If you no longer recommend EM to medical students, what alternative fields would you suggest?

[GatorCHOMPions]

Yeah I live in SoCal and know many new pain attendings getting pretty bad job offers. It's so bad that the fellowship is essentially a waste. But because of sunk cost fallacy, they still take the jobs.

I wouldn’t consider my year a waste despite the mixed offers. As I pointed out above the EM market in these same areas is as bad or worse. SoCal is not where EM docs find their salvation either.

I should have qualified my statements above a bit better. Even in the few saturated markets I’m looking you can find a job with a base of 300k working 40-45 hour weeks. You might be able to work hard up to like 350k or even 400k with productivity after a few years in. There’s just not much room for the growth beyond that because the owners aren’t really offering partnership most of the time.

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[GassYous]

How is the job market looking for pain? I have a friend who recently quit pain medicine (anesthesiology as his base training) to focus on his real estate portfolio. He kept talking about how pain medicine is dead, all taken over by private equity, and the small/solo practitioner is getting destroyed by private equity and conglomeration.

When asked if it was a reasonable specialty to consider in order for me to transition out of EM, he nearly begged me to not "ruin my life" by doing so! I would be interested in your thoughts...

If you can get ownership in a surgicenter or become partners with a bunch of proceduralists it can be lucrative. If you're an employee for some hospital then not so good. Some people are making hay while others are going back to the OR.

 

[BoardingDoc]

I wouldn’t consider my year a waste despite the mixed offers. As I pointed out above the EM market in these same areas is as bad or worse. SoCal is not where EM docs find their salvation either.

I should have qualified my statements above a bit better. Even in the few saturated markets I’m looking you can find a job with a base of 300k working 40-45 hour weeks. You might be able to work hard up to like 350k or even 400k with productivity after a few years in. There’s just not much room for the growth beyond that because the owners aren’t really offering partnership most of the time.

Agree. My opinion was swayed because I'm already entrenched in EM in a good job. If you juxtapose a new grad looking for an EM job in a competitive market with a pain grad looking in the same market, the salary for each is likely to be similar and the lifestyle in pain is clearly better. Pain may also pay more in that scenario. I'm bunkered up in a competitive market in a good job and make considerably more than your listed numbers for 29 hrs/week so it was a nonstarter for me.

If you're willing to look outside large cities, pain still seems like the clear cut winner both in terms of comp and lifestyle.

 

[namethatsmell]

Agree. My opinion was swayed because I'm already entrenched in EM in a good job. If you juxtapose a new grad looking for an EM job in a competitive market with a pain grad looking in the same market, the salary for each is likely to be similar and the lifestyle in pain is clearly better. Pain may also pay more in that scenario. I'm bunkered up in a competitive market in a good job and make considerably more than your listed numbers for 29 hrs/week so it was a nonstarter for me.

If you're willing to look outside large cities, pain still seems like the clear cut winner both in terms of comp and lifestyle.

This is a pretty reasonable thought process relating pain to EM from the financial perspectice. If you're making +300/h in EM in a "desirable" area and like where you live/work it'll be a gamble (financially) going into pain. The floor is usually higher in pain as is the ceiling, but the pain market, especially in pp, is becoming more and more predatory due to insurance BS and w/PE continuing to gobble up shops.

 

[Redrox]

My 2 cents as an attending on year 7 now:

Definitely worry some for my med students going into EM but luckily they all seem pretty in the know about the fields job placement problems. Only ones I see going into it have prior experience as a tech, scribe or nurse so know somewhat about shift work. Really worry about the ones who have tons of loans or have their heart set on a difficult to work location, the others not so much.

Me, I'm very happy with my current job. I work with the poorest of the poor and feel good to be able to help as much as I can, and patients are appreciative and thankful for the most part. Brain bleeds, cpr, chest tubes, intubations still fun. But think they're fun because I know I can stop soon if anything changes.

Payed off my 420k loans aggressively quick, invested heavily in real estate so fairly close to financial freedom which makes a huge difference.

