Should I Quit?

[comp1]

Well the OP's got some insight. Indeed, depression and rationality rarely go together. However, being diagnosed with a mental health condition and being treated for it does not mean you are impaired. Equally, not being diagnosed or treated does not mean you are unimpaired.... Of course if you're in a state with bad medmal law, you might also be in a state that allows arguably federally illegal things like separating out "psychiatric illness" from any other condition that prevents you to complete your work as a physician on a credentialing form.

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[ProReduction]

My 2 cents is that being a physician is just like being a professional fighter (MMA, boxing, Muay Thai). If you are even thinking of hanging it up, then it is time to quit.

You have FI. Like is such a short, beautiful thing. It is meant to be lived, and you now have the ability to live it in-full. Do it.

 

[RuralEDDoc]

My 2 cents is that being a physician is just like being a professional fighter (MMA, boxing, Muay Thai). If you are even thinking of hanging it up, then it is time to quit.

You have FI. Like is such a short, beautiful thing. It is meant to be lived, and you now have the ability to live it in-full. Do it.

Thinking of quitting means you should quit? Well there goes 99% of the workforce!

 

[MechEDoc]

Lastly, we do need serious mental health reform for physicians. Every credentialing form, we have to check off the box that says that you have no psychiatric illness that may your physician duties. For me, that prevented me from seeking mental health assistance.

I think the rational conclussion about mental health right now is to cash pay with someone outside of a major system and then deny ever having sought care.

 

[ERMudPhud]

I'm glad I'm not there. I'm almost 50 and still don't regret going to work. Yes, there are some days that I don't feel well that I wish I had the day off just like with any career, but 99% of the time I still love what I do. I have fun at work. I've been offered a full-time position outside the ER, and although I really want it, my desire to continue practicing clinically may keep me from applying. I plan to continue working until I'm 70 (my magical number).

Same for me. I'm 57. I had a number of non clinical positions over the last 25 years but I never worked less than 4 shift per month and most of the time I was doing 10-15. In the end I realized if I had a day full of meetings I didn't want to get out of bed. A day full of zoom meeting was even worse. I can't describe how much I hate zoom now. In 2018 I took an 8 month leave of absence to travel Asia and the South Pacific while also resigning all my non-clinical positions. It rejuvenated me. Now I only work clinical shifts and I'm much happier. I do 8-15 per month but usually 8 and pretty much just tell my two sites when I 'm available. Rest of my time is my own. I have sovereign immunity at both sites. I could make twice as much money doing locums but I'm happy and could easily see myself doing this until I'm 65. After that I might be too demented.

So this is going to be another "Should I leave EM?" post. No eye-rolls please.



But, are there any reasons for optimism? Anything on the horizon that might reverse the decline?
Maybe unionization or HCA reversing course and closing their residencies? Perhaps real tort reform, I know GA once had gross negligence standard for EM but got overturned.

Seems with anticipated physician oversupply, quitting for > 1 year likely means I won't be able to return. Just looking for reasons not to quit.

Lastly, for the parents, do you feel your children would be embarrassed that you retired early? I feel like I've tied my identity and take pride to being a doctor.

- Just another burned out ER doc.

It's not going to get better though. I made the most per hour I ever made in 2001. That's actual dollars not adjusted for inflation. I don't have any optimism that any of the other things you list are going to change either. So, no, it's not going to get better. So, quit for a year and do something else and see if you like it more. You can go back. I quit for 8 month and went back. I don't think 14 months would have been much harder. The first week felt a bit off. After that it was like I never left. If you are dreading every shift and have reached FI take a year and see what you find. After 2 years licensing and credentialing gets a bit problematic in some places but you could take a year. My guess is you are much happier at the end of the year and never look back.

Your kids won't care. Mine love and admire my wife and I no matter what we do and yours will too. In fact mine probably wish I had quit years ago.

