EM for the long run

[MPMD]

For the lurkers it's not really true that the average career in EM is 10 years. That would mean that people were exiting clinical medicine in their early 40s if not even slightly before. That is definitely not the case.

It's fair to say that you don't meet an overwhelming number of passionate EM docs who are 55+. They are out there but yeah it does start to drop off.

I think it all comes down to a couple things:

1) Make sure you are picking this specialty for the right reasons and that you have the personality for it (see prior posts)

2) Get good training and don't engage in a race to the bottom to see how easy your residency can be. I have been amazed by some new grads I have worked with that seem constitutionally incapable of seeing 2 pts/hr. Going to be tough to have a long happy career if you can't do the job.

3) Educate yourself financially, get out of debt, and save early so if you want to cut back you can. The most unhappy docs I've met are the ones who desperately want to cut back and simply cannot for financial reasons.

[wonka31]

I think MPMD is referring to chambers for acute hyperbaric therapy for CO poisoning, dive dive emergencies, etc.

There are far more chambers in the Chicago area for wound care, but only one center does acute care in it.

[Kamban]

MPMD wrote:

For perspective at the moment there is 1 dive chamber in metro Chicago.

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You must be vastly underestimating the numbers for Chicago. Our tiny small metro area probably 1/10 the size of Chicago has 4 hyperbaric chambers and we are 3 hours from the coast. All owned by wound centers attached to hospital systems.

In fact our whole state has half the population of metro Chicago and we have 10 listed chambers in the state.

[wonka31]

There is nonclinical medicine outside of admin. You may consider educating yourself about other options.

[snowcanyon]

Thanks @MPMD

EM works for many, but the average career in clinical EM is what, ten years? Med students might want to be advised to pick a career with a 20 or 30 year horizon. The exit strategies aren't great, as MPMD notes. Unless you are comfy with admin, Urgent Care, or entrepreneurship, LeanFire or night shifts into your fifties, EM can be rough.

Remember EM fellowships rarely cut down on EM time significantly. I don't know anyone who does FT ultrasound, dive, or wilderness, although I'd love to hear from people who do. The fellowships (including critical care) are slick marketing, IMHO.

[MPMD]

snowcanyon wrote:

I agree there are exit strategies, but I don’t know anyone doing wilderness full time, or even part time, for $. More like a hobby/personal growth thing. Even the fellowship director near me had to work a full clinical load. Would love to hear from folks that have done this. Critical care seems pretty high burnout, also, no? Would love to learn more about dive medicine- presumably you have to be in Florida? Admin is admin, and in my mind it’s not medicine, and lots of clinical folk just aren’t admin types. Same with entrepreneurship. I agree pain is a great exit strategy, although a really, really hard fellowship to get these days.

You don’t see many ortho or urology or plastics or psych folk wanting to leave/cut down. I think students should seriously think about that before they do EM.

 

 

 

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Critical care is a hard fellowship at least 2 years. Job market is still kind of shaky if you want a really great job. Tough to find a "home." MICUs usually want docs who can also take pulm call. Anesthesia units don't seem all that interested. I know for a fact that on the academic side this is still tough, if you are housed in EM you end up being loaned out to another dept, complex salary structure, time etc.

Dive medicine is far from coastal. It's mostly to run hyperbaric chambers. It's a niche but an important little one. The work seems to kind of suck though. Indications are a little shaky except for CO poisoning last time I looked. I think it tends to be more of a little side gig for docs working in centers w/ a dive chamber than an exit strategy. For perspective at the moment there is 1 dive chamber in metro Chicago.

[snowcanyon]

I agree there are exit strategies, but I don't know anyone doing wilderness full time, or even part time, for $. More like a hobby/personal growth thing. Even the fellowship director near me had to work a full clinical load. Would love to hear from folks that have done this. Critical care seems pretty high burnout, also, no? Would love to learn more about dive medicine- presumably you have to be in Florida? Admin is admin, and in my mind it's not medicine, and lots of clinical folk just aren't admin types. Same with entrepreneurship. I agree pain is a great exit strategy, although a really, really hard fellowship to get these days.

You don't see many ortho or urology or plastics or psych folk wanting to leave/cut down. I think students should seriously think about that before they do EM.

 

 

 

[The White Coat Investor]

G wrote:

I disagree. EM is well suited to subspecialty focus…toxicology, sports, EMS, hyperbarics, and also sets you up for other interesting things like public health.

Let’s be realistic about working nights and holidays.
Take this with a grain of salt from someone who rarely works between 12a-6a (yeah, I pay for that): people dont need doctors ONLY from 9-5. There are fleetingly limited jobs where a doc can show up during those hours. Heck even my PCP starts at 7 and has extended hours 2x/wk.

