in the community if you're double-boarded and want to actively work in both fields? I've known EM-CC, EM-Occ med, and EM-sports med docs who split their time about 50-50 but they've all been at very academic places where EM and the other respective department worked to blend things into a single, reasonable schedule. Is something like this too much of a headache for schedulers in the community to want to deal with?

 

[Croooz]

Awesome stuff. You should get banned more often. 🙂

EM is all the rage and precisely because the majority seem to believe they'll be able to work 8 hours per week. In the past month I've spoken to premeds, med students, and a few residents who can't wait to become attendings so they could work just enough to not work. I understand this generation wants to spend more time with family than working but the ones I'm encountering seem a bit delusional about what that will entail.

 

[Birdstrike]

Awesome stuff. You should get banned more often. 🙂

EM is all the rage and precisely because the majority seem to believe they'll be able to work 8 hours per week. In the past month I've spoken to premeds, med students, and a few residents who can't wait to become attendings so they could work just enough to not work. I understand this generation wants to spend more time with family than working but the ones I'm encountering seem a bit delusional about what that will entail.

Yes. LOL. Please direct them to Birdstrike U., particularly my posts on the "$200/hr" thread. The whole concept is "dead on arrival" from an accounting and economic standpoint but...whatever. Some people are determined to learn the hard way.

http://forums.studentdoctor.net/showthread.php?t=1030551

 

[Arcan57]

This is very helpful stuff, thanks for taking the time and initiative to post it.

How feasible is it to work in the community if you're double-boarded and want to actively work in both fields? I've known EM-CC, EM-Occ med, and EM-sports med docs who split their time about 50-50 but they've all been at very academic places where EM and the other respective department worked to blend things into a single, reasonable schedule. Is something like this too much of a headache for schedulers in the community to want to deal with?

I couldn't offer you a month on-month off schedule right now because I don't have enough docs to absorb having to cover 12 shifts on the months you were off. I could easily cram in a part-time (say 6-8 shifts) into 2 weeks each month. You're ability to split by month is going to depend on whether there are enough docs to flex during your off months. If you can alternate with another provider then you're done. Otherwise you need a group with a bunch of docs since docs seem resistant to flexing up more than one shift from their baseline unless it's for an emergency. In fact, you probably need somewhere between 1.5-2x more docs than shifts that have to be covered for it to be a comfortable fit.

 

[Birdstrike]

There are a lot of senior residents that are starting or in the middle of their job search right now. We've had a lot of threads inquiring about the existence of extraordinarily non-typical schedules or payment structures. They exist, but most of you aren't going to be in them. Given the job market today, it's likely your first employer is going to be a CMG and most of you are going to be full-time (which will vary by around 40hrs/mo depending on who's defining it). You've heard the people that are 10+ years out and you're worried about burn-out, so you're trying to come up with some strategy that's differerent from those old-timers so you don't have the same happen. But at least early on, the answer isn't to only work 4 shifts per month or to work 28 shifts/mo and pay off your loans in the first 6 months. Below are some of the things that help make clinical EM a career in the early stages (I'm 5 yrs out currently so have no qualifications to speak about long-term):

1) Invest your time and interest into the job - no matter which residency you're coming out of, there are things you're going to learn as an attending that you weren't taught. Keep learning and keep trying to be a better doctor. This helps maintain a sense of personal satisfaction in what you do, which helps fight the burnout from depersonalization and emotional exhaustion.

2) Don't act like you're burned out before you even start - that strategies that are adaptive for a mid-career doc whose been dealing with the burn for a decade are mal-adaptive for someone just starting out. If you're not working enough shifts in a busy enough environment then you're never going to be able to be successful in a high-acuity environment later in your career. As a corollary, no one with a choice wants a part-time new grad.

3) Don't accept a job where the scheduler doesn't make an attempt at a Circadian schedule. Your quality of life working 14 shifts per month can be great with a good scheduler or absolutely miserable (working lots of Saturday overnights, multiple DOMAs per month, flipping from swing back to am next day, etc). At the same time, don't have so many schedule requests that the only way to cram a FT schedule in is to have a horrible schedule.