I'm at ten shifts a month in the ER now which has freed up time for some interesting side hustles (teaching, plasma donation center medical director, telemed, etc. ) Still everything all together adds up to 35 hours a week, which feels right.

I don't counsel my students to avoid the field, just to be super frugal their first years so they can cut down on shifts fast and soon.

 

[miacomet]

My 2 cents as an attending on year 7 now:

Definitely worry some for my med students going into EM but luckily they all seem pretty in the know about the fields job placement problems. Only ones I see going into it have prior experience as a tech, scribe or nurse so know somewhat about shift work. Really worry about the ones who have tons of loans or have their heart set on a difficult to work location, the others not so much.

Me, I'm very happy with my current job. I work with the poorest of the poor and feel good to be able to help as much as I can, and patients are appreciative and thankful for the most part. Brain bleeds, cpr, chest tubes, intubations still fun. But think they're fun because I know I can stop soon if anything changes.

Payed off my 420k loans aggressively quick, invested heavily in real estate so fairly close to financial freedom which makes a huge difference.

I'm at ten shifts a month in the ER now which has freed up time for some interesting side hustles (teaching, plasma donation center medical director, telemed, etc. ) Still everything all together adds up to 35 hours a week, which feels right.

I don't counsel my students to avoid the field, just to be super frugal their first years so they can cut down on shifts fast and soon.

The problem is they all think they will be the exception to the job placement problems, and that's just not possible

 

[HemorrhagicShock]

interesting side hustles (teaching, plasma donation center medical director, telemed, etc. )

I'd be very interested in learning how you got involved in both teaching and the plasma donation center..

The latter sounds like a very interesting and laid back side hustle

 

[RustedFox]

I'd be very interested in learning how you got involved in both teaching and the plasma donation center..

The latter sounds like a very interesting and laid back side hustle

I got an email awhile ago pitching the plasma donation center position to me.

I looked at it. Seemed more agitating than anything else.

 

[Dr Mantis Toboggan]

I got an email awhile ago pitching the plasma donation center position to me.

I looked at it. Seemed more agitating than anything else.

How much can one get from selling plasma these days?

 

[bravotwozero]

I got an email awhile ago pitching the plasma donation center position to me.

I looked at it. Seemed more agitating than anything else.

Yeah at most you’ll make a couple hundred dollars for 1 day a week.

 

[Redrox]

I got an email awhile ago pitching the plasma donation center position to me.

I looked at it. Seemed more agitating than anything else.

$135 an hour, it's four hours a week that I schedule in block of 2 hours at a time or 4.

I took a course they provided and paid for to get certified to also be laboratory director.

Just sign and review incident reports and other paper work on site, observe people start IVs. Super chill. Just a nice low stress change of pace.

 

[swamprat]

This is a pretty reasonable thought process relating pain to EM from the financial perspectice. If you're making +300/h in EM in a "desirable" area and like where you live/work it'll be a gamble (financially) going into pain. The floor is usually higher in pain as is the ceiling, but the pain market, especially in pp, is becoming more and more predatory due to insurance BS and w/PE continuing to gobble up shops.

Just FYI I am in a desirable area I made over 600K in PP pain in 2021 working M-F 9-5 - well more like 9-330/4. Pain is the way to go if you can tolerate the patients and are competitive enough to get in.

 

[Kryptocoin]

I mean this sounds all fine and dandy but reality is there are a ton of well capitalized online psych platforms.

Conditions Cerebral Treats | Expert Online Therapy + Mental Health Care on Your Schedule

Cerebral experts can treat anxiety, depression, insomnia, and more. Learn about the care you can get today.

cerebral.com

SoftBank leads mental health startup Cerebral's $300M round, propelling valuation to $4.8B

Launched just two years ago, online mental health startup Ce | Launched just two years ago, startup Cerebral is growing rapidly, propelled by increased demand for behavioral health care services during the COVID-19 pandemic. The company banked $300 million in a series C round led by the SoftBank...

www.fiercehealthcare.com

They have raised almost $500m dollars and have a market cap similar to many cmgs (when they were public).

