Possible to work all day shifts?

[cabinbuilder]

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Is it possible to work all day shifts, or are you constantly switching between days/nights at most places? I'm interested in rural EM.

It would depend on how rural (frontier) your ER is. Is your vision to be the only doctor covering the ER? If that is the case it depends on what other coverage (if any is available to you). I have worked where I had a PA cover the night, I have worked where I was there for 14-16 days straight on call for that whole time and did clinic. Been where I was the ONLY doctor in town and did both ER and clinic for over a month. Many rural places only have one doc there at a time.

However, if your vision of rural is more than one ER doctor on staff then it would depend on the contract and what you work out with your colleagues.

Sounds like if you are dead set on day shifts only, then go into urgent care instead.

 

[Mwalk7]

Thanks for the info from everyone.

What is the main advantage of being a nocturnist in a big group? Obviously pay is higher I would expect but less week days/weekend days?

 

[Mwalk7]

Excuse me, less days working total in the month

 

[Arcan57]

Thanks for the info from everyone.

What is the main advantage of being a nocturnist in a big group? Obviously pay is higher I would expect but less week days/weekend days?

Pay isn't necessarily higher. Not all groups have a night differential (we don't). The main advantage is going to be predictability of schedule. Typically the nocturnist has something going on in their lives where they need to have x,y,and z days off every week or there's a childcare situation where they have a spouse who gets kids to school then they are up to take care of kids in afternoon before heading into work. I actually haven't met any nocturnists that don't have kids, although I'm sure they exist.

 

[NinerNiner999]

Pay isn't necessarily higher. Not all groups have a night differential (we don't). The main advantage is going to be predictability of schedule. Typically the nocturnist has something going on in their lives where they need to have x,y,and z days off every week or there's a childcare situation where they have a spouse who gets kids to school then they are up to take care of kids in afternoon before heading into work. I actually haven't met any nocturnists that don't have kids, although I'm sure they exist.

Plus, the biggest advantage is clock regularity. You don't switch your shift times.

 

[docB]

In some small way I agree with you. That would be a fun practice. In a very large way, I just want to say good luck getting a job in Portland (or Denver, or Salt Lake or anywhere else it's tough to get a job as an EP) if all the EPs do there is take care of level 1s and 2s. There would be one ED staffed by 6 docs.

In fact, good luck getting into an EM residency, since we'd only need 1/10th of them. Plus the job would be so great (and pay so well with all those procedures and critical care codes) that it would be more competitive than derm.

Think it through. It just doesn't work. EM will always be what it is, with or without EMTALA. Our for-profit hospital is begging us to MSO people, but there just aren't that many without insurance that don't have an emergency. 5% maybe. Even if you add in the insured patients I can determine don't have an emergency after just an H&P we're only talking about 25% or so. If they need a STAT test to determine if they have an emergency or not, they have an emergent reason to come in. Heck, if they need an exam to determine they don't have an emergency they had a valid reason to come in.

You can't say that Susie with the belly pain doesn't have an emergency after doing a pelvic, an HCG, and a CT. It just doesn't work that way. You have to be willing to say she doesn't have an emergency BEFORE seeing her. It turns out that's really hard and really risky to do.

The level 3s and 4s keep the doors open and the equipment paid for so we can care for the 1s and 2s. That's just the way it is. The intensivists and hospitalists complain about similar stuff. "Why do I have to babysit all these overdoses on ventilators and telling families to let grandpa go? I should be saving septic 30 year olds!" But if all they had to take care of were septic 30 year olds there would only be one 6 bed ICU and 3 intensivists in town.

Sure, having one 6 bed ED and one 6 bed ICU in town would save a lot of money, but so would just shooting everyone when they turn 65.

I'm talking about how things should be. I understand the realities we face that have caused us to become what we are.

But can anyone really say that the best, optimal, most efficient, cost effective use of resources is to have large ERs with EPs charging premiums to see the worried well? Yes they are what allow us to keep the doors open to see the actual emergencies but is that what's best for the system as a whole? Not at all. I know how it is. I'm musing about how it should be.

