"EM applications up 33%"

[Lexdiamondz]

Any transient hope I had for this field is evaporating lol.

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[Dr Mantis Toboggan]

Any transient hope I had for this field is evaporating lol.

Well if a good portion of the applicants are female, who tend to leave the field in their mid 40s, we might be OK lol.

 

[RustedFox]

I get a not-insignificant number of PMs from people on SDN saying something along the lines of: "Either me or my spouse/SO is a [2nd/3rd year] EM resident and is absolutely distraught about what to do because EM is not at all what they thought it would be for all the reasons that you and others have described and we're looking for something, anything else."

 

[Brigade4Radiant]

IMGs now know EM is easy to match to so of course they will still apply to all community IM and FM programs EM is now in that teir.

 

[Apollyon]

I get a not-insignificant number of PMs from people on SDN saying something along the lines of: "Either me or my spouse/SO is a [2nd/3rd year] EM resident and is absolutely distraught about what to do because EM is not at all what they thought it would be for all the reasons that you and others have described and we're looking for something, anything else."

I got a rock.

 

[cyanide12345678]

IMGs now know EM is easy to match to so of course they will still apply to all community IM and FM programs EM is now in that teir.

Yes. I know at least a handful of Pakistani applicants putting EM as a backup after IM - since last year’s match meant that it was the easiest specialty to get in.

 

[The Knife & Gun Club]

Yes. I know at least a handful of Pakistani applicants putting EM as a backup after IM - since last year’s match meant that it was the easiest specialty to get in.

This is concerning (for them) because unlike IM or FM where you can specialize or significantly tailor your practice settings, emergency medicine is really not a good specialty for people that don’t LOVE emergency medicine - because you’re on a one track train doing a very specific job that is both physically and emotionally not easy. Especially if you hate the job and are just doing for the green card/visa.

 

[EctopicFetus]

This is concerning (for them) because unlike IM or FM where you can specialize or significantly tailor your practice settings, emergency medicine is really not a good specialty for people that don’t LOVE emergency medicine - because you’re on a one track train doing a very specific job that is both physically and emotionally not easy. Especially if you hate the job and are just doing for the green card/visa.

I think that doctor money and coming from another country you can learn to tolerate a lot.

Serious question for this group. Would you be as burnt out if you worked 130 hours a month and made 900k a year? I would argue no you wouldn’t.

It’s the trash pay, trash environment for “standard” pay that makes em so painful.

 

[RustedFox]

I got a rock.

Google Image Result for https://keepingitrd.files.wordpress.com/2023/02/i-got-a-rock.jpg

 

[RustedFox]

I got a rock.

 

[Brigade4Radiant]

This is concerning (for them) because unlike IM or FM where you can specialize or significantly tailor your practice settings, emergency medicine is really not a good specialty for people that don’t LOVE emergency medicine - because you’re on a one track train doing a very specific job that is both physically and emotionally not easy. Especially if you hate the job and are just doing for the green card/visa.

But it is worth it especially if we’re talking about what they would make in their country and their lifestyle. Most immigrants from other countries would work 90 hours consecutively if they were making 250 K.

 

[RustedFox]

I think that doctor money and coming from another country you can learn to tolerate a lot.

Serious question for this group. Would you be as burnt out if you worked 130 hours a month and made 900k a year? I would argue no you wouldn’t.

It’s the trash pay, trash environment for “standard” pay that makes em so painful.

For me, it's two things:

1. The patients and their completely unsatisfiable demands, and:
2. The admins and their completely unsatisfiable demands.

Wait...

 

[cyanide12345678]

But it is worth it especially if we’re talking about what they would make in their country and their lifestyle. Most immigrants from other countries would work 90 hours consecutively if they were making 250 K.

The money yes is better in the US.

Lifestyle being better is debatable.

My middle upper class lifestyle in pakistan was one of sheer luxury that i can’t afford with a 2 physician income household. Most of the time i didn’t have to get up to get a glass of water.

