Thinking about switching to FM from EM, advice appreciated

[throwaway9876]

I'm a PGY-1 in EM at a strong program. I have been pretty unhappy in EM going back to the 4th year of med school, kept thinking things would get better but they never really did. In truth, I probably went into the field for the wrong reasons. Thinking about lifestyle, the ability to cut down my work hours/become FI, not taking work home, not dealing with whatever BS other fields deal with. That's not to say I don't enjoy EM at all, the people (attendings/residents) were always the people I got along with best (probably what kept me in it the most up to this point), the sexy stuff is pretty fun and I like having a wide skill-set with the ability to do some procedures. We could go into this more but probably not relevant to this discussion. However, the downsides are very real. The total lack of control on how my day is going to go, the inconsistent schedule with weekends/holidays, dealing with the worst of society and our healthcare system every day. The future appears pretty bleak as well with corporate groups taking over and squeezing everything. I feel like I'm already racing to a point of cutting back/retirement and it leaves me now wanting to be a doctor at all. This leaves me feeling pretty empty, and I wish for something I want to get out of bed for and feel passionate about.

I'm passionate about preventing chronic disease, helping people live healthier lives, etc. I feel like our whole medical system is completely backward in the way it approaches these things. I think I would find it very rewarding to help people reverse their DM, get off meds, etc. Maybe this would help me rediscover my love for being a doctor. If nothing else, seeing patients who are generally happy sometimes I think it would be much easier on my mental health. Additionally, from a lifestyle perspective, FM appears pretty nice with somewhat controllable days (at least in the number of patients you see), consistent schedule, somewhat reasonable patients, and actually being treated like a human by administrators (you know being able to pee or eat sometimes). While EM theoretically has fewer total hours, when you consider the nature of the schedule as well as holidays, actual vacation time, etc I'm not so sure it doesn't even out. That's not even touching the nature of the work itself and how soul-sucking it can be. Sure I'd make less money in FM (for now) but the overall job market actually appears way better and I could probably have a longer and happier career. Hell, I could even practice a little EM if I wanted for a while.

So my questions for ya'll are:
1. Do you think I would be able to transfer as a PGY-2 to a FM program? There's a fair amount of overlap in our PGY-1 schedules but obviously I would be way behind in outpatient care and hospitalist stuff. What would be a good way to find open spots?
2. Are you all happy in your field? I'm sure I have a grass is greener view and I know modern FM with the 15-minute appointments leads to burn out in its own right. I feel like I'd at least have the opportunity to practice medicine the way I want to sometimes. Is this a rose-colored glasses view?

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[EMhawkeye]

Possible swap for you that I know of if you're interested

 

[5150man]

I feel for you. I'm 10 years out of FM/sports med fellowship and I've done 30-50 hours/week of rural ER on top of FT FM since I graduated. I'm sitting in the ER right now even. I have long wondering how someone could do ER for their whole career. I'd say your post is a valid take on both specialties. I've been a partner in a small (3 other docs and 1-2 mid-levels) since fellowship so I can't speak to how I'm treated by administrators but to answer both questions.
1. I believe it would be program dependent but I think doable most anywhere. We had had a resident join us 2nd year that had come from an intern year in General Surgery and I think he just did 2 months of OB instead of electives our 2nd year. If I remember right we had the same thing the year ahead of me where another surgery intern joined that class and had to do some extra OB rotations.

2. I hate medicine in general probably due to the schedule I have willingly put myself through but nothing against FM and there is no other specialty I've wished I'd done. I'm in complete control of my schedule. I can come and go as I want and basically just have to keep patients happy (be there when you need them) and partners happy (they're not always having to cover for your patients). We got hospitalists at our small hospital about 7 years ago so call is now easy phone call with the occasional newborn (I don't do OB). I don't take a lot of days off but I leave early fairly frequently if my wife needs some help with something or for school stuff with my kids. Yesterday realized they have next Friday off from school so had my staff rearrange a few patients and now we're going skiing in the afternoon. I work M-F with Thursdays off. I leave early on Tuesdays to do church stuff. I don't know that an employed physician would be so in control of their schedule. The few people that I feel I've played a part in helping them change their lifestyle have been extremely rewarding. They are bright lights in a sea of chronic pain, depression, and worried well. I should pare down my patient population (limit medicaid) to get rid of headaches because patients are beating down our doors but I'm stupid and haven't been able to bring myself to do that since there are limited options in our town(see below).

