Help me decide: EM or Ortho

[MedLyfee]

Hey fellas,

Current MS3 here that's in turmoil over this decision and could really use your help. I have the scores for both, Ortho and EM, but I can't for the life of me decide on which road to follow.


I'm the type of guy that enjoys life outside of medicine. I enjoy lifting, fishing, cracking a cold one open with the boys, taking a pretty girl on mini vacation, etc. I'm a bro's bro to say the least. I'm also a hard worker and when i'm on, im on. But to be honest with you, the hours in surgery are a huge turn off. Like I said, I'm the type of guy that also enjoys life outside of medicine. I'm also getting an MBA on the side that I would like to see develop as part of my career in the future, which I don't see happening in surgery. Someday i'll want a family that I actually want to be around for. So I'm wondering, is there time off in EM to pursue my hobbies and MBA? Given what I've said about myself, what would you recommend?


I truly enjoy both specialties and would be happy doing either of the two. I'm also in a lot of debt (close to $400k), not sure if that would change anything.


Also, to my ortho bros lurking in the background, I would also appreciate your input.

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[WilcoWorld]

Ortho

 

[BJJVP]

I don't know you. And obviously, you should take any advice with a grain of salt. But you sound more like an EM guy to me. Having said that, I do find it very hard to recommend EM to anyone at this point.

 

[Status Sciaticus]

had the same struggle. Decided on EM.
you're not getting much free time with ortho. 80-100 hr/week in residency and 50-60 hrs/week as an attending. Compare that with 36-40/week in EM as an attending. More free time for your other pursuits. Ortho is amazing though, and you wont find a more grateful patient population or better outcomes.

 

[MedLyfee]

I don't know you. And obviously, you should take any advice with a grain of salt. But you sound more like an EM guy to me. Having said that, I do find it very hard to recommend EM to anyone at this point.

Appreciate the response. Why do you find the specialty difficult to recommend?

had the same struggle. Decided on EM.
you're not getting much free time with ortho. 80-100 hr/week in residency and 50-60 hrs/week as an attending. Compare that with 36-40/week in EM as an attending. More free time for your other pursuits. Ortho is amazing though, and you wont find a more grateful patient population or better outcomes.

Thanks for the reply. Any regret since?

 

[Status Sciaticus]

Appreciate the response. Why do you find the specialty difficult to recommend?


Thanks for the reply. Any regret since?

Im applying this year. But I can say that EM landed coincidentally into my lap and I am extremely relieved that it did because it fits my personality very well (its very similar to your post).

 

[BJJVP]

Appreciate the response. Why do you find the specialty difficult to recommend?

For me, the reasons include but are not limited to the following:

1) The increasing emphasis on irrational metrics and patient satisfaction.
2) Lack of understanding by the general public and other healthcare workers about what the ED is for.
3) Relatively lower level of respect from other physicians when compared to other specialties.
4) Lack of control over the work environment.
5) Monday morning quarterbacking from the rest of the hospital.
6) Lack of a consistent schedule and chronic sleep disruption/deprivation.
7) Burnout due to all of the above along with numerous other reasons.

Don't get me wrong, there are many positives. It's just that when you are younger, things that you don't believe will affect you eventually become more problematic. On the surface, EM always seems cool (3yr residency, see a little of everything, do a little of everything, cool personalities, above avg pay, etc). However, over time, #1-7 eventually catch up to you. This is just my opinion. If I had to do it all over again, I probably would still do EM. But I would have gone in with much lower expectations and more strongly considered doing a fellowship.

 

[MedLyfee]

For me, the reasons include but are not limited to the following:

1) The increasing emphasis on irrational metrics and patient satisfaction.
2) Lack of understanding by the general public and other healthcare workers about what the ED is for.
3) Relatively lower level of respect from other physicians when compared to other specialties.
4) Lack of control over the work environment.
5) Monday morning quarterbacking from the rest of the hospital.
6) Lack of a consistent schedule and chronic sleep disruption/deprivation.
7) Burnout due to all of the above along with numerous other reasons.

Don't get me wrong, there are many positives. It's just that when you are younger, things that you don't believe will affect you eventually become more problematic. On the surface, EM always seems cool (3yr residency, see a little of everything, do a little of everything, cool personalities, above avg pay, etc). However, over time, #1-7 eventually catch up to you. This is just my opinion. If I had to do it all over again, I probably would still do EM. But I would have gone in with much lower expectations and more strongly considered doing a fellowship.

I'm grateful you took the time to write all that, it was very helpful. I understand that it EM isn't really all that glamorous as it seems, but then again, what specialty is? Perhaps the grass is always greener on the other side but at the same time I was glad to hear that if you had to, you would pick EM all over again.

 

[TheOther]

For me, the reasons include but are not limited to the following:

1) The increasing emphasis on irrational metrics and patient satisfaction.
2) Lack of understanding by the general public and other healthcare workers about what the ED is for.
3) Relatively lower level of respect from other physicians when compared to other specialties.
4) Lack of control over the work environment.
5) Monday morning quarterbacking from the rest of the hospital.
6) Lack of a consistent schedule and chronic sleep disruption/deprivation.
7) Burnout due to all of the above along with numerous other reasons.

Don't get me wrong, there are many positives. It's just that when you are younger, things that you don't believe will affect you eventually become more problematic. On the surface, EM always seems cool (3yr residency, see a little of everything, do a little of everything, cool personalities, above avg pay, etc). However, over time, #1-7 eventually catch up to you. This is just my opinion. If I had to do it all over again, I probably would still do EM. But I would have gone in with much lower expectations and more strongly considered doing a fellowship.

Can I ask how long you've been in practice?

 

[Faustian]

For me, the reasons include but are not limited to the following:

1) The increasing emphasis on irrational metrics and patient satisfaction.
2) Lack of understanding by the general public and other healthcare workers about what the ED is for.
3) Relatively lower level of respect from other physicians when compared to other specialties.
4) Lack of control over the work environment.
5) Monday morning quarterbacking from the rest of the hospital.
6) Lack of a consistent schedule and chronic sleep disruption/deprivation.
7) Burnout due to all of the above along with numerous other reasons.

Don't get me wrong, there are many positives. It's just that when you are younger, things that you don't believe will affect you eventually become more problematic. On the surface, EM always seems cool (3yr residency, see a little of everything, do a little of everything, cool personalities, above avg pay, etc). However, over time, #1-7 eventually catch up to you. This is just my opinion. If I had to do it all over again, I probably would still do EM. But I would have gone in with much lower expectations and more strongly considered doing a fellowship.

Based on your experience, what types of personalities have you seen do well in EM? Which traits make a doctor successful and happy in EM?

