EM for the long run

[wonka31]

G-Your comments about the 9-5 physician availability is so spot on it’s not even funny.

People don’t live Monday-Friday 9-5 and the world no longer works this way. Medicine’s lack of adaptation to this with the exception of urgent care that is open until 8pm is unfortunate. Hence the volumes later and later and more urgent care/primary care type presentations that show up to the ED.

SnowCanyon-Your urologists and orthos have a sweet gig. Our’s are also here at all hours of the day and don’t seem to have a great lifestyle, though I’m sure very well compensated.

[G]

My shop is different in several ways from yours, apparently. Our ortho guys operate all night, our ophtho guys get calls and often come in in the night, and our plastics guys are often being consulted, if not operating in hand or facial trauma call....

I did locums years ago in a few different states and my request was no overnight, although did plenty of late swings. Seemed to work. Maybe it's different now.

I have several EM friends who did fellowships. My casual observation is that most of them still work in the ER because they like the acuity and it pays better than their other job. If they had their financial ducks in a row (and desire) they could pull the ripcord.

I say this with utter respect/friendliness, but you mention pay and compensation...you cant have your cake and eat it too (cool cases 9-5 with weekends, federal holidays off and 2 weeks of vaca per year and make top tier cash).

[snowcanyon]

@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?

I know a ton of tox folk. Tox is great, but it doesn't pay. Do you know a private practice toxicologist? Or one that doesn't pull pretty much the name number of shifts in the ER as the rest of us? How many people do you know who have switched totally to hyperbarics? I do know a few public health people, but you can do that without a clinical degree. I'm not sure how these fellowships really help EM docs unless they want an academic job, and I don't see it really improving schedule, stress, quality of life, or compensation. It's not the same as doing a plastics or rheum fellowship.

[G]

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.

[snowcanyon]

@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.

[MPMD]

Jaqen Haghar, MD wrote:

I work with some residents that I know will have a tough time of it when they get out.  They tend to be formal in their interactions, have a bigger ego than they do intelligence, common sense, and procedural ability, and they have trouble interacting with difficult people (a big part of EM).  They would make better sub-specialists than front line warriors.

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That's well put. You are very right about the common sense. So much of our job is applied common sense.

Other really difficult-to-overcome things are indecisiveness, general anxiety, need for recognition, and thin skin.

[Jaqen Haghar MD]

I'd do it again.

I think going into it, you have to know that the majority of your shifts will be nights, weekends, evenings, and holidays.  You're likely to go full throttle all the time when you are at work, but as a trade off you will work less and have more flexibility.

I work with some residents that I know will have a tough time of it when they get out.  They tend to be formal in their interactions, have a bigger ego than they do intelligence, common sense, and procedural ability, and they have trouble interacting with difficult people (a big part of EM).  They would make better sub-specialists than front line warriors.

The politics can be complex also.  You'll often be asked to spend more time with the patients, while moving them through faster.  You'll be asked not to miss anything, and to do less testing and evaluation at the same time.  You may have to know the little preferences of everybody who admits to the hospital. And every time there is a bad outcome, you will be facing the firing squad.

But for some reason, I can't imagine doing anything else.

My first year out I took, what turned out, to be a bad job.  But what did I know?  I though I was a horrible person, and wondered if I made a mistake going into medicine, not that the medicine part was the problem.  After 3.5 years I left.  I took a few months off.  When I started my next job, I was like the hospital hero.  It was night and day.  I got bamboozled as a new grad, it turned out.  Since then it's been good sailing for 10 additional years.  But I did change my perspective a lot.

[snowcanyon]

Agree with lowering hours, but most groups still make you work nights, and you will certainly be working weekends and holidays. This doesn't do a whole lot to decrease burnout. I work very few shifts a month, and I'm left with a lot of boring weekdays off and still too many weekends on. It helps in some ways, but not really enough.

Crispydoc alludes to this problem- he's cut down, but he's hitting those weekend nights hard. Yuck.

[EMscout]

Great response Wonka.

In residency I could sleep until 4-5pm following overnights. Now, I’m lucky if my coffee saturated bladder or my kid lets me sleep past 1pm. Tag that deficit to a 3 day overnight weekend and repeat it about twice a monthl. No way to avoid exhausting yourself.

It takes me 2 days to begin recovering from a couple of overnights now. My wife tells me I’m awful to be around during the first post overnight. She’s right. I’m short, snarcky and just a miserable human being.

I still love what I do but I can tell that it is taking a toll and I am not too far into my career. Luckily, I do have some protected time. Without it, I don’t know that I would work full time for more than 10 years after residency.

So either make enough money in your first 10 years to afford lowering your hours (hard with lifestyle creep), or find non clinical work to supplement your salary.