 

[miacomet]

I think the rational conclussion about mental health right now is to cash pay with someone outside of a major system and then deny ever having sought care

1. I understand that now, having gone through two lawsuits and more mature in my career. However, it's not how someone newly practicing, in their first lawsuit views it.

2. One dismissed early, one did go to trial but verdict was in my favor and dismissed with prejudice. These cases came back to back, which further added to my stress. The one that went to trial, the other side wanted unreasonable sum, so my insurance agency refused to settle. Trust me when I say that the cases that go to trial are mentally very difficult to overcome.

The plantiff's side is incentivized to convince laypeople that you were incompetent and frame you in the worst of lights. You have to sit there and quietly listen to it for days. I'm sure many have the mental fortitude to withstand those kind of mental assaults. I know logically this was all about money (I knew this because my lawyers were amazing and able to subpoena the clinical notes from the defendant's psychiatrist). However, for someone like me who has tied their identity to being a good doctor, it was difficult not to succumb to depression. When you are in deep depression, you are not rational regarding things like a lawsuit's impact on one's career, likelihood of over-the-limit awards.

Lastly, we do need serious mental health reform for physicians. Every credentialing form, we have to check off the box that says that you have no psychiatric illness that may your physician duties. For me, that prevented me from seeking mental health assistance.

OK, you really need to check the facts here. Yes, you can have psychiatric illness. But unless your psychiatrist says you have an illness that affects your physician duties, then the credentialing is not a problem. If you do have an illness that affects your physician duties, then you should deal with that before you credential.

Just stop.

 

[miacomet]

Same for me. I'm 57. I had a number of non clinical positions over the last 25 years but I never worked less than 4 shift per month and most of the time I was doing 10-15. In the end I realized if I had a day full of meetings I didn't want to get out of bed. A day full of zoom meeting was even worse. I can't describe how much I hate zoom now. In 2018 I took an 8 month leave of absence to travel Asia and the South Pacific while also resigning all my non-clinical positions. It rejuvenated me. Now I only work clinical shifts and I'm much happier. I do 8-15 per month but usually 8 and pretty much just tell my two sites when I 'm available. Rest of my time is my own. I have sovereign immunity at both sites. I could make twice as much money doing locums but I'm happy and could easily see myself doing this until I'm 65. After that I might be too demented.


It's not going to get better though. I made the most per hour I ever made in 2001. That's actual dollars not adjusted for inflation. I don't have any optimism that any of the other things you list are going to change either. So, no, it's not going to get better. So, quit for a year and do something else and see if you like it more. You can go back. I quit for 8 month and went back. I don't think 14 months would have been much harder. The first week felt a bit off. After that it was like I never left. If you are dreading every shift and have reached FI take a year and see what you find. After 2 years licensing and credentialing gets a bit problematic in some places but you could take a year. My guess is you are much happier at the end of the year and never look back.

Your kids won't care. Mine love and admire my wife and I no matter what we do and yours will too. In fact mine probably wish I had quit years ago.

How do you avoid nights?

 

[emergentmd]

In my 17 years in the hospital, I maybe did 10 overnight shifts. We had a nocturnist the whole time, so latest was 2am.

You typically can pay someone to do your night shifts. When we lost our nocturnist for a few months, I just paid a doc to cover my 2 nights. Worked out great, and always had a decent overnight sleep.

 

[miacomet]

In my 17 years in the hospital, I maybe did 10 overnight shifts. We had a nocturnist the whole time, so latest was 2am.

You typically can pay someone to do your night shifts. When we lost our nocturnist for a few months, I just paid a doc to cover my 2 nights. Worked out great, and always had a decent overnight sleep.

God, not everywhere. My last job I worked two Saturday overnights per month by the end. I quit. It took three people to fill my slot and now they are short on shifts. Lol.

Can you show me data that you can typically do this, not just that you were able to do it?

 

[xaelia]

Can you show me data that you can typically do this, not just that you were able to do it?

