Medical students ambivalent about EM

[Birdstrike]

From time to time I'll get private messages from medical students ambivalent about whether to choose EM as a career. Rather than reinventing the wheel each time, and since it might help others to hear people's opinions, I figured I'd just post my response in an open forum. My opinion is not the end all, be all, but just n=1. It's a good subject for a thread and other attendings please chime in with your answer to the question, "I'm a medical student who is unsure about whether or not to go into EM. I love it but others are warning me against it. What should I do?" Here's my response:


"I can't tell a stranger what to do with his life, but I will tell you this. There are much easier roads to go down than to choose EM. I'd guess Derm takes less of a toll. Likely, anything 9-5 is easier. EM takes it's toll as you get older. I'm not telling you not to go into it for those reasons, and I'm not telling you to go into it. At some point you just have to shut out all the outside voices, listen to your gut instead, and go all chips in, to do what you love whatever that is. If EM is your passion, then do it. If not, then don't. There's no guarantee any road will be perfect, but you certainly won't be alone whichever road you choose.

If you do choose EM, my advice is to do a fellowship. Let me tell you why. The thing that makes EM take it's toll over the years is the shear pounding of such high-volume, high-stress work, combined with the incessant shift-flipping back and forth. The way to ease that pressure is to work less shifts in the ED, while still working full-time. It's very simple. Notice I did not say "work less." I said work less shifts in the ED.

One guy I did residency with did a hyperbaric fellowship, but not until 5 years after residency. It's worked out very well for him because it gave him the option to ratchet down his general ED shifts gradually, while his administrative and fellowship directorship grew. He now only works 2 shifts per month in the ED. The rest is hyperbaric consults and running the fellowship. He's much happier now after feeling kinda burned out, earlier on. He regrets not doing the fellowship sooner.

As far as Pain goes, I know a few who've applied now. Several got ACGME Pain spots: roughly 50/50. It's not as long of odds as you might think. The ones who seems to do best, applied to literally dozens of programs in the country, even up to 30-80. I know one guy who spit it 50/50 EM/Pain as an employee at Kaiser in CA. The others seemed to use it as a career change. Everyone so far seems very happy with the choice. Pain is Derm like hours, just with much tougher patients, and interesting spinal procedures. The general consensus seems to be, that there's much greater control over your patient population in that setting, compared to the ED.

Palliative care. I know two EM guys who did this. One was mid-career and seemed luke warm on it. Another was late-career and I've heard likes it.

As far as Sports, I don't know anyone personally having done it but it seems pretty straight forward. Do non-operative ortho with an ortho group and do a lot of joint injections and teeing patients up for the ortho guys to operate on. Should be normal hours except for covering sports team games which would likely be on weekends, seasonally.

Another guy I did residency with, did a cardiovascular-EM fellowship and now 10 years post residency runs an EM obs unit and works only 8-10 general EM shifts. He seems pretty happy.

Another guy I did residency with did an MBA post-residency. That allowed him to run the helicopter program at his university job, and move up the academic chain that way. Bottom line: it allowed him to reduce his general ED shifts as the years went on to an 8-10 per month range. He's seems much happier than a lot of general EM docs I've known.

Either way, if you do a fellowship right after residency, dive in right away, don't wait ten years to get involved. Even if you're not doing the Subspecialty full-time right away, definitely put it to use to some extent, right away.

All that being said, I strongly considered IM, for the same reasons you mentioned (Cards). I decided against it and did EM instead. I went back and did my fellowship several years post residency which was very difficult having to uproot my family and lose a years salary, but I'm very happy I did it. I just wish I did it sooner.

All in all, if you choose some other cushy specialty (which EM definitively is not), I'm sure that would be great. I would not try to talk you out of it. But if you do EM, just strongly consider doing one of the fellowships. Hell, apply to them all if you want, and know you'll be able to chart your own course a little bit better than the average doc grinding out shifts for a quarter century of more. Of course, none of these fellowship pathways strips you of the option to continue to work as much in the ED as you wish, should that continue to work out for you.

Either way, don't torture yourself over the decision. None of us have any guarantee our life or career decisions will work out as we hope they will. Listen to your gut, pick what you love and go all-chips-in. Have no regrets. You can always course correct along the way. Half the fun is the journey. No matter what direction you choose, you will have plenty of company along the road."

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[kmb1908]

Any feedback from docs post-critical care fellowship?

 

[Akail]

What about admin fellowships? Helpful for getting directorships in the community and less shifts that way?

 

[Arcan57]

What about admin fellowships? Helpful for getting directorships in the community and less shifts that way?

Admin fellowships are overkill for the majority of community ED directorships. Also, most director jobs suck.

 

[two guys]

Or, you could just take the money you saved by not spending a year in fellowship and reduce your shifts to ten a year and drop your cost of living to that of a pediatrician...

I think fellowships are great but I'm not sure I buy them as a solution for everybody. You have to be pretty interested in the field (or pretty done with EM). I'm still in my first few years out, so I might feel differently soon but so far I'm buying into the plan of eliminating debt, live more cheaply than my peers, work less shifts than my peers and having some non-titled administrative duties that let me feel like I have a say in the way the dept runs. So far this has been almost painless. I will say that my tolerance for night to day switches have gotten surprising rougher each year (despite working some nights since 20 years ago - wow that hurt to type). But, if I'm off for several days following nights it is a little easier to take.

As far as EM vs any other specialty. There are very few jobs in medicine where there aren't unhappy people. I tried pretty hard to like optho and ortho (for different reasons) but just didn't. If you are lucky enough to like optho or derm or something else with predicable hours AND you worked hard enough to match in them then there is really no question.
Otherwise, it's like an election - pick the downsides you can deal with the best. Most unhappy people I met either had unrealistic expectations, spend more than they earn, or are just unhappy people. The consultants I talk to don't sound particularly more happy.

 

[The White Coat Investor]

I don't like night shifts any more than the next guy, but the jobs EM fellowships train you for sound terrible to me.

