Second residency in Emergency Medicine (Part 2)

[Sigrid]

I'm an EM doc at an academic institution in the Upper Midwest who is heavily involved in our residency, and I can tell you right off the bat that we do not accept anyone who has finished another residency. All our positions are ACGME funded, and you don't qualify. We accept residents who have done one year of another residency, but that's it.

Look, I know no one here is going to be able to talk you out of this, but I can't in good conscience tell you anything other than that it's a bad idea. I don't think you have a realistic view of EM, and I don't think you have a realistic view of the EM job market. I also heavily question anyone making the truly life-altering decision of doing a second residency due to burnout. Burnout is even higher in EM than IM! We usually top the chart for burnout! If I were interviewing you, I would want to know exactly what plan you have in place to prevent burnout again, and saying "well I'll be happier in Emergency Medicine" wouldn't cut it.

When it comes to jobs, I'll tell you what I tell EM-hopeful med students: I've watched the job market change significantly over the past five years, and it has become increasingly a game of "who you know". We are an old and relatively prestigious residency program with an extensive network of alumni throughout the country, and increasingly the only way our residents get jobs is by us calling up someone we know and saying, "hey, you need to hire this person". Even with that, it's become harder and harder to place our residents. Everyone we talk to at other residencies is saying the same thing. So my advice to med students has become: if you don't get into an established, well-respected residency, EM probably isn't worth it. Your network is probably going to make or break your job search.

Earning $400k as an EM doc is also getting increasingly difficult. The only way to do that is to pick up extra shifts, which is a lot harder now than it used to be. Most of our residents have gone into jobs earning $250-$300k base recently. We used to place residents at jobs that paid >$300k regularly. Getting to $400k means a lot of extra work, which is more likely to lead to burnout. Again, burnout is higher in EM than other specialties. I'm at an institution that pays $350k and I moonlight and I still don't break $400k. I'd have no time off if I wanted that. (You might be in an area that has a very different job market, given that you make $400k as a hospitalist and our hospitalists make barely over $200k, but we place EM residents all over the country and no one is going into $400k jobs.)

As for rural jobs, I moonlight at a rural ED. None of the rural EDs in our area (the kind that do 24h single coverage) have any full-time staff. They all exist on moonlighting docs from the cities. Perhaps it is different in other states.

You're IM. IM is very flexible. I'd really, really suggest figuring out another path that will improve your burnout without doing the second residency thing. I just don't think it's going to end up the way you want it to. I'm sorry.

[Craigslist]

To sigrid above, as a hospitalist I’ve never made less than 250k maybe those hospitalist you talk about are taking in a base + production. I currently make what op makes and this is not rural area at all. I’ve worked in multiple states and it’s the same the more rural I get the more my base pay is 300k. I was talking to a er doc in naples Florida and he told me he was getting 265$ an hour.

[MPMD]

1. So my advice to med students has become: if you don't get into an established, well-respected residency, EM probably isn't worth it. Your network is probably going to make or break your job search.

2. Earning $400k as an EM doc is also getting increasingly difficult. The only way to do that is to pick up extra shifts, which is a lot harder now than it used to be. Most of our residents have gone into jobs earning $250-$300k base recently. We used to place residents at jobs that paid >$300k regularly. Getting to $400k means a lot of extra work, which is more likely to lead to burnout. Again, burnout is higher in EM than other specialties. I'm at an institution that pays $350k and I moonlight and I still don't break $400k. I'd have no time off if I wanted that. (You might be in an area that has a very different job market, given that you make $400k as a hospitalist and our hospitalists make barely over $200k, but we place EM residents all over the country and no one is going into $400k jobs.)

3. You're IM. IM is very flexible. I'd really, really suggest figuring out another path that will improve your burnout without doing the second residency thing. I just don't think it's going to end up the way you want it to. I'm sorry.

(i chopped your response a bit and numbered it so i could respond clearly)

1. I think this is a little bit extreme but there is some truth in what you say. EM job market is definitely tight and I agree that we are going to see an increase in the established residency --> great community job pipeline. This has existed for a long time but it seems to be getting more established with fewer deviations. The other side of this is that residents and grads of less established programs often "don't know what they don't know" and don't ever hear when the great jobs are hiring.

2. Agree with this. Everyone I know who makes $400k+ in EM is either doing something else (e.g. regional directors for CMG), working hard in a very undesirable area, or working all the time. I think I cracked $400k one year but I did a lot of driving and had kind of a unicorn moonlighting set up that frankly wouldn't be open to everyone.

3. I think that's right. If OP is really willing to be super rural they might consider doing some procedure/airway courses w/ CME money and presenting themselves to rural med directors as an option. If you're a safe hospitalist and you were able to show a CV showing you'd done specific courses in emergency peds, airway management, ATLS, and resus procedures I think you could make a good case for yourself. Not saying it's ideal but it's way easier to do a few courses than 3 more years of residency.