 

[The White Coat Investor]

Pay isn't necessarily higher. Not all groups have a night differential (we don't). The main advantage is going to be predictability of schedule. Typically the nocturnist has something going on in their lives where they need to have x,y,and z days off every week or there's a childcare situation where they have a spouse who gets kids to school then they are up to take care of kids in afternoon before heading into work. I actually haven't met any nocturnists that don't have kids, although I'm sure they exist.

There's plenty without kids. People do it for the pay (in some groups), to avoid weekends and holidays (in some groups), to have a more regular schedule (a group will give you anything you want if you volunteer to do all nights), because you want to work fewer shifts for the same pay, or because you're just weird like that.

There's no way I'd be a nocturnist without a significant differential.

 

[Mwalk7]

Are there big enough groups that allow every third weekend or fourth??

College football in the fall has to take precedence haha just kidding....

 

[gman33]

Are there big enough groups that allow every third weekend or fourth??

College football in the fall has to take precedence haha just kidding....

Volunteer to work every Friday and Sunday. I'm sure you could get off Saturday.

 

[Pure Anergy]

What about the other way around? Would it be possible to only work two weekend overnights (which are presumably the least desirable shifts) per week? Because if my "work week" was just Friday and Saturday overnights (or Saturday and Sunday overnights), I'd be all over that.

 

[docB]

I'm not trying to be difficult but as the questions and situations get more specific the answers will get less and less applicable to any given person. For example, if you come to my group and want all weekend nights you'll get it right now. And you'll be paid a handsome differential to do it. But what about the next guy after you? If you take that niche it won't be open any more. And what about the group in the town where you want to be? Do they already have a weekend night guy? If they don't you're golden, if they do you're screwed.

My point is that, as much as everyone hates to hear it, it depends on the group you sign with as to what's possible or not.

 

[Kal EI]

I'm talking about how things should be. I understand the realities we face that have caused us to become what we are.

But can anyone really say that the best, optimal, most efficient, cost effective use of resources is to have large ERs with EPs charging premiums to see the worried well? Yes they are what allow us to keep the doors open to see the actual emergencies but is that what's best for the system as a whole? Not at all. I know how it is. I'm musing about how it should be.

Well, the best system would be one that focuses on keeping people healthy and not paying doctors to do things to patients (fee for service). Surgical treating patients that neglect their health for decades is what our system is the best at and pays the most for. It's also not efficient or ideal.

The system is designed for what people will pay for (or profit from).

 

[Apollyon]

I'm not trying to be difficult but as the questions and situations get more specific the answers will get less and less applicable to any given person. For example, if you come to my group and want all weekend nights you'll get it right now. And you'll be paid a handsome differential to do it. But what about the next guy after you? If you take that niche it won't be open any more. And what about the group in the town where you want to be? Do they already have a weekend night guy? If they don't you're golden, if they do you're screwed.

My point is that, as much as everyone hates to hear it, it depends on the group you sign with as to what's possible or not.

My first job out of residency, I work Saturday and Sunday day, and Monday overnight, for 2 years. Not a problem. When I went to Hawai'i, my first job, I asked for a similar thing, and the guy scheduling made it sound like it was THE most impossible, undoable thing about which he'd ever heard.

Where I am now, I work Saturday and Sunday day. We have a nights guy who does 22-24 12's per month, and has been for >10 years, and is over 60, and is not dead yet (for those who say it as gospel that it can't be done). So, tapping the nights isn't possible. The schedule is, though, the same month after month (and only changes arise when someone specifically needs something) - the nights guy lives nearby, but the next closest person is 45 miles away, then me at 62 miles, then the medical director at 75 miles, and then a guy who is 99 miles from pillar to post. Finally, there's a guy who commutes from his home, and that is over 300 miles.

 

[deleted547339]

Well, the best system would be one that focuses on keeping people healthy and not paying doctors to do things to patients (fee for service). Surgical treating patients that neglect their health for decades is what our system is the best at and pays the most for. It's also not efficient or ideal.

