Should I Quit?

[miacomet]

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I've been getting locums spam for years (even now, nearly 5 years post retirement), and in my experience, many of them have listed PPH. Whether that number is true (or current) is a whole other question...

Retirement? Tell us more....

 

[ToastyEM80s]

Retirement? Tell us more....

I don't think the locums agency got the message lol.

I change addresses and email but somehow they get my contact info.

Sort of like the AMA - I move and yet their spam follows me around, even though I was never a member

But after getting everyone's helpful feedback, I think I will probably pull the trigger. At least for 6 mos to a year then reassess.

 

[MechEDoc]

...i guess i dont see the “value” the older guys bring to my group as compared to the younger 5-10 years out guys.

Lots of the older folks are slower, have "interesting" practice patterns and aren't as productive as someone 5-15 years post-residency. We all know those docs. Walking around the ER with a clipboard with lots of handwritten notes, slow typing on the computer, perseverating on easy decisions, etc.

 

[EctopicFetus]

Lots of the older folks are slower, have "interesting" practice patterns and aren't as productive as someone 5-15 years post-residency. We all know those docs. Walking around the ER with a clipboard with lots of handwritten notes, slow typing on the computer, perseverating on easy decisions, etc.

Indeed. Many of these docs think their gray hairs provide some particular value to the group. Note for the older docs on here, this is not all encompassing. Some of the older docs i work with are and have been great others not so much.. That being said in EM at least there isnt some amazing value the gray hair gets you. On the other hand some of these new younger docs from no name residencies are equally as terrible and they dont have years of forgetting stuff to blame. The expansion of EM residencies has made a mockery of the specialty.

 

[miacomet]

Lots of the older folks are slower, have "interesting" practice patterns and aren't as productive as someone 5-15 years post-residency. We all know those docs. Walking around the ER with a clipboard with lots of handwritten notes, slow typing on the computer, perseverating on easy decisions, etc.

What's your plan for aging out of ER? There aren't any fellowships. It's bleak.

 

[bky3c]

Retirement? Tell us more....

Oh, I've posted about it here before. Nothing major. Lived below my means, saved a lot, now coast-FIRE on my husband's salary (6 figures but not physician income, loves his job) while our retirement savings continues to grow. He only entered the equation after I was pretty far down the path to FIRE. If he lost his job tomorrow we'd have to do some penny pinching, but we'd be fine. Now I occupy my time with volunteering, dogs, reading, traveling, etc. Sleeping at night, every night, is awesome.

 

[skougess]

Once we start trusting AI to read EKGs properly, I’ll start worrying about them taking the rest of my job.

 

[Mount Asclepius]

What's your plan for aging out of ER?

Cold turkey like an ED sammie. Hopefully just plain FIRE at least >10 years and following many regular, well-slept nights before my sudden, massive fatal MI or SAH.

 

[miacomet]

Oh, I've posted about it here before. Nothing major. Lived below my means, saved a lot, now coast-FIRE on my husband's salary (6 figures but not physician income, loves his job) while our retirement savings continues to grow. He only entered the equation after I was pretty far down the path to FIRE. If he lost his job tomorrow we'd have to do some penny pinching, but we'd be fine. Now I occupy my time with volunteering, dogs, reading, traveling, etc. Sleeping at night, every night, is awesome.

Huh, I love medicine, hate ER, there is no answer for me. I'm glad you are happy. Do you regret EM>

 

[bky3c]

Huh, I love medicine, hate ER, there is no answer for me. I'm glad you are happy. Do you regret EM>

There is an answer for you; there has to be. Maybe you just haven't found it yet.

I don't regret a career that allowed me to retire after <10 attending years and taught me a lot about life and humans that I didn't know as a sheltered high school and college kid. I do wonder if I would have enjoyed a longer career-span in a different specialty or a different field entirely. But I made the best decision I could with the information I had at the time, and thinking about it that way, regret can't exist.

I have a dog who is 17 years old. I got her as a puppy 2 weeks before the start of my intern year. She's the only thing in my daily life that hasn't changed since then (boyfriends/husband, houses, states, cars, etc.), so she's a constant reminder of where all this began. I'm a whole different person from who I was when I brought her home, and she's a little old lady whose adventuring days are over, but we've both had 17 great years, in spite of (and often because of) my career. And now... I am grateful that when her time comes, I'll be free to spend the day hugging my other dogs and NOT holding back tears instead of trying to get through a day at work, in any career. So even though I hated so much about EM (the reality compared to what it should be and what we were told it is), looking at it through the rearview mirror, I don't regret it.