[Jaqen Haghar MD]

The EM job market seems a little worse than “tight” and it’s deteriorating rapidly from here. I know of four EM docs that left their jobs last year, who could not find another position for a very long time. One finally took a job in urgent care, and even though it was framed on social media as a “choice”…. It wasn’t.

The residents are taking whatever they can get at this point, some are doing fellowships to prolong judgement day, others are taking jobs wherever they can find one in the country.

There appears to be no end to this on the horizon.

Best of luck, whatever you choose, but it’s not a good time to be going into EM.

[Sigrid]

To sigrid above, as a hospitalist I’ve never made less than 250k maybe those hospitalist you talk about are taking in a base + production. I currently make what op makes and this is not rural area at all. I’ve worked in multiple states and it’s the same the more rural I get the more my base pay is 300k. I was talking to a er doc in naples Florida and he told me he was getting 265$ an hour.

As I said, I can only report on the hospitalist pay in my area. I have a number of friends in my area who are hospitalists. They are all salary at $210-$230k, no production. I recently asked quite a few of them what the hospitalist job market was around here due to another forum member here on WCI looking to move to the area. They told me that's standard for any employed hospitalist in the area, if you can even get a job in the first place, and it's become nearly impossible to get privileges as a private hospitalist at our local hospitals if you'd rather be paid by production. One of them said, "just tell him no, hospitalist jobs aren't happening around here right now." I'm not IM myself, so I'm taking their word for it. I have no idea what the hospitalist pay is in other areas of the country.

For EM, we did recently have a resident take a job in rural Kentucky that paid $270 an hour, but that job was far and away an exception. Rural jobs around here certainly don't pay that. And like I said, our really rural jobs around here don't even hire full-time docs. They survive on moonlighters. This may well be different elsewhere.

2. Agree with this. Everyone I know who makes $400k+ in EM is either doing something else (e.g. regional directors for CMG), working hard in a very undesirable area, or working all the time. I think I cracked $400k one year but I did a lot of driving and had kind of a unicorn moonlighting set up that frankly wouldn't be open to everyone.

3. I think that's right. If OP is really willing to be super rural they might consider doing some procedure/airway courses w/ CME money and presenting themselves to rural med directors as an option. If you're a safe hospitalist and you were able to show a CV showing you'd done specific courses in emergency peds, airway management, ATLS, and resus procedures I think you could make a good case for yourself. Not saying it's ideal but it's way easier to do a few courses than 3 more years of residency.

I have a colleague who makes >$400k but he adds a truly ridiculous amount of moonlighting on top of our already well paid gig. He works a lot more than a 7/7 hospitalist. Everyone else I know who makes >$400k is someone who got a very good EM job years ago and hasn't left (and has been lucky enough that their employer hasn't renegotiated), or is in administration.

I'd be really interested to discover if the "super rural places will be happy with a non-EM doc" still holds true. With the job market in EM, I imagine it's easier to get EM-trained docs into those jobs. One of our recent graduates went into a job in North Dakota that used to be staffed by FM docs. I'll admit I have no real idea, though!

Oh, and something I forgot to mention to the OP -- full-time EM contracts are usually 12-16 shifts a month, depending on the length of the shifts. Our contract is for 14 shifts a month (10h shifts). That's about what a 7/7 hospitalist works. So you'd be working just as much, in a more stressful job, for less money. You'd also be working nights and evenings a lot.

Just so I'm clear, I absolutely love EM, and would be a lot less happy doing anything else. But the reality of the field is what it is.

[Sampter]

In a previous life I did a fair amount of hospitalist work at different hospitals. The experience at the different hospitals was quite different, including no nights, all nights, more ICU, no ICU, etc. I wonder if adjusting your schedule, as sounds like nights and 7 shifts in a row are not agreeing with you, may allow you to enjoy your work more. That may mean looking at different hospital systems, locums, not working full-time, etc. I would strongly encourage doing that even if you are still going to apply as it may open your eyes on different opportunities.

Based on what the EM docs are saying in the thread, plus your age, I would not go back and do an EM residency. As someone close to your age I cannot imagine having to be a resident again, especially under all new attendings in various specialties who all have their various quirks that you will have to deal with.

[CordMcNally]

I wouldn’t ever recommend someone feeling burned out to go back and do a second residency unless they were able to fix the burnout first.

[F0017S0]

Outsider's perspective: though I'm not a physician yet, I can't imagine OP wanting to be working under an attending who could conceivably be younger than him/her.

[CordMcNally]

Outsider's perspective: though I'm not a physician yet, I can't imagine OP wanting to be working under an attending who could conceivably be younger than him/her.

