Should I re-apply to EM or go be a hospitalist?

[anon12380]

I keep coming back to this forum and to the Reddit forum. During my first three years of medical school, I envisioned becoming an ER doctor. I admit I had rose-tinted glasses and only when I started doing rotations in the ED did I realize how much of an urgent care / PCP office the ED functioned as especially so in the community setting. I ended up applying to Internal Medicine with the goal of becoming a cardiologist. Well, that may not pan out as I have no interviews as a PGY-3. I am not sure why, but I still think about EM from time to time. It was being a hospitalist versus being an ER doc, I feel like the latter would be better than the former. Not sure if it would be worth spending another 3 years in training (I have SLOEs from my first time around still.) Or I could go practice at a critical care access site to get that critical medicine itch I have. Anyways, I just do not know why I have this thought in the back of my mind I made a poor career choice in my current situation. I still remember having people tell me I would be a great ER doctor during my interviews, but even as an MS4 I felt a little exhausted by the shift work, but hospitalist while not nearly as draining can be equally boring.

Sorry for the rant, not sure who to talk to about something so personal.

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[JacobMcCandles]

Financially, the best thing to do is probably make hay while the sun is shining, live beneath your means, and save/invest as much as you can. Going back to training for a specialty rife with its own issues is a gamble upon itself.

 

[Prehealth1011]

CCM/PCCM? Not sure if you're an MD/DO and how your app is but our fellows have almost non-existent research. It might be a more achievable target if you're a DO and sounds more logical than doing a new residency

 

[southerndoc]

You will be at a disadvantage applying to EM because some programs won't consider you because you have no more funding. Funding it set for the program you match into. You matched into IM so you're set at 3 years. If you transfer between PGY-1 and PGY-2 years, then the program accepting you gets 2 years of funding and then eats the third (if you're transferring into an EM program). A surgery resident gets 5 years of funding. If he/she transfers into EM after PGY-2, he/she still has 3 years of funding for the residency that accepts the transfer.

I mention this because most hospitals need the funding (or at least want it) and you're now considered to have no funding. They will take you at a loss of about $150,000 per year that CMS would normally give the hospital to train you. A lot of big programs and university programs don't care and will take you as a second resident, but those are usually more competitive. Even though there were a lot of unmatched programs, it's unlikely that one will take you at a $450,000 loss for the 3 years to train you.

It is what it is unfortunately. I would second @JacobMcCandles' suggestion. Maybe try to work in a smaller ER or a VA ER if you really wanted to do ER.

 

[CoolDoc1729]

I would add that since your Ms 3 year the urgent cares have become useless, the outpatient offices are understaffed, so if anything we are doing MORE minor nonsense and primary care, not less. At least the ER sends home most of the chaff.

In your situation I would definitely at least try hospitalist before committing to another 3 years of crummy hours/pay. I say this as one of those people who could have seen myself doing OB, general surgery, FP, anesthesia - i would be looking for the shift work solution in any of them, though, would do hospitalist if I found myself at the end of an IM residency.

 

[Apollyon]

You will be at a disadvantage applying to EM because some programs won't consider you because you have no more funding. Funding it set for the program you match into. You matched into IM so you're set at 3 years. If you transfer between PGY-1 and PGY-2 years, then the program accepting you gets 2 years of funding and then eats the third (if you're transferring into an EM program). A surgery resident gets 5 years of funding. If he/she transfers into EM after PGY-2, he/she still has 3 years of funding for the residency that accepts the transfer.

I mention this because most hospitals need the funding (or at least want it) and you're now considered to have no funding. They will take you at a loss of about $150,000 per year that CMS would normally give the hospital to train you. A lot of big programs and university programs don't care and will take you as a second resident, but those are usually more competitive. Even though there were a lot of unmatched programs, it's unlikely that one will take you at a $450,000 loss for the 3 years to train you.

It is what it is unfortunately. I would second @JacobMcCandles' suggestion. Maybe try to work in a smaller ER or a VA ER if you really wanted to do ER.

Why do you perpetuate this? You're talking DME, direct medical education, totally correct, but IME, indirect medical education, makes up a BIG portion. They are not getting nothing from taking such residents.

 

[BoardingDoc]

Why do you perpetuate this? You're talking DME, direct medical education, totally correct, but IME, indirect medical education, makes up a BIG portion. They are not getting nothing from taking such residents.

I for one have no idea what DME/IME is. Links/explanation?

 

[Apollyon]

I for one have no idea what DME/IME is. Links/explanation?

This is SDN special. One mod comes in to back up the other. I already stated what was each. It's been discussed ad infinitum here on SDN. I'll invite @NotAProgDirector to chime in.

I believe it's in the Green Book for GME. I don't have links. I do have to admit, though - first time I've ever been asked for links.

DME - direct medical education. That's the funding. IME - indirect medical education. That's money paid to the program, still, for a resident. It's a bit variable, but, usually, turns out to be 65-70% of DME. It's not chump change, and, as I said, the program gets paid. No one works for free.

 

[Splenda88]

A boring job that pays a lot of money is not that bad when you are in your 40s+ with 2-3 kids.

