Residency Predicament - Advice?

[treyc]

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I’m a current third-year medical student setting up audition rotations and would appreciate some advice regarding specialty choice and residency strategy.

For context, I have a wife and a young child. We currently live in our hometown in a house that is fully paid off, and both of our families live here. Having family support nearby is a big benefit for us.

Emergency Medicine is the specialty I enjoy the most and what I would ideally like to do. However, I’m also very aware of the burnout rates in EM and the limited long-term flexibility if I eventually decide to move away from the emergency department. Internal Medicine, particularly hospitalist medicine, is a close second for me.

In my hometown there are two hospitals, both with Internal Medicine residency programs:

Hospital 1

• Larger hospital
• More established IM residency program
• Affiliated/in-network with a top international hospital system
• Level II trauma center
• IM residents only do one EM rotation in the curriculum

Hospital 2

• Smaller hospital
• Brand new IM residency program
• Level III trauma center
• IM residents can do multiple rotations in the ED
• IM physicians and FM physicians currently work in the ED
• IM program leadership has said residents could potentially moonlight in the ED during third year
• Actively trying to recruit me to their program

My long-term goal is to ultimately practice in this town.

Right now I’m struggling with whether I should:

1. Leave town to pursue a full Emergency Medicine residency and get more formal EM training, or
2. Stay in my hometown and complete an Internal Medicine residency, with the possibility of doing some ED work locally afterward.

Hospital 2 leadership has told me that after completing their IM residency they would likely allow me to work in the ER if I wanted. My hesitation is that this isn’t guaranteed forever, since hospitals could eventually require EM board certification. I also worry about the quality of training since the IM program is brand new and the patient population is smaller.

Another factor is lifestyle flexibility. While I love EM, I’m aware of the burnout rates and I’m hesitant about being locked into EM/urgent care long-term. If I burned out after 5–10 years, I like the idea of having the flexibility to transition into outpatient or other IM-based work.

My biggest priorities are:

• Becoming well trained in whatever specialty I choose
• Being present for my family

My current plan is to:

• Do one or two EM audition rotations
• Try to obtain one or two SLOEs
• Apply to both EM and IM

That would give me more time before rank lists are due to make the final decision.

I’d really appreciate hearing perspectives from:

• EM physicians who considered IM
• IM physicians who considered EM
• Anyone who chose residency based heavily on family/location considerations

What factors should I be thinking about that I might be missing?

 

[Birdstrike]

Have you considered either a Pain Medicine or Hospice and Palliative fellowship?

You can go straight into them after EM. There’s no need to retrain. Either gives you a second totally different specialty you can practice with a much more normal lifestyle, in the case of Pain, it’s a completely normal with no nights, weekends or holidays ever again.

Edit: Sorry, I read 3rd year “medical student” as 3rd year “resident.” Ignore what I wrote unless you find yourself in this predicament in a few years wondering why you chose EM. What toll EM can take, the good, the bad, the happy the sad and one man’s walk back from the brink, is what I wrote my book about. I didn’t write it because I wanted to, I had to write it to set myself free, mentally.

 

[Tenk]

Being present for your family >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> a job.

No matter what specialty you choose, everything will get repetitive and boring. In the end, this is just a job to support your family. Choose them.

 

[Groove]

Easy. IM or FM in your home town. You think you want EM but you don’t. If you choose EM, you’ll realize the mistake in, oh about….10 years or so. Maybe 5 or 8 depending on your first couple jobs. Your family will figure it out sooner.

 

[Porfirio]

Definitely IM

 

[JacobMcCandles]

You won't find much love for EM here but it can be a good career. I think being a hospitalist is probably the worst job in the hospital but maybe that's hospital dependent. Either way, if you don't train in EM then you don't have any business working in an emergency department.

 

[Apollyon]

Dude, don't cross post. You agreed to that when you signed up. You're already in violation (but I've never yet see someone banned for it on the first time).

 

[WhatJobDoIPick]

You won't find much love for EM here but it can be a good career. I think being a hospitalist is probably the worst job in the hospital but maybe that's hospital dependent. Either way, if you don't train in EM then you don't have any business working in an emergency department.

There are somethings worse than EM: hospitalist, pediatrician, OBGYN

 

[HemorrhagicShock]

The only job that could even come close to the horror of EM is being a hospitalst.

I would only do IM if you're willing to commit to one of the big three subspecialties (Heme/Onc, GI, or Cards)

It would go without saying that you should do whatever you can to avoid EM. At all costs. This would be the worst career decision you could make.

 

[Porfirio]

I am not sure why so many say hospitalist is worse. I see them all chilling in the doctor’s lounge, get a 30mins to 1hr lunch break, tons of drug rep lunches, and many of them just “round and leave.” They have no need to stay in the hospital after they round (most of the time code blues on the floor/icu are handled by us). Also, they just consult every specialist and have case management figure out the discharge.

Hell, they rarely have to worry about sepsis times/TNK-TPA times/STEMI times.

And they have the luxury of having patients given to them on a silver platter while we spoon feed them.

 

[Brigade4Radiant]

Just be with your family and work in the ER with IM you can do a lot of specialties like pain, sports and sleep.

Hospitalists can leave the hospital and can be round and down my friend works till 5 hour days on his shifts when he doesn't do admits. Then a week off.

People will say if you don't do EM you have no business working in the ED but that isn't the reality with IM and FM being sought

If you choose IM you need to do hospital 1 so you just have more options. Don't do Hospital 2 and think you will work in the ED.

 

[HemeOncHopeful19]

I would want my ER doc to be ER trained

But

I’d take an IM doc who wants to work in the ER over an NP which seems to be all over the place in ERs everywhere

 

[emergentmd]

I am not sure why so many say hospitalist is worse.

Just from my experience, Hospitalist were the most unhappy docs and it was not even close. The ones I knew never "chilled". More often than not, they felt like running on a hamster wheel.

 

[BoardingDoc]

Just from my experience, Hospitalist were the most unhappy docs and it was not even close. The ones I knew never "chilled". More often than not, they felt like running on a hamster wheel.

I agree that being a hospitalist seems miserable. If I were going into IM it would certainly not be to become a hospitalist, but rather to subsequently subspecialize in something like cards/EP, heme/onc, pulm etc.

 

[endo]

19 years in EM. For 2026, 3098 residency spots, 130 new ones this year. ACEP cheering about it on their website… my daughter is going the physician route and I don’t need to even mention to her not to do EM. She would never consider it. Only do it if there’s nothing else you could possibly tolerate, and then think about it again.