Let’s not talk about lifestyle being better in the US. The money…. Yes. Absolutely. Safety is better, absolutely. There is law and order here. Education and literacy is better. But you have no idea what kind of ridiculous life of luxury you can have with 30-40k a year in pakistan.

There’s a reason there’s a decent expat population for the US - there’s just some better places out there lifestyle wise.

 

[The Knife & Gun Club]

Not necessarily even commenting on lifestyle, more just that having a bunch of burnt out docs in the Pit doing EM not because they like it but because that’s all they could get into just sounds miserable.

Maybe I’m biased but we had a few dinosaur attendings where I did residency who were in EM because that was what was available to them at the time rather than liking it. People who trained back in the day when EM was the dregs. They weren’t happy people.

 

[EthylMethylMan]

I get a not-insignificant number of PMs from people on SDN saying something along the lines of: "Either me or my spouse/SO is a [2nd/3rd year] EM resident and is absolutely distraught about what to do because EM is not at all what they thought it would be for all the reasons that you and others have described and we're looking for something, anything else."

I was in this exact position by the end of PGY-1. You feel absolutely trapped because fellowshipping out is hard. Genuinely dread-inducing.

 

[Birdstrike]

EM is a doctor grinder. Put one in. Grind ‘em out. Put another one in. Grind ‘em out.

 

[RustedFox]

I can't help but feel that a sizable percentage of these new applicants and new spots simply either (1.) won't graduate, (2.) if they graduate, won't pass their boards and find meaningful employment, or (3.) will go urgent care or some other route altogether.

 

[ScepticSkeksis]

I can't help but feel that a sizable percentage of these new applicants and new spots simply either (1.) won't graduate, (2.) if they graduate, won't pass their boards and find meaningful employment, or (3.) will go urgent care or some other route altogether.

There is always the option of online penis pills.

 

[RustedFox]

There is always the option of online penis pills.

There's that.

But for real; I genuinely think there's going to be a non-ignorable percent of "failures to launch".

 

[The Knife & Gun Club]

I was in this exact position by the end of PGY-1. You feel absolutely trapped because fellowshipping out is hard. Genuinely dread-inducing.

Currently fellowship-ing out and the hours are pretty painful (this month I had a week of 100 in-hospital hours worked, and a “home” call shift that was 82 hours long), but I’d do it again in a heart beat.

My wife just remarked the other day that I seem happier and less tired now than when I was an EM senior working 50-60 hrs/week.

I think it’s tough to know how you’ll respond to the EM lifestyle until you’re really in it. It’s tough to simulate constant circadian flipping and being treated like dog poo by your hospital ademons and patients.

 

[trackrunner321]

I think the numbers are artificially inflated because more people are now applying to EM as a back-up. The numbers are not up because more people organically want to go into EM.

 

[The Knife & Gun Club]

I think the numbers are artificially inflated because more people are now applying to EM as a back-up. The numbers are not up because more people organically want to go into EM.

It will be interesting to see how it translates to fill rate.

Because if a bunch of people are applying backup EM for their reach specialities I don’t think it’ll affect the fill rate much as most of these people still match.

 

[cyanide12345678]

Currently fellowship-ing out and the hours are pretty painful (this month I had a week of 100 in-hospital hours worked, and a “home” call shift that was 82 hours long), but I’d do it again in a heart beat.

My wife just remarked the other day that I seem happier and less tired now than when I was an EM senior working 50-60 hrs/week.

I think it’s tough to know how you’ll respond to the EM lifestyle until you’re really in it. It’s tough to simulate constant circadian flipping and being treated like dog poo by your hospital ademons and patients.

The circadian switches are the worst part of emergency medicine in my opinion.

 

[HemorrhagicShock]

Currently fellowship-ing out and the hours are pretty painful (this month I had a week of 100 in-hospital hours worked, and a “home” call shift that was 82 hours long), but I’d do it again in a heart beat.

My wife just remarked the other day that I seem happier and less tired now than when I was an EM senior working 50-60 hrs/week.

