Regrets in choosing EM?

[DosEquisDoc]

Currently a PGY2 EM resident in a 3 year Midwestern program. Decided last minute to bail out on Surgery for a career in EM halfway through the interview season as a 4th year med student. Now that I spend my the majority of time in the ER dealing with the worst of the worst patients (some with legitimate emergencies but most of them not), getting talked down to by my subspecialist colleagues ("You're consulting me for WHAT?!" "No, that's not a STEMI...I'm not taking your patient to the Cath Lab" "Do you even know how to read a CT? If so, read it before you consult me for an Appy"), not really being a trauma doctor since all I do is manage the head and the airway while the Trauma surgeons have all the fun with the open thoracotomies, chest tubes, etc., and worst of all - missing out on that appreciation from a patient that you actually did something for them or helped them (and the "thanks for the dilaudid doc - no my phantom abdominal pain is all gone and yes, I will be happy to go home now... you're the best doctor in town!" is not the appreciation I'm talking about).

I'm sure for many of you in EM, these are not uncommon occurrences or feelings. And moreover, I'm sure you all knew these things before going in to Emergency Medicine. But, did you ever think that the burn out would come this quickly? Sure we do shift work, don't have to take call, really don't put in that many hours each month, and still get paid decently. But is it worth it at the cost of not having that continuity with your patients to know if anything you did for them actually mattered, of not ever being taken seriously by your patients or colleagues because you're not a master of anything (but a jack of all trades), of feeling like in the end you're basically a triage doctor, and from a financial standpoint knowing that your earning potential is capped while your friends from med school who went into plastics, ortho, or vascular will eventually (albeit a long eventually) be making 5x's more than you do on a yearly basis?

Has it occurred to anyone that while you may enjoy running around the department seeing anything from a sprained ankle to a traumatic arrest, that one day you'll be 55 or 60 years old doing the same thing that you're doing now as a resident? Kind of a sobering thought. But I guess if you LOVE it, then it's not a big deal. However, let's be honest, many people (if not the majority) who decide to ditch their original aspirations of being a surgeon or cardiologist or whatever for Emergency Med did it not because they thought EM was their calling, but because it allowed them to have a "lifestyle" outside of work. It gave them limited time at work for a nice paycheck and the time to enjoy that paycheck. I agree, that sounds awesome.

What isn't awesome are those times when a STEMI or a gnarly dissection comes in and you're limited to getting an EKG or Chest X-Ray (and maybe you have the opportunity to actually auscultate the patient with your stethescope) and consulting cards or CT surgery, respectively, and then going off to do a pelvic exam and ultimately give her a shot of rocephin with a gram of azithromycin because she has cervical motion tenderness (woopdee****indoo)...all the while your buddies are doing cool **** in the cath lab literally saving this guy from his heart attack or scrubbed in and grafting his patient's aorta and literally saving his life. Sure you had your part in saving those patients' lives - i mean it was you consulted your colleagues... but in the end, who ultimately is the one saving their lives? You or your specialist colleagues? Who walks away with greater pride and satisfaction at the end of the day knowing that all their hard work actually mattered?

So, the point of this self-inflection rant is this question... do any of you (specifically those who ended up in EM secondarily to leaving your initial aspirations to be another type of doctor) have any regrets for selling out early and not going all the way? Do you ever feel that if you had just sacked up and decided to put in the extra few years in training that your status, freedom, and pay eventually as an attending would also be much higher, and thus making all that suffering worth it?

Consider this: had you pursued your aspirations to become a cardiologist or a surgeon, then the more you work along your career path, your status, pay, and autonomy also grow accordingly. For example, you do 5 years as a gen surg resident, then you're a plastics fellow for 3 years, then maybe a hand fellowship, and at the end you're taking call from home (if you even need to take call) only to tell the ER doc to suture or set what they can and have them follow up in the office tomorrow. You have your own practice and you get to operate a few days a week and you're pulling in close to a million a year (if not more). No nights, no weekends, no holidays. Life is sweet. Sure you're probably 55 years old. But at the same time, what's your 55 year old buddy from med school who went into EM doing? He's on his 4th night shift in a row looking forward to switching to days in 2 days dealing with the homeless druggies who are yelling at him because he's trying to be noble and not give them narcotics. He's doing the same crap he was doing as a resident. He doesn't have a PA or a resident that will go in for him to see ED consults or round on patients like you do. You're sleeping next to your beautiful wife in your beautiful home, while he's stressing out and probably having an NSTEMI himself while he's at work.

Sure, EM affords a great lifestyle and job early on when you're young in your career... i mean 3 years of residency and you're out... there's no delay in gratification. Who wouldn't want to take a bite out of that apple? But, take a moment to project long-term and then compare the two career paths... then you'll see my point. Again, this thread is only for those who didn't primarily choose EM because they love EM (these are the guys that I truly envy), but rather this is for those like me who had their hearts set on something else besides EM but somehow ended up choosing this career in the end...

With that said, for those of you who have regrets (not necessarily of choosing medicine in general) but of leaving your dream of being a surgeon or whatever... would you consider going back and chasing that dream? Or have you found a way to accept your career and a way to enjoy EM? If you're like me and can't see yourself pulling full-time shifts in the ED 10, 15 years into your career... then what have you chosen as your alternative?