We had an internal shift market within our department at Kaiser – some docs would "sell" their nights and some docs would "buy" them. The premium the buyers got paid for the additional overnight hours came out of the sellers compensation. This happened before the monthly schedule was published. The premium rate would adjust based on the relative supply and demand for night shifts.

 

[TooMuchResearch]

I just laugh whenever anyone suggests to cut down to 4-8 shifts a month if you start hating the shifts at your hospital.

Pretty sure most of these people have never actually done it and just assume its a quick and easy fix for most docs.

These part time jobs are few and far in between in most cities and its normally only at severely understaffed hospitals.

Depends. We have a few partners that never miss a meeting because we count them for partnership hours, and they need the hours. In your standard CMG hell hole or hospital employed purgatory? I don't know what's possible but probably not as easy.

 

[TooMuchResearch]

In my 17 years in the hospital, I maybe did 10 overnight shifts. We had a nocturnist the whole time, so latest was 2am.

You typically can pay someone to do your night shifts. When we lost our nocturnist for a few months, I just paid a doc to cover my 2 nights. Worked out great, and always had a decent overnight sleep.

Fair enough but we cover places with 50% night shifts. It's hard to get out of those ones, even with multiple nocturnal doctors.

 

[ToastyEM80s]

Same for me. I'm 57. I had a number of non clinical positions over the last 25 years but I never worked less than 4 shift per month and most of the time I was doing 10-15. In the end I realized if I had a day full of meetings I didn't want to get out of bed. A day full of zoom meeting was even worse. I can't describe how much I hate zoom now. In 2018 I took an 8 month leave of absence to travel Asia and the South Pacific while also resigning all my non-clinical positions. It rejuvenated me. Now I only work clinical shifts and I'm much happier. I do 8-15 per month but usually 8 and pretty much just tell my two sites when I 'm available. Rest of my time is my own. I have sovereign immunity at both sites. I could make twice as much money doing locums but I'm happy and could easily see myself doing this until I'm 65. After that I might be too demented.


It's not going to get better though. I made the most per hour I ever made in 2001. That's actual dollars not adjusted for inflation. I don't have any optimism that any of the other things you list are going to change either. So, no, it's not going to get better. So, quit for a year and do something else and see if you like it more. You can go back. I quit for 8 month and went back. I don't think 14 months would have been much harder. The first week felt a bit off. After that it was like I never left. If you are dreading every shift and have reached FI take a year and see what you find. After 2 years licensing and credentialing gets a bit problematic in some places but you could take a year. My guess is you are much happier at the end of the year and never look back.

Your kids won't care. Mine love and admire my wife and I no matter what we do and yours will too. In fact mine probably wish I had quit years ago.

It's good to know that you can actually take a break for > 6 mos and still be okay from a hiring stand point.

I never took more than 3-4 weeks off for fear of having to explain a break. It does help alleviate the concern that I can come back if I decide quitting was the wrong decision after a year.

 

[GatorCHOMPions]

It's good to know that you can actually take a break for > 6 mos and still be okay from a hiring stand point.

I never took more than 3-4 weeks off for fear of having to explain a break. It does help alleviate the concern that I can come back if I decide quitting was the wrong decision after a year.

I took 13 months off from EM to do a Pain fellowship. I have since worked at two separate community hospitals and neither one seemed concerned about my time away from EM from a clinical nor administrative credentialing standpoint. The first job I worked 80-90 hours per month for a few months, single coverage, without a lot of in house services so I threw myself right back in. I felt rusty and a little nervous my first week or so but settled back in. I will say, though, that working the 24-30 hours per month like I've been doing the last several months at a more well staffed bells and whistles type place has made me feel like I've lost a step.

Also think about our toxicology colleagues, most of the time new grads, working like one shift per week max for their first two years out of training.

