Taking a job in a small ER fresh out of residency

[jmpeter]

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So now entering 3rd year I have been looking for jobs and seeing where I should sign after this year. My priorities are really family. My brother and I are good friends and I want to move back towards him, my family, and many of my friends. I have 2 job offers I am really looking at. I want to go back to a place that really is not a really marketable area so I have many offers but am trying to decide between two.

1. Small town of 10,000 people, approximately 1.5 hours from where I want to live. Hospital is 50 bed with 4-5 ICU beds. The ICU beds are managed by FM/IM with intensivist by telemedicine but if a patient needs intubation or a line the ED doc is consulted but has no further management requirements. The ED is 16 beds with 15-17,000 visits. PA/NP coverage 7a-7p but not overnight. General surgery/hospitalist is on call but not in house. In case of a crashing/coding pt the ED doc covers. The contract is for 3 12's per week. I got them to write that I will work 3 12's in a row (i.e. no day off between shifts) with 1/4 weekend coverage. Group has 2 ED trained and 3 FM trained docs. Contract roughly hits 300k/yr with RVU give or take. If I pick up another shift I get $200/hr with no RVU benefit (what they pay locums). PPH is about 1.5.

2. Bigger town of 100,000 people. The ED is 24 beds with a 35,000 patient volume, 200ish bed hospital. It is about 2.5 hours from where I want to live. Lvl 2 with almost all specialty backup minus neurosurg which isn't always available. I show up to my shift, do it and leave. No covering the hospital or being called to their ICU as they have intensivists covering. I don't have to ship much but a few cases to the big academic center. Contract is for 3-4 8 hour shifts per week. It has a larger group that covers several hospitals that I will need to cover through the area as well. The contract is about the same and roughly averages 300k/yr with RVUs. They do not guarantee me all my shifts in a row but "will try" as much as they can.

So I listed that I want to be close to family and friends. Both groups seem happy and have a good stable contract. I know where I want to live as I have a nice plot of land that I will be buying from my parents to build a house which is located on a nice river that feeds into a lake. I can't honestly seeing myself live anywhere else. It is in a medium sized city and I would work there except the contract is awful and I would take almost a 100K hit in salary. The group is pretty malignant especially towards new grads which is why they are always looking for help.

My thought is I would work in one of the two places I looked at. My plan was to get a 1 bedroom apartment and stay there between shifts. This makes the smaller area more desirable as they will let me work all my shifts in a row and then head home. I really do want to work at my 1st option as the hospital is brand new, the group is awesome, and the idea of being able to grab a few more shifts in house to pay off loans makes it attractive. Still I wonder if being in a small ED might make my skills somewhat decline. My idea is that if the town I live in starts offering a better contract I would probably head there. I am just not sure if I should head to a smaller ED straight out of residency. What are your guys thoughts?

 

[goodoldalky]

Sounds like you should do some more job interviews. As far as location two, if you have the impression they are malignant in some way simply through the interview process, move on.

As far as your skills declining at job one, this will depend on the acuity of the site. It sounds low if the majority of the docs there are not EM boarded. If you want to remain capable intubating, placing lines, taking care of peds and sepsis and stroke and trauma patients, then you need to do those things or else your skills will decline.

 

[Angry Birds]

I work at a small shop like that and do not feel that my skills have declined. In fact, I've been forced to do procedures that I never had a chance to do in residency due to specialty coverage. The learning curve has been high, and I couldn't have been more satisfied with my decision to pick a smaller place over a busy Mecca. I don't think I'd ever go back. But, to each their own. Nobody can tell you what you would want.

As for the fact that there are FP doctors there, that could be less about the acuity and more about the inability to fill spots due to it being in the boonies. Also, I've often seen my FP colleagues doing things incorrectly. So, the acuity is there, but they may just be mismanaging it.

Having said that, I'm sure your skills may increase faster if you pick the busier/bigger place but I think you will be fine either way.

 

[Groove]

Honestly, as long as you aren't working in an urgent care center or freestanding ED 24/7/360, your skills should be fine. In my experience, those smaller shops get some of the craziest **** at odd hours of the night. Some of my most brutal cases were at a low volume ED like that while I was moonlighting. I think it's hard to lose the trauma skills. It's like riding a bike. Putting in a chest tube is not rocket science. I feel like I intubate and drop lines more in my current gig than I ever did during residency but I'd probably be just fine to do one every other month. You should be fine with whichever job you choose.

Also, keep in mind that if you ever feel like you are getting rusty and need a busier place, just credential somewhere and pick up a few extra shifts a month. Regardless, spending 1-2 years at a place to figure out if that's the right environment for you should not be detrimental to your EM skill set.