 

[RoyBasch]

Several years ago I was debating the very same thing, orthopedics vs EM. At the time as a medical student it seemed like a very tough decision that could have gone either way. I am currently an attending ER physician. I believe I made the right decision. Looking back I cannot imagine the hours and lifestyle of orthopedics (even in attending practice). Like you I had and have many interest outside of medicine that I am fairly freely able to pursue. Both specialities will afford you enough money to pay off even very significant loans. I know ER physicians grinding hard at locums in god-awful places that make $700,000/yr (more than most orthopedists except a busy spine practice).

After actually rotating on an orthopedic service as a resident (was a required rotation in my residency) I realized how glad I was that I chose emergency medicine. I am generally very satisfied with my career but the issues BJJVP brings up are very real. The insane metrics (which I anticipate will only get worse) that the surgeons do not seem to be held to certainly irritate me. I agree there is a very poor understanding about what the ER is actually supposed to do among patients in the general public and other physicians. You can practice perfectly and many patients will be upset because they did not get what they wanted (because what they want is not what we do). Other physicians will condescend to you that you could not make a diagnosis in 15 minutes in the ER that took them a week long hospitalization, 2 MRIs, 4 send out studies, and 2 sub-specialist consultations to make. If commanding respect from patients and physicians is a high priority for you, orthopedics would be a great specialty.

As stated above, orthopedists are able to help patients achieve excellent outcomes and really improve their quality of life. We do save some lives here and there, but for the average ER patient it is more about screening for serious disease then making an absolute diagnosis and I don't know that our workups or treatments drastically improve patient health or wellbeing in these cases.

That being said, for me, I didn't get in to this business to impress other physicians or patients. I take tremendous satisfaction in knowing I have performed an adequate emergent workup on patients and ruled out serious threats to their life and risk stratified them appropriately. I enjoy catching the zebras and getting the initial workup and treatment going of more common diseases. I love resuscitations, medical codes, and quick resuscitative procedures like chest tubes, intubations, and central lines, etc. I also enjoy the "quick fix" easy satisfaction cases like lac repairs, shoulder dislocations, etc. I am very grateful I have absolutely no call, no pager, no rounding, and even the worst patients I'm done with in 2 hours or so.

Fundamentally I see some students debate between "surgical specialty x" and EM. Many students seem to view EM as a "surgical" or procedural specialty. Let me tell you up front this is not the case. 90-95% of the cases I see involve no procedures. Most of what we do is "medicine." The procedures we perform although critical and life saving (some of them) are in no way as invasive or complex as the types of procedures surgeons perform. If you love the OR and must do operative cases, EM will not satisfy your procedural cravings. Orthopedics as a specialty although it involves conservative management and non-operative care is defined by the OR (and I think must surgeons fell the same about this). Their ability to take patients to the OR and do ORIF, arthroplasty, arthroscopy, etc. is what separates them from us (closed reduction, splinting, diagnostic exam and imaging, injections, etc.) In my experience, people are drawn to orthopedics because they MUST be in the OR.

 

[gro2001]

Hey fellas,

Current MS3 here that's in turmoil over this decision and could really use your help. I have the scores for both, Ortho and EM, but I can't for the life of me decide on which road to follow.


I'm the type of guy that enjoys life outside of medicine. I enjoy lifting, fishing, cracking a cold one open with the boys, taking a pretty girl on mini vacation, etc. I'm a bro's bro to say the least. I'm also a hard worker and when i'm on, im on. But to be honest with you, the hours in surgery are a huge turn off. Like I said, I'm the type of guy that also enjoys life outside of medicine. I'm also getting an MBA on the side that I would like to see develop as part of my career in the future, which I don't see happening in surgery. Someday i'll want a family that I actually want to be around for. So I'm wondering, is there time off in EM to pursue my hobbies and MBA? Given what I've said about myself, what would you recommend?


I truly enjoy both specialties and would be happy doing either of the two. I'm also in a lot of debt (close to $400k), not sure if that would change anything.


Also, to my ortho bros lurking in the background, I would also appreciate your input.

Have you done an EM rotation? In my opinion, as a general rule of thumb, if you are still seriously agonizing over the decision of EM vs Something Else by the time you are done with an EM rotation, go for the Something Else.

I say this as someone who loves EM and thinks its the best and most fun specialty (for me). But while medical school does a somewhat decent job of exposing you to the pros and cons of many other fields, it's really impossible for you to fully appreciate the pros and cons of EM. I believe you can see how the ups and downs of ortho will affect your life, but I don't believe you can see the same thing for EM until you've done it for a bit.

So if its a close thing between EM and anything else, do anything else.

 

[MedLyfee]

Several years ago I was debating the very same thing, orthopedics vs EM. At the time as a medical student it seemed like a very tough decision that could have gone either way. I am currently an attending ER physician. I believe I made the right decision. Looking back I cannot imagine the hours and lifestyle of orthopedics (even in attending practice). Like you I had and have many interest outside of medicine that I am fairly freely able to pursue. Both specialities will afford you enough money to pay off even very significant loans. I know ER physicians grinding hard at locums in god-awful places that make $700,000/yr (more than most orthopedists except a busy spine practice).

After actually rotating on an orthopedic service as a resident (was a required rotation in my residency) I realized how glad I was that I chose emergency medicine. I am generally very satisfied with my career but the issues BJJVP brings up are very real. The insane metrics (which I anticipate will only get worse) that the surgeons do not seem to be held to certainly irritate me. I agree there is a very poor understanding about what the ER is actually supposed to do among patients in the general public and other physicians. You can practice perfectly and many patients will be upset because they did not get what they wanted (because what they want is not what we do). Other physicians will condescend to you that you could not make a diagnosis in 15 minutes in the ER that took them a week long hospitalization, 2 MRIs, 4 send out studies, and 2 sub-specialist consultations to make. If commanding respect from patients and physicians is a high priority for you, orthopedics would be a great specialty.

As stated above, orthopedists are able to help patients achieve excellent outcomes and really improve their quality of life. We do save some lives here and there, but for the average ER patient it is more about screening for serious disease then making an absolute diagnosis and I don't know that our workups or treatments drastically improve patient health or wellbeing in these cases.

That being said, for me, I didn't get in to this business to impress other physicians or patients. I take tremendous satisfaction in knowing I have performed an adequate emergent workup on patients and ruled out serious threats to their life and risk stratified them appropriately. I enjoy catching the zebras and getting the initial workup and treatment going of more common diseases. I love resuscitations, medical codes, and quick resuscitative procedures like chest tubes, intubations, and central lines, etc. I also enjoy the "quick fix" easy satisfaction cases like lac repairs, shoulder dislocations, etc. I am very grateful I have absolutely no call, no pager, no rounding, and even the worst patients I'm done with in 2 hours or so.

