Rural EM will not advantageously provide skill polishing. I'd say overall polishing, proceduralism, autonomy and independence can be attained anywhere. The busier shops will provide you with more opportunities to grow. If you're fresh out, I think it's relatively always advantageous to pick a busy community shop with double or triple coverage, preferably staffed by other ABEM docs. It's useful to bounce cases off the veterans and you can undergo a tremendous amount of growth in a shop like that within 1-2 years. You learn a great deal in dealing with all your consultants, also. Rural medicine is another animal altogether. It's good experience but it's more about functioning independently without backup and without as many specialists. Creative emergency medicine, stabilization and shipment...smooth transfers, etc.. It's lonelier. It's also less stress (most of the time, but not always). I'd work in a busy community ED or level 2 gig for 2-3 years outside of residency to figure out whether you even want to do dedicated CCM. Academics generally always pays less. My advice to newish grads is to maximize your earning potential for at least the first half of your career, or at least for 10 years. Then you've banked enough money and gained a lot of great experience that will serve you well in an academic setting.
See if you like bread and butter EM first. All sorts of things tickled my interest when I graduated but I wouldn't even consider additional training at this point. I'm too far down the rabbit hole and don't want to sacrifice the carrots that it would take to do something else. I don't consider that a bad place to be and you might not either after a few years out. I'd say at least 75% of the "EM burn out" sentiment can be solved by changing job environments and/or decreasing hours. Simple as that.