That doesn't mean I would advise a med student to go into it now -- just that it worked out as a net positive for me. And I'm not sure I would have answered the same way the day after my last shift. As I think I've said elsewhere on here, after that last shift, I went backpacking in Costa Rica, spent ALL the winter holidays with people I love (not possible before, with ED scheduling), and then came home and got a puppy, and that was just the beginning of getting past the bitterness and the burnout.

 

[miacomet]

There is an answer for you; there has to be. Maybe you just haven't found it yet.

I don't regret a career that allowed me to retire after <10 attending years and taught me a lot about life and humans that I didn't know as a sheltered high school and college kid. I do wonder if I would have enjoyed a longer career-span in a different specialty or a different field entirely. But I made the best decision I could with the information I had at the time, and thinking about it that way, regret can't exist.

I have a dog who is 17 years old. I got her as a puppy 2 weeks before the start of my intern year. She's the only thing in my daily life that hasn't changed since then (boyfriends/husband, houses, states, cars, etc.), so she's a constant reminder of where all this began. I'm a whole different person from who I was when I brought her home, and she's a little old lady whose adventuring days are over, but we've both had 17 great years, in spite of (and often because of) my career. And now... I am grateful that when her time comes, I'll be free to spend the day hugging my other dogs and NOT holding back tears instead of trying to get through a day at work, in any career. So even though I hated so much about EM (the reality compared to what it should be and what we were told it is), looking at it through the rearview mirror, I don't regret it.

That doesn't mean I would advise a med student to go into it now -- just that it worked out as a net positive for me. And I'm not sure I would have answered the same way the day after my last shift. As I think I've said elsewhere on here, after that last shift, I went backpacking in Costa Rica, spent ALL the winter holidays with people I love (not possible before, with ED scheduling), and then came home and got a puppy, and that was just the beginning of getting past the bitterness and the burnout.

I'm glad you are happy and at peace and have found a life that works for you. My values and life are just so different, I would just hate everything you describe about your current life. And I mean everything, like I would rather drop dead.

I hope so. Really, it didn't work out for me. At all, and I had a pretty good job by EM standards. Wow, < 10 years? Amazing. It took me 12+ to meet minimum FI, and I scrimped.

I don't like any of the EM fellowships (ABEM has clearly picked stupid fellowships for a reason, like forcing people to stay in the ER), so I don't know if there is an answer. I'd do a plastics, derm or ENT residency, but that's...impossible. It's sadly not true there is always or even frequently a decent answer. Sometimes there isn't, and life just sucks and is utterly miserable. That happens, too.

 

[HemorrhagicShock]

I'm glad you are happy and at peace.

I hope so. Really, it didn't work out for me. At all, and I had a pretty good job by EM standards. Wow, < 10 years? Amazing. It took me 12+ to meet minimum FI, and I scrimped.

I don't like any of the EM fellowships (ABEM has clearly picked stupid fellowships for a reason, like forcing people to stay in the ER), so I don't know if there is an answer. I'd do a plastics, derm or ENT residency, but that's...impossible. Sometimes there isn't, and life just sucks. That happens, too.

I am in your boat except still working at about 0.75 "FTE" (I work with a famously "democratic" CMG, which really only works on on the taxes and isn't much of a democratic situation at all)

I desperately wish I could quit and am about 1-2 years from a lean FI number

The problem is what to do afterward.

I like the idea of being a physician, but the options seem like they bring more of the same

Urgent care? Still high volume productivity churn and burn, with terrible pay. Are urgent cares even hiring physicians anymore?

Critical Care? Aside from having to do two years for training, they're still hospital-based and I suspect that much of the same downfall of EM will plague critical care soon enough

Academics? God no

 

[HemorrhagicShock]

Sports medicine? Just look at SDN and Reddit and you'll see that this isn't some chosen land subspecialty. Injections reimburse terribly, and the field is saturated to hell. Also very encroachable by well-trained mid levels

Pain medicine? I guess this is a potential option, but if I'm being honest the subject matter and being a procedure grinder doesn't strike me as enjoyable. I have a lot of IRL anesthesia and PMR colleagues who do pain medicine and are somehow burned out on it? Grass is greener? I know @Birdstrike is doing well in it, and @GatorCHOMPions. Maybe it's one of those fields where if you burned your soul in EM, then Pain is pure heaven. Whereas for the PMR and Gas dudes their base specialties are pretty darn awesome to begin with and pain isn't the chosen land.

