Second residency in Emergency Medicine (Part 2)

[IMMD]

Hi everyone,

As I have previously posted, I'm interested in pursuing a second residency in Emergency Medicine. I completed an Internal Medicine residency in 2017 and I have been working as a hospitalist since then. I'm ABIM board certified. Although the hospitalist gig has been good to me financially, making $400K yearly with bonus + extra shifts, I would like to be a more versatile doc - peds, ortho, OB, performing lifesaving procedures, working up undifferentiated patients, etc. I'm planning to apply to many of the 270 EM residencies next month.
I would appreciate it if any of you, good folks, can give me some insight into which programs are willing to accept applicants who have completed another residency?
Thanks!

[Huggy]

I imagine that the majority of EM programs would be willing to accept a board certified internal medicine physician. Although you mentioned why you want to make the switch, maybe the EM providers can provide some input on your idealistic view of emergency medicine compared to being a hospitalist. From my POV, EM may not be the specialty worth entering in four years given recent market changes, mid-level creep and residency expansion... Especially when it sounds like you have such a great gig right now.

[pierre]

Hi everyone,

As I have previously posted, I'm interested in pursuing a second residency in Emergency Medicine. I completed an Internal Medicine residency in 2017 and I have been working as a hospitalist since then. I'm ABIM board certified. Although the hospitalist gig has been good to me financially, making $400K yearly with bonus + extra shifts, I would like to be a more versatile doc - peds, ortho, OB, performing lifesaving procedures, working up undifferentiated patients, etc. I'm planning to apply to many of the 270 EM residencies next month.
I would appreciate it if any of you, good folks, can give me some insight into which programs are willing to accept applicants who have completed another residency?
Thanks!

Do you have a specific job in mind after you complete said residency?

Aren’t there rural ERs that would hire you as is, without a second residency and you can do all this stuff without taking a giant pay cut?

disclaimer: the only stuff I know about the ER job market is what I’ve read on this forum

[MPMD]

w/o knowing your overall goals as someone in EM residency education i'm not sure this is a good idea.

$400k for a hospitalist is pretty good cash, remember as WCI says you are never more than 10 years from FI.

the other thing i'm going to throw out is that occasionally people apply to EM after IM b/c they have decided they need to "fix" the ED and bring a more IM mindset down there, these folks tend to have difficulties in training. being trained in IM brings you very few useful skills to your EM residency, you may be surprised by this. i have worked with tons of EM/IM trained people and i can't tell any difference at all except maybe in some marginal stuff like heme.

if you decide to go this route i would try to find a program that will give you credit for some of your IM training. almost any EM training program will consider applicants who have completed other residencies.

i just think you need to think long and hard before giving up a very high paying job to go back and be an intern.

[Sampter]

Good luck.

Why not see if the hospital where you work would allow you to shadow/help in the ER (unpaid) to get some extra skills that way?

I feel ill just thinking about doing another residency at this point in my life (little farther along that you).

Where I did my medical school one of the General surgery residents was a Family medicine doc in a small town that went back to residency as his community lost their surgeon. He was like 50 when he did it.

[Craigslist]

How does it even work when you need letter of recommendations for new residency applications?

[Sundance]

Ugh.

Another option would be to staff a rural ER.. just figure things out as you go and build your skills on your own. Although not ideal it’s still better for that community than some random cycle of PAs

[VentAlarm]

I’m EM/CCM. If I was a board certified internist and was unhappy with being a hospitalist, I would consider PCCM or cards before doing a second residency in EM.

[MPMD]

How does it even work when you need letter of recommendations for new residency applications?

eh, we see it.

it's really easy to tell on the back end when someone has completed other training. kind of jumps right out at you.

you look at those apps differently than M4s obviously.

true for people doing prelim years or switching specialties.

[Craigslist]

eh, we see it.

it's really easy to tell on the back end when someone has completed other training. kind of jumps right out at you.

you look at those apps differently than M4s obviously.

true for people doing prelim years or switching specialties.