Fundamentally I see some students debate between "surgical specialty x" and EM. Many students seem to view EM as a "surgical" or procedural specialty. Let me tell you up front this is not the case. 90-95% of the cases I see involve no procedures. Most of what we do is "medicine." The procedures we perform although critical and life saving (some of them) are in no way as invasive or complex as the types of procedures surgeons perform. If you love the OR and must do operative cases, EM will not satisfy your procedural cravings. Orthopedics as a specialty although it involves conservative management and non-operative care is defined by the OR (and I think must surgeons fell the same about this). Their ability to take patients to the OR and do ORIF, arthroplasty, arthroscopy, etc. is what separates them from us (closed reduction, splinting, diagnostic exam and imaging, injections, etc.) In my experience, people are drawn to orthopedics because they MUST be in the OR.

Awesome reply, thank you!

Have you done an EM rotation? In my opinion, as a general rule of thumb, if you are still seriously agonizing over the decision of EM vs Something Else by the time you are done with an EM rotation, go for the Something Else.

I say this as someone who loves EM and thinks its the best and most fun specialty (for me). But while medical school does a somewhat decent job of exposing you to the pros and cons of many other fields, it's really impossible for you to fully appreciate the pros and cons of EM. I believe you can see how the ups and downs of ortho will affect your life, but I don't believe you can see the same thing for EM until you've done it for a bit.

So if its a close thing between EM and anything else, do anything else.

My school's ER rotation isn't until 4th year so spending a few weekends in the ED during downtime on other rotations is the only way I can get exposed to the specialty until I do my aways

 

[BJJVP]

Can I ask how long you've been in practice?

I will be taking the ConCert recertification exam this year.

 

[BJJVP]

Based on your experience, what types of personalities have you seen do well in EM? Which traits make a doctor successful and happy in EM?

I am being honest when I say that I know of NO happy ER doctors that have been in practice for more than 5 years. One thing I should say is that I do not know any academic EM physicians. For no specific reason, I seem to only hang out with community, private practice EM physicians. I know many successful EM physicians, but none that I believe would recommend EM to a premed or med student.

The people that seem to be attracted to EM are ones that have an interest outside of medicine, are action oriented, generally happy/jolly type personalities. However, I am not sure that necessarily means EM is a good choice for them since I know of zero emergency physicians that are completely happy with their career choice.

On the other hand, I have a family member who's a PCP, and when I told him I was thinking of switching into a clinic setting, he told me that I would be no happier there. When I asked our interventional cardiologist, who always seemed quite content with his work, what he wants his children to do, he told me he would recommend primary care to them. So I don't really know. Maybe we simply always think the grass is greener elsewhere.

 

[Angry Birds]

BJJVP has a really great post here. I'll add my two cents here.

I've said it a million times before on this forum... If I could go back in time, I wouldn't go into medicine at all. But, I would probably still pick Emergency Medicine if forced to decide specialties again. The key reason for me is that it is possible to do other things while being an ER doctor, although it is not easy. For example, I am currently getting a PhD and hoping it will lead to another career, with clinical EM being reduced significantly.

So, I think the OP should think about how truly badly he wants to make use of his MBA and go down an alternate career path. If this is a very strong concern, then I do think EM over Ortho makes a lot of sense. I know I wouldn't have been able to do a PhD if I was doing Ortho, or probably any other specialty other than EM.

But then again, the fact that I am doing other things to get out of EM/medicine might make you think twice as well.

Also, don't underestimate how hard our work is. Each shift takes a piece of my soul.

 

[Faustian]

I am being honest when I say that I know of NO happy ER doctors that have been in practice for more than 5 years. One thing I should say is that I do not know any academic EM physicians. For no specific reason, I seem to only hang out with community, private practice EM physicians. I know many successful EM physicians, but none that I believe would recommend EM to a premed or med student.

The people that seem to be attracted to EM are ones that have an interest outside of medicine, are action oriented, generally happy/jolly type personalities. However, I am not sure that necessarily means EM is a good choice for them since I know of zero emergency physicians that are completely happy with their career choice.

On the other hand, I have a family member who's a PCP, and when I told him I was thinking of switching into a clinic setting, he told me that I would be no happier there. When I asked our interventional cardiologist, who always seemed quite content with his work, what he wants his children to do, he told me he would recommend primary care to them. So I don't really know. Maybe we simply always think the grass is greener elsewhere.

Thanks for your honesty. I'm still pretty set on EM at the moment, so hopefully hearing both sides will keep me wide open to explore my opportunities when I begin as a med student.

 

[Faustian]

To all EM physicians here, how did you learn to cope with the bad outcomes during shifts and after shifts? Were you the type that was naturally able to compartmentalize your feelings? Or did more experience over time allow you to formulate your own MO for talking to families and patients after adverse outcomes?

 

[shoal007]

To all EM physicians here, how did you learn to cope with the bad outcomes during shifts and after shifts? Were you the type that was naturally able to compartmentalize your feelings? Or did more experience over time allow you to formulate your own MO for talking to families and patients after adverse outcomes?

each bad outcome and horrible talk is taxing. You lose part of your soul. In 5 consecutive shifts, i diagnosed someone with cancer including a 4 year old girl (my daughters 4), a mother of 3, and a new grandmother who took care of herself. I didnt want to go to work again after that stretch.

I had a few days off then went back and have got back into the "normal" groove. But the shiz is real, rotating schedule, weekends, bullshiz admin metrics and pts satsification be damned.

Sent from my Pixel using Tapatalk

 

[Faustian]

each bad outcome and horrible talk is taxing. You lose part of your soul. In 5 consecutive shifts, i diagnosed someone with cancer including a 4 year old girl (my daughters 4), a mother of 3, and a new grandmother who took care of herself. I didnt want to go to work again after that stretch.

I had a few days off then went back and have got back into the "normal" groove. But the shiz is real, rotating schedule, weekends, bullshiz admin metrics and pts satsification be damned.

Sent from my Pixel using Tapatalk

Thanks for sharing your input shoal007. I'm sorry. I'm aiming for EM because I was really inspired after working as a scribe in the ED and meeting a lot of great physicians. I know it's a lot more glamorous looking in than out. If it means anything, I still find the work you do amazing. Take care.

 

[sum dude]

Hey fellas,

Current MS3 here that's in turmoil over this decision and could really use your help. I have the scores for both, Ortho and EM, but I can't for the life of me decide on which road to follow.


I'm the type of guy that enjoys life outside of medicine. I enjoy lifting, fishing, cracking a cold one open with the boys, taking a pretty girl on mini vacation, etc. I'm a bro's bro to say the least. I'm also a hard worker and when i'm on, im on. But to be honest with you, the hours in surgery are a huge turn off. Like I said, I'm the type of guy that also enjoys life outside of medicine. I'm also getting an MBA on the side that I would like to see develop as part of my career in the future, which I don't see happening in surgery. Someday i'll want a family that I actually want to be around for. So I'm wondering, is there time off in EM to pursue my hobbies and MBA? Given what I've said about myself, what would you recommend?