The system is designed for what people will pay for (or profit from).

New around here?

 

[Pons Asinorum]

Well, the best system would be one that focuses on keeping people healthy and not paying doctors to do things to patients (fee for service). Surgical treating patients that neglect their health for decades is what our system is the best at and pays the most for. It's also not efficient or ideal.

The system is designed for what people will pay for (or profit from).

Holy thread hijack, Superman!

 

[WilcoWorld]

I dunno, KE's point seems pretty relevant to the direction that this discussion has taken:
1- Can work all day shifts?
2- One's unlikely to work all day shifts, because, among other reasons, staffing based on patient arrivals necessitates a lot of evening shifts.
3- Staffing based on arrival times is motivated by revenue, not actual patient need.
4- DocB points out that this fact of EM isn't good for society.
5- Kal El argues that this fact of EM may be a symptom of the fee for service model, and that this too isn't good for society.

 

[Kal EI]

I dunno, KE's point seems pretty relevant to the direction that this discussion has taken:
1- Can work all day shifts?
2- One's unlikely to work all day shifts, because, among other reasons, staffing based on patient arrivals necessitates a lot of evening shifts.
3- Staffing based on arrival times is motivated by revenue, not actual patient need.
4- DocB points out that this fact of EM isn't good for society.
5- Kal El argues that this fact of EM may be a symptom of the fee for service model, and that this too isn't good for society.

Thanks Wilco. Exactly what I was getting at.

 

[LiamNeesons]

Thanks everyone, seems like urgent care plus occasional ER shifts would be a good fit for my goals.

 

[Arcan57]

Thanks everyone, seems like urgent care plus occasional ER shifts would be a good fit for my goals.

I feel obligated to inform you that you'll be piss poor at emergency medicine if that is your plan. Being able to function in the ED is not like riding a bike. If you're not working enough shifts then your skills deteriorate and typically don't come back.

 

[Birdstrike]

I feel obligated to inform you that you'll be piss poor at emergency medicine if that is your plan. Being able to function in the ED is not like riding a bike. If you're not working enough shifts then your skills deteriorate and typically don't come back.

Agree. You need to be so sharp on such a broad array of subjects and skills, that if you fall below a certain threshold of shifts per month, you be become very rusty, and your reaction time goes in the tank. What that number of shifts per month it is, I can't say for sure. There so many super important things you see and do too infrequently as is, let alone when your not constantly seeing patients.

Urgent care is essentially Family Practice with a skew toward acuity vs. chronicity, and not really Emergency Medicine, per se. Others may disagree.

I haven't worked clinical EM for a while now, but if I was to go back it would have to be full time so that I'd be clicking on all cylinders ASAP. I definitely wouldn't go back and work only 4 shifts per month or something like that. I'd never be back at it long enough to blast the rust out of the engine.

 

[LiamNeesons]

Would working full time in a very rural ER make one become rusty?

 

[Birdstrike]

Would working full time in a very rural ER make one become rusty?

No. In fact, that's where your skills would be most put to the test with the least speciality support and codling. In that setting, you're less able to become a "consultologist," like you could if you worked somewhere with 24/7 availability of every sub-specialty service.

 

[RustedFox]

I feel obligated to inform you that you'll be piss poor at emergency medicine if that is your plan. Being able to function in the ED is not like riding a bike. If you're not working enough shifts then your skills deteriorate and typically don't come back.

+1.

Don't take this the wrong way, I actually got a little mad when I read "urgent care plus occasional ED shifts would fit my goals".

 

[LiamNeesons]

+1.

Don't take this the wrong way, I actually got a little mad when I read "urgent care plus occasional ED shifts would fit my goals".

I wasn't intending to equate emergency room care to urgent care. I merely assumed that a board certification in EM would give one the flexibility to practice in a variety of settings.

 

[RustedFox]

I wasn't intending to equate emergency room care to urgent care. I merely assumed that a board certification in EM would give one the flexibility to practice in a variety of settings.