I guess what i meant by my post is how do people apply for a new residency when you are say 4 years out of training? Do you get LORs from your colleagues? like say you want to do anesthesia from ER, you dont have any anesthesia rotations to get one from an attending.

[IMMD]

Thank you all for the replies! The EM job market is getting tighter but that's true for other specialties too. Anesthesiology is an example but how many unemployed anesthesiologists are there? How many unemployed EM docs do you know? The Golden Age of EM (lots of locum jobs paying $300+/hr) may be over but I think EM will continue to pay higher per hour than hospital medicine and even CCM. Hence, I'll be able to resume making $400K / year after EM residency but I'll be working fewer shifts. Working three 12 hour shifts a week in EM seems more sustainable than seven 12 hour shifts in a row as a hospitalist which will improve longevity and in turn lead to greater financial gains over the course of my career. I don't need to make $400K a year. I'd be happy working three 24 hour shifts a month at $190-200 / hour at a low volume ED - my friend has a gig like this in WI seeing ~ 16 patients in 24 hours. I could work a similar job or six 12s a month until I'm physically and mentally able to and feel more professionally fulfilled in EM than in hospital med.

Cardiology and GI have clinic which I don't like and it's much harder to work part-time in those fields. It also takes time to build up adequate patient base and / or become a partner in Cards, GI, Heme-Onc, etc to be able get to the $500K+ yearly income. I'm 39 years old and I don't aspire becoming partner or working full time after age 50. I've thought about CCM but, ultimately, I'd be happier in EM. I truly enjoy the versatility of EM more than rounding on vented patients 7 days in a row while being on call at night. Scheduling in EM, although not ideal, seems more flexible and conducive to normal life than the 7 on / 7 off in hospital medicine and CCM. It's difficult on you and your family when you are working 84 hour stretches every other week.

I don't feel comfortable working in the ED with my current skill set. I think I'd be underprepared even if I go through the 1 year non-ABEM accredited EM fellowship available to FM and IM docs or the 6-12 months on the job training offered to non-EM boarded docs by TeamHealth, etc.

My EM letters of recommendation are from the ED docs I work with as a hospitalist, so not strong letters but it is what it is 😂. It is very difficult to set up EM clinical rotations as an attending. My requests to do so have been turned down several times. I had 3 months of EM rotations in residency but that was in 2015-2016, so I doubt the ED docs remember me and those letters would not be current. I know this is an uphill battle for me but I'll put those hosptialist $ to good use and apply to most of the 270 EM programs.

I'm teachable and I would think EM residency would change my mindset from IM to EM.

[White.Beard.Doc]

I did IM/Pulm/Crit care/ and then finally got boarded by ABEM in EM via a creative path. I worked at an academic hospital for many years. In the early years I was a teaching attending in all 4 areas. I did blocks in the ICU. I did rounds on the Pulm consult service. I did teaching rounds on the medicine wards. I did blocks of time as an ED attending. I did all of this at one of the leading academic medical centers in the country. I grew to deeply understand how each of those specialties thinks a bit differently when approaching problems. It was quite an interesting career and I got to work with and learn from talented, brilliant colleagues in so many areas of medicine. I love learning so that setup suited me well.

You are correct that the life of an emergency physician is different from that of a hospitalist. The hour by hour pressure in most EDs is often intense. The work hours are typically much less. The pace for a hospitalist can be quite busy, but not nearly as intense at any given moment. In the ED, it is often somewhat easier to be creative with how many hours you want to work, at least with some groups. Unless you cover admitting, as a hospitalist you need to do long blocks of days in a row to maintain continuity of care. The ED has a much broader variety of patients than a hospitalist typically does, but just the same, within internal medicine you can find variety if you look for it. In a small, rural or in some suburban EDs, you can find a slower pace if you are looking for that.