I truly enjoy both specialties and would be happy doing either of the two. I'm also in a lot of debt (close to $400k), not sure if that would change anything.


Also, to my ortho bros lurking in the background, I would also appreciate your input.

It's easy--do you enjoy the OR? Do you love surgery? If not, pick something not in surgery. IF you do, then pick surgery. Picking a specialty based on what you do with free time is a foolish way to pick a specialty. As above, there's not as many procedures in community ED's once you get out to "real world." True, ortho tends to work longer/tougher hours, particularly in the beginning.

But that counters that the mental pressures/stress of the ED are tougher, which involve life/death, time pressures, unrealistic patient expectations, dysfunction in the system. Rotate both, pick the one you like best, just don't do it based on your free time, as you'll regret it later on.

 

[Angry Birds]

Thanks for sharing your input shoal007. I'm sorry. I'm aiming for EM because I was really inspired after working as a scribe in the ED and meeting a lot of great physicians. I know it's a lot more glamorous looking in than out. If it means anything, I still find the work you do amazing. Take care.

Honestly if you scribed at a busy ED, I think that's the best experience and a good gauge of whether it's a good fit for you. That is of course if you were a good scribe and able to keep up and were not considered a sucky scribe.

Scribing in my opinion is better than rotating as a Med student, due to having actual responsibilities. If you sucked as a scribe due to falling behind, forgetting thing, not knowing what's going on, etc. then that's a good sign that EM might not be for you. But if you kicked butt and enjoyed it, that's a good sign. It's not perfect because nothing short of being a senior resident or attending can really tell you the life, but it's better than any other experience in my humble opinion.

 

[BJJVP]

I also happen to like primary care, so I don't mind when a mom requires a simple reassurance about her baby (but then proceeds to ask me to test her for stds). At least I got to see the cool baby!

I'm not in residency yet, but In my opinion, there is no other field that is more versatile than EM. You're trained to literally handle primary care on steroids. So if you're unhappy with your current work climate, why don't you change it? There seems to be so many options- urgent care, academics, locums where you pick the hours, fellowships in sports med (more normal schedule?).. I see urgent care jobs working 10hr days M-Th making as much as PCPs- it's almost the same work, maybe more acute things than managing HTN and diabetes (although I'm sure it's a lot of that too). Why couldn't you do UC and then work locums with a few hospitals in the area to get out of the erratic schedule while still getting the thrill and pay of EM?

I guess I just get confused with all the negativity towards the field when you can do so much with your training. Thoughts?

Using your examples, we should start with "simple reassurances" usually aren't that simple. A lot of patients want a ridiculous test, admission, or they are simply too impatient to wait out that URI, diarrheal illness, etc. The career options you mentioned all have their drawbacks. Urgent care usually requires you to see a high volume of people with self limited conditions. However, convincing the patients that their conditions are self limited requires a lot of patience and/or skill which most physicians do not have or want to deal with. Academics often requires dealing with stressed out and/or overworked residents with no incentive to do more. Academics also usually means a pay cut with longer work hours and responsibilities not everyone wants (teaching, research, papers, lectures, etc). I don't think the sports med market is as robust as many think it is.

I used to think that I would rather give the benefit of the doubt to 100 drug seekers than to become jaded and possibly under treat someone's pain. Now that I have seen my share of ODs, ED's cluttered/overwhelmed with drug seekers distracting the staff from critical pts, completely jaded nurses and medics, I feel somewhat differently. Encouraging drug seekers actually hurts the ED in the long term and negatively affects the care of ill pts.

I used to think that being capable of treating both URIs and septic shock was an asset. Now, I see that having to treat URIs is a burden in that URIs do not usually need much treatment, and it's just one more thing distracting me from the complex pt.

I used to think that not having to deal with staffing issues was a blessing. Now I realize that I am not really in charge of the ED staff since I can't fire or hire the nurses/techs. I will never get to tell someone to come to my office and I will fix their medical issue.

The bottom line is that it is much easier to be positive when you have less responsibility and you don't feel the pressures of the job. As time has gone on, I find that being a specialist and having control of my practice are more integral to professional satisfaction than I would have believed when I was in my late 20s/early 30s.

 

[Angry Birds]

I'm not in residency yet, but In my opinion, there is no other field that is more versatile than EM. You're trained to literally handle primary care on steroids. So if you're unhappy with your current work climate, why don't you change it? There seems to be so many options- urgent care, academics, locums where you pick the hours, fellowships in sports med (more normal schedule?)..

It's almost the exact opposite. There is very little versatility in EM compared to, for example, IM. In IM, you can do a fellowship and never see IM again...and there are tons of options to pick from, with well trodden paths to success. If you do EM, on the other hand, there is a 95% chance that you are stuck doing clinical EM for the rest of your life.

1) We are not trained to handle primary care on steroids. I don't know where you get this strange idea from.

2) Urgent care: Not a viable option for me. The pay is less than half of EM so you'd have to work so many extra shifts that it wouldn't make your schedule better but worse.

2) Academics: This is an option with any specialty.

3) Locums: Sure. Same stressful work with the addition of varying environments, many of them in troubled places. And you only pick the hours to an extent, from a practical perspective. Locums vs a regular job is a pick your poison scenario.

4) Fellowships: Most fellowships in EM, including Sports Medicine, are not viable options to move away from clinical EM being your bread and butter. Sports Medicine in particular is very difficult to make a living out of if you are EM trained.

There are definitely pluses to doing EM but versatility is not one of them. At all. Unless by that you mean that you can do other stuff on your days off, which is what I am doing. But that is in addition to EM.

 

[MedLyfee]

It's almost the exact opposite. There is very little versatility in EM compared to, for example, IM. In IM, you can do a fellowship and never see IM again...and there are tons of options to pick from, with well trodden paths to success. If you do EM, on the other hand, there is a 95% chance that you are stuck doing clinical EM for the rest of your life.

1) We are not trained to handle primary care on steroids. I don't know where you get this strange idea from.

2) Urgent care: Not a viable option for me. The pay is less than half of EM so you'd have to work so many extra shifts that it wouldn't make your schedule better but worse.

2) Academics: This is an option with any specialty.

3) Locums: Sure. Same stressful work with the addition of varying environments, many of them in troubled places. And you only pick the hours to an extent, from a practical perspective. Locums vs a regular job is a pick your poison scenario.

4) Fellowships: Most fellowships in EM, including Sports Medicine, are not viable options to move away from clinical EM being your bread and butter. Sports Medicine in particular is very difficult to make a living out of if you are EM trained.

There are definitely pluses to doing EM but versatility is not one of them. At all. Unless by that you mean that you can do other stuff on your days off, which is what I am doing. But that is in addition to EM.

I appreciate all the responses fellas, definitely a lot of well-made points have been said.