 

[NYEMMED]

OK, you really need to check the facts here. Yes, you can have psychiatric illness. But unless your psychiatrist says you have an illness that affects your physician duties, then the credentialing is not a problem. If you do have an illness that affects your physician duties, then you should deal with that before you credential.

Just stop.

Depends on that one.

I’ve seen several hospital systems ask
“Do you have any psychiatric condition for which you sought treatment, or take medication for?”

 

[miacomet]

Depends on that one.

I’ve seen several hospital systems ask
“Do you have any psychiatric condition for which you sought treatment, or take medication for?”

Wow, that's wild. I assume this is back east?
That question is also blatantly illegal under the ADA. I would actually challenge it.

 

[miacomet]

I took 13 months off from EM to do a Pain fellowship. I have since worked at two separate community hospitals and neither one seemed concerned about my time away from EM from a clinical nor administrative credentialing standpoint. The first job I worked 80-90 hours per month for a few months, single coverage, without a lot of in house services so I threw myself right back in. I felt rusty and a little nervous my first week or so but settled back in. I will say, though, that working the 24-30 hours per month like I've been doing the last several months at a more well staffed bells and whistles type place has made me feel like I've lost a step.

Also think about our toxicology colleagues, most of the time new grads, working like one shift per week max for their first two years out of training.

Agreed on all.
If one wants to use a locums company (specifically CompHealth in this case) they have some bull**** rule (they claim it's because their medmal requires this, but they are lying) that you have to have worked 1500 hours in the last two years. I took a year off and they kind of pushed me to lie, which is insane, but I then called to the hospital directly, they were happy to have me, and everything worked out fine. But locums companies are particularly weird about taking time off. It's not just CompHealth, either.

 

[miacomet]

Fair enough but we cover places with 50% night shifts. It's hard to get out of those ones, even with multiple nocturnal doctors.

Right? This doesn't work with single coverage ERs unless you hire a crew that only wants to do nights.

 

[Ironspy]

I think the rational conclussion about mental health right now is to cash pay with someone outside of a major system and then deny ever having sought care.

I am a private practice psychiatrist and agree with this. I have had patients who I suspect use a fake name while seeking care as well.

Some state boards are more draconian than others in questions about mental health. The better states ask about current impairment but a number of states still ask about any Hx of diagnosis or treatment for mental health so I don’t blame people for being anxious about seeking care

 

[ERMudPhud]

How do you avoid nights?

I don't. I still work my fair share. Works out to 50% at one site but I sometimes get 6 hours of sleep at that site. 25% nights at the other site. I don't handle nights as easily as I used to but I don't mind them. I try to put them in a row and I try to bounce back to a morning 24 hours after my last night. That way I don't have screwed up circadians for days. Works for me.

We had an internal shift market within our department at Kaiser – some docs would "sell" their nights and some docs would "buy" them. The premium the buyers got paid for the additional overnight hours came out of the sellers compensation. This happened before the monthly schedule was published. The premium rate would adjust based on the relative supply and demand for night shifts.

This is a great system. We used to use that for nights and holidays although ours didn't reset every month. Just whenever people started whining they were getting too many nights or that the nocturnists were getting too much money. I used to joke though about getting someone to write a little software package to hold a reverse dutch auction for nights every month. I think it would have worked great.

It's good to know that you can actually take a break for > 6 mos and still be okay from a hiring stand point.

I never took more than 3-4 weeks off for fear of having to explain a break. It does help alleviate the concern that I can come back if I decide quitting was the wrong decision after a year.

Check with your state and the hospitals you might be interested in as their policies may vary. I've been on credentials committees and places I have the most experience with required you to jump through some major hoops if you took a clinical break longer than 23 months. Anything less than that and we didn't care. My 8 month break had absolutely no effect. My group also used to support an unpaid sabbatical program that pretty much let you take 4-6 weeks off in a row each year. I availed myself of that every year. Things like that and my 8 month break kept me going.