I had a chance about 5 years ago to do FT ER. The schedule would have been a 24 and 12 hr shift/week. My wife really wanted me to do it due to the schedule but I spent about 6 years after residency severely sleep deprived due to the ER schedule. I found over that short time that I wasn't falling asleep as quickly after getting woken up and didn't bounce back as well after a long night. I also didn't like the idea of signing up for a career of mandatory holidays, night and weekends as opposed to willingly doing it and knowing I could quit at any time. That along with the fact that it truly sucked my soul and made me hate humanity...joking....kind of. Trying to please my wife and not feeling strongly against it at the time, I even called the administrator to tell him I'd take it and he happened to be out of town. I'm forever grateful that call never made it through. I've cut down my ER quite a bit the last 2 years and I'm in burnout recovery now .

At this point I'm just tired of the constant demands of people and always being on call even when not on call (probably more of a small town thing). Home health nurses always calling for whatever, home health paperwork, disability paperwork, and "quality measures" that have changed our focus from practicing medicine to checking boxes and trying to keep *****s out of the ER. In my 10 years here we've had 6/10 family docs retire (4 in the last 2 years) and I'm still the newest guy in town (had another doc join the other clinic in town but she only lasted 2 years then went to urgent care) so I feel like we are constantly just trying to keep people out of the clinic while unsuccessfully trying to recruit some new blood (just hired a couple NPs and waiting for a couple guys to finish residency). I think I could have handled it better if the ER hadn't sucked all the humanity out of me though.

More than you wanted but I had the time.

P.S. If you are already hating the parts of ER you mentioned, I can't imagine those things getting better. Those are the things you put up with because you like the money, "freedom", and adrenaline. If you already don't care about the positives and hate the negatives then your dissatisfaction will only get worse imo.

 

[throwaway9876]

I feel for you. I'm 10 years out of FM/sports med fellowship and I've done 30-50 hours/week of rural ER on top of FT FM since I graduated. I'm sitting in the ER right now even. I have long wondering how someone could do ER for their whole career. I'd say your post is a valid take on both specialties. I've been a partner in a small (3 other docs and 1-2 mid-levels) since fellowship so I can't speak to how I'm treated by administrators but to answer both questions.
1. I believe it would be program dependent but I think doable most anywhere. We had had a resident join us 2nd year that had come from an intern year in General Surgery and I think he just did 2 months of OB instead of electives our 2nd year. If I remember right we had the same thing the year ahead of me where another surgery intern joined that class and had to do some extra OB rotations.

2. I hate medicine in general probably due to the schedule I have willingly put myself through but nothing against FM and there is no other specialty I've wished I'd done. I'm in complete control of my schedule. I can come and go as I want and basically just have to keep patients happy (be there when you need them) and partners happy (they're not always having to cover for your patients). We got hospitalists at our small hospital about 7 years ago so call is now easy phone call with the occasional newborn (I don't do OB). I don't take a lot of days off but I leave early fairly frequently if my wife needs some help with something or for school stuff with my kids. Yesterday realized they have next Friday off from school so had my staff rearrange a few patients and now we're going skiing in the afternoon. I work M-F with Thursdays off. I leave early on Tuesdays to do church stuff. I don't know that an employed physician would be so in control of their schedule. The few people that I feel I've played a part in helping them change their lifestyle have been extremely rewarding. They are bright lights in a sea of chronic pain, depression, and worried well. I should pare down my patient population (limit medicaid) to get rid of headaches because patients are beating down our doors but I'm stupid and haven't been able to bring myself to do that since there are limited options in our town(see below).

I had a chance about 5 years ago to do FT ER. The schedule would have been a 24 and 12 hr shift/week. My wife really wanted me to do it due to the schedule but I spent about 6 years after residency severely sleep deprived due to the ER schedule. I found over that short time that I wasn't falling asleep as quickly after getting woken up and didn't bounce back as well after a long night. I also didn't like the idea of signing up for a career of mandatory holidays, night and weekends as opposed to willingly doing it and knowing I could quit at any time. That along with the fact that it truly sucked my soul and made me hate humanity...joking....kind of. Trying to please my wife and not feeling strongly against it at the time, I even called the administrator to tell him I'd take it and he happened to be out of town. I'm forever grateful that call never made it through. I've cut down my ER quite a bit the last 2 years and I'm in burnout recovery now .