To avoid the doom and gloom of SDN, could you or someone else, give us reasons why EM could be a great choice?
Just for the sake of being neutral since we've discussed the negatives

 

[deleted547339]

It's almost the exact opposite. There is very little versatility in EM compared to, for example, IM. In IM, you can do a fellowship and never see IM again...and there are tons of options to pick from, with well trodden paths to success. If you do EM, on the other hand, there is a 95% chance that you are stuck doing clinical EM for the rest of your life.

1) We are not trained to handle primary care on steroids. I don't know where you get this strange idea from.

2) Urgent care: Not a viable option for me. The pay is less than half of EM so you'd have to work so many extra shifts that it wouldn't make your schedule better but worse.

2) Academics: This is an option with any specialty.

3) Locums: Sure. Same stressful work with the addition of varying environments, many of them in troubled places. And you only pick the hours to an extent, from a practical perspective. Locums vs a regular job is a pick your poison scenario.

4) Fellowships: Most fellowships in EM, including Sports Medicine, are not viable options to move away from clinical EM being your bread and butter. Sports Medicine in particular is very difficult to make a living out of if you are EM trained.

There are definitely pluses to doing EM but versatility is not one of them. At all. Unless by that you mean that you can do other stuff on your days off, which is what I am doing. But that is in addition to EM.

CCM moved away from clinical EM. Mostly.

 

[BoardingDoc]

I appreciate all the responses fellas, definitely a lot of well-made points have been said.

To avoid the doom and gloom of SDN, could you or someone else, give us reasons why EM could be a great choice?
Just for the sake of being neutral since we've discussed the negatives

I love EM. I like procedures, but only to a point. The idea of working on a single procedure for an hour --> many many hours as you do in the OR is not my cup o tea. 10-20 min procedures though? Yeah, sounds good. That covers your lac repairs, intubations, LPs, CVLs, a-lines (if you're into doing those in the ED) etc etc etc.

I'm also a big fan of undifferentiated patients, and you don't get those outside of EM anywhere near as often as you do in the ED. They come in, you figure out what's wrong with them (or at least what to do with them) and then they GTFO.

As for schedule: nights and weekends suck. Circadian disruption sucks. As I get older, it's going to suck even more than it already does. That said, I have so much free time each month that I literally don't know what to do with it all. I'm sure that will fill up quickly (I recently finished residency) but for now I feel like I'm almost never working.

 

[Faustian]

Honestly if you scribed at a busy ED, I think that's the best experience and a good gauge of whether it's a good fit for you. That is of course if you were a good scribe and able to keep up and were not considered a sucky scribe.

Scribing in my opinion is better than rotating as a Med student, due to having actual responsibilities. If you sucked as a scribe due to falling behind, forgetting thing, not knowing what's going on, etc. then that's a good sign that EM might not be for you. But if you kicked butt and enjoyed it, that's a good sign. It's not perfect because nothing short of being a senior resident or attending can really tell you the life, but it's better than any other experience in my humble opinion.

Thanks @Angry Birds. I was chief scribe just before getting accepted this cycle. I really wanted to go back to work because I loved it, but decided to pursue some hobbies instead. I love being in the ED, but I'm afraid that I'll resent the negative aspects as I grow older. Right now EM is still my dream. I'm glad to know that I have good experience to help me in the future on rotations.

 

[Angry Birds]

Thanks @Angry Birds. I was chief scribe just before getting accepted this cycle. I really wanted to go back to work because I loved it, but decided to pursue some hobbies instead. I love being in the ED, but I'm afraid that I'll resent the negative aspects as I grow older. Right now EM is still my dream. I'm glad to know that I have good experience to help me in the future on rotations.

I would take all of this as a good sign for your compatibility with EM. Good luck with your eventual decision.

 

[TheComebacKid]

I started off residency wondering if I made the wrong choice of a specialty. Now as a second year resident, I love it. Will it change when I get out and practice on my own? Probably.

One thing I will say... I have absolutely no idea what the huge aversion to going into academics is. For some reason in EM in particular, everyone is looking to get out of residency and head straight into the community and bag 400K or do locums work. This is an absolute recipe for burnout. Single coverage community ED's are brutal places to work, especially if you are working many shifts a month. In addition with the huge metrics that are placed on providers, it can be physically and mentally taxing.

I am without a doubt going to go into academic EM. I recognize that I will likely take a 50% paycut which is not a trivial amount of money. But I go to a fairly academic EM residency program, and I have never seen a happier group of attendings. Many of them work between 4-8 clinical shifts a month, and then spend the rest of the time doing whatever it is that they love within emergency medicine. That includes research, resident education, hospital administration, committees. They go to multiple conferences a year and enjoy themselves. Yes, they still put in long hours, sometimes more than 60-70 per week. But if you are doing research, you essentially make your own schedule. You can work from home. And a lazy day at the office in jeans is a really nice break compared to doing a 12 hour shift in a high acuity shop.

Again, I recognize the financial implications of going into academics, and for some, this is simply not feasible with kids/loans etc. But if you have the financial flexibility, I would recommend considering going into academics. I have several of my attendings who are in their 70s and still going strong and happy to come to work every day. If you hate research and education, that's a different story. I love research and will be doing fellowship and looking for an academic position. Although I will say academics is probably quite more competitive from a job perspective especially in more desirable geographical areas.

And I could be completely wrong about this, but at academic teaching hospitals, the emphasis on metrics while it still probably exists, it doesn't seem as overwhelming as it does in the community. I haven't done my community rotation yet so I could be way off on this, but from the few people I've talked to at my program who split time between community and academic practice, they feel like academics is a nice break because they have residents to share some of the burden of writing notes/calling consults and the administrators seem a little less tyrannical. But again this is an n=2 so I could be way off on this.

 

[The White Coat Investor]

These specialties are very different. Have you rotated in both yet? Chances are that would clear up the confusion.

If the number of hours in medicine are a huge turnoff, EM is probably your best bet. If the type of hours in medicine are a huge turnoff, ortho is probably your best bet. While there is some call in ortho, it's pretty easy to keep it reasonable and most orthopods are getting paid for it these days anyway.

 

[alpinism]

I started off residency wondering if I made the wrong choice of a specialty. Now as a second year resident, I love it. Will it change when I get out and practice on my own? Probably.

One thing I will say... I have absolutely no idea what the huge aversion to going into academics is. For some reason in EM in particular, everyone is looking to get out of residency and head straight into the community and bag 400K or do locums work. This is an absolute recipe for burnout. Single coverage community ED's are brutal places to work, especially if you are working many shifts a month. In addition with the huge metrics that are placed on providers, it can be physically and mentally taxing.