 

[miacomet]

I am a private practice psychiatrist and agree with this. I have had patients who I suspect use a fake name while seeking care as well.

Some state boards are more draconian than others in questions about mental health. The better states ask about current impairment but a number of states still ask about any Hx of diagnosis or treatment for mental health so I don’t blame people for being anxious about seeking care

Nearly all have updated their policies. The rest of the states are mostly in the process of updating their standards. I urge everyone to donate in memory of my friend and colleague, to make this better for everyone. Please also realize these questions are illegal and violate the ADA and that hospitals and medical boards (it's mainly hospital credentialing, most medical boards are being forced to reform) are in violation if they refuse to accommodate you or discriminate.

Can @Ironspy please clarify which states ask about a history of mental health disorders? BTW "mental health disorder" is still open to interpretation.

Improving Licensure & Credentialing Applications - Dr. Lorna Breen Heroes Foundation

drlornabreen.org

 

[Ironspy]

Nearly all have updated their policies. The rest of the states are mostly in the process of updating their standards. I urge everyone to donate in memory of my friend and colleague, to make this better for everyone. Please also realize these questions are illegal and violate the ADA and that hospitals and medical boards (it's mainly hospital credentialing, most medical boards are being forced to reform) are in violation if they refuse to accommodate you or discriminate.

Can @Ironspy please clarify which states ask about a history of mental health disorders? BTW "mental health disorder" is still open to interpretation.

Improving Licensure & Credentialing Applications - Dr. Lorna Breen Heroes Foundation

drlornabreen.org

Mental Health Questions on State Medical License

This cross-sectional study evaluates the consistency of US medical license renewal applications with the Federation of State Medical Boards recommendations for questions regarding physician mental health.

jamanetwork.com

 

[Birdstrike]

I urge everyone to donate in memory of my friend and colleague, to make this better for everyone.

I'm so sorry about this. I remember reading about her. Was she on SDN-EM? You don't need to answer, if you don't feel it's appropriate.

 

[miacomet]

I'm so sorry about this. I remember reading about her. Was she on SDN-EM? You don't need to answer, if you don't feel it's appropriate.

Not ASFAIK. Thank you. She really loved her job and career.

@Ironspy the data gathering for that paper was from 2020-2022. There has, thankfully, been a sea change since then, with many states reforming their process to be in line with the law, although there are still holdouts (Wyoming and Nevada get with the program). The JAMA paper even notes that they can only ask about current impairment to be ADA compliant, so it seems likely that the holdouts will have to change, and that docs have safe haven for shielding their previous mental health issues. I actually find this study optimistic- states ignore the FSMB and the ADA at their peril.

 

[Dr Mantis Toboggan]

Fair enough but we cover places with 50% night shifts. It's hard to get out of those ones, even with multiple nocturnal doctors.

Yup one of the many reasons I abhor the trend of the freestanding ED.

 

[emergentmd]

God, not everywhere. My last job I worked two Saturday overnights per month by the end. I quit. It took three people to fill my slot and now they are short on shifts. Lol.

Can you show me data that you can typically do this, not just that you were able to do it?

Sure its not everywhere but its not really that difficult. Like everything else in a job, you got to decide what is important. If avoiding nights is important, you may have to sacrifice location.

 

[miacomet]

Sure its not everywhere but its not really that difficult. Like everything else in a job, you got to decide what is important. If avoiding nights is important, you may have to sacrifice location.

Sure, and for some people they both need location and no nights, and a compromise just isn't workable or tolerable. I can decide that both of these is equally important and that therefore there isn't a tolerable solution.

 

[EctopicFetus]

I work very few nights and do 10-15 clinical shifts per month.

We have nocturnists. I would advise folks who are long term at their sites to create a system to let younger docs who usually want more money earn more and then let the older guys who should have more money and value not working at night.