Given another chance, I would do IM all over again. I am ok with a job in which I can FULLY watch two soccer games while at work in most days and still make it home at 4:15pm

 

[NotAProgDirector]

Let's start with the easy question: resident funding. The best source of information is here: Medicare’ Payments for Graduate Medical Education: What Every Medical Student, Resident, and Advisor Needs to Know

Residents completing a second residency (or a fellowship) get partial finding - 50% of DME and 100% of IME. because the IME > DME, this ends up being about 80% of funding for most places. IME varies widely so in some places it may be much larger than DME. Smaller places may not be able / willing to deal with a 20% cut in funding from a single residents, others may be over cap and hence get zero funding for some of their residents and it won't matter at all.

The hard question is the OP's. There's no right answer. Personally, I think being happy in your career is worth extra investment up front if needed. But the question is: will you really be happier in EM? The constant shift work, nights, people with minor complaints, etc. All of those things are real in the ED. And there's lots of concerns about ED staffing agencies being bought up by VC and staffing with midlevels to save money.

You need to sit down with some trusted people and think this through. There are ziollions of open EM spots so you'll likely get one if you want one. You might want to work as a hospitalist for a year or two and then make a decision.

 

[NotAProgDirector]

Looking at your post history (which I usually do first), your interests have been all over the place. IM, EM, Anesthesia, Radiology, etc. In a prior post you mentioned you're a DO with USMLE scores of 237/240 or something close to that. Those scores shouldn't keep you out of Cardiology, so if you're not getting interviews you need to review your research and Cards rotations / experience / references. Bottom line is you need to sit down with someone and figure out where you want to head your career.

 

[Brigade4Radiant]

Do a chief year at some IM program then apply to cards

 

[sylvanthus]

Hospitalist, or fellowship. Not EM. /thread.

 

[emergentmd]

5 yrs into EM residency making 400K/yr working 32hrs/wk. "Ambitious" 33 yr old me yearned to do radiology/interventional as this was one of my top 3 choices. Looked down the barrel of 4 yrs residency + 1 yr interventional, uprooting my family, working 60-100 hrs/wk, losing $2M salary.

Older and less "ambitious" 20 yrs older me would have slapped the 33 Yr old me back into college.

 

[BoardingDoc]

This is SDN special. One mod comes in to back up the other. I already stated what was each. It's been discussed ad infinitum here on SDN. I'll invite @NotAProgDirector to chime in.

I believe it's in the Green Book for GME. I don't have links. I do have to admit, though - first time I've ever been asked for links.

DME - direct medical education. That's the funding. IME - indirect medical education. That's money paid to the program, still, for a resident. It's a bit variable, but, usually, turns out to be 65-70% of DME. It's not chump change, and, as I said, the program gets paid. No one works for free.

You stated what the acronyms stood for, you did not explain the difference in your original post.

I've been here for over 10 years and I have never seen a post explaining the difference or I suppose I simply cannot recall having seen one. Being a mod does not grant a person infallible memory. Also, there isn't some mod conspiracy directed against you here, nor am I doubting you. I'm legitimately curious about the topic, which is why I asked for more information.

Thanks to @NotAProgDirector for the info/links.

As an FYI, the link on the page you posted goes to a 403 error for me. I was able to search the title for the report, however, I found another copy here: https://gme.med.ufl.edu/files/2013/02/Medicare-Payments-for-Graduate-Medical-Education-2013.pdf

 

[Splenda88]

5 yrs into EM residency making 400K/yr working 32hrs/wk. "Ambitious" 33 yr old me yearned to do radiology/interventional as this was one of my top 3 choices. Looked down the barrel of 4 yrs residency + 1 yr interventional, uprooting my family, working 60-100 hrs/wk, losing $2M salary.

Older and less "ambitious" 20 yrs older me would have slapped the 33 Yr old me back into college.

Would have been probably more. Don't underestimate opportunity cost.

 

[Apollyon]

I love it when some rando I've never heard of gives me a dislike.

 

[Apollyon]

I love it when some rando I've never heard of gives me a dislike.

Now that's funny!!

 

[Tenk]

I love it when some rando I've never heard of gives me a dislike.

Take it baby.

 

[southerndoc]

Why do you perpetuate this? You're talking DME, direct medical education, totally correct, but IME, indirect medical education, makes up a BIG portion. They are not getting nothing from taking such residents.

Because I did not know anything about the other. Calm down @Apollyon. Not sure why you're so upset about it.

I'm only repeating what I've heard talked about both in my own program as well as other programs. Perhaps reduced funding = no funding in the eyes of many hospitals.

@NotAProgDirector thanks for explaining. Learned something new about residency funding that I've yet to hear discussed within my own program. Maybe it's not discussed because they want to simply it.

 

[Apollyon]

"Calm down" - that epitomizes condescension. You way overstate "upset".

If I don't know about something, I don't confidently make a statement about it. When that happens, it gets repeated, and erroneous information is normalized.

As NaPD stated, positions over cap (set in 1997) are unfunded. That is not the norm. The large majority of positions are funded.