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[Tiger26]

Dude--I feel kinda bad for you. Hope you have the stones to switch into something you really enjoy and will allow you to make $1,000,000, score a smoking hot wife +/- mistress, and not have to spend another moment with a chronic pain/drug seeking patient again for the rest of your life.

Honestly, I love going to work the few days a week that I actually have to and I couldn't say that about any of the other specialties I rotated in during med school. Sure, most of them have a few certain cool attributes, but I never loved them.

Cheers to your future no-call, high pay, baller status as a a life-saving interventional hand surgeon ....

 

[dotcb]

Sounds like you switched into the wrong field for you. May need to flip back toward surgery. The concerns you posed about EM don't bother me. I'm very happy practicing it.

 

[Mighty Mouse]

I love what I do. Some patients are difficult, but the majority are not (particularly if your ultimate practice is outside of the urban trauma center). I think there's a reality that hits all of us towards the end of residency (when elective and off service months tail off) and into beginning of attendingship that this is what you'll be doing day in, day out, for the rest of your life. The sweet surgeries and stuff you're talking about missing out on I think get old hat for most of the surgeons too. On the STEMIs, traumas, etc....I personally love the easy dispo and move on.

You need to consider which specialty has the bread and butter cases most in line with what you like. I personally think being a cardiologist would suck. Cath lab cases are few and far between (besides elective cases I suppose). I feel like it would suck to have to admit or be consulted on a lot of the admittedly BS chest pain cases we bring in.

I effectively work half of the year. When I'm not there, nobody is calling me. I don't find it hard to deal with administrative pressures or Press Gainey crap -- I just make sure I play the game well and appreciate the challenge of it.

You may have made a poor decision, or it may be the doldrums of being halfway through your second year of residency, it being dark and cold out, and it sucking being a resident.

Overall, EM is very challenging and can burn you out. But I don't think there's any easy medical specialty. They all have unique challenges and types of patients that are hard to deal with. I worry about doing this 30 years from now, but I will have accumulated enough wealth and made sure I have made administrative or academic in-roads where I can have a viable financial out when I want to step down my clinical time but still have a reason to get out of bed in the morning.

 

[Arcan57]

It sound like you are figuring the grass is greener, which it may or may not be. Plastics fellowships don't get passed out like party favors after a gen surg residency and a significant percentage of the hand fellowship trained surgeons in my area still have a heavy cosmetic practice to subsidize the hand work.

Interventional cardiology and CT surgery both have very lengthy training programs and (usually) brutal schedules. If there's one disease process, organ system, etc. that you want to dedicate your life too or if the downsides of EM are intolerable, then I think it makes complete sense to switch into another specialty. If you're just thinking that you'd like to get paid more when you're older, then you have to think about opportunity costs and that getting paid bank in the future is going to be far more a function of your ability as an entrepreneur then your specialty.

 

[goodoldalky]

I hear you. As a third year resident I too have had some of the same thoughts from time to time. I have often wondered if EM was right for me and those feelings over time have gotten fewer and far between. Residency is hard and no matter what field you choose. There is a fair share of crap to keep you down and feeling like this, generally moreso during residency. You just got through intern year and I imagine you are now swamped in the ED, getting your butt-kicked as a second year and in general your shifts are not enjoyable, you spend a lot of time screwing things up and getting yelled at by everyone inside the department and out, including patients. I get that. I’ve been there.


My take is that the idea of choosing a specialty based on what others will think of you or to try and gain approval is a bad idea. No matter what field you choose, you will get your fair share of crap from someone. If you’re in Ortho, other docs such as IM may give you a hard time for consulting them for simple medical problems because, well… you’re ortho. If you’re in cards, you will get consulted endlessly for what you feel are bogus chest pain complaints. Go into GI and you’ll be swarmed with chronic abdominal pain and requests for scopes for ‘tummy aches’ from everyone’s PCP.


Granted, no one will kiss your feet in EM. Your patients are just as likely to be homeless as anything else, and you’ll probably save their lives from time to time and no one will seem to care or know. You will eventually probably save the life of someone rich and famous, and the inpatient team will get the credit and do the news interviews. Most of the time, though, when you do something good for a patient, no one will know but you (only rarely, the patient).


You also have a hard job. You make decisions about patients with no information, with little time, and not enough resources or staff. You do the best you can to do what is right for the patient. In order to do that, you are going to make some consults that are appropriate and some that in hindsight later appear to be unnecessary (easy to say with all the information at hand). But you did it for the patient and no professional should fault you for that.


If you want an easy job with fame, fortune, a million dollars a year, no call, no nights, no weekends, no holidays, no difficult patients, and consultants that walk around with your photo in their wallet because they love you so much… I’ve got news for you.. It’s not emergency medicine. That job also doesn’t exist.


We are one of the few specialties out there still practicing real medicine. We take care of anyone, anytime, no matter how big of a pain in the ass it is or the fact that no one cares. We all do our best to care for people during their hardest time and (as has been said before) we have done so much with so little for so long that we can do just about anything with just about nothing.


There’s no other job in the hospital I would do… but I didn’t always think that. I don’t think what you are feeling is that unexpected.

 

[gman33]

If it is your dream to be a surgeon and hate EM, the decision is pretty easy.
You only live once. Switch fields.