Some places this is $40/hr, some places this is more, sometimes much more. Nonetheless there is a system where everyone wins. You could see if you have 5 shifts a day for the other 4 shifts to make $10/hr less and voila thats a $40/hr bump for the night doc and it is budget neutral.

 

[emergentmd]

I work very few nights and do 10-15 clinical shifts per month.

We have nocturnists. I would advise folks who are long term at their sites to create a system to let younger docs who usually want more money earn more and then let the older guys who should have more money and value not working at night.

Some places this is $40/hr, some places this is more, sometimes much more. Nonetheless there is a system where everyone wins. You could see if you have 5 shifts a day for the other 4 shifts to make $10/hr less and voila thats a $40/hr bump for the night doc and it is budget neutral.Y

Yup, you can always money whip some docs to do your nights. Even in single coverage 12 hr places, there is always a price. If you want no nights and keep your regular pay, not going to happen. But if you are willing to pay, someone will cover your nights. This is how my place always worked, nocturnist made $500/shift more and whoever doesn't want nights supplemented it. If you want more $, do more nights. If you didn't want to supplement, then you keep your share of nights.

 

[deuist]

If you want to continue practicing medicine without the burdens you described above, look into government contracting, such as the VA or military hospitals. You can also try medical missions, free clinics through the county health department, or cruise ship medicine. All of these options come with a lower salary, which is why most of us will not pursue them. Other options include working for the State Department or the CIA if you don't mind traveling.

 

[Apollyon]

Last time I looked at the CIA, they were paying $90k, and you had to live in the DC metro area. About 8 years ago.

 

[southerndoc]

Last time I looked at the CIA, they were paying $90k, and you had to live in the DC metro area. About 8 years ago.

I think you were looking at the wrong position. CIA pays physicians >$300k/year and allows moonlighting.

 

[Apollyon]

I think you were looking at the wrong position. CIA pays physicians >$300k/year and allows moonlighting.

As I said, years ago. That was low, then. Maybe they realized they had to pay more to recruit.

In fact, it was much longer ago, maybe 2008-9. I wasn't married at the time.

 

[EctopicFetus]

Yup, you can always money whip some docs to do your nights. Even in single coverage 12 hr places, there is always a price. If you want no nights and keep your regular pay, not going to happen. But if you are willing to pay, someone will cover your nights. This is how my place always worked, nocturnist made $500/shift more and whoever doesn't want nights supplemented it. If you want more $, do more nights. If you didn't want to supplement, then you keep your share of nights.

Problem is older docs often want to have their cake and eat it too. They want some special treatment for their seniority. It’s just not that way in most EM practices. Even SDGs here older docs dont do nights they pay for the younger ones to do the nights.

 

[Janders]

Problem is older docs often want to have their cake and eat it too. They want some special treatment for their seniority. It’s just not that way in most EM practices. Even SDGs here older docs dont do nights they pay for the younger ones to do the nights.

Exactly. Its OK for seniority to come with some minor perks. But if you want to not work nights because you've been at a shop for 10 years... you should still PAY for that perk. Its a BIG perk. We do a night tax where if you work more than your share of nights you make bonus money, less than your share you pay into it. Zero sum game, all internally funded. Our nocturnist makes significantly more than he would for his compliment of shifts due to this; if you happen to pick up two extra nights one month you also get a little gravy.

With one nocturnist, we basically all do about 1/3 or 40% less nights than we would otherwise. We basically share that evenly. When we've had partners who've been with us 10+ years and were 55yo+, they were allowed to go zero nights, but paid the exact same tax for said privilege. Two of them chose that, one didn't want to pay so much, so he just decreased his night compliment partially. Seemed to work well enough.

 

[miacomet]

Problem is older docs often want to have their cake and eat it too. They want some special treatment for their seniority. It’s just not that way in most EM practices. Even SDGs here older docs dont do nights they pay for the younger ones to do the nights.

This is why EM is a stupid career choice. Most other fields of medicine give you something for seniority.

