EM for the long run

[EMscout]

There have been a few recent threads on exit strategies from EM and potential EM burnout.

For those of you just starting a career in EM, it can be brutal as the nights and holidays chip away at your sanity.

I love the field but recognize the need to diversify the practice. In my opinion you need to find non clinical FTE in order to preserve your career longevity. Do admin, quality roles, teaching, write a blog about doctors and managing finances... whatever it is try to cut down on the number of clinical shifts. After just a few years on the treadmill you will start to feel the burn.

Would choose EM all over again in a heartbeat but would diversify early.

[GXA]

Agree!

Manage your expenses so you can work a reasonable hour/patient load.  Maintain your varied interests both in the house of medicine and during your time off.

I would pick EM again as well if starting over.

[snowcanyon]

Important thread. I would not do EM again for these reasons, but I try and remind myself that I just didn't know. Some people really just want to be docs, and there's not a great clinical exit strategy in EM, and I think people need to think twice about picking a field where there needs to be an exit strategy at all. All that training for admin? No thanks.

EM is in crisis. Australia and the UK don't make attendings work crazy hours. We need to follow suit.

[CordMcNally]

I wouldn't say that EM is in crisis and I wouldn't call the hours we work crazy. I'm really concerned about you being burned out @snowcanyon. I hope you're able to take some time away from your job and parental situation for some time for yourself. Having EM attendings work banker hours would never fly in the US and I would never support it.

 

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.

[Drop it into MD]

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.

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We use cell phones now.  :P

 

I really do not understand people who still use pagers.

[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?

 

[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.

[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]

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.

[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.

[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.

[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.

[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.

[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.

[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.