At this point I'm just tired of the constant demands of people and always being on call even when not on call (probably more of a small town thing). Home health nurses always calling for whatever, home health paperwork, disability paperwork, and "quality measures" that have changed our focus from practicing medicine to checking boxes and trying to keep *****s out of the ER. In my 10 years here we've had 6/10 family docs retire (4 in the last 2 years) and I'm still the newest guy in town (had another doc join the other clinic in town but she only lasted 2 years then went to urgent care) so I feel like we are constantly just trying to keep people out of the clinic while unsuccessfully trying to recruit some new blood (just hired a couple NPs and waiting for a couple guys to finish residency). I think I could have handled it better if the ER hadn't sucked all the humanity out of me though.

More than you wanted but I had the time.

P.S. If you are already hating the parts of ER you mentioned, I can't imagine those things getting better. Those are the things you put up with because you like the money, "freedom", and adrenaline. If you already don't care about the positives and hate the negatives then your dissatisfaction will only get worse imo.

Thanks for the reply, it's tough because residency sucks in a number of ways. Working 2x as many hours as an attending, feeling dumb, etc. Ultimately everything has its pros/cons and I'm not sure which I'd prefer. I wish our system allowed for a little more professional agility. I'm quite envious of PAs in this regard.

 

[AMEHigh]

Thanks for the reply, it's tough because residency sucks in a number of ways. Working 2x as many hours as an attending, feeling dumb, etc. Ultimately everything has its pros/cons and I'm not sure which I'd prefer. I wish our system allowed for a little more professional agility. I'm quite envious of PAs in this regard.

I think most FM programs look at fit. So matching/switching in to a FM likely won't be a problem if you explain why you're switching. I can think of multiple people off the top of my head that switched in to FM from other specialties.

I bolded the above because "agility" is what I love about family med. I think it gives you a lot of freedom to do whatever you want. Sure there are still those "classic" family docs who practice in 1 outpatient clinic for 30 years, but I think that happens less and less.

You can scroll down in this forum and see a recent post about the variety of options that FM allows you to pursue.
I know 1 doctor who works in urgent care, fast track of an ED, at planned parenthood and then a couple sessions of outpatient.
I know another doctor who does telemedicine, a couple sessions of outpatient and works for the local health department.
I'm also doing something similar where I have a variety of practice settings.

So yeah the grass is always greener on the other side, but I do think that overall FM does have a better lifestyle that is sustainable. Of course you'd likely make more money doing ED, but at what expense to your lifestyle?

 

[Sushirolls]

Catastrophic thinking, if healthcare really circles the drain really fast, FM also has the ability to more aptly open your own practice/clinic and do Direct (cash) Primary Care and completely extricate yourself from the hospital which is a mind field of headaches. That wild card in your back pocket is true professional freedom, and can be done far more readily then EM. And if there were a surge of doctors doing this as healthcare really circled the drain fast, FM will out compete the EM docs opening up clinics. Just another variable to think about.

 

[PalmTreeDreamer]

Based on what you’ve said, I think you should switch. Even if that means having to do internship here again, starting from scratch in a family medicine residency. Things that you have issues with in EM sound like the same things I have issues with. I actually switched into EM from another specialty, but looking back, knowing what I do now, family medicine probably would’ve been a better choice. The reasons mentioned above, including the flexibility that comes with family medicine, are spot on. In addition, there is such a need for family medicine physicians that my friends who have done FM have basically been able to find practice environments that are exactly what they were looking for, and recently EM jobs – good ones anyway – are getting much harder to find. Feel free to PM me with any questions.

 

[mcat_taker]

This was an interesting thread for me to read. As someone who liked all their rotations in med school I struggled picking a specialty. I really enjoyed my EM rotation in 4th year but didn't feel competitive enough for it due to low board scores and didn't have any aways set up for SLOEs etc since it was late. I'm applying FM because I feel it opens a lot of doors to different types of practice environments but I always found the EM schedule appealing with shift work, not taking work home, no social work, etc. I like that you can pick up shifts or drop shifts to suit your lifestyle. I like the procedural aspect of it as well. I worry with FM that most of the good full scope stuff is out rurally where I may not necessarily want to be based and that you get all this training in OB and peds that is wasted as a lot of FM docs don't even practice that stuff and of course the FNP and other mid level encroachment into the field of primary care.

