la gringa

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Oct 14, 2004
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anyone with any experience? i finished residency in 2009. feeling a need for an area of expertise, change up in job situation, and to extend my longevity in the field.

my interests would lead me to CC and palliative care... considered peds or sports med long ago but i don't think those would create the types of opportunities i'm looking for.

thinking of taking a job for the $$ for a bit so i can afford it and maybe an academic job after - had a personal financial and medical disaster that has left me in a less than optimal place for this type of thing, but community practice, at least with my current group, is wearing me down. i know i can't do THIS job for 20 more years. it's not even the patients per se... more corporate expectations vs my desire to be an excellent physician who puts patients first. if anyone has advice for THAT one either, i'm all ears.
 

suckstobeme

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Oct 9, 2004
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Let me preface this by saying I'm trying to offer sincere advice and not trying to be mean, at all.

1) Most ER fellowships, to me, are a total waste.
Critical care is interesting because critical patients are what we love. On the other hand, do you want to be the ICU doc that inherts 17 ventilated pateints on Monday morning and has to figure out how much Jevity to give in the tube feeds and figure out sodium deficits and all the other minutia that goes into being an ICU doc. I like codes and resucitation and putting in lines/tubes, but the slow meticulous management of ICU patients is generally not what ER doctors like- though you maybe the exception. There are ICU/ER hybrid models but there are very few of those and I think there would probably be more than enough people wanting to do that.
I'm not sure what a palliative care fellowship teaches you. I'm not sure what an ER doctor with a palliative care fellowship can offer a patient that a plain old ER doctor can't (especially if you are in a hurry to see the next 5 patients that have not been seen yet).
I really wanted to do a peds fellowship coming out of residency. I'm glad I didn't. It would have been flushing money down the toilet. First, in most ERs, the ER doc gets paid more than the peds ER doc. Second, I already see a bunch of sick kids. In fact, in my shop, we have peds hospitalists that staff the ER in the evening. If there's a very sick kid (imminent intubation) or a trauma, I'm seeing it, not them. Point being, I'm already very competent seeing sick kids and I think doing a fellowship would only make me marginally better than just getting ongoing community experience. Third, I think a Peds ER fellowship really only helps you if you work in a Pediatric Academic Center where you will be more comfortable with weird/genetic diseases that we typically don't get in a standard ER. Those families typically know that they have to go to THEIR hospital to get specialized treatment.
Ultrasound-schmultrasound. Just kidding. Though, I think it's been discussed on this forum that in most community settings, it's hard to make doing a bedside ultrasound make financial sense. I'm actively looking for good ultrasound courses to take to get better at very limited/specific exams (see related thread), but 1-2 yrs seems like overkill.

Now some people say that if you do a fellowship you can get your foot in the door of an academic program. I guess that makes sense. BUT, you know those little glossy fliers you get in the mail advertising job offers- but sometimes they don't tell you exactly which hospital they're hiring for? So I got one the other day, and I'm like 80% sure it's for the University of Chicago Hospitals. U of C! Like, Peter "I wrote the book" Rosen was program director there! And they're just like sending out job ads trying to hire faculty. Also, there are new residency programs popping up every year (too many, in my opinion, but that's another issue). I don't think you need a fellowship to do academic medicine because it is still moderately wide open- as long as you're not married to a single location.

2) It sounds like you are not trying to get into a field that you are passionate about as much as you are trying to get away from a job that you don't like. If that's the case, a fellowship is not the answer- a new job is. What is wearing you down about your current job? Is it the structure? Are you with a Mega-Group? Are you seeing 4.5 pts/hr? Are the patients in that part of town hard to deal with?
If the powers above are trying to make you prioritize anything over good patient care, I think you should consider voting with your feet. There is such a strong demand for ER doctors right now (outside of a few tight markets) that you should be able to find a job easily. You can find a hospital employed position or a nice smallish group. There are good groups out there that want to provide excellent patient care, I promise.
It sounds like you have had some financial setbacks. I guess it's hard to give advice without knowing details, but I think there's a temptation to make a lot of money all at once and tell yourself you will relax after that. It works for some people, but it's not worth it if you hate your job/life/the care you provide.

3) I've been reading your posts for a long time, Gringa, and have gained a lot from your comments over the years. Thanks!
 
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la gringa

Senior Member
10+ Year Member
Oct 14, 2004
847
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Attending Physician
1. doing CC would be to mostly move to that. i really excelled in the ICU in residency and sometimes i wonder if i'd rather do jevity than work notes and fight with drug seekers. Palliative care is moving into the ED - i'd use it to get into an academic niche and/or maybe move to that entirely at the end of my career. i have a strong interest in end of life care and medical ethics, which drives my interest in those 2 areas.

2. my job... does not seem to care about quality provided as long as it's above some standard. we get ZERO quality feedback of any sort. i think my director notices and cares, but anyone higher in the rather large group doesn't one bit. i'm with a quasi-mega group that pretends to be run by the physicians. it's still run by "corporate", in another state. my group was a smaller group that was taken over by a larger one.

without being too specific, there are metrics that are being met but i'm at one end and being harassed for this. when the nurses are asked, this is because i spend time with patients, give excellent care, and am on the meticulous side. i am willing to go the extra mile to help less advantaged patients. that takes time. i feel like my efforts are largely unnoticed beyond the patients and their PCP's. i'm not a self-promoter, and god knows if i were that would not be interpreted well since i am a woman. the turnover here is pretty high and the compensation is below average. it's hard to want to stay given the above... unfortunately my current city doesn't have a large # of attractive or available employment situations. it's my hometown and this whole situation is breaking my heart.

thinking of applying for a TX license... i'm fluent in Spanish and trained in a city with a lot of Mexican patients, so i think i'm rather qualified, ha!

3. thank you!
 
Oct 30, 2009
31
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Attending Physician
I was feeling a lot like you a few years ago. I went and did a Palliative care fellowship and have not regretted it one bit. It is a great growth area for the future, I have a ton more control over my practice and have not been hit at all financially. As far as academics you are correct you will be sought after.
 
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la gringa

Senior Member
10+ Year Member
Oct 14, 2004
847
13
esse quam videri
Status
Attending Physician
I was feeling a lot like you a few years ago. I went and did a Palliative care fellowship and have not regretted it one bit. It is a great growth area for the future, I have a ton more control over my practice and have not been hit at all financially. As far as academics you are correct you will be sought after.
do you still do EM at all, or just PC? did you find that you were at any kind of disadvantage when looking for a fellowship? i'm trying to boost my CV in that regard, not on purpose per se but because it's an interest of mine.
 
Oct 30, 2009
31
2
Status
Attending Physician
I do occasional EM shifts. I did not notice any disadvantage for fellowship, the program(OSU) in my town(Columbus OH) did not fill the year I applied.