 

[BAM!]

sounds like you want to do job #1. closer to where you want to live. what is the number of patients per hour in job #2? Sounds busier. You may want to calculate reimbursement per patient. This may help put things in perspective. Flip a coin and see if you're happy with the outcome.



Also, going to the floor to run codes or intubate is NOT a bad thing. Actually, I like it, and I'm not just rationalizing it to myself.
1. it's fun and what we trained for.
2. you can bill for it.
3. it adds a nice break in the middle of the shift.

 

[docdragon]

If things look good on the ground, either job could be feasible. Covering multiple EDs has advantages and disadvantages - are they all equally efficient? Well set up? Or better yet, all stocked identically with streamlined flow? Or is each a random community ED free-for-all find-me-if-you-can?

Working a lower-volume, single-coverage ER is fun though if things get busy you are all there is. When you say you cover codes, does that include at night, when you are truly single-coverage without MLPs? Are you comfortable with that?

If your contract says that you will get your shifts as scheduled, then you have a basis to get the shifts as scheduled. They can ask you to make an exception if needed. If you have a verbal "will try", then plan on working whatever shifts they schedule, making a lot of noise about the schedule, and generally being unhappy.

Your skills will probably not decline in a small-town, single coverage ER. Did you read Edwin Leap's recent column about rural EDs? Worth a gander. As per above, you may see crazy pathology more frequently. You will probably be pushed a little harder medically, especially if you are working with good IM-to-EM docs who really know medicine and start discharge planning by mixing extra family/internal medicine with their ED management. It can get lonely, though, and you may eventually want to challenge your practice with some higher-resource shifts.

 

[Arcan57]

I don't think I would consider a job that required a 5 hr round trip commute for an 8 hr shift.

 

[Birdstrike]

The most important thing is..............




...none of that.

It is to rent, not buy, housing your first year. The chance of you staying at your first job long-term is very low, statistically. This is your best insurance policy against a miserable job. It's also your best insurance policy against the perfect job that's sucks mightily 90 days after you start because the contract was taken over and now it's a totally different job than what it was 3 months ago. If you're not job-mobile as an EP, you make a very easy victim.

 

[dotcb]

Doing a job w/ commutes like those does not sound anywhere near sustainable. I would get a job much closer to where I wanted to live.

 

[Angry Birds]

I agree that your commute of 1.5 hours and 2.5 hours is insane.

I have an hour commute but I do 24 hour shifts so I tolerate it. Just barely. I would certainly not agree to do even an hour commute for 12 hour shifts.

 

[jmpeter]

So I get the commute and that would be awful on a daily basis. My actual plan is that I would get an apartment where I work so I could go there a few days, work, and then go home. That is why I feel the first would be ideal as I can get them to schedule me 3 shifts in a row. So I would only commute the day of my first shift then go home after my 3rd shift. Also I am single so I don't have get home for kids or a wife. Obviously this might change but I can always adjust this when that happens. I also will definitely not build or buy right away. I can live with my brother for a bit of time to make sure the job is viable. Again I would love to work in the town I want to live but man the contract is bad. My hope is that a few years down the road it becomes better and I can consider working there.

 

[Mighty Mouse]

if these are the only 2 options on the table, smaller shop 1.5 hrs away (with a commute only on front end and back end) seems to make far more sense. wouldn't worry about the "small shop." agree with above....small does not equal easy. you'll find you're doing a lot more stuff if you're the only doc in house and have limited specialist coverage. if that hospital is the only show in town, plenty of pathology will come through your door. plus, i'm of the opinion that intubating and central lines are like riding a bike. and if there's inpatient procedures you'll be expected to do, then it seems you'll have the necessary exposure and opportunity. i'm not crazy about doing inpatient procedures and leaving my ED doctorless, but that's just me.

agree with Bird....your biggest asset is your portability....don't lock yourself into a place by buying a house just yet.

 

[Angry Birds]

So I get the commute and that would be awful on a daily basis. My actual plan is that I would get an apartment where I work so I could go there a few days, work, and then go home. That is why I feel the first would be ideal as I can get them to schedule me 3 shifts in a row. So I would only commute the day of my first shift then go home after my 3rd shift. Also I am single so I don't have get home for kids or a wife. Obviously this might change but I can always adjust this when that happens. I also will definitely not build or buy right away. I can live with my brother for a bit of time to make sure the job is viable. Again I would love to work in the town I want to live but man the contract is bad. My hope is that a few years down the road it becomes better and I can consider working there.