I think it’s tough to know how you’ll respond to the EM lifestyle until you’re really in it. It’s tough to simulate constant circadian flipping and being treated like dog poo by your hospital ademons and patients.

From my ICU rotations in residency (which seems like ages ago) and hearing from current friends who have completed CCM fellowship I get the idea that even on those deep hell weeks during CTICU/CVICU/surgeon-infested-ICU you still get the opportunity to sit down, take a dump, and grab a coffee when you want. There's meaningful downtime that makes 100 hour weeks sound like magic compared to a 50-60 hour week with balls to the wall patient volume/idiocy and switching circadian rhythms.

Any truth to this? I am heavily looking into a CCM fellowship but my current hang-up is whether I'd be able to deal with the workload of fellowship. Most of my friends tell me it was easier than the workload of EM residency, but that also seems program-dependent.

Thoughts?

 

[BoardingDoc]

From my ICU rotations in residency (which seems like ages ago) and hearing from current friends who have completed CCM fellowship I get the idea that even on those deep hell weeks during CTICU/CVICU/surgeon-infested-ICU you still get the opportunity to sit down, take a dump, and grab a coffee when you want. There's meaningful downtime that makes 100 hour weeks sound like magic compared to a 50-60 hour week with balls to the wall patient volume/idiocy and switching circadian rhythms.

Any truth to this? I am heavily looking into a CCM fellowship but my current hang-up is whether I'd be able to deal with the workload of fellowship. Most of my friends tell me it was easier than the workload of EM residency, but that also seems program-dependent.

Thoughts?

Not CCM but I agree it's program dependent. I still vividly remember my ICU time as a resident. One MICU rotation was easier than the ER (but boring). One MICU rotation was easier in terms of work done per hour there but the hours there definitely started to outweigh that benefit. My trauma ICU rotation was significantly more hours AND sometimes more work than the ER. That place was a **** show.

Grass isn't always greener.

 

[The Knife & Gun Club]

From my ICU rotations in residency (which seems like ages ago) and hearing from current friends who have completed CCM fellowship I get the idea that even on those deep hell weeks during CTICU/CVICU/surgeon-infested-ICU you still get the opportunity to sit down, take a dump, and grab a coffee when you want. There's meaningful downtime that makes 100 hour weeks sound like magic compared to a 50-60 hour week with balls to the wall patient volume/idiocy and switching circadian rhythms.

Any truth to this? I am heavily looking into a CCM fellowship but my current hang-up is whether I'd be able to deal with the workload of fellowship. Most of my friends tell me it was easier than the workload of EM residency, but that also seems program-dependent.

Thoughts?

I completely agree - I’m in an anesthesia program but by virtue of the setup most of my rotations are surgical ICUs and co-fellows are surgeons. It’s busy for sure - you’re responsible for 27 intubated vented clusterF’s - but there’s no real dispo issues and it’s rare that more than 1-2 will be actively crashing at a given time.

I almost always have time to say “I want to go grab lunch then we can address this” or go take 20 minutes to sit at the computer when someone isn’t getting better and comb through their chart/numbers to see if there’s something I’m missing. Occasionally my friends from the ED will call me talk through a case or help trouble shoot a vent and I can easily tell the charge nurse or resident my cell and dip out for a bit.

The worst worst worst day in our busiest ICU, Trauma, doesn’t even hold a candle to a bad shift in the pit.

One other thing to consider is that the surgeons aren’t nearly as abrasive when you’re playing on their “team.” As the ICU doc they are relying on you to take care of their patients and you have something they want (a bed for their post op disaster). You’re seen as a specialist and they recognize you have knowledge to offer that will help them. The relationship is far more cordial than I expected. The first time a surgeon came by my work station and sat down to ask if they could “run something by me” I was literally floored after years of being that same person’s ED punching bag.

 

[The Knife & Gun Club]

Not CCM but I agree it's program dependent. I still vividly remember my ICU time as a resident. One MICU rotation was easier than the ER (but boring). One MICU rotation was easier in terms of work done per hour there but the hours there definitely started to outweigh that benefit. My trauma ICU rotation was significantly more hours AND sometimes more work than the ER. That place was a **** show.