 

[dudeliness]

Thanks for posting this @Birdstrike
I'm just a lowly 2nd yr student so I'm still in the pre-clinical process. In other words no real experience to point me any particular direction for specialty.
All I know is that I want to be "hands on", do some procedures, and not have to live in a big city somewhere in order to practice. I've got a family and spending time with them is important to me, but that's not to say that I'm opposed to working long hours, I just don't want to be on call.
These all seem to be reasons to think that EM might be right for me, which I'm sure I'll get a clearer idea of when I start rotations.
My question to the attendings here is what are your favorite and least favorite parts of EM? Anybody here practice more rural? I would like to know what differences there are in types of patients you see and hours one might work in a rural setting.

 

[LostinLift]

I was a scribe in a really solid suburban group based ED for 1.5 years. Docs had 8 hour shifts, triple coverage during the day, only 1 night shift. No trauma. One doctor alluded to his partner salary stating $3K was one shift. PPH I think started averaging above 2 when I left because a nearby ED closed down, but seeing 3 PPH was not unusual but with a good % being fast track it didn't bog people down much. Scribes helped, especially for some of the older docs... but I think a young whipper snapper who grew up in the age of EMR would be able to do just fine without one.

Hard to not like EM after working there. Good hours, good pay, fun people in the ED, good mix of things, and patients for the most part weren't that sick - I believe we had a relatively low admission rate. I'm guessing this is not the average ED?


I'm only an M1 but I'm leaning towards EM with a part of me interested in surgery *** only *** if I LOVE my surgery rotation and couldn't imagine doing anything else.

 

[dotcb]

I don't love every day in EM, but I don't think I'd love any days doing those jobs listed...

 

[Birdstrike]

I don't love every day in EM, but I don't think I'd love any days doing those jobs listed...

If you truly love what you're doing and know you will always love it, I suppose there's no reason to hedge your bets on ever possibly doing anything else.

 

[Mad Jack]

From time to time I'll get private messages from medical students ambivalent about whether to choose EM as a career. Rather than reinventing the wheel each time, and since it might help others to hear people's opinions, I figured I'd just post my response in an open forum. My opinion is not the end all, be all, but just n=1. It's a good subject for a thread and other attendings please chime in with your answer to the question, "I'm a medical student who is unsure about whether or not to go into EM. I love it but others are warning me against it. What should I do?" Here's my response:


"I can't tell a stranger what to do with his life, but I will tell you this. There are much easier roads to go down than to choose EM. I'd guess Derm takes less of a toll. Likely, anything 9-5 is easier. EM takes it's toll as you get older. I'm not telling you not to go into it for those reasons, and I'm not telling you to go into it. At some point you just have to shut out all the outside voices, listen to your gut instead, and go all chips in, to do what you love whatever that is. If EM is your passion, then do it. If not, then don't. There's no guarantee any road will be perfect, but you certainly won't be alone whichever road you choose.

If you do choose EM, my advice is to do a fellowship. Let me tell you why. The thing that makes EM take it's toll over the years is the shear pounding of such high-volume, high-stress work, combined with the incessant shift-flipping back and forth. The way to ease that pressure is to work less shifts in the ED, while still working full-time. It's very simple. Notice I did not say "work less." I said work less shifts in the ED.

One guy I did residency with did a hyperbaric fellowship, but not until 5 years after residency. It's worked out very well for him because it gave him the option to ratchet down his general ED shifts gradually, while his administrative and fellowship directorship grew. He now only works 2 shifts per month in the ED. The rest is hyperbaric consults and running the fellowship. He's much happier now after feeling kinda burned out, earlier on. He regrets not doing the fellowship sooner.

As far as Pain goes, I know a few who've applied now. Several got ACGME Pain spots: roughly 50/50. It's not as long of odds as you might think. The ones who seems to do best, applied to literally dozens of programs in the country, even up to 30-80. I know one guy who spit it 50/50 EM/Pain as an employee at Kaiser in CA. The others seemed to use it as a career change. Everyone so far seems very happy with the choice. Pain is Derm like hours, just with much tougher patients, and interesting spinal procedures. The general consensus seems to be, that there's much greater control over your patient population in that setting, compared to the ED.

Palliative care. I know two EM guys who did this. One was mid-career and seemed luke warm on it. Another was late-career and I've heard likes it.

As far as Sports, I don't know anyone personally having done it but it seems pretty straight forward. Do non-operative ortho with an ortho group and do a lot of joint injections and teeing patients up for the ortho guys to operate on. Should be normal hours except for covering sports team games which would likely be on weekends, seasonally.

Another guy I did residency with, did a cardiovascular-EM fellowship and now 10 years post residency runs an EM obs unit and works only 8-10 general EM shifts. He seems pretty happy.

Another guy I did residency with did an MBA post-residency. That allowed him to run the helicopter program at his university job, and move up the academic chain that way. Bottom line: it allowed him to reduce his general ED shifts as the years went on to an 8-10 per month range. He's seems much happier than a lot of general EM docs I've known.

Either way, if you do a fellowship right after residency, dive in right away, don't wait ten years to get involved. Even if you're not doing the Subspecialty full-time right away, definitely put it to use to some extent, right away.

All that being said, I strongly considered IM, for the same reasons you mentioned (Cards). I decided against it and did EM instead. I went back and did my fellowship several years post residency which was very difficult having to uproot my family and lose a years salary, but I'm very happy I did it. I just wish I did it sooner.

All in all, if you choose some other cushy specialty (which EM definitively is not), I'm sure that would be great. I would not try to talk you out of it. But if you do EM, just strongly consider doing one of the fellowships. Hell, apply to them all if you want, and know you'll be able to chart your own course a little bit better than the average doc grinding out shifts for a quarter century of more. Of course, none of these fellowship pathways strips you of the option to continue to work as much in the ED as you wish, should that continue to work out for you.

Either way, don't torture yourself over the decision. None of us have any guarantee our life or career decisions will work out as we hope they will. Listen to your gut, pick what you love and go all-chips-in. Have no regrets. You can always course correct along the way. Half the fun is the journey. No matter what direction you choose, you will have plenty of company along the road."

So your advice boils down to, "If you get into EM, set yourself up to get as far away from EM as possible"

 

[Birdstrike]

So your advice boils down to, "If you get into EM, set yourself up to get as far away from EM as possible"

Funny, ha ha. But no. I don't want EM to be a wasteland devoid of quality recruits. EM can be extremely fun, and challenging at times. The point is to diversify your options, so that if you decide someday when you're no longer 26 after your umpteenth 3am intubation, that sleeping at night and being awake during the day is actually a basic human need, you have some options. Also, these fellowships are not "far away" from EM. They are EM. They are subspecialties of EM. EM has endorsed them. So if you practice them fully or in part, you are practicing EM, specifically, a "subspecialty of" EM.