I get you, amigo. - the hangup is that what you wrote *almost* sounds like:

"My goal is to be an urgent care doctor that also moonlights in the ED."

I can be wrong when I say this, but - nobody's 'goal' should be to be a👎 UC doc with the ability to 'do other stuff n'at.' UC is where dip****asauruses do things like send home PEs with xanax and a diagnosis of "anxiety" that you (me) need to mop up later [true story].

If I had a nickel for every patient that said to me - "Well, I first went to urgent care, and the doc there (which is really a PA/NP) said to me.... aljsdf;lkjasf;lkjadsf;kj."

Also, consider the fact that if you're a FT, steady-rotation guy in a decent ED... you don't want some UC 'tourist' coming thru your shop, screwing things up, and then mouthing off about how he's a steady-rotation ED guy/gal that.... (in reality)... isn't. At all.

 

[KinesiologyNerd]

I get you, amigo. - the hangup is that what you wrote *almost* sounds like:

"My goal is to be an urgent care doctor that also moonlights in the ED."

I can be wrong when I say this, but - nobody's 'goal' should be to be a👎 UC doc with the ability to 'do other stuff n'at.' UC is where dip****asauruses do things like send home PEs with xanax and a diagnosis of "anxiety" that you (me) need to mop up later [true story].

If I had a nickel for every patient that said to me - "Well, I first went to urgent care, and the doc there (which is really a PA/NP) said to me.... aljsdf;lkjasf;lkjadsf;kj."

Also, consider the fact that if you're a FT, steady-rotation guy in a decent ED... you don't want some UC 'tourist' coming thru your shop, screwing things up, and then mouthing off about how he's a steady-rotation ED guy/gal that.... (in reality)... isn't. At all.

Maybe it's because you trained at UT (did you also do med school there?), but I like you. But yeah, I mean obviously I was only a scribe, but I've been able to diagnose stuff that was missed by UC. It scared me. We've also had a couple of docs who don't work much and the difference between them and the regular guys was huge. You gotta want it, OP. I really hope everything works out and I can return to my ED as an attending.

 

[RustedFox]

Maybe it's because you trained at UT (did you also do med school there?), but I like you. But yeah, I mean obviously I was only a scribe, but I've been able to diagnose stuff that was missed by UC. It scared me. We've also had a couple of docs who don't work much and the difference between them and the regular guys was huge. You gotta want it, OP. I really hope everything works out and I can return to my ED as an attending.

LiamNeesons: Hey, I'm on your side, amigo - don't take offense to my post. The moral of the story here is: "Urgent Care is a hellhole where bad docs do bad things." Don't.

K-nerd: I did not do med-school at UT. I'm an SGU grad. PM me if we've worked together. Our scribes both at UT and TTH were killer. Killer. They worked hard and were hungry for knowledge. Good on yah.

 

[deleted77919]

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[Pinner Doc]

Is it possible to work all day shifts, or are you constantly switching between days/nights at most places? I'm interested in rural EM.

Right out of residency? Not at my gig. I actually make the schedule for my group. We're a seniority-based group, and the 4 (or so) doctors who have been there longest get the 8-4p shifts exclusively. It's pretty sweet for them.

I try to give the doctors who are newer at least 25% day shifts, but the rest are swing shifts.

We have a bunch of docs who prefer nights, so those are usually taken care of.

 

[deleted547339]

Right out of residency? Not at my gig. I actually make the schedule for my group. We're a seniority-based group, and the 4 (or so) doctors who have been there longest get the 8-4p shifts exclusively. It's pretty sweet for them.

I try to give the doctors who are newer at least 25% day shifts, but the rest are swing shifts.

We have a bunch of docs who prefer nights, so those are usually taken care of.

hey, a somewhat derailed thread managed to find it's way back on topic. someone sticky this as proof it can happen? lol

 

[Snelgrave]

I feel obligated to inform you that you'll be piss poor at emergency medicine if that is your plan. Being able to function in the ED is not like riding a bike. If you're not working enough shifts then your skills deteriorate and typically don't come back.