Grass isn't always greener.

One big thing I considered is how the programs structured their hours. I chose a place that uses a call system (Q2 home call) rather than a 7a-7p type of gig. Because with call you only are sticking around if stuff is happening, in which case I want to be there anyway.

Some people prefer the 7-7, b it I’d actually rather be on home call and go in at 3am if **** hits the fan but be able to leave at 3-4pm if the unit is quiet.

As an EM person nothing drives me crazy more than sitting around when nothing is going on.

 

[Lexdiamondz]

I think the numbers are artificially inflated because more people are now applying to EM as a back-up. The numbers are not up because more people organically want to go into EM.

I don't know if I agree with that.

EM may be less competitive than in previous years, but it's still a somewhat labour-intensive application process relative to other uncompetitive specialties (FM, IM, Peds, etc) Having a viable application in EM still requires doing away rotations, obtaining SLOEs and other LORs. While some may be applying as a back up, I don't think they make up anywhere near a majority of the increase from last year.

 

[Brigade4Radiant]

I don't know if I agree with that.

EM may be less competitive than in previous years, but it's still a somewhat labour-intensive application process relative to other uncompetitive specialties (FM, IM, Peds, etc) Having a viable application in EM still requires doing away rotations, obtaining SLOEs and other LORs. While some may be applying as a back up, I don't think they make up anywhere near a majority of the increase from last year.

It's not viable if you have many of those spots SOAPing like 25%. When EM was hot sure but now not so much EM last year was way below all those specialties

 

[cyanide12345678]

I don't know if I agree with that.

EM may be less competitive than in previous years, but it's still a somewhat labour-intensive application process relative to other uncompetitive specialties (FM, IM, Peds, etc) Having a viable application in EM still requires doing away rotations, obtaining SLOEs and other LORs. While some may be applying as a back up, I don't think they make up anywhere near a majority of the increase from last year.

You don’t need a viable application.

When 500 spots remain open, and the thousands of people that didn’t match the year before look at it, all they think is if they can get an interview at one of those places then they will get a spot.

Little did they know that everyone else thought the same thing and there won’t be 500 open spots lol.

I mean…. Just look at the bump in IMG applicants.

No IMG wants to do EM. They don’t even know what EM is. There’s no real emergency medicine specialty in countries like pakistan, India, Bangladesh. ER in pakistan is literally the fresh med school graduate who is a glorified triage nurse who directs patients to ‘specialists’ while caring for minor urgent care like things themselves.

All the IMGs eye IM and then IM subspecialties.

Heck I’m not even an IMG, did med school in Dallas, but still come from Pakistani roots, it took my parents 3-4 years before they realized that EM was a real specialty. My mother could not have been any more disappointed in learning that I’m not becoming a cardiologist or a surgeon - those are culturally the real doctors in the subcontinent 🤣 no one grows up in the subcontinent wanting to do EM…..

 

[Restart13]

There's that.

But for real; I genuinely think there's going to be a non-ignorable percent of "failures to launch".

I agree. Anecdotally, I see it happening with new residents, but sometimes it's hard to determine "Am I turning into the douchebag attending". I often wonder what the medium to long term trends will be. Will the bad docs bring down the common denominator and decrease wages but increase staffing as no one is equipped to run an ER adequately? Will the good groups keep compensation high while attracting the true EM docs who want to work hard/make more money? I think rural locums will only proliferate as the new docs don't want to/are unable to work at the 'top of the skillset' shops.

 

[rokshana]

i saw someone on the physician community FB page post that they thought that an FM trained doc made a better emergency doc in a rural ED than EM...all i could think is that there would be a lot of heads exploding over here in SDN...but that certainly may be the mentality of those that are applying to EM right now.

 

[The Knife & Gun Club]

i saw someone on the physician community FB page post that they thought that an FM trained doc made a better emergency doc in a rural ED than EM...all i could think is that there would be a lot of heads exploding over here in SDN...but that certainly may be the mentality of those that are applying to EM right now.