 

[EctopicFetus]

This is why EM is a stupid career choice. Most other fields of medicine give you something for seniority.

The reason is in EM you have no patient list, you dont own anything meaningful like equipment. Frankly im not sure you are generally more valuable than a young guy who wants to work and make money. Some of the older guys wont even help out if there is a need. The younger guys will often step up as they are in the work mindset. I am a mid career guy myself but i guess i dont see the “value” the older guys bring to my group as compared to the younger 5-10 years out guys.

Just cause you have been here 20+ years doesnt mean you are special. Instead as I mentioned it makes more sense to create a win win scenario. They exist for everyone in each group. The simplest is the money part. I value money much less now than I did. I earned a decent couple of nickels. When i was early in my career I worked extra nights. Heck even recently I worked extra nights as we had some people who wanted out and were willing to pay a number that I was happy with.

 

[miacomet]

The reason is in EM you have no patient list, you dont own anything meaningful like equipment. Frankly im not sure you are generally more valuable than a young guy who wants to work and make money. Some of the older guys wont even help out if there is a need. The younger guys will often step up as they are in the work mindset. I am a mid career guy myself but i guess i dont see the “value” the older guys bring to my group as compared to the younger 5-10 years out guys.

Just cause you have been here 20+ years doesnt mean you are special. Instead as I mentioned it makes more sense to create a win win scenario. They exist for everyone in each group. The simplest is the money part. I value money much less now than I did. I earned a decent couple of nickels. When i was early in my career I worked extra nights. Heck even recently I worked extra nights as we had some people who wanted out and were willing to pay a number that I was happy with.

I agree. That's why picking EM as a field is stupid.

 

[ToastyEM80s]

The reason is in EM you have no patient list, you dont own anything meaningful like equipment. Frankly im not sure you are generally more valuable than a young guy who wants to work and make money. Some of the older guys wont even help out if there is a need. The younger guys will often step up as they are in the work mindset. I am a mid career guy myself but i guess i dont see the “value” the older guys bring to my group as compared to the younger 5-10 years out guys.

Just cause you have been here 20+ years doesnt mean you are special. Instead as I mentioned it makes more sense to create a win win scenario. They exist for everyone in each group. The simplest is the money part. I value money much less now than I did. I earned a decent couple of nickels. When i was early in my career I worked extra nights. Heck even recently I worked extra nights as we had some people who wanted out and were willing to pay a number that I was happy with.

I think in the old days of small SDG practices, there was a case to be made for seniority perks.

However, now-a-days we're all basically employees of large CMG's or large hospital systems. Unfortunately, we've all become interchangeable cogs.

 

[emergentmd]

The reason is in EM you have no patient list, you dont own anything meaningful like equipment. Frankly im not sure you are generally more valuable than a young guy who wants to work and make money. Some of the older guys wont even help out if there is a need. The younger guys will often step up as they are in the work mindset. I am a mid career guy myself but i guess i dont see the “value” the older guys bring to my group as compared to the younger 5-10 years out guys.

Just cause you have been here 20+ years doesnt mean you are special. Instead as I mentioned it makes more sense to create a win win scenario. They exist for everyone in each group. The simplest is the money part. I value money much less now than I did. I earned a decent couple of nickels. When i was early in my career I worked extra nights. Heck even recently I worked extra nights as we had some people who wanted out and were willing to pay a number that I was happy with.

But isn't this the same with most other fields. Its not just EM but medicine in general. Young hospitalists, Rad, Anesthesiologist, etc are just as good as the 60 yr old that never kept up with literature.