I think you are viewng all the bad parts of EM and fantasizing about what it's like to practice another field.
In my mind, doing a procedure isn't what "saves a life".
That might be a part of it, but a small part.
Finding the guy that needs a cath with a subtle EKG finding, that's the life saver.
In truth, it's both parts, but only one part interests me.

 

[gman33]

Also, i had serious thought about switching fields last year.
Really thought about it, even found myself checked out for a little while.

Doing some serious soul searching, I came to realize there are pros/cons to every fields.
Are there things that suck about EM? Yep.
There are also things in every field that suck.

 

[MSmentor018]

I know a surgeon who use to be EM, after 10 yrs as an attending he went back and completed gen surg residency. another was a guy that after 15 yrs of anesthesia came to EM. if you got a few more years in you to do another residency, do it. or complete em residency then fellowship in something else like pain mgt, surgical cc, palliative care, tox, consulting....etc. the last thing you want to be is 55, unhappy, burned out, and not having the option or stamina to change.

 

[Sam212]

I stumbled upon this thread while browsing the forum, I am an Ortho resident and my brother is EM, I have to say that OP is living in fantasy world.

Dude, you're way off!!

No one is making a million dollars in Ortho, or for that matter in plastics, with weekends off and light call. Only guys that even come close are spine guys, or Orthos who are seniors partners in very high volume groups that are still operating like mad men.

I don't know about you but EM residents at my hospital work 18 or 19 ten hour shifts a month, their PD even has a rule that they can't work more than 5 shifts in a row. And while I agree the nature of work in EM is intense, your work hours are a joke compared to surgical subspecialties. Also, you bailed on surgery for EM, apparently due to lifestyle reasons so I am not sure what you're complaining about.

As far as EM compensation is concerned, my brother is a senior resident and just signed his contract. His package is $350K/year+, and will be over $400k+ once he becomes board certified. This includes 4 weeks of paid vacation, also, this is not some BFE but a 350k+ town close to a major metropolis. Not bad for 3 year residency and the hours he will be working, huh? for comparison, average ortho probably makes just about $500k, works twice as long and twice as hard to get there.

 

[Apollyon]

I stumbled upon this thread while browsing the forum, I am an Ortho resident and my brother is EM, I have to say that OP is living in fantasy world.

Dude, you're way off!!

No one is making a million dollars in Ortho, or for that matter in plastics, with weekends off and light call. Only guys that even come close are spine guys, or Orthos who are seniors partners in very high volume groups that are still operating like mad men.

I don't know about you but EM residents at my hospital work 18 or 19 ten hour shifts a month, their PD even has a rule that they can't work more than 5 shifts in a row. And while I agree the nature of work in EM is intense, your work hours are a joke compared to surgical subspecialties. Also, you bailed on surgery for EM, apparently due to lifestyle reasons so I am not sure what you're complaining about.

As far as EM compensation is concerned, my brother is a senior resident and just signed his contract. His package is $350K/year+, and will be over $400k+ once he becomes board certified. This includes 4 weeks of paid vacation, also, this is not some BFE but a 350k+ town close to a major metropolis. Not bad for 3 year residency and the hours he will be working, huh? for comparison, average ortho probably makes just about $500k, works twice as long and twice as hard to get there.

Dude, we need more of you. Just from this one post, this post calls it like it is - some things just "are", whether one likes it or not.

 

[Alvarez13]

I stumbled upon this thread while browsing the forum, I am an Ortho resident and my brother is EM, I have to say that OP is living in fantasy world.

Dude, you're way off!!

No one is making a million dollars in Ortho, or for that matter in plastics, with weekends off and light call. Only guys that even come close are spine guys, or Orthos who are seniors partners in very high volume groups that are still operating like mad men.

I don't know about you but EM residents at my hospital work 18 or 19 ten hour shifts a month, their PD even has a rule that they can't work more than 5 shifts in a row. And while I agree the nature of work in EM is intense, your work hours are a joke compared to surgical subspecialties. Also, you bailed on surgery for EM, apparently due to lifestyle reasons so I am not sure what you're complaining about.

As far as EM compensation is concerned, my brother is a senior resident and just signed his contract. His package is $350K/year+, and will be over $400k+ once he becomes board certified. This includes 4 weeks of paid vacation, also, this is not some BFE but a 350k+ town close to a major metropolis. Not bad for 3 year residency and the hours he will be working, huh? for comparison, average ortho probably makes just about $500k, works twice as long and twice as hard to get there.

Not to mention that building your own practice or starting out at someone else's requires a lot of extra work to build up a referral base and establish yourself in the industry. A know one ortho girl who is part time and works around 36 hr/wk like the avg EM doc, but a few of the guys in that practice are still >60 hrs/wk and have been for a long time. It's an awesome field, but not for the weak of heart.

 

[EvoDevo]

Sure, I can see where you're coming from. I went from neurosurgery to EM and it was a "whoa!" kind of switch. Occasionally I fantasize about what it would be like to have stayed the course, but then I realize:

- I'd still be in residency
- I'd be a LOT (and I mean a LOT) more stressed than I am now.
- I'd know more about one thing and be (relatively) clueless about a broader scope of medicine.
- Yeah, lots of BS in the ER, but occasionally not, and when the chips are down? You probably want that good EM guy doing the stabilization/airway/resus. Then I get to hand off to others for the long term care.
- Didn't you HATE being in the OR for HOURS at a time? I mean, cool stuff to do and you get to focus one one thing and do it well but the TIME.....
- I get to see my kids a LOT.
- I get to see my wife a LOT
- I have a relationship with my friends and family that residency and medical school took away.
- Of course, I'll never make what I *could* have made once NSGY residency was done, but I'll take my life right now.