An exception to this (possibly) is if you run the simulation center at a residency, and you're constantly writing and testing residents on difficult topics. Even then, you should be working in a "real" ER to keep your skills up.

 

[deleted109597]

An exception to this (possibly) is if you run the simulation center at a residency, and you're constantly writing and testing residents on difficult topics. Even then, you should be working in a "real" ER to keep your skills up.

This isn't an exception. People who don't work in EDs should not teach EM residents clinical skills, period. I don't care if they're excellent at simulation. If they aren't able to use real world cases, they quickly fall behind (think standardized tests).
I've haven't ever seen a core faculty member work less than 6 shifts per month. I'm sure there are some out there, but see the first paragraph. (Research faculty that are teaching research don't count).

 

[Pinner Doc]

hey, a somewhat derailed thread managed to find it's way back on topic. someone sticky this as proof it can happen? lol

Ha, probably should have read all the way through, eh?

 

[SoCuteMD]

An exception to this (possibly) is if you run the simulation center at a residency, and you're constantly writing and testing residents on difficult topics. Even then, you should be working in a "real" ER to keep your skills up.

As someone with a significant interest in simulation, I disagree with this completely. I don't think you'll find a physician in charge of EM resident simulation who only works urgent care. I do happen to know one person who runs a university-owned simulation center who is mostly non-clinical at this point, but this person has many years of clinical experience. There is a difference, however, between administrating a simulation center and running a simulation program/curriculum. The former can be done by someone who is outside the clinical arena, the latter can not - at least not well and effectively.

 

[Arcan57]

An exception to this (possibly) is if you run the simulation center at a residency, and you're constantly writing and testing residents on difficult topics. Even then, you should be working in a "real" ER to keep your skills up.

So I'm not so worried that the part time "not used to the acuity" doc is going to blow a AAA case because they haven't seen one in 10 years (although that's a valid concern) but that:

1) they're going to see 1 pph/hr less than my regular docs and
2) they're going to piss off the nurses and the consultants and
3) mismanage a bunch of bread and butter cases not because of lack of medical knowledge but the inability to bring that knowledge to bear

Expanding on #3, the ED is an incredibly abrasive environment. Residents develop a thick protective coat to deal with the adverse stimuli and become functional in the ED (think of it as an Hazmat suit for your frontal lobe). But the coating wears off over time if it's not needed and being plunged back into the ED without that coat is to suck in toxic fumes. You may still have the knowledge base, but you're so busy trying to breathe that you don't have ready access to it. And sure if you had time to think you'd get it right away, but here comes another tech with an EKG to sign and the string of consultants on that patient you admitted an hour ago have finally called back all at once, and the nurse needs to know if room 10 can have anything more for pain, and the batphone just rang with a possible STEMI coming in but the engine can't transmit the EKG, etc.

 

[docB]

Great points. Also, totally aside from medical knowledge, the culture of how a place does certain things is tough for part timers to pick up. This PMD admits his own patients and that insurance has to go to that hospitalist and we never admit a chest pain rule out until 2 troponins are back and neurosurg doesn't want to be called unless the patient will really need to go to the OR and so on. In that case #3 happens and results in #2.

3) mismanage a bunch of bread and butter cases not because of lack of medical knowledge but the inability to bring that knowledge to bear

2) they're going to piss off the nurses and the consultants

 

[WilcoWorld]

Great points. Also, totally aside from medical knowledge, the culture of how a place does certain things is tough for part timers to pick up. This PMD admits his own patients and that insurance has to go to that hospitalist and we never admit a chest pain rule out until 2 troponins are back and neurosurg doesn't want to be called unless the patient will really need to go to the OR and so on. In that case #3 happens and results in #2.

Stated otherwise - the hardest part of EM is not the medicine. [tho the medicine can be pretty tough at times]

 

[Apollyon]

And, on 31 July, the OP, who hasn't apparently started med school yet, elucidated a plan to do general surgery, and asked about doing a fellowship after a few years out of residency. This was in the surgery forum.

Hmmm....