4) Go in to your shift fresh - this makes a huge difference in your satisfaction during the shift but it's also the hardest to pull of consistently. If you're going to make a career out of EM, accept that the shifts are hard and that you need time for rest before and (to a lesser extent) after. Have an honest talk with your spouse regarding what is and isn't reasonable to expect on days you're working. Nobody but you is going to know what it feels like to short yourself on sleep continuously. And when you're tired and cranky this job sucks.

5) Get involved - get on a committee and actually go to it. Have a passable understanding of hospital politics. Develop relationships with your consultants. Just like you learned in residency, you get no points for just identifying the problem. If you're willing to help be part of the solution than you'd be suprised what can improve in the ED (even staying budget neutral).

This is actually a very good post. I'll have to think more about this and see what else I can add later, but one thing I think is super, super, important is this:

Any time you take a new job in EM, absofrickinlutely refuse the temptation to buy a house the first year, if you at all can. If there's anything the housing crisis should have taught all of us is that real estate doesn't "always go up" and if you lock yourself into a house day one into a new job, you just forfeited one of the big advantages of EM - mobility. This is how some jobs can get you by the n--s: with a glorious interview experience plus real estate tour ("Oh yeah, you can live on the water for cheap, only work 8 shifts a month, cut your shifts back anytime, never work nights, and still make $400,000! It's awesome, man! And also, you know that rule about things being 'too good to be true'? It doesn't apply down here, man! Really. IT DOESN"T!") to get you locked in for the long haul. Once you are locked in, they own you. If you can bail out of a lease within a few months, with nothing lost, you have a lot more leverage and freedom.

These are words to the wise, that I will admit, I ignored in the past, and paid the price as a result.

O u c h

 

[The White Coat Investor]

Agreed. Although I think the figure I heard quoted was that TH alone scooped up about 25% of the graduating residents from 2012.

Can you speak about what it was like going through the partnership track and what your current level of involvement in the operations of the group is? Did your mindset change when you became a partner? All the places I've worked have either been dominated by CMGs or had one guy that held the contract.

Well, I admit I didn't consider any job that didn't lead to partnership in a small democratic group. Period. I didn't want to be the employee of a CMG. I've heard that some are better than others, but I really wanted to be a business owner, with its risks and rewards.

The partnership track was very straightforward. I worked for a straight hourly wage (increased every 6 months) for two years, then I became a partner. It was pretty clear after 6 months to them and me that we were a fit, so it was no surprise when I made partner. I acted like a partner before, and after. Books were open to me before and after. There were no surprises. Our group expects every new hire to become a partner and stay with us for 2 or 3 decades. It's very disappointing when it doesn't work out.

Operations of the group? I'm a voting member and I got to the 4 hour meeting with all my partners every month where we rehash all the same issues over and over again. It's like a family really.

The most important thing when choosing a job is who you work with IMHO. Everything else, including CMG vs small democratic, is less important.

 

[The White Coat Investor]

This is very helpful stuff, thanks for taking the time and initiative to post it.

How feasible is it to work in the community if you're double-boarded and want to actively work in both fields? I've known EM-CC, EM-Occ med, and EM-sports med docs who split their time about 50-50 but they've all been at very academic places where EM and the other respective department worked to blend things into a single, reasonable schedule. Is something like this too much of a headache for schedulers in the community to want to deal with?

Schedulers are subordinate employees. They'll deal with what they're told to deal with. Our group could work with this, and would probably welcome an EM-CC doc that also covered our ICU.

 

[The White Coat Investor]

, absofrickinlutely refuse the temptation to buy a house the first year, if you at all can.

O u c h

I don't think you have to wait a year. You usually know if it is going to work out within 3-6 months and can buy then. It turns out it's really hard to find a place to rent for less than a year though, and it's definitely a pain to do the extra move.

 

[TooMuchResearch]

I don't think you have to wait a year. You usually know if it is going to work out within 3-6 months and can buy then. It turns out it's really hard to find a place to rent for less than a year though, and it's definitely a pain to do the extra move.

For a while now I've been going just a little crazy wondering what happened to ActiveDuty and why a lot of old threads and posts I thought he authored were now credited to The White Coat Investor. Turns out the Android app doesn't show the little blurb under the user name/handle.