I am without a doubt going to go into academic EM. I recognize that I will likely take a 50% paycut which is not a trivial amount of money. But I go to a fairly academic EM residency program, and I have never seen a happier group of attendings. Many of them work between 4-8 clinical shifts a month, and then spend the rest of the time doing whatever it is that they love within emergency medicine. That includes research, resident education, hospital administration, committees. They go to multiple conferences a year and enjoy themselves. Yes, they still put in long hours, sometimes more than 60-70 per week. But if you are doing research, you essentially make your own schedule. You can work from home. And a lazy day at the office in jeans is a really nice break compared to doing a 12 hour shift in a high acuity shop.

Again, I recognize the financial implications of going into academics, and for some, this is simply not feasible with kids/loans etc. But if you have the financial flexibility, I would recommend considering going into academics. I have several of my attendings who are in their 70s and still going strong and happy to come to work every day. If you hate research and education, that's a different story. I love research and will be doing fellowship and looking for an academic position. Although I will say academics is probably quite more competitive from a job perspective especially in more desirable geographical areas.

And I could be completely wrong about this, but at academic teaching hospitals, the emphasis on metrics while it still probably exists, it doesn't seem as overwhelming as it does in the community. I haven't done my community rotation yet so I could be way off on this, but from the few people I've talked to at my program who split time between community and academic practice, they feel like academics is a nice break because they have residents to share some of the burden of writing notes/calling consults and the administrators seem a little less tyrannical. But again this is an n=2 so I could be way off on this.

The major reason why many people don't do academics is that you don't really practice EM anymore.

As you said above most of your time is spent doing other things (attending meetings, teaching classes, doing research, etc...) and when you do work an occasional shift you basically sit there and take presentations and watch the residents do everything (put in orders, call consultants, do procedures, etc...). If you love teaching and hate seeing patients on your own its a good gig but most people don't want to do that as a full time career.

 

[WilcoWorld]

The major reason why many people don't do academics is that you don't really practice EM anymore.

As you said above most of your time is spent doing other things (attending meetings, teaching classes, doing research, etc...) and when you do work an occasional shift you basically sit there and take presentations and watch the residents do everything (put in orders, call consultants, do procedures, etc...). If you love teaching and hate seeing patients on your own its a good gig but most people don't want to do that as a full time career.

This has not been my experience.

 

[Birdstrike]

Hey fellas,

Current MS3 here that's in turmoil over this decision and could really use your help. I have the scores for both, Ortho and EM, but I can't for the life of me decide on which road to follow.


I'm the type of guy that enjoys life outside of medicine. I enjoy lifting, fishing, cracking a cold one open with the boys, taking a pretty girl on mini vacation, etc. I'm a bro's bro to say the least. I'm also a hard worker and when i'm on, im on. But to be honest with you, the hours in surgery are a huge turn off. Like I said, I'm the type of guy that also enjoys life outside of medicine. I'm also getting an MBA on the side that I would like to see develop as part of my career in the future, which I don't see happening in surgery. Someday i'll want a family that I actually want to be around for. So I'm wondering, is there time off in EM to pursue my hobbies and MBA? Given what I've said about myself, what would you recommend?


I truly enjoy both specialties and would be happy doing either of the two. I'm also in a lot of debt (close to $400k), not sure if that would change anything.


Also, to my ortho bros lurking in the background, I would also appreciate your input.

Let me make this painfully simple and to the point:

O R T H O


/ThreadOver


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[anbuitachi]

Hey fellas,

Current MS3 here that's in turmoil over this decision and could really use your help. I have the scores for both, Ortho and EM, but I can't for the life of me decide on which road to follow.


I'm the type of guy that enjoys life outside of medicine. I enjoy lifting, fishing, cracking a cold one open with the boys, taking a pretty girl on mini vacation, etc. I'm a bro's bro to say the least. I'm also a hard worker and when i'm on, im on. But to be honest with you, the hours in surgery are a huge turn off. Like I said, I'm the type of guy that also enjoys life outside of medicine. I'm also getting an MBA on the side that I would like to see develop as part of my career in the future, which I don't see happening in surgery. Someday i'll want a family that I actually want to be around for. So I'm wondering, is there time off in EM to pursue my hobbies and MBA? Given what I've said about myself, what would you recommend?


I truly enjoy both specialties and would be happy doing either of the two. I'm also in a lot of debt (close to $400k), not sure if that would change anything.


Also, to my ortho bros lurking in the background, I would also appreciate your input.

Cant tell if serious. Did you even read up on the different specialties? Is there time off in EM to pursue your hobbies? Have you looked at how many hours EM doctors work? Obviously there are many sources, but i like AAMC.org. Sounds more official than some random site with some #. According to AAMC.org EM physicians work 46.4 hours on average per week. Hopefully you can find time to work on hobbies when working 46.4 hr weeks. Orthopedics work average of 57 hours per week. Not only that, orthopedic residency is 5 years. EM is 3-4, so you save 1-2 years. Both specialties are highly paid among doctors. Ortho is about 100k higher salary, but you start earning 1-2 years later.
EM is one of the hottest fields right now. Getting way more competitive, for a reason. If you look at all the competitive specialties, the thing they have in common is good lifestyle/money.

 

[anbuitachi]

For me, the reasons include but are not limited to the following:

1) The increasing emphasis on irrational metrics and patient satisfaction.
2) Lack of understanding by the general public and other healthcare workers about what the ED is for.
3) Relatively lower level of respect from other physicians when compared to other specialties.
4) Lack of control over the work environment.
5) Monday morning quarterbacking from the rest of the hospital.
6) Lack of a consistent schedule and chronic sleep disruption/deprivation.
7) Burnout due to all of the above along with numerous other reasons.

Don't get me wrong, there are many positives. It's just that when you are younger, things that you don't believe will affect you eventually become more problematic. On the surface, EM always seems cool (3yr residency, see a little of everything, do a little of everything, cool personalities, above avg pay, etc). However, over time, #1-7 eventually catch up to you. This is just my opinion. If I had to do it all over again, I probably would still do EM. But I would have gone in with much lower expectations and more strongly considered doing a fellowship.

Confused about #2. Can you give some example of what you mean by healthcare workers lacking understanding of what ED is for?
For #3, i agree, but i think EM is one of the better respected fields in the community outside of the hospital. Look at how many EM shows there are!

 

[shoal007]

Confused about #2. Can you give some example of what you mean by healthcare workers lacking understanding of what ED is for?
For #3, i agree, but i think EM is one of the better respected fields in the community outside of the hospital. Look at how many EM shows there are!

pcps sending in asymptomatic hypertension, hyperglycemia, ptosis thinking its a brain aneurysm requiring imaging -- they can order it too. just a few

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[anbuitachi]

pcps sending in asymptomatic hypertension, hyperglycemia, ptosis thinking its a brain aneurysm requiring imaging -- they can order it too. just a few

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I dont think its cause they dont understand what a ED is for. I think they are just trying to shift responsibilities and dump them on you. Lets say patient comes in to PCP with BP of 230/140, asymptomatic. sure pcp can give anti HTN meds, and follow up in a week. but if, even if very small chance, something happens, the PCP will be screwed. So they shift the responsbility to the ED. but obviously if they are sending bp of 160/90 then yea thats messed up

 

[Angry Birds]

FLgator123, you are a medical student. We are EM attendings. Believe it or not, but we might know a bit more than you about what we are trained in and what we do for a living.