That's me, two years out from residency. Talk to me in five more and we'll see.

 

[EM4life]

I didn't transition from surgery to EM, but loved surgery as a med student and really considered it an option. If there even exists some surgical subspecialty where you can sit on your butt and make a million dollars and not take call when you are in your 50s, you are working terribly hard for it in your 20s and 30s. I wanted to have a family, a life, have money while I'm still young, have a family to take care of and be able to spend time with them. The vast majority of people in my group are able to get time off for their kid's concerts, events, with the exception of holidays, they spend plenty of time with their families and don't miss important events. Most people in my group who are over 50 are doing less hours and have a lot more administrative time as well. I'm happy with my life, if I ever have the occasional regret about my job, it's sometimes about picking medicine in general, not the speciality I chose.

 

[lightthelamp4]

I'm glad I found this thread. I am a third year student and have been thinking long and hard about what to do with myself. I really appreciate the thoughts everyone is sharing here. As I stand right now I am torn between three paths...

-IM= only for the possibility for specialist training, but the more I think about it the more I don't like the idea of basically being a master of any one particular organ system
-EM= I (think) I love the scope of practice, the patient populations, and the ability to do procedures I would not being doing in IM; I am afraid of "burn out" when I grow older though
-EM + FM = I feel this would be a great path, being able to open/join a FM practice if I actually do get burnt out later in my career; whenever I get asked about what I want to do however, I get nothing but weird looks and sarcasm about combination residency ( "you can only do one anyway, why waste your time"/"the extra training wont help you" etc)


I am very much struggling with this. Any advise would be appreciated.

 

[Groove]

To the OP:

You're in the wrong specialty. It's really that simple. You have 3 posts on this forum and were following PRS match list in March of last year along with inquisitions in this forum about a sudden EM PGY2 opening in the context of "What did that EM resident switch into?". It's obvious that you've had "one leg out the door", so to speak, before you had even completed your PGY1 year of residency in EM. That's awfully early for genuine disillusionment in a specialty where you probably had relatively limited exposure. Were you a PRS hopeful with low scores who jumped into EM for the wrong reasons? Last minute cold feet? I have no idea and can only postulate. That being said, I have a really hard time resonating with some of your complaints. It's not that they aren't valid, merely atypical for most of us who went into the field for genuine reasons.

I'm not far out from residency and can bitch and moan all night long after a shift but when it comes down to it, I love what I do and wouldn't do anything else. Where else can you make half a mill and only work ~45hrs/week with no call? Want to work 8 shifts a month? Go for it. Want to work 21? No problem. You could move and work in a new state every year if you felt like it with no worry about a patient base or generating referrals. Excellent job security. As for feeling mistreated by consultants, that's not really specific to EM. Hospitalists and Gen Surgeons feel dumped on too and are routinely ridiculed for their "floor consults". I don't have a problem with my consultants but everyone has to deal with the occasional dingus. It's easier to become more jaded in residency where you are primarily dealing with residents and not attendings.

Either way, my best advice would be to follow your gut. It doesn't sound like EM is for you if you've been straddling the fence since last year and are suffering from this degree of disillusionment in your PGY2 year. Pursue what would make you most happy and don't let forum opinions or speculative salary/lifestyle/subjective opinions ("You're crazy!"), etc.. adversely influence your decision. Good luck.

 

[deuist]

-IM= only for the possibility for specialist training, but the more I think about it the more I don't like the idea of basically being a master of any one particular organ system

Only you can decide if that's worth it. Some specialists such as nephrologists and some infectious disease docs continue to practice general medicine in addition to their specialty focus.

-EM= I (think) I love the scope of practice, the patient populations, and the ability to do procedures I would not being doing in IM; I am afraid of "burn out" when I grow older though

The burn out is real. I'm not sure what you love about the patient populations---they are the reason for the burn out.

-EM + FM = I feel this would be a great path, being able to open/join a FM practice if I actually do get burnt out later in my career; whenever I get asked about what I want to do however, I get nothing but weird looks and sarcasm about combination residency ( "you can only do one anyway, why waste your time"/"the extra training wont help you" etc)

A total waste of your time. To be a competent EM doc you need to read a lot. Adding a second specialty and trying to keep up with its literature---particularly while not practicing it---would be brutal. Also, as people mentioned above, building a private practice takes time. How are you going to do that at the age of 50 when you're already burned out on medicine?

I did a surgical internship before doing EM. I even liked cardi-thoracic surgery. But as I told one of the CT attendings, "This specialty is cool, but it's not 8 years cool."

 

[The White Coat Investor]

If you don't love the work, then you're in the wrong specialty. It is important to factor in lifestyle and money when making a specialty decision, but it shouldn't be the primary factor.

There are some awesome things about EM that you don't get anywhere else. If these things don't outweigh the downsides, then you might want to look at something else.