Read this article from Greg Henry. It's very much in the same vain, as what I'm try to get across to anyone who cares to listen, in my own way:

"EM's Mid-Life Crisis"

(As an aside, here's an interesting pearl from Biblical history, for you history buffs. Remember that story when Moses was reading the tablet of stone, with the Ten Commandments on it? The part most people aren't aware of, is when you flip over the stone, it says this on the back of Moses' stone tablet: "It’s a lot harder to wrestle drunks when you are 65" - Greg Henry M.D.)

 

[deuist]

I feel about the subspecialties the way I felt about most residency options when I was a medical student. They are nice, and I'm sure there are some fun aspects to each of them, but they just aren't for me. Although you are a subspecialist of emergency medicine, you are missing out on many of the procedures and the "I never know was going to roll through the door next" aspect of the specialty. It's kind of hard to intubate an altered 40-year-old and then play detective figuring out what happened to him when you are a sports medicine doctor. I think I would get bored. I once worked with a hand surgeon who said he only sees ten diagnoses in the office. I couldn't imagine spending every day seeing the same thing when I could just as easily work in an emergency department seeing those ten things, as well as a thousand more.

Palliative care – probably nice when I'm middle-aged and want to slow down, but who wants to spend the remaining years of their 20s doing this?

Pain management – some of the procedures sound interesting, but I already spend much of my day trying to push drug seekers away. I could not imagine welcoming them with open arms.

Toxicology – probably the smartest emergency physicians around, but good luck getting a job doing only tox.

Administration – probably overkill. You can learn much about business through the MOOC's for free, make contacts through hospital management and your CMG and then work your way up.

Pediatric emergency medicine – you are joking, right?

Critical care – awesome fellowship; would have done it myself, but then the Air Force stepped in and said no.

Hyperbarics – I don't really know that much about the specialty to give an opinion. It's not an entirely sexy subspecialty, but if it gets you out of the ED and working only day shifts doing stuff you love, then I'm all for it.

 

[Birdstrike]

Another option for the adventurous might be to work in EM in another country like Australia or New Zealand where bosses/consultants (attendings) rarely if ever work night shifts.

That's how it should be here, but it's not, unfortunately. In a lot of cases the PAs and NPs have better schedules than the most senior attendings. It's backwards, but fits right in with the customer-service profit-driven system here. "I want to see the most highly-trained provider, 24 hrs per day, 365 days a year, on demand, for whatever non-emergency need I have, and within < 15 minutes. And I want it done with a smile!" It also shows you what the power balance is here, between the doctors and those who are really in charge, in the system that's involved here in the US. So the end result is that you have to make your own arrangements.

 

[EctopicFetus]

I agree with Bird that options are good. I also feel that if fellowships dont interest you why waste the time and money. Outside of pain none of those would seem to pay as well as EM. Perhaps palliative care? But from the tox guys I know they dont make more doing that then EM.

If you factor in your opportunity cost of that fellowship there is no financial win except for pain. Personally, I would recommend being prudent with your money. This way you can work as little as you want when you get burnt out or like the poster from a month or 2 you can just quit.

If you fail to educate yourself on the financial matters of EM and personal finance you will be miserable if you ever get burnt out.

I am 5+ years post residency, I still enjoy my job. Yesterday had a super sick lady (hypotensive, hypoglycemic and a temp of 90.1 rectal, lactate of 8) and another patient with a jaw dislocation. I like those cases. they are still fun. I honestly cant imagine when they wouldnt be.

At the same time I realize I am not invincible and have been trying to sock money away like the well is about to dry up.

 

[EMIM2011]

I agree with Bird that options are good. I also feel that if fellowships dont interest you why waste the time and money. Outside of pain none of those would seem to pay as well as EM. Perhaps palliative care?

Palliative is going to loose you a good chunk of money. You'll make 20-40k more a year in critical care, with comparable hours. But, as you said, there is the opportunity cost of a two year fellowship.

 

[AlmostAnMD]

No mention of ultrasound for fellowship. Although I suppose its value depends on whether your hospital allows you to read them vs. radiology (makes a difference for billing)?

 

[Hercules]

No mention of ultrasound for fellowship. Although I suppose its value depends on whether your hospital allows you to read them vs. radiology (makes a difference for billing)?

You don't need an us fellowship to bill for it. It also gets much less use in the community than academics because it simply doesn't pay enough to justify the time in many (not all) scenarios. Only reason to do an us fellowship really is to be the director of an us fellowship or maybe to have a side job of teaching us courses in the community.

 

[deuist]

Ultrasound is nice to learn about in residency. But as most community attendings on this board have stated, performing your own ultrasounds in the emergency department needlessly slows you down. In fact, the greatest determinant of whether or not I perform an ultrasound on a patient is the number of people in the waiting room. Taking the time to find the machine, bring it to the patient's room, turn it on and wait for it to load, and then examine the kidneys for hydronephrosis takes up precious minutes when if I really need to know if someone has a kidney stone, I can simply write an order for noncontrast CT scan. Doing that fellowship will likely not lead to any increase in salary and will therefore be a lost year of income.

 

[Doctor Bob]

Critical care – awesome fellowship; would have done it myself, but then the Air Force stepped in and said no.

They said no the first time I asked. They said yes the second time.
But I will say, critical care isn't one of those fellowships that is easy to return to after working for a few years. Unlike a lot of the other fellowships which can be M-F 9-5, critical care is a two year return to the most time intensive part of residency. The longer you've been out of residency, the more brutal the reality check.

You'll make 20-40k more a year in critical care, with comparable hours. But, as you said, there is the opportunity cost of a two year fellowship.

The other difficulty is finding a job. You need a hospital where the ICU is closed (so it has an intensivist service) then apply when both the ED group and ICU group are hiring. If it's an academic place where both are employees of the hospital, then you have to talk one of the departments into letting you work half time somewhere else.
The split-time jobs exist... they're just not that easy to find. You can more easily find a job in one world or the other. And if you're putting all of this time into the fellowship and are only going to practice in one world, you might as well choose the ICU because you could have done the ED job without the 2 year hassle. If you don't mind having multiple sets of credentials, get a job in an ICU, then work the occasional shift at the ED down the street.