 

[byrneboy]

I'm a PGY-1 in EM at a strong program. I have been pretty unhappy in EM going back to the 4th year of med school, kept thinking things would get better but they never really did. In truth, I probably went into the field for the wrong reasons. Thinking about lifestyle, the ability to cut down my work hours/become FI, not taking work home, not dealing with whatever BS other fields deal with. That's not to say I don't enjoy EM at all, the people (attendings/residents) were always the people I got along with best (probably what kept me in it the most up to this point), the sexy stuff is pretty fun and I like having a wide skill-set with the ability to do some procedures. We could go into this more but probably not relevant to this discussion. However, the downsides are very real. The total lack of control on how my day is going to go, the inconsistent schedule with weekends/holidays, dealing with the worst of society and our healthcare system every day. The future appears pretty bleak as well with corporate groups taking over and squeezing everything. I feel like I'm already racing to a point of cutting back/retirement and it leaves me now wanting to be a doctor at all. This leaves me feeling pretty empty, and I wish for something I want to get out of bed for and feel passionate about.

I'm passionate about preventing chronic disease, helping people live healthier lives, etc. I feel like our whole medical system is completely backward in the way it approaches these things. I think I would find it very rewarding to help people reverse their DM, get off meds, etc. Maybe this would help me rediscover my love for being a doctor. If nothing else, seeing patients who are generally happy sometimes I think it would be much easier on my mental health. Additionally, from a lifestyle perspective, FM appears pretty nice with somewhat controllable days (at least in the number of patients you see), consistent schedule, somewhat reasonable patients, and actually being treated like a human by administrators (you know being able to pee or eat sometimes). While EM theoretically has fewer total hours, when you consider the nature of the schedule as well as holidays, actual vacation time, etc I'm not so sure it doesn't even out. That's not even touching the nature of the work itself and how soul-sucking it can be. Sure I'd make less money in FM (for now) but the overall job market actually appears way better and I could probably have a longer and happier career. Hell, I could even practice a little EM if I wanted for a while.

So my questions for ya'll are:
1. Do you think I would be able to transfer as a PGY-2 to a FM program? There's a fair amount of overlap in our PGY-1 schedules but obviously I would be way behind in outpatient care and hospitalist stuff. What would be a good way to find open spots?
2. Are you all happy in your field? I'm sure I have a grass is greener view and I know modern FM with the 15-minute appointments leads to burn out in its own right. I feel like I'd at least have the opportunity to practice medicine the way I want to sometimes. Is this a rose-colored glasses view?

Hey, incoming pgy-1 and feeling similar like I made a mistake now that I'm doing a legitimate FM rotation. Did you have any luck switching into a pgy2 spot? Or did you reapply and redo intern year?

 

[Make Or Break]

My opinion. I think family medicine has the best of every world in that you’re a true generalist and can do a whole bunch of things however don’t switch if you think clinic is going to be a cakewalk. I don’t find seeing 25-30 patients/day easy and you will take your work home with you. There’s always a pile of things to do when you get back from the weekend and if you want to do justice to every patient you will burn out. You can already tell that I do not enjoy clinic solely based on the administrative bs and notes I’m having to keep up with. If I could just walk in the room, chit chat with the patient, tell them what it is they’ve got and what I’m going to do and walk into the next room I would be so happy but unfortunately a large part of what family medicine is isn’t actual medicine. Maybe I’ve got the wrong setup and I’m getting pushed around being in a residency clinic but I would go crazy having to do this 4-5 days a week every week.

Just as a side note I do not regret doing family medicine because I knew going in I wanted to do hospital medicine and emergency medicine. Only doing EM would have limited me from doing the former and IM would have limited me doing the latter.