I went to see a guy on the wards that I gave TPA to the other day. He had an NIHSS score of 6 or 7 then, and now his score is 2. He can use his dominant hand again and speak in a comprehensible way. I've made a huge difference in his life. Yes, 1/3 of my income comes from anxiety and reassurance. I see drug-seekers and undiagnosable belly pain (often both in the same patient) every single day. But you know what, I work 30 hours a week for $3-400K. If you don't like EM, get another job and do EM on the side. If being a surgeon is your dream, then go be a surgeon.

 

[HooliganSnail]

A total waste of your time. To be a competent EM doc you need to read a lot. Adding a second specialty and trying to keep up with its literature---particularly while not practicing it---would be brutal. Also, as people mentioned above, building a private practice takes time. How are you going to do that at the age of 50 when you're already burned out on medicine?

Not a waste of time. FM and EM are extremely compatible specialties, as they are the only ones who treat patients regardless of age, gender, organ system, or pregnancy status. EM training focuses on the acute setting, while FM focuses on the chronic. My goal is to practice both. 2-3 days a week in office, 2-3 days a week in the ER. I think it will be a nice career, personally.

And furthermore, health care is changing so rapidly that it is impossible to say what either job will be like in 20 years. Taking the extra time in training to ensure that you are double board certified gives you lots and lots of options later in life.

 

[RustedFox]

Not a waste of time. FM and EM are extremely compatible specialties, as they are the only ones who treat patients regardless of age, gender, organ system, or pregnancy status. EM training focuses on the acute setting, while FM focuses on the chronic. My goal is to practice both. 2-3 days a week in office, 2-3 days a week in the ER. I think it will be a nice career, personally.

And furthermore, health care is changing so rapidly that it is impossible to say what either job will be like in 20 years. Taking the extra time in training to ensure that you are double board certified gives you lots and lots of options later in life.

Hey man; I hope you make your dreams come true... but at your level, I think that you faaar underestimate the amount of time that non-clinical stuff takes (paperwork, dealing with admin/complaints, meetings, 'continuing' competency nonsense, etc.) If I had to show up to clinic after a swing shift of EM, I'd effing scream.

 

[VA Hopeful Dr]

Not a waste of time. FM and EM are extremely compatible specialties, as they are the only ones who treat patients regardless of age, gender, organ system, or pregnancy status. EM training focuses on the acute setting, while FM focuses on the chronic. My goal is to practice both. 2-3 days a week in office, 2-3 days a week in the ER. I think it will be a nice career, personally.

And furthermore, health care is changing so rapidly that it is impossible to say what either job will be like in 20 years. Taking the extra time in training to ensure that you are double board certified gives you lots and lots of options later in life.

Speaking ss an outpatient FP, don't do this. If you're only in the office for 2-3 days per week that means your partners are stuck seeing your patients on those days if they need same-day appointments.

 

[HooliganSnail]

Look,

I don't know exactly how my career will work out. I don't even know if what I want is even possible.

All I know is that if you want something, then you should try to have it. Either way, having the options to do what I love in many different ways 20 years from now is important enough for me to spend an extra 2 years in residency.

Therefore, and combined EM/FM program is not a waste of time.

 

[lightthelamp4]

I agree with you hooligansnail. The option of leaving the ER after I have had enough seems to make a lot of sense. This is why I don't get why people are so critical of this pathway. Perhaps I am more niave than I realize.

I did have a resident tell me the other day that if I was an ER doc and wanted to change careers to a slower pace that you can just practice in the role of family medicine without being board certified in it; that was news to me.

 

[deuist]

Perhaps I am more niave than I realize.

Yep, you are being a naive pre-med. And HooliganSnail is being a naive medical student. You talk about options as if at the age of 50 you're going to drop emergency medicine (because you're burned out) and then pick up the slow pace of family medicine after having not practiced it for 20 years. Family med is not slow paced---although the hours may be more set. It's also not an easy specialty, which is why the resident who told you that practicing FM without ever doing a residency in it is an idiot. He might have been referring to urgent care, which is certainly a possibility for EM docs, but that's vastly different than having a clinic where you follow chronic medical conditions.

 

[Dr.CCM]

Not a waste of time. FM and EM are extremely compatible specialties, as they are the only ones who treat patients regardless of age, gender, organ system, or pregnancy status. EM training focuses on the acute setting, while FM focuses on the chronic. My goal is to practice both. 2-3 days a week in office, 2-3 days a week in the ER. I think it will be a nice career, personally.

And furthermore, health care is changing so rapidly that it is impossible to say what either job will be like in 20 years. Taking the extra time in training to ensure that you are double board certified gives you lots and lots of options later in life.

These are very different specialities though that require a vast amount of knowledge in order to be proficient in either one. Much of FM is chronic disease, follow up appts in nature. You also staff urgent care centers too. But, you do also see a lot of relatively minor, acute complaints in FM similar to fast track in the ED. Stuff most people going into EM absolutely hate. While on paper, it sounds good to do 2-3 days week in clinic, 2-3 days in ED. It may be hard to join a group that will allow you to do this while maintaining your sanity. Imagine 3-12s a week in EM is full time in the community. Now, you are saying you'd want to do 2 days of clinic on top of that and then repeat. Sounds really rough due to the stress of an ED. It's difficult to build your patient base in a primary care speciality like FM constantly taking days or weeks off at a time to do work in the ED unless you are talking about moonlighting (which at this time you can do a FM doc in a rural and smaller metro EDs) . There is a caveat in that EM/FM would probably work in an academic environment. This is just my two cents from an MS4 who for awhile considered IM/EM. Before really going further, I'd seek out those EM/FM boarded mentors at your institution or email the PDs for those particular residencies that offer EM/FM combined residency. Get more info about practice patterns not just as backup plans.