 

[Bigeminy]

Very helpful thread, and this is something the PD at my program already has begun advocating. Only being a few months in to intern year, I can see why you'd want to develop a niche and be able to cut back on clinical shifts -- they are hard. The attendings who do Sim, ultrasound, international medicine, sports medicine, and admin are definitely in the department less because they've been able to carve out a place for themselves within EM. And they seem happier than the ones just doing shifts. I do love my shifts, but in 20 years i don't know that I'll want to be working multiple shifts per week.

But maybe I'm skewed on this because the volume of the ER I am training in. It's a three year program and the third years see ~30 patients per shift and attendings carry more.

 

[emergentmd]

I am so tired of all of these doom threads about EM. If you are an EM attending, and really hate your job, you should just get out. Join the Ortho, Neurosurg, Fp, pedi, radiology, anesthesiology, etc attendings that hate their job.

If you really want to do an EM fellowhip b/c you enjoy tox, peds, wilderness, etc then great do it. But you are doing it for less money. You will spend another 2-3 yrs working for cheap and then come out and make less money as an EM attending. So do it for the love bc financially it makes no sense.

EM is a great field with great flexibility. If you are working a crappy job, there are many openings all over the country. If you are getting old or burned out working in a busy ED, go work in Urgent care and free standing EDs. I work at a Free standing ED and I see between 3-10 pts a day. Some days, I do not even draw any blood.

If you are tired of working nights, there are groups out there that are structured to do very little/no nights. We pay our guys alot more to do overnight and so I have not done an overnight in 10 years. If your group does pay extra, you can switch your nights for someone's day shift and pay them out of your own pocket.

Are you tired of doing nights and working in a busy ED? do urgent care at 100/hr or do a freestanding ED contract where you only work days. Its not that easy to negotiate such a schedule.

I am 14 yrs into my career as an attending and I still love the busy ED. I don't mind seeing 3/hr b/c I am wired to be able to hand such a load. But I can tell that I am not as young as I used to be. So what do I do? I do a few Free standing shifts a month. I now do 10 busy ED shifts a month and 3 free standing. I moonlight going to desperate EDs where they need boarded ED docs. I just did a 12 shift last week and was paid 7K. I turn down about many shifts a month paying 6k/shift b/c I am busy outside of work.

Guess what I will do when I get older or slower? 6 main ED + 6 FSED shifts.
Older than this? 12 FSED shifts.
If I can't handle FSED Shifts, that will be a sign that I just can't hack it anymore and retire.

When I get old enough where I want freedom, flexibility, and travel? I will be doing 5 moonlighting shifts a month getting paid 4-6K/shift.

How can anyone complain with making so much money with the flexibility to dictate
1. How many shifts I want to do a month
2. Work in a slow FSED
3. Moonlight when I want

is beyond me. To all the med students interested in ED, its a great field with great flexiblity. It may change in 5 years, who can predict. But right now, its a great field.

 

[hoot504]

I just did a 12 shift last week and was paid 7K.

Come again?

 

[Birdstrike]

I am so tired of all of these doom threads about EM. If you are an EM attending, and really hate your job, you should just get out. Join the Ortho, Neurosurg, Fp, pedi, radiology, anesthesiology, etc attendings that hate their job.

If you really want to do an EM fellowhip b/c you enjoy tox, peds, wilderness, etc then great do it. But you are doing it for less money. You will spend another 2-3 yrs working for cheap and then come out and make less money as an EM attending. So do it for the love bc financially it makes no sense.

EM is a great field with great flexibility. If you are working a crappy job, there are many openings all over the country. If you are getting old or burned out working in a busy ED, go work in Urgent care and free standing EDs. I work at a Free standing ED and I see between 3-10 pts a day. Some days, I do not even draw any blood.

If you are tired of working nights, there are groups out there that are structured to do very little/no nights. We pay our guys alot more to do overnight and so I have not done an overnight in 10 years. If your group does pay extra, you can switch your nights for someone's day shift and pay them out of your own pocket.

Are you tired of doing nights and working in a busy ED? do urgent care at 100/hr or do a freestanding ED contract where you only work days. Its not that easy to negotiate such a schedule.

I am 14 yrs into my career as an attending and I still love the busy ED. I don't mind seeing 3/hr b/c I am wired to be able to hand such a load. But I can tell that I am not as young as I used to be. So what do I do? I do a few Free standing shifts a month. I now do 10 busy ED shifts a month and 3 free standing. I moonlight going to desperate EDs where they need boarded ED docs. I just did a 12 shift last week and was paid 7K. I turn down about many shifts a month paying 6k/shift b/c I am busy outside of work.

Guess what I will do when I get older or slower? 6 main ED + 6 FSED shifts.
Older than this? 12 FSED shifts.
If I can't handle FSED Shifts, that will be a sign that I just can't hack it anymore and retire.

When I get old enough where I want freedom, flexibility, and travel? I will be doing 5 moonlighting shifts a month getting paid 4-6K/shift.

How can anyone complain with making so much money with the flexibility to dictate
1. How many shifts I want to do a month
2. Work in a slow FSED
3. Moonlight when I want

is beyond me. To all the med students interested in ED, its a great field with great flexiblity. It may change in 5 years, who can predict. But right now, its a great field.

In my opinion, this thread a positive one. It's a thread about helping medical students make tough career decisions and if they choose EM, how best to approach that decision early on. My view is that fellowships can enhance a career in EM for those interested. EM fellowships are EM. They are a part of it. Supporting EM fellowships and subspecialties equals supporting EM. Also, there's nothing about doing an EM fellowship that takes any of the positives you see in EM, away from anyone who does one. Those who do a fellowship can feel free to partake in as much of the positives you see in EM, as they want. Doing a fellowship may not be for everyone, but it's worked out well for some, even though they may not always pay off in dollar signs.

From my perspective EM fellowships and subspecialties are part of EM, a positive for EM recruits, offer a wider range of options for them, and in no way need to take away from your, or anyone else's version EM. After all, they are all under the same umbrella. I don't think EM having fellowships and subspecialty options takes away from EM anymore than anesthesia, ortho or internal medicine subspecialty options take away from those specialties. Personally, I choose to view this as a positive.