I don’t see psych salaries being all that impressive. Just as there are em practices that are unicorns I am sure there are similar psych practices.

ADHD Drugs Are Convenient To Get Online. Maybe Too Convenient

Backed by SoftBank and promoted by Simone Biles, Cerebral has built the fastest-growing online mental health business. Former employees say the rapid expansion comes at the expense of patient care.

www.bloomberg.com

200k paying subscribers. Keep in mind these online places are typically subscription based and np heavy.

PE pumping into cerebral and others is an example. Fwiw cerebral is worth 10x the capital they have raised.

Looks like Cerebral will stop prescribing stimulants (aka adderall) after the DEA started applying some heat. That's like their #1 cash cow. I wonder how long they will stay in business, losing that much revenue.

 

[VA Hopeful Dr]

Looks like Cerebral will stop prescribing stimulants (aka adderall) after the DEA started applying some heat. That's like their #1 cash cow. I wonder how long they will stay in business, losing that much revenue.

Well, not quite:

• Cerebral Chief Medical Officer David Mou said in an email to clinicians that the company would continue to prescribe controlled substances for other conditions, according to the Wall Street Journal. It also said it will continue to treat existing ADHD patients with stimulants.

 

[Kryptocoin]

Well, not quite:

• Cerebral Chief Medical Officer David Mou said in an email to clinicians that the company would continue to prescribe controlled substances for other conditions, according to the Wall Street Journal. It also said it will continue to treat existing ADHD patients with stimulants.

So it looks like they stopped it for all new patients but will continue it for existing patients.....for now. Only a matter of time before the DEA closes that loophole. Still, new patients are a significant chunk of their patient population so they'd be losing some serious revenue there.

Also, patients can easily follow up with their PCP to refill their meds if they have an existing diagnosis; not sure why they'd need Cerebral. Unless patients are using Cerebral for drug diversion, which would put the company in further crosshairs with the DEA.

 

[EctopicFetus]

Looks like Cerebral will stop prescribing stimulants (aka adderall) after the DEA started applying some heat. That's like their #1 cash cow. I wonder how long they will stay in business, losing that much revenue.

They will stop prescribing to "new" patients. so the cash cow they have will keep running.

 

[EctopicFetus]

So it looks like they stopped it for all new patients but will continue it for existing patients.....for now. Only a matter of time before the DEA closes that loophole. Still, new patients are a significant chunk of their patient population so they'd be losing some serious revenue there.

Also, patients can easily follow up with their PCP to refill their meds if they have an existing diagnosis; not sure why they'd need Cerebral. Unless patients are using Cerebral for drug diversion, which would put the company in further crosshairs with the DEA.

People use these services for the convenience. Lets be real going into the office of a doctor is super terrible. they are always running behind, spend 3 mins with you and you end up spending 2-3 hours of your time for something that often feels useless. Online they are on time, cheap and you can do it in between episodes of your favorite show.

 

[VA Hopeful Dr]

People use these services for the convenience. Lets be real going into the office of a doctor is super terrible. they are always running behind, spend 3 mins with you and you end up spending 2-3 hours of your time for something that often feels useless. Online they are on time, cheap and you can do it in between episodes of your favorite show.

Or because they know that telemedicine providers are more likely to give you whatever the heck you ask for. If I decided I wanted a stimulant, I sure wouldn't go to a real doctor because I know I don't have ADHD.

The hospital tracks check in to check out time. I'm the second lowest at my office at 58 minutes average. I feel for people who spend 2-3 hours at the doctor.

 

[Kryptocoin]

Or because they know that telemedicine providers are more likely to give you whatever the heck you ask for. If I decided I wanted a stimulant, I sure wouldn't go to a real doctor because I know I don't have ADHD.

This

 

[painballer27]

This is a good thread. As a med student who liked EM early on but crossed it off due to things I've read on here, I'd like to know what the better fields are

 

[BoardingDoc]

This is a good thread. As a med student who liked EM early on but crossed it off due to things I've read on here, I'd like to know what the better fields are

Anything with normal human hours and little mid-level encroachment.