 

[VA Hopeful Dr]

Yep, you are being a naive pre-med. And HooliganSnail is being a naive medical student. You talk about options as if at the age of 50 you're going to drop emergency medicine (because you're burned out) and then pick up the slow pace of family medicine after having not practiced it for 20 years. Family med is not slow paced---although the hours may be more set. It's also not an easy specialty, which is why the resident who told you that practicing FM without ever doing a residency in it is an idiot. He might have been referring to urgent care, which is certainly a possibility for EM docs, but that's vastly different than having a clinic where you follow chronic medical conditions.

Perfectly said.

 

[DeadCactus]

Like all the combined programs, the EM/FP programs are great for a select subset of people whose practice environment immediately out of residency would benefit from training in both (namely rural areas where you're forced to wear many hats because that's what the population needs of you). This nonsense about doing a combined residency "for when I burn out of EM" comes up on any thread about EM/FP, EM/IM, EM/Peds, EM/Veterinary, etc and it's asinine. It's not an intelligent career plan and it's not what the programs were intended for...

 

[e30ftw]

My goal is to practice both. 2-3 days a week in office, 2-3 days a week in the ER. I think it will be a nice career, personally.

in order for this to work with an ED schedule you will either need to join a group that makes the entire schedule around your "office schedule" (not going to happen) or you will need to work weekend nights/holidays for your whole career.

I would also agree that the plan of doing EM/FM residency, practicing EM for 20 yrs then going to FM for a "slower pace" is unrealistic. Do you really think after 20 years in EM you will remember anything about primary care/family med? Definitely not ideal and atypical for ER docs.. much more likely to work in admin/partner an UC/work 5 shifts a month/ or just work at a slower ER for "only" $150/hr.

 

[Groove]

I don't believe in the utility of combined residencies with the exception for rare candidates seeking very specialized and niche oriented practice environments. I've heard a plethora of creative and seemingly logical reasons for "Why?" from med students and residents alike but the person almost always ends up choosing one over the other. EM/FM innocuously seems at first glance to be synergistic or very compatible but I find the philosophical approaches to patient management and practice environments to be very dichotomous. Sure, there are extreme examples of people using both but let's face it... Who's going to finish a combined residency and choose FM when you can make so much more money in EM? What kind of personality is realistically attracted to both practice environments? Who's going to go bother with dabbling in FM during their EM career? Who's going to rationally consider "slowing down...yea right" with a FM practice as they get older versus just working part time in EM (6-8 shifts a month? Easy...)? I've worked with many EM guys well into their 60s who swing their weight with ease and haven't even begun to slow down although I'm sure they probably want to in the near future.

Another favorite of mine is the IM/Peds crowd. I loved asking them to explain their decision throughout residency. They were so excited telling me about this potential practice environment or that, etc.. 100% all chose IM or Peds (most IM) at the end of residency.

I just think combined residencies to be creative GME money making drop box programs for all med students who just can't quite make their mind up about what they want to do when they grow up. They want to maximize their options beyond the point of pragmatism. My 2 cents.

 

[sylvanthus]

Ehhh I disagree with some of the naysayers. Combined residencies can be valuable if you have a specific plan in mind. Im doing EM/IM/CC and intend to spend roughly half my time in an ED and half in the MICU. The length of training is essenially equivalent to many foing EM>>>CC. One year more if a person does a 3 year EM program. Also the added IM training is likely to be of benefit in the ICU setting.

On the other hand, I have a hard time figuring out how to make it doable for EM/FM.

Forgive typos on my phone.

 

[Groove]

Sylvanthus.. IM, EM, and Pulmonary Critical Care are all vastly differing practice environments, styles, training, and all require sufficiency mastery and dedication to their specific fields. How many guys do you know that can juggle all 3? How many EM attendings to do you know that spent time last week doing bronch's and floor consults, worked pulmonary clinic, rounded on MICU patients and now are "off call" spending a few days doing EM shifts? After that, does he help round on medicine wards for a week as a hospitalist because they're short staffed? How many groups would be ok with a part timer spreading himself around so thinly with atypical and unorthodox demands on call schedules, work schedules, etc..? EM takes a lifetime of dedication and learning to master. As does any specialty for that matter. Hence, the term.. "specialty". I've never known or heard of a physician practicing in the manner in which you describe. You're also sacrificing many more years of attending level salary to keep your options maximized beyond the point where you should have made a decision. In the end, you will inevitably migrate toward your favored practice environment.

I've known one physician who somewhat resembled your training map and he was anesthesia trained, pain management fellow, EM residency trained, and then went for critical care fellowship. He seemed to try to juggle ICU with EM near the end, after time spent as an anesthesiologist (before he left for CC fellowship) and last I heard was a relative full time intensivist in the Anesthesiology department at an academic center. Another point is that your likely to never find a practice environment in the way you envision... but if so, it will likely be in an academic center. So, as a PGY1, I really hope you're committed to academics. I don't know too many interns who know enough about their specialty and long term plans to be able to make that assertion with any confidence. You may be different. In either case, your road is an arduous one, so good luck.