Toxicology? This means going into academics, industry, or something that doesn't meet my mental model of being a physician. Seems like a field full of pedantry too (apologies to the tox crew)

Palliative? I have a hot take on this but I believe this will be a very mid-level driven field in a few years. I don't see what an MD/DO can bring that a well-trained midlevel can't. Yes, I know there are a lot of actual answers to that question, but you need to think like a hospital administrator, not a physician when it comes to predicting the future of palliative. I hear a lot of financial/budget/revenue strife from colleagues on the management side of palliative.

EMS? Too niche, and it seems like many of them still have to work EM shifts

Admin? I'd rather die. I have plenty of admin experience already and know what it's about. Either you die a hero or live long enough to be the villain. I've seen it over and over.

DPC type practice? This sounds way more romantic than it is. I don't know of a single ER doc who has been successful at this, and the stories I've read suggest that it's incredibly difficult to start up a practice de novo. Takes resolve, business acumen, marketing skill, and a fairly high level of hustle.

Med spa/Aesthetics? Wildly saturated and incredibly competitive from a business perspective. I've looked into this and it's not an easy street at all. You're competing with midlevels and RN injectors who've mastered the Instagram and social media marketing game. They're all way more attractive than me too.

The options out of EM are just terrible

 

[VA Hopeful Dr]

Sports medicine? Just look at SDN and Reddit and you'll see that this isn't some chosen land subspecialty. Injections reimburse terribly, and the field is saturated to hell. Also very encroachable by well-trained mid levels

Pain medicine? I guess this is a potential option, but if I'm being honest the subject matter and being a procedure grinder doesn't strike me as enjoyable. I have a lot of IRL anesthesia and PMR colleagues who do pain medicine and are somehow burned out on it? Grass is greener? I know @Birdstrike is doing well in it, and @GatorCHOMPions. Maybe it's one of those fields where if you burned your soul in EM, then Pain is pure heaven. Whereas for the PMR and Gas dudes their base specialties are pretty darn awesome to begin with and pain isn't the chosen land.

Toxicology? This means going into academics, industry, or something that doesn't meet my mental model of being a physician. Seems like a field full of pedantry too (apologies to the tox crew)

Palliative? I have a hot take on this but I believe this will be a very mid-level driven field in a few years. I don't see what an MD/DO can bring that a well-trained midlevel can't. Yes, I know there are a lot of actual answers to that question, but you need to think like a hospital administrator, not a physician when it comes to predicting the future of palliative. I hear a lot of financial/budget/revenue strife from colleagues on the management side of palliative.

EMS? Too niche, and it seems like many of them still have to work EM shifts

Admin? I'd rather die. I have plenty of admin experience already and know what it's about. Either you die a hero or live long enough to be the villain. I've seen it over and over.

DPC type practice? This sounds way more romantic than it is. I don't know of a single ER doc who has been successful at this, and the stories I've read suggest that it's incredibly difficult to start up a practice de novo. Takes resolve, business acumen, marketing skill, and a fairly high level of hustle.

Med spa/Aesthetics? Wildly saturated and incredibly competitive from a business perspective. I've looked into this and it's not an easy street at all. You're competing with midlevels and RN injectors who've mastered the Instagram and social media marketing game. They're all way more attractive than me too.

The options out of EM are just terrible

DPC with a little planning isn't that hard to be moderately successful at. You will never make ER money doing it, but it is significantly less stressful.

 

[miacomet]

Sports medicine? Just look at SDN and Reddit and you'll see that this isn't some chosen land subspecialty. Injections reimburse terribly, and the field is saturated to hell. Also very encroachable by well-trained mid levels

Pain medicine? I guess this is a potential option, but if I'm being honest the subject matter and being a procedure grinder doesn't strike me as enjoyable. I have a lot of IRL anesthesia and PMR colleagues who do pain medicine and are somehow burned out on it? Grass is greener? I know @Birdstrike is doing well in it, and @GatorCHOMPions. Maybe it's one of those fields where if you burned your soul in EM, then Pain is pure heaven. Whereas for the PMR and Gas dudes their base specialties are pretty darn awesome to begin with and pain isn't the chosen land.