Surgical subspecialty
Derm
Rads
Gas
IM and then doing a GI or cards fellowship

There are a lot of options. If you literally hate every other specialty, sure, go into EM with your eyes open. That said, I like EM when it is what it's supposed to be. I have a unicorn job making a very high hourly rate in a saturated market. All of that said, I think if I had it to do all over again, I'd have done one of the above instead. EM simply isn't sustainable.

 

[TheComebacKid]

Anything with normal human hours and little mid-level encroachment.

Surgical subspecialty
Derm
Rads
Gas
IM and then doing a GI or cards fellowship

There are a lot of options. If you literally hate every other specialty, sure, go into EM with your eyes open. That said, I like EM when it is what it's supposed to be. I have a unicorn job making a very high hourly rate in a saturated market. All of that said, I think if I had it to do all over again, I'd have done one of the above instead. EM simply isn't sustainable.

To me some of it is about prediction... the way private equity is infiltrating into specialties like derm is terrifying. I suspect derm, currently considered to be the holy grail of work/life balance and good physician compensation, is ripe for midlevel takeover within the next decade. If some of these other specialties don't get it together, they'll be scratching their heads just like the EM docs asking, "what the hell happened" before they know it.

While it seems like EM was unfairly targeted and set up to fail, I fear in reality we were just one of the first pillars to fall. Private equity/midlevel encroachment is coming for everyone.

 

[Dr Mantis Toboggan]

To me some of it is about prediction... the way private equity is infiltrating into specialties like derm is terrifying. I suspect derm, currently considered to be the holy grail of work/life balance and good physician compensation, is ripe for midlevel takeover within the next decade. If some of these other specialties don't get it together, they'll be scratching their heads just like the EM docs asking, "what the hell happened" before they know it.

While it seems like EM was unfairly targeted and set up to fail, I fear in reality we were just one of the first pillars to fall. Private equity/midlevel encroachment is coming for everyone.

Yup the only way to truly be irreplaceable to do something that very few people can.

Yes there are midlevels doing scopes etc but I don’t see them ever banding varices, dilating the esophagus, performing ERCP etc. Based on the call schedule at my hospital I’d say GI is still a very safe choice. Particularly since they can do a lot of their work at ambulatory surgery centers.

Urology is the poster child for a specialty that does right by its members for allowing thus far comparatively little residency expansion. Ditto ENT. I know PE is buying derm and opthy practices as much as they can. I haven’t heard about them invading those two at all.

But in general the future of medicine as far not being an employee of some entity, hospital or PE etc seems pretty bleak. It would be great if the older owners of such practices wouldn’t sell them to these folks but that’s a naive hope to have.

 

[Waterlover]

I was initially all over the place when deciding specialties, chose EM, still enjoy it, but doing a sports fellowship and plan to try to do a mix of both. There are fellowships you can do from EM that allow you to have a non-EM job if needed.

 

[TheComebacKid]

I was initially all over the place when deciding specialties, chose EM, still enjoy it, but doing a sports fellowship and plan to try to do a mix of both. There are fellowships you can do from EM that allow you to have a non-EM job if needed.

Yes this is true. And just for the record, as someone who did a fellowship and does some non-EM stuff... it's not the same as what other specialties offer.

Again I applaud you for doing sports medicine, I think you are on the right track. I did an EMS fellowship and do some EMS work on the side. But what we do, at least in the current state, is not the equivalent of "interventional cardiology" or "gastroenterology" or "allergy/immunology". The earning potential is not the same. The job security is not the same. The respect within the house of medicine is not the same.

 

[painballer27]

I was initially all over the place when deciding specialties, chose EM, still enjoy it, but doing a sports fellowship and plan to try to do a mix of both. There are fellowships you can do from EM that allow you to have a non-EM job if needed.

Sounds like me. What other specialties were you considering?