What is Urgent Care then? 90% of it is general bread and butter primary care. The other 10% is what your unique EM training can fulfill, such as suturing etc. Many UC centers now OFFER APPOINTMENTS for patients. What would you call this?

First of all, I am not trained as an Urgent Care doctor. I am trained as an EM doctor. Yes, people do come to the ER with complaints that they should see their PCP for, but I do not treat their conditions in the same way that their PCP would. I am not trained to do so, nor is it a good idea for me to do so.

For example, a patient comes in for a BP of 175/95. For me, this is a PCP-level complaint. How do you think I treat this versus a PCP who does? What do you think the differences are? I'll let you figure this one out on your own, since you seem to be insistent on not just trusting people who do this for a living.

The point is: I see people for PCP-level complaints, but I was never trained to handle them the way a PCP doctor is trained to do so.

As for urgent care, I could work there and continue practicing like an EM doctor, precisely because I am not expected to treat the visit as a PCP visit with follow up. Urgent care doctors would still refer the patient to their PCP.

I was referring to versatility as in your general broad based knowledge and ability to handle almost everything (besides surgery).

Absurd medical student statement, not worthy of serious response.

I was not stating that you have the option to apply to 90+ fellowships (when only a handful of them really matter- GI, Cards, Heme/onc, rheum, ID, maybe nephro?)

Huh!? Endo doesn't matter? Why maybe nephro?

Strange.

Do you need to make 350k to be happy? I come from a humble middle class working family. Even with more loans than anyone on this page a 200k base salary is bananas to me.

Once again, you don't get it. What I am saying is that it doesn't make sense for an EM-trained doctor to work at an urgent care center when you make less than 1/2 the hourly pay there. This would mean you would have to work twice as many shifts at an urgent care shop in order to make the same amount of money, which would make your quality of life and work-life balance worse.

To this, you will say "I am a great person who is happy with half the money" to which I say, it doesn't matter how much money you want to make. If you want to make 200k instead of 350k, why on earth would you want to work 20 shifts/mo in an urgent care center instead of 8 in an ER?

For example, I'm going down to 108 hours from 144 in order to pursue a PhD, precisely because I am not a person one would consider "money-driven." But, for the life of me, I cannot understand why someone who is EM-trained would want to work at an urgent care center, unless they simply want less stressful work*, change of pace, as a side thing now and then, or because they have a stake in the urgent care center.

* I don't think seeing 5 patients/hour is necessarily less stressful, but I don't know, as I haven't worked at an urgent care center before.

Idk I feel like 2 types of people get on SDN. People like me who are excited/nervous about a field and seek reassurance, and people like y'all who are burnt-out/cynical. Therefore, neither side really gets what they searched for.

You are correct in saying there are two types on SDN: practicing physicians and medical students.

And, if you read my posts carefully, I still admit that there are some major positives to EM, as I noted to the person who was a scribe. I just can't stand silly medical student nonsense about the specialty. I'm glad you are enthusiastic and hopefully you will thrive in EM. I also do believe that people always think the grass is greener on the other side, i.e. all specialties have their downsides. But, that's the rub: know the downsides before you go into it. Too many medical students have rose-tinted glasses going into EM. Buyer beware is all.

 

[BJJVP]

Have you ever worked in an FM practice? This is literally every other patient (eh hem, fibromyalgia?). I happen to like primary care and am not cynical (yet) about medicine, and can be very patient when needed.

Idk I feel like 2 types of people get on SDN. People like me who are excited/nervous about a field and seek reassurance, and people like y'all who are burnt-out/cynical. Therefore, neither side really gets what they searched for.

You are right in that we have to convince most of our pts that everything is OK. The type of cases and reassurances given often differ. In the UC setting, which I worked part time for several yrs, I have to reassure people that their URI will not get better with abx, their diarrhea ill not improve with abx, etc. I've completely given up trying to tell them conjunctivitis will resolve spontaneously. I am not a PCP but from what they tell me, they do some of the above but more often have to convince people they don't have cancer, they don't have a low level of whatever the newest info-commercial says they have, they don't need testosterone supplements, etc. The conditions we miss are different as well. If I miss anything, it will likely be a retained foreign body, tendon injury, spinal injury etc. You can imagine that the PCP will be diagnostically challenged differently.

I am glad you are not cynical. Please don't misunderstand me. The purpose of my posts is not to produce a bunch of cynical graduating physicians. In fact, it's the opposite. My hope is that you go into medicine fully informed about its limitations as a career. I believe this will make you less likely to be disappointed and hopefully more satisfied. Someone needs to tell the pre-meds and med students that you're not just going to go around shocking VF, putting in chest tubes, then just reassuring mothers their newborn only has a cold, and going home with enough time off to climb Mt Everest. I guess EM is closer to that picture than any other medical field. However, we need to tell them that reality is so very far from that ideal picture.

 

[BJJVP]

Confused about #2. Can you give some example of what you mean by healthcare workers lacking understanding of what ED is for?

There's a lot of what Angry Birds posted above. More examples include doctors who see pts in the office, order a CXR which shows pneumonia, then send the pt to the ED so I can call their partner to get them admitted. Or an orthopedic surgeon gets a post op US showing a small DVT. Instead of calling the PCP, they send to the ED. Now I have to talk to the pt, call the PCP, become the doctor that assesses risk of embolism, bleeding risk, fall risk, likelihood of compliance, coordinates follow-up or initiates anticoagulation. The ED is not the ideal setting for this and the ED physician, who is meeting the pt for the first time in a chaotic environment, is not the ideal physician to coordinate long term care. Sometimes the pts drive 45 minutes to the ED when they could've gone down the street to see their PCP. Another one is when nursing homes sending pts in for PICC line placements or transfusions that are non-emergent. Pts often have some weird recurrent sx (abd pain, HA, transient behavioral problems) with multiple neg workups and demand a dx from me in the ER. Sometimes, people think that coming to the ER will expedite their specialist referral or that the specialist will see them in the ER. I have had pts come in with slowly growing masses on some body part and decided to come to the ED that day hoping for a dx or an excision. Individually, each one of these cases can be handled easily. However, when combined with the time pressures of the ED, the more critical pts, and my other ED frustrations (suboptimal nursing, poor ancillary support, ridiculous metrics, rude/lazy/unreasonable consultants), these types of cases become more taxing.

 

[Birdstrike]

200k base salary is bananas to me.

.