Toxicology? This means going into academics, industry, or something that doesn't meet my mental model of being a physician. Seems like a field full of pedantry too (apologies to the tox crew)

Palliative? I have a hot take on this but I believe this will be a very mid-level driven field in a few years. I don't see what an MD/DO can bring that a well-trained midlevel can't. Yes, I know there are a lot of actual answers to that question, but you need to think like a hospital administrator, not a physician when it comes to predicting the future of palliative. I hear a lot of financial/budget/revenue strife from colleagues on the management side of palliative.

EMS? Too niche, and it seems like many of them still have to work EM shifts

Admin? I'd rather die. I have plenty of admin experience already and know what it's about. Either you die a hero or live long enough to be the villain. I've seen it over and over.

DPC type practice? This sounds way more romantic than it is. I don't know of a single ER doc who has been successful at this, and the stories I've read suggest that it's incredibly difficult to start up a practice de novo. Takes resolve, business acumen, marketing skill, and a fairly high level of hustle.

Med spa/Aesthetics? Wildly saturated and incredibly competitive from a business perspective. I've looked into this and it's not an easy street at all. You're competing with midlevels and RN injectors who've mastered the Instagram and social media marketing game. They're all way more attractive than me too.

The options out of EM are just terrible

Yeah, I agree. I mean it's nice for people who are happy not working to say there has to be an answer, and I'm glad that works for them, but clearly if one wants to work...there is really not an answer aside from Pain, which is really saturated. It's easy to say if one is at peace not working. It's just not that easy and it's pretty invalidating for people to say there "has to be" an answer. I mean I guess it's true there always is an answer, but sometimes the answer is really bad and pure misery. We are all different with different needs.

 

[GatorCHOMPions]

Sports medicine? Just look at SDN and Reddit and you'll see that this isn't some chosen land subspecialty. Injections reimburse terribly, and the field is saturated to hell. Also very encroachable by well-trained mid levels

Pain medicine? I guess this is a potential option, but if I'm being honest the subject matter and being a procedure grinder doesn't strike me as enjoyable. I have a lot of IRL anesthesia and PMR colleagues who do pain medicine and are somehow burned out on it? Grass is greener? I know @Birdstrike is doing well in it, and @GatorCHOMPions. Maybe it's one of those fields where if you burned your soul in EM, then Pain is pure heaven. Whereas for the PMR and Gas dudes their base specialties are pretty darn awesome to begin with and pain isn't the chosen land.

Toxicology? This means going into academics, industry, or something that doesn't meet my mental model of being a physician. Seems like a field full of pedantry too (apologies to the tox crew)

Palliative? I have a hot take on this but I believe this will be a very mid-level driven field in a few years. I don't see what an MD/DO can bring that a well-trained midlevel can't. Yes, I know there are a lot of actual answers to that question, but you need to think like a hospital administrator, not a physician when it comes to predicting the future of palliative. I hear a lot of financial/budget/revenue strife from colleagues on the management side of palliative.

EMS? Too niche, and it seems like many of them still have to work EM shifts

Admin? I'd rather die. I have plenty of admin experience already and know what it's about. Either you die a hero or live long enough to be the villain. I've seen it over and over.

DPC type practice? This sounds way more romantic than it is. I don't know of a single ER doc who has been successful at this, and the stories I've read suggest that it's incredibly difficult to start up a practice de novo. Takes resolve, business acumen, marketing skill, and a fairly high level of hustle.

Med spa/Aesthetics? Wildly saturated and incredibly competitive from a business perspective. I've looked into this and it's not an easy street at all. You're competing with midlevels and RN injectors who've mastered the Instagram and social media marketing game. They're all way more attractive than me too.

The options out of EM are just terrible

Good summary overall. You hit the nail on the head with Pain. Just today I was reflecting how a lot of what I do doesn't work as I'd like it to, patients are draining, how I regret not going into urology. Then I reflected back on my time in the ED and felt a sense of joy that at least I "got out", intact, working in medicine with daytime hours making decent money. It's all relative.

There are truly good parts to Pain as well. I received at least a handful of gifts from patients in less than 2 years in this field and none in EM in 8 years. While some patients are draining, many are thankful, and I do make a difference in a not insignificant portion.