 

[sylvanthus]

Not doing pulm. My program is one of the 3 that lets EM/IM residents add a year onto their training to become boarded in crit care.

Also, take a look at a survey sent out to EM/IM graduates (you can find it online) recently. 1/3 worked both EM and IM. I dont see data on those who went on to crit care.

Again doing EM and then critical care would be 5-6 years. My training is 6. So not really sacrificing more time than many doing EM to CC and there is a definite growing interest out there for EM graduates to do CC per my albeit only a couple year experience on EMRAs critical care committee.

 

[Groove]

Although about half of dual training graduates are working primarily in an Emergency Department (ED), more than one-third of recent EM/IM graduates practice both in the EM and IM and more than two thirds practice in an academic setting. About 10% work in internal medicine or a medical subspecialty only and about one out of four graduates has pursued formal fellowship training after residency.

Again, the majority end up practicing primarily EM. The minority end up pursuing a specialty and/or practicing EM/IM together and those that do...usually facilitate it within an academic setting.

The reason cited by most of those applicants are: (Older study, but I would imagine it translates very well to today's applicant.)

The most common reasons for having chosen an EM/IM program are to be a better physician (22/23, 95.7%), to practice in both fields (15/23, 65.2%), and to become better prepared for an academic career (15/23, 65.2%).

So, what does that tell me in a nutshell? It tells me that a majority of residents start out with plans to practice in both fields, while a minority actually realize that goal. I.E. They change their mind or become disillusioned.

"Becoming a better physician" and "Becoming better prepared for an academic career" are two goals easily obtained with primary EM training and self directed efforts while avoiding roughly $1 million in lost revenue secondary to the extended training. In your case... ~$1.5 million (assuming top 5% income). Important caveat: That is NOT taking into account your accrued interest in educational loans during that extra training, assuming you have them.

I hope it's worth it.

 

[namethatsmell]

The reality is that you can split time between the ICU and ED...but it will generally constrict you to academic places who are receptive to having you in both departments. Maybe that will change but that seems to be the general lay of the land right now.

If you want to work in both environments and doing so will make you happier (vs only working in either the ICU or the ED) in the long run then it's worth it. You will lose $ to do the fellowship, although I don't see how the above poster came up with the $1 - 1.5 million dollars.

 

[HooliganSnail]

There is too much talk about what "can't" be done on this thread right now.

If you want to make something happen then you can. Period.

All the great creators/entrepreneurs/explorers were told that "it couldn't be done" until they did it. Go back in time and tell Steve Jobs or Bill Gates that they will never succeed......

And for all those trying to tell me what it is like to practice in each of the FM/EM specialties, do you really think I have not thought long and hard about my career choice? Do you really think that you are telling me something that I did not already know? Do you really think I don't know that primary care is really hard?

And furthermore, I am not choosing to do EM/FM because 'I might burn out of EM". Choosing the specialty with the second highest rate of burnout to compliment the specialty with the #1 highest rate of burnout would seem rather obtuse wouldn't it.....

 

[RustedFox]

There is too much talk about what "can't" be done on this thread right now.

If you want to make something happen then you can. Period.

All the great creators/entrepreneurs/explorers were told that "it couldn't be done" until they did it. Go back in time and tell Steve Jobs or Bill Gates that they will never succeed......

And for all those trying to tell me what it is like to practice in each of the FM/EM specialties, do you really think I have not thought long and hard about my career choice? Do you really think that you are telling me something that I did not already know? Do you really think I don't know that primary care is really hard?

And furthermore, I am not choosing to do EM/FM because 'I might burn out of EM". Choosing the specialty with the second highest rate of burnout to compliment the specialty with the #1 highest rate of burnout would seem rather obtuse wouldn't it.....

Ohh, maaan.

 

[Groove]

although I don't see how the above poster came up with the $1 - 1.5 million dollars.

3 yr EM residency. $500K/yr (High end... I work in a higher compensated area (South). You can't make that in NYC, etc.. and although I don't clear that number, several of my colleagues do who put in the requisite shifts. Either way you slice it, it's going to be a chunk of change on the sacrificial altar.) 2-3 years extra training roughly equates to $1-1.5 million. I'm ignoring resident salary, etc...

That's a hefty investment into continued training for the ever elusive happiness factor. Med students and residents... I'm not trying to be a dream crusher, but just think it through. Make sure you aren't the kid who grew up hearing.. "Just pick one!". For some...knock yourself out and call it happiness. For me? Early retirement on a sun glazed beach surrounded by half naked women.

Big smile on my face too...

 

[Dr.CCM]

3 yr EM residency. $500K/yr (High end... I work in a higher compensated area (South). You can't make that in NYC, etc..) 2-3 years extra training roughly equates to $1-1.5 million. I'm ignoring resident salary, etc...

That's a hefty investment into continued training for the ever elusive happiness factor. Med students and residents... I'm not trying to be a dream crusher, but just think it through. Make sure you aren't the kid who grew up hearing.. "Just pick one!". For some...knock yourself out and call it happiness. For me? Early retirement on a sun glazed beach surrounded by half naked women.

Big smile on my face too...

Question though. Does a full time intensivist earn more than a full time EP in most markets? Does the fellowship increase your earning potential?