10/10 head exploding but I do think for some of the ultra-rural jobs FM may make a bit more sense. I see postings from time to time for these 5 bed ED and 8 bed inpatient hospitals in the way way critical access territory where you’re the Hospitalist and the ED doc at the same time.

You could make a case for some of these ultra-rural places being better served by one FM who can have a clinic and see some peds and OB, do some very slow moving EM, admit the occasional low acuity inpatient. Not because they’d do the EM part particularly well but because it’d probably be better for the community overall to have one person that can offer all of that rather than someone who’s trained (albeit more thoroughly) only for EM.

 

[AlmostAnMD]

...who is a glorified triage nurse who directs patients to ‘specialists’ while caring for minor urgent care like things themselves.

....I read this like 4 times and I can't say it doesn't apply to me

 

[TooMuchResearch]

10/10 head exploding but I do think for some of the ultra-rural jobs FM may make a bit more sense. I see postings from time to time for these 5 bed ED and 8 bed inpatient hospitals in the way way critical access territory where you’re the Hospitalist and the ED doc at the same time.

You could make a case for some of these ultra-rural places being better served by one FM who can have a clinic and see some peds and OB, do some very slow moving EM, admit the occasional low acuity inpatient. Not because they’d do the EM part particularly well but because it’d probably be better for the community overall to have one person that can offer all of that rather than someone who’s trained (albeit more thoroughly) only for EM.

I work in a 4 bed ED. But we get plenty of days of 10 patients at a time and overflow to a nearby unit. We also get our fair share of two critically ill patients at once. If you want dedicated ED coverage, there is one true choice.

 

[The Knife & Gun Club]

I work in a 4 bed ED. But we get plenty of days of 10 patients at a time and overflow to a nearby unit. We also get our fair share of two critically ill patients at once. If you want dedicated ED coverage, there is one true choice.

That’s super interesting- how do you have the resources to do 2 rooms at once? What does the staffing model look like for an ED that small?

Also curious how far out you are from the nearest city and if you travel to work there or live there full time?

I’ve always thought it’d be interesting to pick up some shifts in a tiny ED like that.

 

[Apollyon]

I’ve always thought it’d be interesting to pick up some shifts in a tiny ED like that.

Trust me, it's not. I know you're squared away and on top of your game, but, this is like the med students that think EM is so active all the time. Rural has their sick pts, with essentially no support. It's not sleep all night. It's a post stroke 65 year old guy coming in at 4am with a STEMI (true case). It's a VERY fat retired nurse, hammered, at 2am, who fell, struck the bed, fractured rib, and got a pneumo, who I had to cut twice to get a chest tube in (true case).

Your might do it once, maybe twice, and then say, "Yep, had enough".

 

[Tipsy McStagger]

From my ICU rotations in residency (which seems like ages ago) and hearing from current friends who have completed CCM fellowship I get the idea that even on those deep hell weeks during CTICU/CVICU/surgeon-infested-ICU you still get the opportunity to sit down, take a dump, and grab a coffee when you want. There's meaningful downtime that makes 100 hour weeks sound like magic compared to a 50-60 hour week with balls to the wall patient volume/idiocy and switching circadian rhythms.

Any truth to this? I am heavily looking into a CCM fellowship but my current hang-up is whether I'd be able to deal with the workload of fellowship. Most of my friends tell me it was easier than the workload of EM residency, but that also seems program-dependent.

Thoughts?

ICU is far easier. It has all of the plus sides of the ED and far fewer downsides. There is a barrier to entry, and I don’t have to be the final dispo of the patient. On my busiest days when I’m getting pulled in 10 directions, I’m still not run as ragged as I was in the ED.

Everything is better in the ICU (this is obviously my own perspective). The patients are sicker, the pathophysiology is fascinating, and I have acquired a much deeper understanding of it.