200k salary is not 200k

It's 100k


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[anbuitachi]

There's a lot of what Angry Birds posted above. More examples include doctors who see pts in the office, order a CXR which shows pneumonia, then send the pt to the ED so I can call their partner to get them admitted. Or an orthopedic surgeon gets a post op US showing a small DVT. Instead of calling the PCP, they send to the ED. Now I have to talk to the pt, call the PCP, become the doctor that assesses risk of embolism, bleeding risk, fall risk, likelihood of compliance, coordinates follow-up or initiates anticoagulation. The ED is not the ideal setting for this and the ED physician, who is meeting the pt for the first time in a chaotic environment, is not the ideal physician to coordinate long term care. Sometimes the pts drive 45 minutes to the ED when they could've gone down the street to see their PCP. Another one is when nursing homes sending pts in for PICC line placements or transfusions that are non-emergent. Pts often have some weird recurrent sx (abd pain, HA, transient behavioral problems) with multiple neg workups and demand a dx from me in the ER. Sometimes, people think that coming to the ER will expedite their specialist referral or that the specialist will see them in the ER. I have had pts come in with slowly growing masses on some body part and decided to come to the ED that day hoping for a dx or an excision. Individually, each one of these cases can be handled easily. However, when combined with the time pressures of the ED, the more critical pts, and my other ED frustrations (suboptimal nursing, poor ancillary support, ridiculous metrics, rude/lazy/unreasonable consultants), these types of cases become more taxing.

Yea sounds like dumping

 

[BJJVP]

Yea sounds like dumping

I want to clarify and add that I can't & don't blame the PCPs or the pts. I believe our healthcare system has become so dysfunctional and difficult to navigate that these types of events are an inherent part of every specialty's practice.

At least I feel this way when I am at home and I've had several days off. During a shift? I am cursing everyone internally.

 

[Status Sciaticus]

200k salary is not 200k

It's 100k


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Not sure where you live but thats an absolutely terrible return. In non-income tax states, your tax would be approximately 50k, not 100k, and this is assuming you do not contribute into your standard IRA, Roth IRA, SEP IRA, 401(k), 529, HSA, and make no deductions.

 

[anbuitachi]

I want to clarify and add that I can't & don't blame the PCPs or the pts. I believe our healthcare system has become so dysfunctional and difficult to navigate that these types of events are an inherent part of every specialty's practice.

At least I feel this way when I am at home and I've had several days off. During a shift? I am cursing everyone internally.

yea i can imagine. it's one reason why i didn't go into EM. too many BS patients who shouldn't be in the ED in the first place. its not just bad for you guys, its super awful for those who truly need to be in the ED. Just had a patient 2 weeks ago with large AAA that's leaking transferred to our hospital, and somehow got lost in the ED. No one told the receiving surgeon that the patient arrived in the ED. We thought the guy died or something before transport. After discussion the surgeon decided to go take a quick look in the ED, found out the guy has been sitting in the ED for 3 hours in a corner, with no monitors on, with 22 and 20G IV thats hep locked. Something needs to be done about all the inappropriate dumping to the ED. Shame i dont think thats happening anytime soon

 

[Birdstrike]

Not sure where you live but thats an absolutely terrible return. In non-income tax states, your tax would be approximately 50k, not 100k, and this is assuming you do not contribute into your standard IRA, Roth IRA, SEP IRA, 401(k), 529, HSA, and make no deductions.

People who are blissfully unaware of how much they're truly paying in some combination of:

Federal income tax, state income tax, city income tax, property tax, real estate tax, federal gas tax, state gas tax, sales tax, social security tax, medicare tax, Obamacare tax (21 separate taxes), capital gains taxes, inheritance taxes, cigarette tax, alcohol taxes, luxury taxes on high end cars and jewelry, user fee-type taxes on airline tickets, rental cars, toll roads, utilities, hotel rooms, licenses, and financial transaction.



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[Status Sciaticus]

People who are blissfully unaware of how much they're truly paying in some combination of:

Federal income tax, state income tax, city income tax, property tax, real estate tax, federal gas tax, state gas tax, sales tax, social security tax, medicare tax, Obamacare tax (21 separate taxes), capital gains taxes, inheritance taxes, cigarette tax, alcohol taxes, luxury taxes on high end cars and jewelry, user fee-type taxes on airline tickets, rental cars, toll roads, utilities, hotel rooms, licenses, and financial transaction.

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You lost me with that one. Clearly, when discussing base salary after taxes, putting in things like taxes on airlines, rental cars, toll roads, utilities, hotel rooms, licenses, financial transactions, cigarettes, alcohol, high end cars, and jewelry to validate your claim seems stupid as these things are not expenses that befalls every EP. The main taxes you will pay that I mentioned from a base of 200K, includes fed, ss and medicare. Real-estate tax is variable based on the state and the size of the property. Cap gains for most people will be 15-20% depending on the bracket but this isnt included in your annual income as the principal you put in was from previous incomes.

 

[Birdstrike]

You lost me with that one. Clearly, when discussing base salary after taxes, putting in things like taxes on airlines, rental cars, toll roads, utilities, hotel rooms, licenses, financial transactions, cigarettes, alcohol, high end cars, and jewelry to validate your claim seems stupid as these things are not expenses that befalls every EP. The main taxes you will pay that I mentioned from a base of 200K, includes fed, ss and medicare. Real-estate tax is variable based on the state and the size of the property. Cap gains for most people will be 15-20% depending on the bracket but this isnt included in your annual income as the principal you put in was from previous incomes.

All those taxes listed, are funds that go to a government, that you're not able to spend on yourself. It comes out of your take home pay. It doesn't matter what a tax is named, what government it goes to, or whether it's deducted from your paycheck, or paid to you, then paid out by you. Either way, it's money confiscated from you, that you can't spend on yourself or your family. Money paid to government for income, fica, sales, gas or any other tax, come out of funds you're paid, that you don't get to spend on yourself. Hidden taxes are no less "taxes" than the one you see on your pay stub or W-2. They all make you poorer, just the same. If it makes you feel better to to pretend they don't exist, aren't real, "don't matter," don't add up or don't reduce the amount of net take home pay at your disposal, then feel free to do so. That's okay by me.

But if you make a point to be aware of them, and add them up to the best of your ability (or at least estimate), then your net take home pay is a lot closer to the 50% number in my post, than it is to your 150k (or 75% of 200k). If your income is higher, >$400k, and you're in a high tax city in a high tax state, your tax home is likely even lower than 50%. This is even after maximizing 401ks, 529s, HSA and other deductions.


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[vm26]

My small community hospital has orthopedic hospitalists that seem to have a good lifestyle. ER docs also overall seem pretty content. Also job quality can have a tremendous influence over ones perception of their given field. A few years ago I would have vehemently bad-mouthed my field bc my job s*cked. Current job is excellent so of course my views of the field have substantially changed.