 

[deleted547339]

3 yr EM residency. $500K/yr (High end... I work in a higher compensated area (South). You can't make that in NYC, etc.. and although I don't clear that number, several of my colleagues do who put in the requisite shifts. Either way you slice it, it's going to be a chunk of change on the sacrificial altar.) 2-3 years extra training roughly equates to $1-1.5 million. I'm ignoring resident salary, etc...

That's a hefty investment into continued training for the ever elusive happiness factor. Med students and residents... I'm not trying to be a dream crusher, but just think it through. Make sure you aren't the kid who grew up hearing.. "Just pick one!". For some...knock yourself out and call it happiness. For me? Early retirement on a sun glazed beach surrounded by half naked women.

Big smile on my face too...

500k? Whoa....ya'll hiring in 2 years? lol.

 

[e30ftw]

There is too much talk about what "can't" be done on this thread right now.

If you want to make something happen then you can. Period.

All the great creators/entrepreneurs/explorers were told that "it couldn't be done" until they did it. Go back in time and tell Steve Jobs or Bill Gates that they will never succeed......

omg epic.

do whatever you want, no one here is holding you back. No one is saying you "can't" do FM/EM. We're giving advice based on our collective experience. I will however say that working in a clinic 2-3 days/wk and pulling ED shifts 2-3 days a week would be extremely difficult to schedule because of sheer logistics and the unfortunate impossibility of omnipresence.

maybe someday when your dreams come true and you work M-T-W in clinic and F-Sa-Su in the ED someone will make an ashton kutcher movie about it and you can give billions of dollars away then come back to SDN and say "F U i told ya so".

 

[HooliganSnail]

omg epic.

do whatever you want, no one here is holding you back. No one is saying you "can't" do FM/EM. We're giving advice based on our collective experience. I will however say that working in a clinic 2-3 days/wk and pulling ED shifts 2-3 days a week would be extremely difficult to schedule because of sheer logistics and the unfortunate impossibility of omnipresence.

maybe someday when your dreams come true and you work M-T-W in clinic and F-Sa-Su in the ED someone will make an ashton kutcher movie about it and you can give billions of dollars away then come back to SDN and say "F U i told ya so".

Ummm, my dream would be better described as working M-T clinic, and W-Th ED ( not overnight) followed by a pleasant 3 day weekend on the regular. Hey a man is allowed to dream.....

 

[RustedFox]

Ah, no nights then, with all weekends off.

that's especially rich.

 

[namethatsmell]

3 yr EM residency. $500K/yr (High end... I work in a higher compensated area (South). You can't make that in NYC, etc.. and although I don't clear that number, several of my colleagues do who put in the requisite shifts. Either way you slice it, it's going to be a chunk of change on the sacrificial altar.) 2-3 years extra training roughly equates to $1-1.5 million. I'm ignoring resident salary, etc...

New grads get paid $500k and get to work in a (presumably) non-toxic environment? Where is this paradise? I may be interested in 2 years...PM if you don't want to post here.

 

[deuist]

All the great creators/entrepreneurs/explorers were told that "it couldn't be done" until they did it.

Yeah, cause you're ****ing Magellan.

 

[Cooperd0g]

Maybe Hooligan will have his own direct primary care business with a small number of patients so he only makes appointments on M-Tu and then picks up moonlighting ER shifts W-Th.

 

[EM2BE]

The observation unit (if you are lucky enough to have one) could be run by a dual-certified physician. They understand the ED point of view and know why the patient can't go home (therefore, won't argue), then have the medicine point of view for workups. Perfect world....

 

[smq123]

Maybe Hooligan will have his own direct primary care business with a small number of patients so he only makes appointments on M-Tu and then picks up moonlighting ER shifts W-Th.

The entire point of concierge medicine (which is what you're describing) is that, for a sizable annual/monthly fee, you are pretty much always available to your patients. Asking your patients to pay you $200-$500 a month, only to tell them that, sorry, you're not available for a large part of the week because you're covering the local ED, is not going to fly particularly well.

Also the point of concierge medicine is that you see fewer patients a day, and spend more time with each patient. Cramming all of your office appointments into just 2 days is defeating the purpose.

 

[VA Hopeful Dr]

There is too much talk about what "can't" be done on this thread right now.

If you want to make something happen then you can. Period.

All the great creators/entrepreneurs/explorers were told that "it couldn't be done" until they did it. Go back in time and tell Steve Jobs or Bill Gates that they will never succeed......

And for all those trying to tell me what it is like to practice in each of the FM/EM specialties, do you really think I have not thought long and hard about my career choice? Do you really think that you are telling me something that I did not already know? Do you really think I don't know that primary care is really hard?

And furthermore, I am not choosing to do EM/FM because 'I might burn out of EM". Choosing the specialty with the second highest rate of burnout to compliment the specialty with the #1 highest rate of burnout would seem rather obtuse wouldn't it.....

Its not that you haven't thought this through, its that you're a medical student and don't actually have any idea what the real world of doctoring is all about. I don't mean this as an insult as we were all the exact same way as medical students. Many of us here, on the other hand, DO have that real world experience. So, when we tell you that what you're hoping to do is going to be either A) damned near impossible or B) a huge imposition on your patients/partners, maybe, just maybe, we know what we're talking about.

 

[SeekerOfTheTree]

I wanna be an astronaut doctor like Bones!

 

[TooMuchResearch]

I wanna be an astronaut doctor like Bones!

Move to Houston, dude.