 

[pandahunter]

I just did a 12 shift last week and was paid 7K.

... say what?

 

[BoardingDoc]

I just did a 12 shift last week and was paid 7K. I turn down about many shifts a month paying 6k/shift b/c I am busy outside of work.

Yeah, where exactly is this that you are able to easily pick up shifts that pay $500-600/hour?

 

[EvoDevo]

Yeah, where exactly is this that you are able to easily pick up shifts that pay $500-600/hour?

It's definitely not impossible. At all. Just have to be in the right places and be available at the right times.

 

[goodoldalky]

Can't help myself, have to post on this one.

Let me say to preface that I always enjoy reading Birdstrike's posts and have done so for a long time. They are generally well thought out, he is persuasive, a superb writer, and he makes a lot of sense.

However, let me go on to say that Birdstrike is not exactly a glass-half-full kind of guy. Many of his posts are relatively negative and alarmist (actually all of SDN is like that). I would encourage everyone trying to decide what field to go into to take most of the posts on this forum (Birdstrike's included, mine included, all of them), with a grain of salt. Remember, Bird, as great an asset he is to this forum, is one of those guys who disliked his job enough to walk away from it, and do Pain, which is a completely different, lifestyle-oriented subspecialty. One that, to me, sounds pretty terrible outside of the lifestyle. He really enjoys it, though. I think if you asked the general SDN EM population of attendings if they would do pain as a career, they would say no (I agree with Deuist's post above).

EM is a difficult job. Almost all jobs within medicine are pretty hard. Pain and derm maybe being two of VERY FEW examples. If you overextend yourself financially or get into a situation where you have to work too many shifts, EM can be unmanageable. But many people have long and happy careers in the field.

Everyone needs to figure out what they want to do for themselves. I would be wary of a lot of the external advice you can find out there, especially on SDN. It is important to know what you are getting into, but in the end, following your heart and gut is the way to the optimal decision.

 

[Birdstrike]

take most of the posts on this forum (Birdstrike's included, mine included, all of them), with a grain of salt.

I agree with this completely and even preface many of my posts with a similar disclaimer, like in this threads original post:

My opinion is not the end all, be all, but just n=1...I can't tell a stranger what to do with his life... Listen to your gut, pick what you love ..

let me go on to say that Birdstrike is not exactly a glass-half-full kind of guy. Many of his posts are relatively negative and

As far as the "glass half full/empty" thing, I suppose it's how you look at it. In my original post, I give several examples of people who went in to EM and found various pathways and were "happy," myself included. To me that's "glass half full." Personally, on these forums and in life, I tend to value honesty over any particular predetermination towards optimism or pessimism, as false representations of either, can lead people down the wrong path. Regardless, thanks for the post for balance (but please know that by your own advise, I'm taking it with a "grain of salt.")



All "glass half-full" stuff:

http://drwhitecoat.com/blown-away/

http://drwhitecoat.com/what-i-can-tell-you-is-thanks/

http://drwhitecoat.com/an-amazing-little-girl/

http://drwhitecoat.com/tony-the-doorman/



By the way: There is only one poster on SDN who's words need to be taken without a grain of salt. He goes by the handle "goodoldalky" and his words are below:

...I find Birdstrike to be wise like Buddha...

(Sorry, lol. Just kidding man. I couldn't help myself. You tee'd it right up for me. I couldn't resist.)

 

[Birdstrike]

As an aside, goodoldalky, I'm also ten long grizzled years further down the road than you. Not that it means what I write is any more relevant than what you write. But it's from a very different vantage point. I'm not saying your posts will mirror mine 10 years from now, or be any more negative or positive than they are now, but you may view things differently. My views 10 years ago, were a lot more like your views now, than they are like my views now. Regardless, it's good to give a wide range of viewpoints. Mine is only one. Take it for what you're all paying for it. Now I've got to get back to arguing with the pre-med lawyers about Ebola...

 

[bashwell]

As a med student, I really appreciate all these comments from both sides, and thanks again Birdstrike for weighing in with your seasoned perspective on all this too! Really helpful.

 

[Robinson EM]

I am so tired of all of these doom threads about EM. If you are an EM attending, and really hate your job, you should just get out. Join the Ortho, Neurosurg, Fp, pedi, radiology, anesthesiology, etc attendings that hate their job.

If you really want to do an EM fellowhip b/c you enjoy tox, peds, wilderness, etc then great do it. But you are doing it for less money. You will spend another 2-3 yrs working for cheap and then come out and make less money as an EM attending. So do it for the love bc financially it makes no sense.

EM is a great field with great flexibility. If you are working a crappy job, there are many openings all over the country. If you are getting old or burned out working in a busy ED, go work in Urgent care and free standing EDs. I work at a Free standing ED and I see between 3-10 pts a day. Some days, I do not even draw any blood.

If you are tired of working nights, there are groups out there that are structured to do very little/no nights. We pay our guys alot more to do overnight and so I have not done an overnight in 10 years. If your group does pay extra, you can switch your nights for someone's day shift and pay them out of your own pocket.

Are you tired of doing nights and working in a busy ED? do urgent care at 100/hr or do a freestanding ED contract where you only work days. Its not that easy to negotiate such a schedule.

I am 14 yrs into my career as an attending and I still love the busy ED. I don't mind seeing 3/hr b/c I am wired to be able to hand such a load. But I can tell that I am not as young as I used to be. So what do I do? I do a few Free standing shifts a month. I now do 10 busy ED shifts a month and 3 free standing. I moonlight going to desperate EDs where they need boarded ED docs. I just did a 12 shift last week and was paid 7K. I turn down about many shifts a month paying 6k/shift b/c I am busy outside of work.

Guess what I will do when I get older or slower? 6 main ED + 6 FSED shifts.
Older than this? 12 FSED shifts.
If I can't handle FSED Shifts, that will be a sign that I just can't hack it anymore and retire.

When I get old enough where I want freedom, flexibility, and travel? I will be doing 5 moonlighting shifts a month getting paid 4-6K/shift.

How can anyone complain with making so much money with the flexibility to dictate
1. How many shifts I want to do a month
2. Work in a slow FSED
3. Moonlight when I want

is beyond me. To all the med students interested in ED, its a great field with great flexiblity. It may change in 5 years, who can predict. But right now, its a great field.

This poster has nailed it.

There is lots of flexibility out there.