So you're going to pay for two apartments? Seems like a pricey decision.

 

[jmpeter]

Angry Birds I wouldn't be paying for two apartments. I would be paying for one at the job location (approx. $300-$400/month for a 1 bedroom) and staying at my brothers at least for a bit. Granted I will be pitching in a bit for his mortgage but it will be around $250/month. So if I take the job at the smaller shop it will be $650/month. After 6 months if I like the job I will buy the land from my parents and start to build my own place.

Either way thanks everyone for all the advice! I was nervous about the smaller volume but seems that it won't matter too much. I have a contract on the table and negotiated 20k per year for student loan repayment as long as I stay 2 years. Get another 20K per year up to 5 years if I stay that long. I'm going to sit on it for a few days but I'm not as nervous signing a contract for a smallish ER.

 

[Docinthetrenches]

As for the jobs, the first one has benefits - going in less often, getting better experience with doing procedures you'd never do in a larger place, potential for slow periods, shifts in a row, really being in charge and not dealing with private MD's. Still, the larger place probably has less headaches and less transferring. More backup for when you are just not sure. And I know some other ppl like it but I have worked in a place where the ER doc has to cover floor and ICU codes and it is not pleasant. It totally disrupts your flow and you come back and it's all jacked up with ppl waiting.
Still, neither of these options would sit with me since I could never do that commute - either one. My current job has a 30-40 minute commute on public transit and I love it. Driving all that distance is a nightmare - traffic, wear and tear on the car, gas, etc. It's a set up for road rage when you are running late.

Find somewhere within an hour absolute max.

 

[Angry Birds]

Good luck. I can't however warn you enough about how painful a long commute is.

 

[emergentmd]

I don't think driving 90 minutes 6-7 times a month is all that big of a deal. The harder part is living away from home 12+ days a month. That would get tiring. But if you are single, with no kids its not that big a deal

 

[Apollyon]

I don't think driving 90 minutes 6-7 times a month is all that big of a deal. The harder part is living away from home 12+ days a month. That would get tiring. But if you are single, with no kids its not that big a deal

I have an hour and 45-50 minute commute each way, but it's a straight shot. I listen to Sirius/XM at 38 (as the highest setting on my radio isn't "25" or "40", but "38"), and enjoy my trip in. I always marvel (mildly) at people that are so dogmatic. I work 24s, but am going to make the most I ever have this year doing it. Then again, I describe myself as "the idiot working 24s".

 

[Angry Birds]

I have an hour and 45-50 minute commute each way, but it's a straight shot. I listen to Sirius/XM at 38 (as the highest setting on my radio isn't "25" or "40", but "38"), and enjoy my trip in. I always marvel (mildly) at people that are so dogmatic. I work 24s, but am going to make the most I ever have this year doing it. Then again, I describe myself as "the idiot working 24s".

I'm another such idiot.

What's your volume like? I think mine is a tad too high to be sustainable for me long term.

 

[Apollyon]

I'm another such idiot.

What's your volume like? I think mine is a tad too high to be sustainable for me long term.

We see about 7K, maybe 8K now.

 

[Apollyon]

I'm another such idiot.

What's your volume like? I think mine is a tad too high to be sustainable for me long term.

Arcan57 wrote about guys doing 24s that saw 50 or 60 patients a shift. 60 in 24 hours? 2.5/hour, EVERY hour, for 24 hours? The first shift would be, concomitantly, the last one.

 

[Angry Birds]

We see about 7K, maybe 8K now.

Yeah, mine is 13k, which is why for my next gig I want to search for something in the range you are doing...

 

[Apollyon]

Yeah, mine is 13k, which is why for my next gig I want to search for something in the range you are doing...

They just need to pay me more.

 

[Arcan57]

Arcan57 wrote about guys doing 24s that saw 50 or 60 patients a shift. 60 in 24 hours? 2.5/hour, EVERY hour, for 24 hours? The first shift would be, concomitantly, the last one.

That wasn't the average (I think it was 37/day) but there would be spikes in that range. Of course this was back in the days of paper t-sheets and after 11 or so the nurses were expected to work up the patient and only wake you when they were ready for dispo.

 

[Angry Birds]

They just need to pay me more.

My salary is mediocre as well. But I'm unfortunately geographically tied to the area for the year.

 

[Apollyon]

That wasn't the average (I think it was 37/day) but there would be spikes in that range. Of course this was back in the days of paper t-sheets and after 11 or so the nurses were expected to work up the patient and only wake you when they were ready for dispo.

Yeah, but that would be 20 patients or so at the 60/day spike. That ain't good rest, man!