What type of career are you looking for when you finish the EM training? You mentioned 24 hour shifts in a rural ED. I have done that too, and it offers a wonderful respite from the pace of the large, high volume, fast paced urban ED. It can be very enjoyable to slow down and deeply interact with patients without the pressure of a STEMI and an acute stroke rolling through the door simultaneously while you are trying to delve into the finer details of a complex but lower acuity patient.

There are some programs that will want to be funded for your years of EM training. If you do a second residency, your hospital will not get funding support for training you. Some programs won’t consider you because of that factor. I know that the community hospital based EM program I am most familiar with currently would not favor your application for that reason. Perhaps MPMD can comment further on how many programs take funding into account when reviewing applications.

[VentAlarm]

Thank you all for the replies! The EM job market is getting tighter but that's true for other specialties too. Anesthesiology is an example but how many unemployed anesthesiologists are there? How many unemployed EM docs do you know? The Golden Age of EM (lots of locum jobs paying $300+/hr) may be over but I think EM will continue to pay higher per hour than hospital medicine and even CCM. Hence, I'll be able to resume making $400K / year after EM residency but I'll be working fewer shifts. Working three 12 hour shifts a week in EM seems more sustainable than seven 12 hour shifts in a row as a hospitalist which will improve longevity and in turn lead to greater financial gains over the course of my career. I don't need to make $400K a year. I'd be happy working three 24 hour shifts a month at $190-200 / hour at a low volume ED - my friend has a gig like this in WI seeing ~ 16 patients in 24 hours. I could work a similar job or six 12s a month until I'm physically and mentally able to and feel more professionally fulfilled in EM than in hospital med.

Cardiology and GI have clinic which I don't like and it's much harder to work part-time in those fields. It also takes time to build up adequate patient base and / or become a partner in Cards, GI, Heme-Onc, etc to be able get to the $500K+ yearly income. I'm 39 years old and I don't aspire becoming partner or working full time after age 50. I've thought about CCM but, ultimately, I'd be happier in EM. I truly enjoy the versatility of EM more than rounding on vented patients 7 days in a row while being on call at night. Scheduling in EM, although not ideal, seems more flexible and conducive to normal life than the 7 on / 7 off in hospital medicine and CCM. It's difficult on you and your family when you are working 84 hour stretches every other week.

I don't feel comfortable working in the ED with my current skill set. I think I'd be underprepared even if I go through the 1 year non-ABEM accredited EM fellowship available to FM and IM docs or the 6-12 months on the job training offered to non-EM boarded docs by TeamHealth, etc.

My EM letters of recommendation are from the ED docs I work with as a hospitalist, so not strong letters but it is what it is 😂. It is very difficult to set up EM clinical rotations as an attending. My requests to do so have been turned down several times. I had 3 months of EM rotations in residency but that was in 2015-2016, so I doubt the ED docs remember me and those letters would not be current. I know this is an uphill battle for me but I'll put those hosptialist $ to good use and apply to most of the 270 EM programs.

I'm teachable and I would think EM residency would change my mindset from IM to EM.

Your view or EM is not super realistic. This does not sound like a great idea.

[VentAlarm]

I did IM/Pulm/Crit care/ and then finally got boarded by ABEM in EM via a creative path. I worked at an academic hospital for many years. In the early years I was a teaching attending in all 4 areas. I did blocks in the ICU. I did rounds on the Pulm consult service. I did teaching rounds on the medicine wards. I did blocks of time as an ED attending. I did all of this at one of the leading academic medical centers in the country. I grew to deeply understand how each of those specialties thinks a bit differently when approaching problems. It was quite an interesting career and I got to work with and learn from talented, brilliant colleagues in so many areas of medicine. I love learning so that setup suited me well.

You are correct that the life of an emergency physician is different from that of a hospitalist. The hour by hour pressure in most EDs is often intense. The work hours are typically much less. The pace for a hospitalist can be quite busy, but not nearly as intense at any given moment. In the ED, it is often somewhat easier to be creative with how many hours you want to work, at least with some groups. Unless you cover admitting, as a hospitalist you need to do long blocks of days in a row to maintain continuity of care. The ED has a much broader variety of patients than a hospitalist typically does, but just the same, within internal medicine you can find variety if you look for it. In a small, rural or in some suburban EDs, you can find a slower pace if you are looking for that.