Life is what you make it.

A lot of the negativity assumes worst case scenarios and no flexibility.

Good luck everyone.

 

[emergentmd]

There are unhappy people in every field. I see happy people in every field. I see it all the time.

Some people know what they want to specialize in before they even set foot in medical school. Most have no clue what they want to do when they have to make a decision in 3rd yr medical school. I mean, how can you really know? I know I didn't.

The beauty about EM RIGHT NOW, is that even if you picked EM and didn't really like the field, you have so much options to make yourself happy.

Some people are not a fit to work in EM where you have to make daily life/death decisions, have to make quick decision without really knowing what is going on, make decisions no knowing the outcome or have continuity of care. There are alot to EM that people do not like. Some docs have to follow a patient until they are discharged. We follow them for 2 hrs.

But the beauty of EM is if you find out the pressure cooker of the EM Dept is too much, you can do so much.

1. Work in slow Free standing EDs
2. Work part time
3. Work in Urgent care
4. Do locums and work as much as you like in a busy ED
5. Do locums almost any state in the country including Hawaii

I could literally get fired today and be working somewhere in a week.

Even if you made a mistake picking EM, you still have alot of opportunities other than doing typical EM stuff.

You can not say this if you are an anesthesiologist, surgeon, etc

 

[tima]

It might be helpful to shadow in the ER for a couple of shifts during days you are off during 3rd year rotations to see if EM is for you. You can read all you want on SDN, but first-hand exposure beats all.

 

[Birdstrike]

@emergentmd ,

In your recent posts, you seem super positive about your EM career lately, which is great, to the extent of almost seeming incredulous about some other posters who've expressed going through some difficult times, or a need to re-energize their careers in EM.

This post is ridiculous..."some people are never happy"...How any EM doc could be unhappy is beyond me...Even if I had 4 mil in the bank right now...I would still work in EM.

..I love EM. I have one of the best jobs in this world...

I think EM burn out is WAY over exaggerated...

I am so tired of all of these doom threads about EM...

I'm curious as to what you did to turn things around so dramatically, since in the past you had been very open about being ambivalent about your career choice, and even considered leaving EM for radiology residency. What was it that turned things around for you, in such a positive way?

...Please help me with my dilemma. I am 36 years old, finished an ED residency 7 years ago and ...I am getting somewhat burned out and am looking into a radiology residency... I think I can work longer and be happier as a radiologist.
Please help me...

...all the info I have posted are not exaggerated...the point is I am getting somewhat burned out and don't want to work more...

When I was finished with medical school, I was down to radiology and ER. I picked ER. I guess I have always thought if this was a mistake.

 

[hoot504]

Haha, oops.

Hey emergentmd, could you also clarify the 7k for a shift nonsense? Thanks

 

[bashwell]

But the beauty of EM is if you find out the pressure cooker of the EM Dept is too much, you can do so much.

1. Work in slow Free standing EDs
2. Work part time
3. Work in Urgent care
4. Do locums and work as much as you like in a busy ED
5. Do locums almost any state in the country including Hawaii

I could literally get fired today and be working somewhere in a week.

Even if you made a mistake picking EM, you still have alot of opportunities other than doing typical EM stuff.

Thanks emergentmd. Just wondering though (sorry if this is a dumb med student question), but apart from #3 urgent care, aren't these all still in EM? Maybe slower paced, or more flexible, but essentially still working in the ED and thus still "in the pressure cooker" even if it's to a lesser degree? So it seems like you'd still be "doing typical EM stuff," or hopefully I'm wrong?

Urgent care might be good, but I thought you'd get paid a lot less?

Thanks for your help!

 

[Arcan57]

There are unhappy people in every field. I see happy people in every field. I see it all the time.

Some people know what they want to specialize in before they even set foot in medical school. Most have no clue what they want to do when they have to make a decision in 3rd yr medical school. I mean, how can you really know? I know I didn't.

The beauty about EM RIGHT NOW, is that even if you picked EM and didn't really like the field, you have so much options to make yourself happy.

Some people are not a fit to work in EM where you have to make daily life/death decisions, have to make quick decision without really knowing what is going on, make decisions no knowing the outcome or have continuity of care. There are alot to EM that people do not like. Some docs have to follow a patient until they are discharged. We follow them for 2 hrs.

But the beauty of EM is if you find out the pressure cooker of the EM Dept is too much, you can do so much.

1. Work in slow Free standing EDs
2. Work part time
3. Work in Urgent care
4. Do locums and work as much as you like in a busy ED
5. Do locums almost any state in the country including Hawaii

I could literally get fired today and be working somewhere in a week.

I'm glad you're so up on EM, I also enjoy it. But the product you're pushing is not what's being offered for sale. There are always 2 weekend days/week and there are always 12 overnight hours in the day. That means that there's always going to be EM docs working nights and weekends. If you're more enterprising then the average EM doc then you can definitely find niche situations (staying licensed and credentialed at multiple hospitals in multiple states to allow for those opportunities takes time and money) but advising someone that doesn't like EM to go into it anyway because of "options" and "flexibility" is frankly irresponsible. It may be sampling bias, but I know plenty of docs that work at 3-4 hospitals with widely varying acuity and some that do locums and none of them seem happier than the docs that work at only 1-2 places. Most of the highly diversified crowd are also working 20-25 shifts a month in order to keep their options open and to stay flexible at all their hospitals. I have no doubt that there are a certain number of bon vivant EPs that are living the dream but it doesn't work if everyone tries it. Nobody's consistently billing $600/hr in the ED (regardless of practice setting) and CMGs don't lose money on contracts long-term. So either that job is about to disappear or that rate is coming off the backs of the EPs that work there for $10-50/hr less than actual market price. Be very clear, I'm not judging you for going after those jobs, I'm saying that they're unicorns. If you're a unicorn hunter then you'll find them more often than the average EP, but your job will look very little like the average EPs. There simply aren't enough unicorns (or at least unicorns that are accessible) for all of us.

 

[Birdstrike]

As a med student, I really appreciate all these comments from both sides, and thanks again Birdstrike for weighing in with your seasoned perspective on all this too! Really helpful.

Well, thanks. Some others on here would say I'm, "alarmist," pessimistic, "glass half empty," or even a EMs "Anna Chapman." Lol

Oh well. Whatev...