 

[VA Hopeful Dr]

My opinion. I think family medicine has the best of every world in that you’re a true generalist and can do a whole bunch of things however don’t switch if you think clinic is going to be a cakewalk. I don’t find seeing 25-30 patients/day easy and you will take your work home with you. There’s always a pile of things to do when you get back from the weekend and if you want to do justice to every patient you will burn out. You can already tell that I do not enjoy clinic solely based on the administrative bs and notes I’m having to keep up with. If I could just walk in the room, chit chat with the patient, tell them what it is they’ve got and what I’m going to do and walk into the next room I would be so happy but unfortunately a large part of what family medicine is isn’t actual medicine. Maybe I’ve got the wrong setup and I’m getting pushed around being in a residency clinic but I would go crazy having to do this 4-5 days a week every week.

Just as a side note I do not regret doing family medicine because I knew going in I wanted to do hospital medicine and emergency medicine. Only doing EM would have limited me from doing the former and IM would have limited me doing the latter.

Residency clinic is nothing like attending clinic. I'll expand more later but most of what you describe isn't a problem out in practice.

 

[byrneboy]

Residency clinic is nothing like attending clinic. I'll expand more later but most of what you describe isn't a problem out in practice.

I'm sure you're busy, but care to expand more? I am interested in hearing what you have to say.

 

[VA Hopeful Dr]

I'm sure you're busy, but care to expand more? I am interested in hearing what you have to say.

Thanks for the reminder, this had completely skipped my mind.

So attending clinic, at least for my group and most of the PCPs I know, has significant advantages over residency clinic.

First and most importantly, we're paid on production. The more patients we see, the more money we make. Residents are salaried. 5 patients per half day or 12 the money is the same. Production based pay makes it MUCH easier to be busy. Sure you still work hard but you're compensated for it. I hate slow days because I'm at work twiddling my thumbs and not earning money.

Second, you can train your staff to do what you want. I haven't done more than sign a prior auth in years. Same with DME forms, FMLA forms, disabled placards, and so on. My wife's nurses go ahead and have all refills needed at every office visit ready so all she has to do is sign them. My nurses order all preventative stuff that is due before I even walk in the room.

Third, residency clinic gives you a skewed view of patients. They are usually patients who can't go anywhere else and have limited means, health literacy, and support systems. Lots of complicated patients who can't afford/understand/accomplish what you recommend. I routinely see patients with a handful of well controlled issues that require very little effort on my part other than checking labs and refilling medications. They have jobs, can understand what you say, have good support systems, and are able to get done whatever needs doing.

Fourth, I control my schedule. If I only want to see 22 patients per day, I can arrange that. If I don't want any new patients, all I have to do is say so. Patient being a jerk? Dismissal letter in the mail. My kids' school is having an Easter Egg hunt next week, so this morning I canceled my morning clinic for that day.

Those are the main areas that I can think of, the other attendings here might be able to add on things that I have forgotten.

 

[Ironheme]

I haven't done more than sign a prior auth in years. Same with DME forms, FMLA forms, disabled placards, and so on. My wife's nurses go ahead and have all refills needed at every office visit ready so all she has to do is sign them. My nurses order all preventative stuff that is due before I even walk in the room.

Wow.

What @VA Hopeful Dr describes is the ideal way to run a clinic.

I routinely fill out my own DME, FMLA, disability forms, etc. I have trained staff to do this, but this can be tough at a residency clinic when staff turnover is high. I have trained many nurses on how to catch patients that are overdue for their preventative, but this can be frustrating when they leave after a few months, and you have to train again.

Burnout from clinic is typically from the large amounts of paperwork, hours spent after the patient leaves, and being double booked without any compensation for more work and told that it's 'in the best interest of patients' and your employer is the one profiting....

I think it would be an entirely different story if you could:
1. limit the amount of paperwork, train staff for the things that don't require MD level knowledge
2. control your schedule/breaks, and patient panel
3. Be appropriately compensated - work more, make more.

Residency clinic can be frustrating as a resident because - you have to run most things by an attending, just as your patients get used to you and you to them, you graduate, you're inheriting a patient panel that you haven't tailored (sometimes the last guy prescribed 120 MME for half the patients on that list, good luck with tapering), and you aren't making extra money for extra work. I think most residents would not mind working more if they made more for it (hello moonlighting).

Anyways, TLDR version - I agree with VA Hopeful Dr. You can design private practice how you want. FM gives a lot of flexibility.