Plus at 45, I am lean FI and I have the option of working part time and paying to get out of nights. (I dont have enough yet to get off holidays….) Compare that to a general surgeon, cardiologist or stroke neurologist or anybody on the call schedule.

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Wilderness med, pain, critical care, dive medicine, administration and entrepreneurship in general are all options.

[Kamban]

I don't think there is any primary or specialty in Medicine where one can confidently say with certainty that it is great for the long term. Every field has its drawbacks.

Even if you are office based IM working 8-5 you cannot cut back too much as the fixed portion of the overhead is high enough that you need to work at least to overcome it. More like a 3 day/ week minimum even in the final years of retirement.

If you are employed, the employer might force the issue. If you are self employed like me you might end up paying the employees out of your savings if you don't work the minimum hours and see the minimum number of patients who have good insurance. Add to it the costs of keeping up with the field and the mental energy required to be a competent physician it is very difficult to ease and fade away slowly.

 

[Tim]

@snowcanyon,
You and I can easily make a killing.
Tech startup type food courts with the ping pong tables and freebies. Team building spinning classes or yoga on the night shift. Make EM fun again!
Never mind. Tried a mood switch. Bout time for vacation? Me thinks your too smart to follow a path to a dead end. What you gonna do?

[Zaphod]

Vagabond MD wrote:

fatlittlepig wrote:

ER? not for fatlittlepig. still remember ER rotation in MS and residency. Fun for the first week, then not too much fun. Stuck in the same place for X number of hours, no where to hide, no privacy, RN’s and patients milling around. Stuck in ER the whole time, can’t leave. no way no how.

 

 

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I think that there is something to that argument, being in a fishbowl. Our ER docs don’t mill around much, might grab a sandwich in the doctor’s lounge, but they are generally not out schmoozing.

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This was what was great about surgery, you wandered all over the hospital.

[VagabondMD]

fatlittlepig wrote:

ER? not for fatlittlepig. still remember ER rotation in MS and residency. Fun for the first week, then not too much fun. Stuck in the same place for X number of hours, no where to hide, no privacy, RN’s and patients milling around. Stuck in ER the whole time, can’t leave. no way no how.

 

 

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I think that there is something to that argument, being in a fishbowl. Our ER docs don't mill around much, might grab a sandwich in the doctor's lounge, but they are generally not out schmoozing.

[fatlittlepig]

ER? not for fatlittlepig. still remember ER rotation in MS and residency. Fun for the first week, then not too much fun. Stuck in the same place for X number of hours, no where to hide, no privacy, RN's and patients milling around. Stuck in ER the whole time, can't leave. no way no how.

 

 

[Zaphod]

snowcanyon wrote:

@G- I think it’s great that you and WCI can pay your nights away. That’s not all, or even most EM jobs. It’s not even most locums. It’s not generalizable to the field. I haven’t seen ortho or ophtho or derm or plastics or urology in the hospital after hours. Or PMDs or sports medicine or occ med. There are plenty of docs with regular schedules; med students should take note because those are frequently the fields with lower burnout rates. Why not consider those?

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With optho and derm you are mostly correct.

With urology and plastics you are certainly incorrect and at any large hospital they will be working normal days and take night, weekend, and holiday calls. Who do you call for hand injuries, facial fractures, big wounds in trauma, priaprism, etc...? Maybe some smaller places its not bad for them, but bigger places those specialties are very rough and call is busy. Not abnormal to be in the hospital late regularly, not for ER stuff but because you never left. Used to get calls from ER all the time at 9-11pm, "sorry to bother you at home", was always like, ugh, im upstairs operating, no big deal.

Now, in private practice just doing the easy stuff, yes, its much easier in plastics. However the residency and such is very tough (6-7 years and hard). My private Uro friends have a good life but they are certainly coming in and doing things in the middle of the night still, just less frequently.

[MPMD]

snowcanyon wrote:

@Jaqen Haghar, MD I think you make a super important observation, and one that I’ve noticed, too- there are number of EM docs who would make better sub-specialists. But EM is one of the few fields aside from FM where that’s impossible. I really hope that changes. CC, Pain, and Occ Med just aren’t enough. We are losing a lot of medical talent from the pipeline with this issue; we need a way for these docs to find their niche.

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Also said with all due respect and the understanding that it sounds like you are going through a pretty tough time in your professional life but:

It's not really the job of ABEM to find exit strategies for docs. The point of a primary specialty is never to be a launch pad into something else and the job of that specialty's governing orgs is not to create glide paths out of the field for dissatisfied physicians.

If you wanted to do CCM, you should have done IM or Anesth, much easier path. If you wanted to do Pain you should have done Anesth. I could go on and on.

It sounds like you're really burnt out. I get it, that really sucks. I hope your situation improves dramatically.