 

[WilcoWorld]

Well, thanks. Some others on here would say I'm, "alarmist," pessimistic, "glass half empty," or even a EMs "Anna Chapman." Lol

Oh well. Whatev...

A pessimist can be defined as "one who foresees undesirable outcomes." Not only do I think that this is nothing to be ashamed of, I think it's an essential skill for an Emergency Physician.

 

[Robinson EM]

@emergentmd ,

In your recent posts, you seem super positive about your EM career lately, which is great, to the extent of almost seeming incredulous about some other posters who've expressed going through some difficult times, or a need to re-energize their careers in EM.










I'm curious as to what you did to turn things around so dramatically, since in the past you had been very open about being ambivalent about your career choice, and even considered leaving EM for radiology residency. What was it that turned things around for you, in such a positive way?

I don't see any problem with any of those posts. You seem to be more positive about EM and now less so. So it's fair that someone could have an opposite experience.

He stated he hasn't worked nights in years, has a top income that people call unicorns, and isn't over worked. So maybe his situation changed for the better.

 

[arkdoc]

I am a 4th year interview for a residency spot. I was recently at a program that has a huge neuro side of things (tPA, Critical care, etc). They are brining in a guy to help with this side of EM. I was wondering if doing a fellowship in neurocritical care or something like that would be worthwhile financially or for career security/advancement. They are planning on starting a fellowship in this.

 

[Birdstrike]

I am a 4th year interview for a residency spot. I was recently at a program that has a huge neuro side of things (tPA, Critical care, etc). They are brining in a guy to help with this side of EM. I was wondering if doing a fellowship in neurocritical care or something like that would be worthwhile financially or for career security/advancement. They are planning on starting a fellowship in this.

Two facts needed to best answer your question:

1- Is it ACGME accredited?

2- Would it allow you to sit for the critical care subspecialty boards?

 

[arkdoc]

Two facts needed to best answer your question:

1- Is it ACGME accredited?

2- Would it allow you to sit for the critical care subspecialty boards?

I believe that both of these will be yes from what I was told.

 

[Birdstrike]

I don't see any problem with any of those posts. You seem to be more positive about EM and now less so. So it's fair that someone could have an opposite experience.

He stated he hasn't worked nights in years, has a top income that people call unicorns, and isn't over worked. So maybe his situation changed for the better.

I don't see any problem with the posts either, in isolation. I do think it's very normal for people to have challenges and bumps in the road along the way in their careers. So I don't think there's anything wrong with him posting about it, as I have my own. But I was surprised to see another poster called "ridiculous"...

This post is ridiculous...How any EM doc could be unhappy is beyond me.

...for posting things very similar to what emergentMD was posting in the past. That being said, I don't see any problem with him posting whatever he wants. I just think that it would be potentially super valuable for people possibly going through a similar tough situation he was posting about 6 years ago, to have an explanation as to how one got from considering a drastic career change due to burnout, to a situation so great he couldn't understand "How any EM doc could be unhappy." Please, connect the dots for us. Help someone going through the same situation or help prevent someone from falling in the same hole. Otherwise, it's a missed opportunity.

I don't think it does medical student or residents any favors to give them half of the story. That's the whole point of a forum like this, that it's anonymous and one assumes they're getting a less white-washed and candy coated version of reality than you'd get from the people recruiting for the machine. It's not about being "positive" about EM or "negative" about EM. It's not black and white.

There are enormous positives about EM as a specialty as long as people have,

1-Proper expectations,
2-Going into EM for the right reasons, and
3-Are realistic about, properly prepare for and manage the potential downsides.

It's like anything else in life, or in Medicine. Weigh pro's and con's. Manage risks vs. benefits. It's a pet peeve of mine when people blow smoke up others **** and candy coat the truth when they could otherwise help give them a leg up, by giving some realistic advice rather than presenting some utopian version of reality to just make themselves look like they are perfect and always made the right decisions. To some people that's "negative," "doom and gloom," and glass half empty. To me, it's preparing for the worst and hoping for the best. It's served me well. EM has served me well. Transitioning to an EM subspecialty has served me well. But there's been plenty of wrong turns, course corrections and lemonade made from lemons along the way.

 

[two guys]

I don't see any problem with any of those posts. You seem to be more positive about EM and now less so. So it's fair that someone could have an opposite experience.

He stated he hasn't worked nights in years, has a top income that people call unicorns, and isn't over worked. So maybe his situation changed for the better.

I see a problem with it. Frankly, its dishonest and harmful to cheer-lead half truths like this.

There's a thread like this about every month. People ask are you happy? Some folks come on and say the field is all milk and honey and it's AWESOME and people are ridiculous if they complain. Some come on and say they rather work in fast food. Most of us post that it is important to have a realistic understanding of the field and try to temper the expectations set by the milk and honey crowd. We then get told we're negative and we'd complain in any field and must just be prone to whining.

If you read emergents posts, he/she implies that they have been happy throughout their career and are fulfilled in EM. He goes on to wonder how anyone can be unsatisfied. Well, he was unsatisfied just a few years ago. I'm not saying he is being intentionally dishonest and malicious. I do think he's not telling the whole story. There is nothing wrong at all with forgetting any adversity you've been through and desiring to only talk about the good stuff. I'd say that's a good trait. But, we are on a board where people are asking those of us with experience for realistic expectations - we should try to paint the whole picture.

I don't really want to work with someone who got into this only expecting the field to be the way Emergent describes. They're going to be unhappy. I'd much rather work with someone who knew what they were getting in to.

For the record, I'm a few years out and happy as a hog in sheet. This is by far the best job I've ever had (and I've had a bunch)

 

[Birdstrike]

I am a 4th year interview for a residency spot. I was recently at a program that has a huge neuro side of things (tPA, Critical care, etc). They are brining in a guy to help with this side of EM. I was wondering if doing a fellowship in neurocritical care or something like that would be worthwhile financially or for career security/advancement. They are planning on starting a fellowship in this.

Assuming ACGME accredited allowing you to be doubled boarded in EM and CCM, of course it could potentially be worthwhile, if it's worthwhile to you. Any time you're dual board, yes, you could potentially open up some doors for career advancement, whether in academics or the community. The non-accredited fellowships are harder to predict the value of.