To those still frustrated and searching, I don't have much more advice than what's already been said. Just know there's a large portion of EM docs going through the exact same thing. It's not you, it's the specialty/system. Easier said than done but don't let it control your happiness. If Pain hadn't worked out, my strategy was to try as much as possible to adopt the clock in clock out mentality, a lot of mindfulness/meditation, and find at least a couple good things on shift to focus on as corny as it sounds.

 

[miacomet]

Good summary overall. You hit the nail on the head with Pain. Just today I was reflecting how a lot of what I do doesn't work as I'd like it to, patients are draining, how I regret not going into urology. Then I reflected back on my time in the ED and felt a sense of joy that at least I "got out", intact, working in medicine with daytime hours making decent money. It's all relative.

There are truly good parts to Pain as well. I received at least a handful of gifts from patients in less than 2 years in this field and none in EM in 8 years. While some patients are draining, many are thankful, and I do make a difference in a not insignificant portion.

To those still frustrated and searching, I don't have much more advice than what's already been said. Just know there's a large portion of EM docs going through the exact same thing. It's not you, it's the specialty/system. Easier said than done but don't let it control your happiness. If Pain hadn't worked out, my strategy was to try as much as possible to adopt the clock in clock out mentality, a lot of mindfulness/meditation, and find at least a couple good things on shift to focus on as corny as it sounds.

I'm glad Pain is working moderately well for you.

Knowing it's the specialty/system does't really change anything; in fact it's worse, because if it were me I could change me relatively easily, but as I know from my battle with ABEM regarding Sleep, it's impossible to change the system. As to controlling one's happiness, circadian rhythm disruption does actually control one's happiness. So this all seems a bit optimistic.

 

[sloh]

Sports medicine? Just look at SDN and Reddit and you'll see that this isn't some chosen land subspecialty. Injections reimburse terribly, and the field is saturated to hell. Also very encroachable by well-trained mid levels

Pain medicine? I guess this is a potential option, but if I'm being honest the subject matter and being a procedure grinder doesn't strike me as enjoyable. I have a lot of IRL anesthesia and PMR colleagues who do pain medicine and are somehow burned out on it? Grass is greener? I know @Birdstrike is doing well in it, and @GatorCHOMPions. Maybe it's one of those fields where if you burned your soul in EM, then Pain is pure heaven. Whereas for the PMR and Gas dudes their base specialties are pretty darn awesome to begin with and pain isn't the chosen land.

I’m PM&R and my gf is anesthesia. You nailed it.

 

[ToastyEM80s]

"Med spa/Aesthetics? Wildly saturated and incredibly competitive from a business perspective. I've looked into this and it's not an easy street at all. You're competing with midlevels and RN injectors who've mastered the Instagram and social media marketing game. They're all way more attractive than me too."

No one wants fillers from old unattractive salty EM physicians w/ no social media skills. Ouch, what a reality check [emoji23]

 

[HemorrhagicShock]

DPC with a little planning isn't that hard to be moderately successful at. You will never make ER money doing it, but it is significantly less stressful.

Realistically, what kind of money are we talking about here?

"ER money" isn't that good in a lot of parts of the country. About 300k.

 

[xaelia]

I'm curious what you think of this as someone who I think is pretty bright and thoughtful about this stuff -- the one thing that I intuitively believe will protect our job is the lack of a desire on most reasonable humans' part to be The Person Responsible when a limp / seizing / pulseless child gets carried into an ER or a baby is half out or a GSW to the chest gets dropped off at a non-trauma center. Perhaps I underestimate how protective this will be, but it seems like there's a lot of things that you can't use a LLM for where you need someone who is more or less ready to act right away and also to act as a liability and emotional trauma sponge for these very high-risk scenarios. There's probably some PAs and NPs out there who are eager to do this for $120k/year, but I don't think there's enough to staff the CMS-mandated ERs of all the hospitals out there.

The scenarios for which you describe – welcome to a world of single physician coverage, directing an army of midlevels. That's effectively the model in AUS/NZ – a consultant specialist directing patient flow most of the time, present to perform or supervise critical procedures or resuscitations. Extreme rural sites without physician coverage have telemedicine video support.

It's absolutely below the general ED standard of care in the U.S. – but not by much, and for much less financial outlay. The focus on "patient satisfaction" and issues of medicolegal liability are the main barriers to this sort of cost savings in the U.S.