I’m not a big fan of procedures, but I do far more in the ICU than I ever did in the emergency department. I actually feel like I get to help people through a difficult time instead of shuffling them along and my chances of meeting expectations are significantly better than the emergency department. There’s also a level of respect, given to me by fellow physicians of all specialties, which should not be the case, but it is. People value your opinion, they respect your time and abilities, and often lean on you for help.

One complaint, I often see from medical students and residents is that they don’t want to spend “six hours rounding“. But that is really only in academic centers run by inefficient attending. I work in a busy community hospital, my patient census is typically around 15 and I generally round in about 30 minutes. I come in, review the labs, start my notes, make my plan, talk to the overnight nurse and rounding is really just so I can touch base with the pharmacist.

On my busiest day, I have still had time to get lunch, use the bathroom if I need to and drink water. I remember countless emergency shifts where I never use the bathroom, never had a drink of water and barely sat down at all. There is still disruption of the circadian rhythm, but it is not nearly as often as it was in the emergency department.

For me, the fact of the matter is that my worst day in the ICU is better than my best day in the emergency department. But it is taxing work, and watching a patient decline day after day despite all of your best efforts hurts in a way that is difficult to describe to people who do not work inpatient medicine. It does bring a dread that is different than the emergency department, but still painful.

All in all, it’s a much better specialty in my opinion, but it certainly has its drawbacks, limitations and painful realities. There are still people and families with unrealistic expectations, but the longer I do this the less I care. I’ll give it my all, but my self worth is no longer tied to outcomes.

I am in a much better place physically, emotionally, and spiritually that I was in the ED. I work about the same number of shifts each month, but I’m paid more, and the work is more enjoyable and less soul crushing. 10/10, I’d recommend.

 

[Birdstrike]

I am in a much better place physically, emotionally, and spiritually that I was in the ED. I work about the same number of shifts each month, but I’m paid more, and the work is more enjoyable and less soul crushing. 10/10, I’d recommend.

“Less soul crushing” than EM always gets a thumbs up from me.

 

[bky3c]

That’s super interesting- how do you have the resources to do 2 rooms at once? What does the staffing model look like for an ED that small?

Also curious how far out you are from the nearest city and if you travel to work there or live there full time?

I’ve always thought it’d be interesting to pick up some shifts in a tiny ED like that.

You weren't asking me specifically, but I'll throw in my 2 cents in case it helps. I did a handful of critical access shifts in addition to my urban shifts for most of the years of my career. They were a nice break sometimes, and when they did get busy/high acuity, it felt like time traveling to when there were no specialists and every doctor was just a doctor. Patients tend to be nicer, and staff tend to be rock stars because they don't last if they're not. That includes physicians. Some of the nicest surgeons I've ever met were at these places.

They were 2-5 hours from the nearest major airport. I went for a few days at a time. At night, I was the only physician in the hospital, and gen surg, anesthesia, and Ob/gyn were on call. They had 1-2 nurses (and sometimes a tech) both day and night in the ED, and if they got busy, they could usually pull in another nurse or two from the floor.

Shifts were 12-96 hours. The longer ones provided a call room with a mini kitchen. I once had 4 major traumas at the same time, from the same incident, and we got them stabilized and transferred without a problem. You just hop from room to room and do what you can with the resources you have, and you get them out asap. I don't think anyone expects the care to be identical in the middle of nowhere compared to a Level 1 trauma center, a stroke center, etc., but you do the best you can.

 

[Apollyon]

You weren't asking me specifically, but I'll throw in my 2 cents in case it helps. I did a handful of critical access shifts in addition to my urban shifts for most of the years of my career. They were a nice break sometimes, and when they did get busy/high acuity, it felt like time traveling to when there were no specialists and every doctor was just a doctor. Patients tend to be nicer, and staff tend to be rock stars because they don't last if they're not. That includes physicians. Some of the nicest surgeons I've ever met were at these places.

They were 2-5 hours from the nearest major airport. I went for a few days at a time. At night, I was the only physician in the hospital, and gen surg, anesthesia, and Ob/gyn were on call. They had 1-2 nurses (and sometimes a tech) both day and night in the ED, and if they got busy, they could usually pull in another nurse or two from the floor.