Career security? Considering general EM is in high demand and has extremely high job security to begin with, there may be less pay off there. In theory though, you could potentially be less expendable if you had a role in two departments, but who knows.

As far as financially, that's not static. You'd have to follow MGMA averages or job offers in your area, as you get closer to deciding on a fellowship or not. Salary averages change. Per MGMA 2013, EM mean was $318,000 vs a critical care intensivist at $380,000. But if you work hard the 75th percentiles deviate more with CCM at $437,000, and EM at $368,000. Might be worth it to some, but maybe not to others. Obviously there's a bell curve to salaries within each specialty, plus regional differences.

The one intangible, is that the lifestyles would be pretty similar with a large amount night, weekend and holiday work and being at risk for shift-work sleep disorder as much in CCM as in EM. Personally, I always liked critical care a lot, but that was the biggest drawback for me, when I considered and decided against, this specific subspecialty track. But that's just me.

Do what's best for you.

 

[emergentmd]

@emergentmd ,

In your recent posts, you seem super positive about your EM career lately, which is great, to the extent of almost seeming incredulous about some other posters who've expressed going through some difficult times, or a need to re-energize their careers in EM.

I'm curious as to what you did to turn things around so dramatically, since in the past you had been very open about being ambivalent about your career choice, and even considered leaving EM for radiology residency. What was it that turned things around for you, in such a positive way?

When I first started working 15 yrs ago, I did get burned out by yr 3. I have always wanted to do radiology and the early years were more difficult as we worked longer hours, had less coverage, etc. I brought alot of work home with me which made it more difficult. I was also immature at 30, just married. So there was alot of adjustment.
Our group changed over the years. I stopped doing nights. I became a partner. Our shifts were shortened to 8 hr dys. Overall the better work environment + great marriage + getting older/more mature = made me realize how great I have it. I am so glad that I did not go back and do radiology and would have made a big mistake not only from a monetary standpoint (2 mil loss earning).

Haha, oops.

Hey emergentmd, could you also clarify the 7k for a shift nonsense? Thanks

Its not nonsense. Its available. Its offered when they can't cover a shift. It happens weekly where I do some locums. Its not my primary job but I know some where it is their primary and they pull in close to 1 mil/yr.

Thanks emergentmd. Just wondering though (sorry if this is a dumb med student question), but apart from #3 urgent care, aren't these all still in EM? Maybe slower paced, or more flexible, but essentially still working in the ED and thus still "in the pressure cooker" even if it's to a lesser degree? So it seems like you'd still be "doing typical EM stuff," or hopefully I'm wrong?

Urgent care might be good, but I thought you'd get paid a lot less?

Thanks for your help!

FSED is Urgent care with few sick patients mixed in. Very nice environment. Seeing 1pt/hr vs 3/hr and lower acuity is not a pressure cooker

I'm glad you're so up on EM, I also enjoy it. But the product you're pushing is not what's being offered for sale. There are always 2 weekend days/week and there are always 12 overnight hours in the day. That means that there's always going to be EM docs working nights and weekends. If you're more enterprising then the average EM doc then you can definitely find niche situations (staying licensed and credentialed at multiple hospitals in multiple states to allow for those opportunities takes time and money) but advising someone that doesn't like EM to go into it anyway because of "options" and "flexibility" is frankly irresponsible. It may be sampling bias, but I know plenty of docs that work at 3-4 hospitals with widely varying acuity and some that do locums and none of them seem happier than the docs that work at only 1-2 places. Most of the highly diversified crowd are also working 20-25 shifts a month in order to keep their options open and to stay flexible at all their hospitals. I have no doubt that there are a certain number of bon vivant EPs that are living the dream but it doesn't work if everyone tries it. Nobody's consistently billing $600/hr in the ED (regardless of practice setting) and CMGs don't lose money on contracts long-term. So either that job is about to disappear or that rate is coming off the backs of the EPs that work there for $10-50/hr less than actual market price. Be very clear, I'm not judging you for going after those jobs, I'm saying that they're unicorns. If you're a unicorn hunter then you'll find them more often than the average EP, but your job will look very little like the average EPs. There simply aren't enough unicorns (or at least unicorns that are accessible) for all of us.

I still do weekends but not nights. I never stated that I did not do weekends. Doing weekends do not bother me. I don't find it irresponsible to tell someone that high paying jobs and only doing locums is an option. Many docs do this as their primary job and make alot more than I do. No one consistently make 600/hr. I make 400-600/hr on my locums shifts. I work my primary job and pick up a high paying shift when they need me to. So I may do 1-2 shift a month. But there are docs that only do locums and make well over 600K/yr doing 15 shifts a month. I could get the same job tomorrow if I wanted but I like where I live and I have a family. Sure these jobs may disappear but they have been available for the past 5 yrs that I know of and I really do not see any changes in the near future. If you think its a unicorn, then you are not informed. I am offered referral bonuses all the time to find them ED docs. Of course these jobs are not some magical job b/c you have to either live their or travel to do the shifts.


I apologize to all that I have offended but these are my feelings. All jobs have issues and EM is no different. My point is in EM, if you have a big issue with it, there are options to make the job more bearable. I would love to ba a pro basketball player and make millions with fame but if Lebron Broke his legs tomorrow he would have no choice but quit playing basketball.

My point is in EM, if you hate working in a hospital ED, there are choices that are available to you. All you need to do is make some phone calls and you can work in a FSED/UC easily. As with other specialites like cardiology/gen surgery, they can't just pick up their practice and move somewhere next month. EM can. So there are options to still practice EM medicine but in a less stressful environment.

 

[EMIM2011]

Two facts needed to best answer your question:

1- Is it ACGME accredited?

2- Would it allow you to sit for the critical care subspecialty boards?

Neurocritical care is not ACGME-accredited, afaik. They have an alternative body where you can sit for board-exams. You may be better served doing an ACGME-accredited fellowship pathway (IM, Anes, Surg). Ideally, this would be a place that has a true interdisciplinary critical care philosophy, and you could do extra electives and research in neurocritical areas.

 

[Birdstrike]

Neurocritical care is not ACGME-accredited, afaik .

I know. That's why I asked, wondering if he meant it was an accredited critical care program that happened to just be a little Neuro heavy, or of it was a non-accredited program of some sort. There still can be value to a good non-accredited program, depending on what it is, but obviously the ACGME stamp of approval is better if available.