 

[VA Hopeful Dr]

Realistically, what kind of money are we talking about here?

"ER money" isn't that good in a lot of parts of the country. About 300k.

250k would be what I'd expect with a reasonably full DPC practice.

 

[miacomet]

I realized I need experiential avoidance. I need a career I can do until I have one foot in the grave. What think you all? Palli? Apply for psych residency? Any other ideas?

 

[dr_shark]

I'm worried for you. Sounds like you do need to walk out for your own sanity. My redline would be having SI. You should take care of yourself first. A colleague of mine quit for several years after severe depression from death of a spouse and was able to return to practice without problems. That doctor was more happy with medical practice after coming back. I also volunteered at an indigent primary care clinic with another ED doc who had quit to prevent a break in his medical practice history. Leaving completely may cause credentialing problems unless you have connections and able to obtain work once you are ready. Make sure you keep your medical license(s) active.

I think this thread is both recent and dead enough. Tried to send a message your way. Did you ever find a route for an FP into critical care? I'd love to hear back from you.

 

[cyanide12345678]

So this is going to be another "Should I leave EM?" post. No eye-rolls please.

Worked community ER for > 10 years. Early 40s, and finally hit my FI number.

Experienced firsthand all the usual reasons for wanting to quit.

• Sued twice, which led to a period of depression and suicidal thoughts. Thankfully, both cases were dismissed after years of litigation, but still fear the next possible lawsuit
• I've worked at a lot of different hospitals in multiple cities and have never found a unicorn practice. All have been plagued by some or all of the following: loss of autonomy, a difficult patient population, unreasonable expectations (high pph, responsible for floor codes/procedures), hostile consultants, difficult admits/transfers, understaffed ancillary staff, etc
• Night shifts getting harder in my 40s
• Most shifts are so brutal now that I have palpitations and a sinking feeling of despair on my drive to work.

But the thing is, I still love practicing emergency medicine but just hate what it's become. Also, feel a bit guilty about retiring early, read some EM statistics that most retire in their 50s.

I know there are a lot of headwinds - physician oversupply, declining reimbursements, midlevel creep, corporatization.

But, are there any reasons for optimism? Anything on the horizon that might reverse the decline?
Maybe unionization or HCA reversing course and closing their residencies? Perhaps real tort reform, I know GA once had gross negligence standard for EM but got overturned.

Seems with anticipated physician oversupply, quitting for > 1 year likely means I won't be able to return. Just looking for reasons not to quit.

Lastly, for the parents, do you feel your children would be embarrassed that you retired early? I feel like I've tied my identity and take pride to being a doctor.

- Just another burned out ER doc.

How big is the nest egg, what are your expenses? Alot of retirement depends on those two numbers.

 

[miacomet]

How big is the nest egg, what are your expenses? Alot of retirement depends on those two numbers.

This.
Also we've had high inflation and we aren't getting an interest rate cut per the Fed so???

 

[cyanide12345678]

This.
Also we've had high inflation and we aren't getting an interest rate cut per the Fed so???

I have very very high concern for a bump in inflation with the proposed tariffs sinc a lot of groceries are imported especially fruits and veggies.

A bump in inflation may lead to a hawkish federal reserve.

 

[Mount Asclepius]

Recent tariff based inflation is really just local class warfare in the guise of international disagreement over perceived trade deficit. Inflation hits our poorest hardest. The wealthy (including even physicians) do not feel its punch. This indirectly shifts more money and power to the ‘oligarchs’ of our country. Our country overspends on military and healthcare for the elderly. There will eventually be a reckoning with our national debt. This may very well be delayed and gradual given its current degree as a percentage of GDP. Fighting in the sandbox with tariffs and trade wars is shallow and temporary. Weather this storm and quit instead if necessary based upon other more personal, although universal, factors.

 

[Old_Mil]

Not IL or PA, but a state with ZERO tort reform.

If that's the case, if I was in the situation you are in I'd probably do some serious thinking. If you've truly hit a FI number, that number is probably higher than your medmal cap. If you're in the wrong place at the wrong time, that could incentivize a really bad financial outcome. I'd either (1) look at restructuring how you hold your assets to reduce risk, (2) continue practice in a state with better medmal protections, (3) get out and do something else.