That's not incredibly uncommon. There's a decent amount of non-traditional med students who end up being older than some of their attendings in residency. I wasn't in that situation but I don't think I'd see it being an issue unless you let it be.

[Anne]

Outsider's perspective: though I'm not a physician yet, I can't imagine OP wanting to be working under an attending who could conceivably be younger than him/her.

I spent 4 years after internship as a Navy GMO/flight surgeon before returning to residency and had several attendings who graduated medical school the same year I did and a few who graduated the year after me, and were younger than me. It wasn’t a problem for me—i had good relationships with them all. I may have had more general life experience and definitely had more experience treating patients in austere conditions but they had much more experience and knowledge than me in the field I was learning about. Plenty of other “non traditional” students who have dealt with the same. I have had older residents as an attending, they almost always (not always) are more mature and better residents than the younger ones. The issue isn’t age/years of experience as a doctor, it’s when you disagree with your attending based on your experience (e.g. in a situation that you may have had more experience with than your attending). You just have to remember that you can make your case but the attending has the final say.

[G]

Missed this thread last time.

OP, you have good advice above. I never heard of someone who burned out of another specialty that picked EM as the cure. Kudos to you if you are the first. But what are the odds?

Although it is immaterial (or should be) to the OP's decision making, I'm surprised by Sigrid's and MPMD's salary experiences. I will say that those of us who are not employed by a university, hospital, or CMG can make decent money without working all the time or living in an undesireable area. Personally, I've never divulged my hourly to my old academic colleagues. FWIW, I've also never filled out any of those salary surveys.

Sigrid, I've always taken some umbrage to the burnout issue in EM. Many folks here have hung up the stethoscope to do other things. Quitting the EM workforce to do aesthetics or build guitars or refurbish porsches is not necessarily burned out. (That said, this ER doc is thoroughly crispy!)

[G]

I spent 4 years after internship as a Navy GMO/flight surgeon before returning to residency and had several attendings who graduated medical school the same year I did and a few who graduated the year after me, and were younger than me. It wasn’t a problem for me—i had good relationships with them all. I may have had more general life experience and definitely had more experience treating patients in austere conditions but they had much more experience and knowledge than me in the field I was learning about. Plenty of other “non traditional” students who have dealt with the same. I have had older residents as an attending, they almost always (not always) are more mature and better residents than the younger ones. The issue isn’t age/years of experience as a doctor, it’s when you disagree with your attending based on your experience (e.g. in a situation that you may have had more experience with than your attending). You just have to remember that you can make your case but the attending has the final say.

Interesting! My trauma attending when I was an intern was a vascular fellow when I was a senior. I never heard any good stories from that, but could you imagine being his attending?!

[F0017S0]

I spent 4 years after internship as a Navy GMO/flight surgeon before returning to residency and had several attendings who graduated medical school the same year I did and a few who graduated the year after me, and were younger than me. It wasn’t a problem for me—i had good relationships with them all. I may have had more general life experience and definitely had more experience treating patients in austere conditions but they had much more experience and knowledge than me in the field I was learning about. Plenty of other “non traditional” students who have dealt with the same. I have had older residents as an attending, they almost always (not always) are more mature and better residents than the younger ones. The issue isn’t age/years of experience as a doctor, it’s when you disagree with your attending based on your experience (e.g. in a situation that you may have had more experience with than your attending). You just have to remember that you can make your case but the attending has the final say.

CordMcNally and @anne: Mea culpa: I stand corrected. Certainly with non-traditional applicants increasing (i.e. yours truly) there will always be that dynamic and of course professionals wouldn't throw a fit over an age difference.

My thought (which didn't originally come through) was that it might be difficult for OP to go from being an attending back to being a resident trainee, with the loss of autonomy that goes with that transition. Although physicians (and other clinicians) are life-long learners, I can't seem to understand how that would be an easy transition. And that transition has to occur literally from day one of the second residency, akin to flipping a switch between the two roles.

[Ekanive23]

Interesting! My trauma attending when I was an intern was a vascular fellow when I was a senior. I never heard any good stories from that, but could you imagine being his attending?!

I think it’d be wonderful to be his or her attending. You have to respect them for the or knowledge base. If you’re someone who gets off to belittling your trainees, I think he’d have a right to say one liners back, I know I would

[Turf Doc]

It'll be interesting to see how the job market is for EM by the time im an attending in 7+ years. Right now, especially last year, everyone's hair was on fire about how difficult it was to get a job, the ACEP report about oversaturation, etc. But I know in 2013 at the nadir of the rads job market people were extremely negative on the specialty, and those who bought low made out like bandits in 2019+ when the job market was red hot (still is). Maybe it'll happen with EM?

Would be a shame not to do EM because of concerns over a job market that may not be as bad when one is finally practicing. But would also be terrible to actively go into a specialty whose job market was bad and getting worse. Grateful im not interested in EM at all...