What type of career are you looking for when you finish the EM training? You mentioned 24 hour shifts in a rural ED. I have done that too, and it offers a wonderful respite from the pace of the large, high volume, fast paced urban ED. It can be very enjoyable to slow down and deeply interact with patients without the pressure of a STEMI and an acute stroke rolling through the door simultaneously while you are trying to delve into the finer details of a complex but lower acuity patient.

There are some programs that will want to be funded for your years of EM training. If you do a second residency, your hospital will not get funding support for training you. Some programs won’t consider you because of that factor. I know that the community hospital based EM program I am most familiar with currently would not favor your application for that reason. Perhaps MPMD can comment further on how many programs take funding into account when reviewing applications.

It varies from program to program. Some large hospitals have more trainees than ACGME trainee slots. In that case, we just have to make sure that all of our trainees who are eligible are labeled appropriately. That’s at least how our PD explained it to me. Basically, our hospital is huge and is over the number of acgme funded spots by, let’s say, 50. So long as all programs, in aggregate, don’t admit more than 50 folks who don’t have funding, we’re fine. I don’t know if the hospital gives him an actually cap, but we’ve taken someone with previous training about once every third year or so and it hasn’t been an issue for us.

Also, your career sounds fascinating.

[Turf Doc]

Thank you all for the replies! The EM job market is getting tighter but that's true for other specialties too. Anesthesiology is an example but how many unemployed anesthesiologists are there? How many unemployed EM docs do you know? The Golden Age of EM (lots of locum jobs paying $300+/hr) may be over but I think EM will continue to pay higher per hour than hospital medicine and even CCM. Hence, I'll be able to resume making $400K / year after EM residency but I'll be working fewer shifts. Working three 12 hour shifts a week in EM seems more sustainable than seven 12 hour shifts in a row as a hospitalist which will improve longevity and in turn lead to greater financial gains over the course of my career. I don't need to make $400K a year. I'd be happy working three 24 hour shifts a month at $190-200 / hour at a low volume ED - my friend has a gig like this in WI seeing ~ 16 patients in 24 hours. I could work a similar job or six 12s a month until I'm physically and mentally able to and feel more professionally fulfilled in EM than in hospital med.

Cardiology and GI have clinic which I don't like and it's much harder to work part-time in those fields. It also takes time to build up adequate patient base and / or become a partner in Cards, GI, Heme-Onc, etc to be able get to the $500K+ yearly income. I'm 39 years old and I don't aspire becoming partner or working full time after age 50. I've thought about CCM but, ultimately, I'd be happier in EM. I truly enjoy the versatility of EM more than rounding on vented patients 7 days in a row while being on call at night. Scheduling in EM, although not ideal, seems more flexible and conducive to normal life than the 7 on / 7 off in hospital medicine and CCM. It's difficult on you and your family when you are working 84 hour stretches every other week.

I don't feel comfortable working in the ED with my current skill set. I think I'd be underprepared even if I go through the 1 year non-ABEM accredited EM fellowship available to FM and IM docs or the 6-12 months on the job training offered to non-EM boarded docs by TeamHealth, etc.

My EM letters of recommendation are from the ED docs I work with as a hospitalist, so not strong letters but it is what it is 😂. It is very difficult to set up EM clinical rotations as an attending. My requests to do so have been turned down several times. I had 3 months of EM rotations in residency but that was in 2015-2016, so I doubt the ED docs remember me and those letters would not be current. I know this is an uphill battle for me but I'll put those hosptialist $ to good use and apply to most of the 270 EM programs.

I'm teachable and I would think EM residency would change my mindset from IM to EM.

i havent heard of anesthesia being like EM in any way re: job market. I think i read that 20 years ago there were concerns