Shifts were 12-96 hours. The longer ones provided a call room with a mini kitchen. I once had 4 major traumas at the same time, from the same incident, and we got them stabilized and transferred without a problem. You just hop from room to room and do what you can with the resources you have, and you get them out asap. I don't think anyone expects the care to be identical in the middle of nowhere compared to a Level 1 trauma center, a stroke center, etc., but you do the best you can.

96 hour shifts, and you had GSx, anesthesia, and OB/GYN? I had a surgeon from Tuesday evening to Thursday 5pm sharp. Gas was CRNAs on call, but, without a surgeon, what did they do? But, I have to say, in 7 years, one birth.

We lost the majority of nurses due to a toxic nurse manager. The "rock stars" ALL left. The only ones left were garbage.

If I had 4 traumas at once, more than one would suffer.

No hospitalists, no intensivist (which was fine, because there was no ICU), no neuro, no ENT. Had Ortho M-F.

Now, it looks like the hospital is down to 2 doctors TOTAL. They booted docs from the ED, and replaced them with NPs.

Times, they changed. The pts I had were people unable to "adult" (hat tip to @RustedFox ). Not gracious, not good people (for the most part), just poor and rural. Bad decisions, no options in life.

 

[bky3c]

96 hour shifts, and you had GSx, anesthesia, and OB/GYN? I had a surgeon from Tuesday evening to Thursday 5pm sharp. Gas was CRNAs on call, but, without a surgeon, what did they do? But, I have to say, in 7 years, one birth.

We lost the majority of nurses due to a toxic nurse manager. The "rock stars" ALL left. The only ones left were garbage.

If I had 4 traumas at once, more than one would suffer.

No hospitalists, no intensivist (which was fine, because there was no ICU), no neuro, no ENT. Had Ortho M-F.

Now, it looks like the hospital is down to 2 doctors TOTAL. They booted docs from the ED, and replaced them with NPs.

Times, they changed. The pts I had were people unable to "adult" (hat tip to @RustedFox ). Not gracious, not good people (for the most part), just poor and rural. Bad decisions, no options in life.

I wasn't implying that your experience didn't happen. I just had different experiences. I can certainly believe that some places are (or at least were) decent and others are terrible.

 

[The Knife & Gun Club]

ICU is far easier. It has all of the plus sides of the ED and far fewer downsides. There is a barrier to entry, and I don’t have to be the final dispo of the patient. On my busiest days when I’m getting pulled in 10 directions, I’m still not run as ragged as I was in the ED.

Everything is better in the ICU (this is obviously my own perspective). The patients are sicker, the pathophysiology is fascinating, and I have acquired a much deeper understanding of it.

I’m not a big fan of procedures, but I do far more in the ICU than I ever did in the emergency department. I actually feel like I get to help people through a difficult time instead of shuffling them along and my chances of meeting expectations are significantly better than the emergency department. There’s also a level of respect, given to me by fellow physicians of all specialties, which should not be the case, but it is. People value your opinion, they respect your time and abilities, and often lean on you for help.

One complaint, I often see from medical students and residents is that they don’t want to spend “six hours rounding“. But that is really only in academic centers run by inefficient attending. I work in a busy community hospital, my patient census is typically around 15 and I generally round in about 30 minutes. I come in, review the labs, start my notes, make my plan, talk to the overnight nurse and rounding is really just so I can touch base with the pharmacist.

On my busiest day, I have still had time to get lunch, use the bathroom if I need to and drink water. I remember countless emergency shifts where I never use the bathroom, never had a drink of water and barely sat down at all. There is still disruption of the circadian rhythm, but it is not nearly as often as it was in the emergency department.

For me, the fact of the matter is that my worst day in the ICU is better than my best day in the emergency department. But it is taxing work, and watching a patient decline day after day despite all of your best efforts hurts in a way that is difficult to describe to people who do not work inpatient medicine. It does bring a dread that is different than the emergency department, but still painful.