[wonka31]

I think it depends on what you mean 'for the long run'. First and foremost, you have to love it during med school. If you're 'in like' with EM, you probably should find another specialty. It can be a very trying profession and the ups and downs from shift to shift are not a great fit for many people. Also, I feel that most people fall out of love with their specialty as time goes on. I've seen the same general sentiment in EM amongst friends and colleagues.

 

There are a ton of upsides, however, assuming you love it early on. The various practice environments are endless. You can live in a city, suburb, rural, bufu, wherever. Every hospital has one and needs EM physicians. Secondly, the schedule flexibility is unbelievable. Do you like 8s, 9s, 12s, 24s, 48s? Guess what, you can find it. This is a personal decision, but lends to a ton of life flexibility. Lastly, in my opinion, this is the absolutely perfect job for financially savvy individuals. This is one of the easiest specialties to push the pedal to the metal early on in order to pay off student loans, build up a nest egg, etc and ease off as you get older. It's the target retirement date fund of medical specialties. Not to mention you can easily transition to many other things-admin, urgent care, consulting, occupational medicine, I can keep going.

 

Do I love it as much as I did on day one of residency, probably not. Most attendings feel the same. Would I choose it again? You Betcha.

[MPMD]

snowcanyon wrote:

I know of very few groups that allow docs to opt out of night shifts, or they try to and then someone quits and everyone is stuck working nights again, so it’s just really hard for most docs to opt out. I see few cases where docs are guaranteed no nights, making the field even tougher for middle-aged docs.

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One thing I am constantly telling med students is to try to visualize how much harder the schedule will get going forward. It's just tough to simulate fatigue that comes with age to a group of 28 year olds. Such is life.

Here's the thing, most of us work around 32 hours a week and EM is full of chronically exhausted, worn out people. So either we are systematically just weaker people than our colleagues or there's something about our job. I know my vote.

 

snowcanyon wrote:

@mpmd makes some great points. Weird- I never thought of EM as sexy. More sort of for misfits, maybe. But I agree. The field is very bent on improving its profile and competitiveness, not finding people who are going to be happy EM clinicians. There’s also a strange emphasis in EM on exit strategy (I’m guilty) as opposed to making this a lifelong clinical career.

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Nah dude it is an appealing field for students. They like ER docs and think it's cool. It's the highest rated clinical rotation at my shop and was the highest rated rotation at my last shop.

Excellent clinical training is key for avoiding burn out. That's hard to get without having a lot of unpleasant training experiences. Those are harder to sell than 3 elective months and a month of orientation/drinking.

[snowcanyon]

I know of very few groups that allow docs to opt out of night shifts, or they try to and then someone quits and everyone is stuck working nights again, so it's just really hard for most docs to opt out. I see few cases where docs are guaranteed no nights, making the field even tougher for middle-aged docs.

[The White Coat Investor]

CordMcNally wrote:

I’d certainly do EM again. I couldn’t imagine being those guys/gals that go to clinic M-F all day long or that carry around a pager hoping it doesn’t go off. It certainly isn’t a lifestyle field but it’s been good to me and I do enjoy it. Almost no other field can give you the flexibility and the pay that comes along with it.

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Certainly there is nothing else in medicine I'd rather be doing. Clinic? Ugh. Standing for hours in the OR? Ugh. Waiting for the anesthesia machine and monitors to lull me to sleep? Not gonna work for my ADHD. Pathology? Radiology? Super hyperspecialized field? No, no no.

That said, I agree with the sentiment that the vast majority of emergency docs will want to work fewer shifts and most likely no night shifts at some point in their 40s or 50s and better plan their finances so that can happen.

[snowcanyon]

@CordMcNally Maybe. I don't think it's burnout, more that I picked the wrong field. I have plenty of time off. I just don't like EM, and for now I have to do it. I hope EM sponsors some more subspecialties.

@MPMD makes some great points. Weird- I never thought of EM as sexy. More sort of for misfits, maybe. But I agree. The field is very bent on improving its profile and competitiveness, not finding people who are going to be happy EM clinicians. There's also a strange emphasis in EM on exit strategy (I'm guilty) as opposed to making this a lifelong clinical career.

[MPMD]

7 years in, would pick again although would have looked harder at anesthesia.

Lots of terrible jobs in EM, tough not to burn out if your job sucks.

#1 way to be unhappy into EM is to convince yourself that you're correct for the field just b/c you are attracted to the sex appeal and the perception of lifestyle. this is rampant in EM, frankly educational leaders have not helped by basically telling every student and resident "you can do it!" compare to say, neurosurgery or orthopedics where we all feel tacitly ok with recognizing they aren't for everyone. we've somehow ended up with a significant chunk of the workforce that finds codes and nasty traumas anxiety-inducing instead of interesting and rewarding. if critical stuff stresses you out i'm not sure what this job has left for you? first trimester bleeding? otitis? christmas eve night shifts?