 

[RoyBasch]

To me some of it is about prediction... the way private equity is infiltrating into specialties like derm is terrifying. I suspect derm, currently considered to be the holy grail of work/life balance and good physician compensation, is ripe for midlevel takeover within the next decade. If some of these other specialties don't get it together, they'll be scratching their heads just like the EM docs asking, "what the hell happened" before they know it.

While it seems like EM was unfairly targeted and set up to fail, I fear in reality we were just one of the first pillars to fall. Private equity/midlevel encroachment is coming for everyone.

I agree with you. I would not be going long on derm. If I were a student now, by the time you finish training, you will find the best days of derm are already done. The private equity encroachment is already happening now. The field is very ripe for it. Fundamentally a lot of it can be done by midlevels. I think the hours will remain good (few emergencies, not hospital based) but the big profits are going to be captured by PE/wallstreet and the physician compensation that trickles down will fall in line with primary care/office based IM subspecialties like rheumatology. I think the future of very high physician compensation in derm will be in the subspecialties such as derm-path and Mohs surgery, but these are already very hard to get into.

 

[Waterlover]

Sounds like me. What other specialties were you considering?

I was seriously considering Anesthesia and PM&R also, thought Ortho would've been cool but I was so anti-surgical fields when I was in med school, I didn't go for it.

 

[vm26]

Being a kicker on an NFL team. Can have career longevity with decent pay and less chance Of serious injuries - I.e concussions etc

I would also add back-up QB that never really plays but is good enough to stick around for 10-12 years

 

[Splenda88]

I know that many EM Docs feel cornered into the type of practice you describe. I did at one point as well. I decided it wasn't worth doing that to keep my job, so I stopped doing it. That was around five years ago - I haven't been fired.

You have your experience, I have mine. That's OK.

You are one of the brave ones. How many tests we have ordered (I mean physicians in general not just EM) just to placate to patient or family members. It's easier to not have patient relation department calling about someone who requested an MRI...

I was saying 50% of healthcare utilization is a waste 4 months ago, now I am convinced it's closer to 70%.

People should have a 10-yr exit plan in most specialties. You are foolish if you don't.

 

[TulaneUnderdog]

Repping IM over here; absolutely don’t choose IM neither because we still carry the same burnout baggage of call shifts, being ridiculed at by our consultants, and dealing with patients who have more of a social problem than a health one. Only IM if it’s just a stepping stone for you to better things … such as to your future kush Rheumatology clinic that your dad owned where all he does is inject hyaluronic acid into happy old ladies complaining of 4/10 BLE osteoarthritic pain

 

[Birdstrike]

such as to your future kush Rheumatology clinic that your dad owned where all he does is inject hyaluronic acid into happy old ladies complaining of 4/10 BLE osteoarthritic pain

This is what I do, but in Pain. Lot's of joint (and spine) injections on little old ladies. And very few (or now) opiates. The bring me jam, cookies, donuts and call me cutie (I'm not). "I'm only able to get up out of this chair and walk, because of YOU."

 

[doctalaughs]

I agree with you. I would not be going long on derm. If I were a student now, by the time you finish training, you will find the best days of derm are already done. The private equity encroachment is already happening now. The field is very ripe for it. Fundamentally a lot of it can be done by midlevels. I think the hours will remain good (few emergencies, not hospital based) but the big profits are going to be captured by PE/wallstreet and the physician compensation that trickles down will fall in line with primary care/office based IM subspecialties like rheumatology. I think the future of very high physician compensation in derm will be in the subspecialties such as derm-path and Mohs surgery, but these are already very hard to get into.

Anyone can do a skin biopsy but Derm is more like radiology or path than it is like other specialties.

Right now, there are few barriers to PA/NP “biopsy mills” where they just biopsy everything (hey the PE masters are happy taking the money). But believe me - most mid levels do *not* know what they are doing in Derm.

If care in this country moves to value-based care where you can’t just slice off everything to generate money, then the value of these biopsy-monkeys is not going to continue.