All in all, it’s a much better specialty in my opinion, but it certainly has its drawbacks, limitations and painful realities. There are still people and families with unrealistic expectations, but the longer I do this the less I care. I’ll give it my all, but my self worth is no longer tied to outcomes.

I am in a much better place physically, emotionally, and spiritually that I was in the ED. I work about the same number of shifts each month, but I’m paid more, and the work is more enjoyable and less soul crushing. 10/10, I’d recommend.

The barrier to entry thing is such a game changer honestly compared to the ED. It’s the reason I actually like the surgical units more than i thought I would.

In an SICU/CVICU another physician has requested my services, not a patient. Sure there’s a bit of dumping from surgical services that accept/operate on a patient then just drop them off but those are tiny percentage. The vast majority of cases are patients who were already vetted and determined to have some real problem that is potentially fixable. And the name of the game isn’t to fix all their problems, it’s just fix the physiology until they can maintain homeostasis enough to be stable in a normal inpatient unit. Which for surgical patients is usually an achievable goal.

 

[wholeheartedly]

Having spent lots of time seeing EM docs manage pts at both a true county shop and a poorly resourced rural critical access place and FM and some other a specialists at the latter, I still prefer EM for both. We had no gen surg., anesthesia, or OB. Sometimes really slow sometimes busy place. At the rural shops we’re rarely getting some rock star old school generalist do it all FM type doc.

The EM docs were just better at keeping the dept flow going and making quick sick vs not sick determinations.

The distinction between the two was clear as night and day even for a non physician like me.

 

[ToKingdomCome]

How much does EM make ? I’m glad I didn’t pick this speciality

 

[watermanMD]

How much does EM make ? I’m glad I didn’t pick this speciality

250-600k, depending on location and hours worked. Works out to 150ish/hr low end and 400/hr upper end. Some outliers above and below, for sure. I think avg is 210/hr

 

[ProReduction]

From my ICU rotations in residency (which seems like ages ago) and hearing from current friends who have completed CCM fellowship I get the idea that even on those deep hell weeks during CTICU/CVICU/surgeon-infested-ICU you still get the opportunity to sit down, take a dump, and grab a coffee when you want. There's meaningful downtime that makes 100 hour weeks sound like magic compared to a 50-60 hour week with balls to the wall patient volume/idiocy and switching circadian rhythms.

Any truth to this? I am heavily looking into a CCM fellowship but my current hang-up is whether I'd be able to deal with the workload of fellowship. Most of my friends tell me it was easier than the workload of EM residency, but that also seems program-dependent.

Thoughts?

I'm NCC and you summarized it perfectly. Yes, you have emergencies (codes, airways, etc.) but you can largely plan out your rounds and procedures. You get to poop, eat, go to the cafeteria, and even to local restaurants. It is nowhere near the insanity of the ED where anything can come in at any second.

 

[ToKingdomCome]

250-600k, depending on location and hours worked. Works out to 150ish/hr low end and 400/hr upper end. Some outliers above and below, for sure. I think avg is 210/hr

Is this all 1099?

 

[BoardingDoc]

Is this all 1099?

Many, but not all. Some are W2. Fewer are K1.

 

[TooMuchResearch]

That’s super interesting- how do you have the resources to do 2 rooms at once? What does the staffing model look like for an ED that small?

Also curious how far out you are from the nearest city and if you travel to work there or live there full time?

I’ve always thought it’d be interesting to pick up some shifts in a tiny ED like that.

Practice the art of being in two places at once. You don't have to be at bedside all the time on critically ill patients. They call other resources (nurses) to the ED with variable levels of experience and helpfulness.

The physician staffing model is that it's one doctor and after 5-7 pm we're often the only doctor in the facility. There are generally two ED nurses.

It's around an hour to the nearest tertiary care hospital. I commute but only work at these places 30-50% of my shifts. We have good contracts and I'd work full time in the rural sites if possible.

But yes, there is no one available to back you up. It can be very nice to have another EM doc available to back you in tough situations but you get used to it.