 

[comp1]

I'm glad so many of us are pushing government work! I think the OP might genuinely be more happy in a less litigious environment. Federal employment for physicians is...federal employment for physicians. The salary is going to vary slightly by specialty as there is a three tier system for that. It varies much more based on the physical location of your home, but it's not going to be $90k anywhere in US. NP salaries are not $90k anywhere in the US. Physician salaries in the federal government are re-evaluated every three years to basically match the average in a given geographic area, hence $300k for DC metro. It can be way off for extremely high paying surgical specialties, but certainly not EM. Here's a CIA job for example: Physician

 

[EctopicFetus]

But isn't this the same with most other fields. It’s not just EM but medicine in general. Young hospitalists, Rad, Anesthesiologist, etc are just as good as the 60 yr old that never kept up with literature.

I think it depends right. If you own the group there is often wisdom and knowledge in running the practice, dealing with insurers, vendors etc.

In Em thats basically gone and in most SDGs the mid career docs tend to be the ones doing much of the work. The folks within 10 years of retirement have generally mailed it in in EM unless they have a very special deal they are trying to protect.

 

[miacomet]

But isn't this the same with most other fields. Its not just EM but medicine in general. Young hospitalists, Rad, Anesthesiologist, etc are just as good as the 60 yr old that never kept up with literature.

These are also stupid fields to go into (at least rads and gas pay, and there's a shortage, so not as stupid as EM) for the same reason. Only real reason to go to medschool these days is subspecialty surgery.

 

[xaelia]

These are also stupid fields to go into (at least rads and gas pay, and there's a shortage, so not as stupid as EM) for the same reason. Only real reason to go to medschool these days is subspecialty surgery.

Probably the unfortunate truth – the non-surgical specialties are going to be required to dramatically evolve in an environment that, frankly, needs fewer of them.

There is a real percentage of patients through my pod every shift that require zero to minimal input from a boarded EM doc but require someone with medical training and a cookbook, a continuum of patients who receive a subjective benefit from my input, and a handful whose care is definitively improved by someone who can make confident decisions based off years of experience.

The old bogeyman of midlevel-creep is only going to become more potent as AI augmentations to clinical care can offload more cognitive burden and need for deep subject matter knowledge – autonomous and/or open-loop systems will emerge and make a big difference in the way care is delivered (as soon as the payment structures accomodate doing so, ha!).

 

[DrDrummer]

The old bogeyman of midlevel-creep is only going to become more potent as AI augmentations to clinical care can offload more cognitive burden and need for deep subject matter knowledge – autonomous and/or open-loop systems will emerge and make a big difference in the way care is delivered (as soon as the payment structures accomodate doing so, ha!).

I'm curious what you think of this as someone who I think is pretty bright and thoughtful about this stuff -- the one thing that I intuitively believe will protect our job is the lack of a desire on most reasonable humans' part to be The Person Responsible when a limp / seizing / pulseless child gets carried into an ER or a baby is half out or a GSW to the chest gets dropped off at a non-trauma center. Perhaps I underestimate how protective this will be, but it seems like there's a lot of things that you can't use a LLM for where you need someone who is more or less ready to act right away and also to act as a liability and emotional trauma sponge for these very high-risk scenarios. There's probably some PAs and NPs out there who are eager to do this for $120k/year, but I don't think there's enough to staff the CMS-mandated ERs of all the hospitals out there.

 

[miacomet]

I'm curious what you think of this as someone who I think is pretty bright and thoughtful about this stuff -- the one thing that I intuitively believe will protect our job is the lack of a desire on most reasonable humans' part to be The Person Responsible when a limp / seizing / pulseless child gets carried into an ER or a baby is half out or a GSW to the chest gets dropped off at a non-trauma center. Perhaps I underestimate how protective this will be, but it seems like there's a lot of things that you can't use a LLM for where you need someone who is more or less ready to act right away and also to act as a liability and emotional trauma sponge for these very high-risk scenarios. There's probably some PAs and NPs out there who are eager to do this for $120k/year, but I don't think there's enough to staff the CMS-mandated ERs of all the hospitals out there.

I'm so much less concerned with EM itself, which is an utterly lost cause, and with expanding plastics and derm and ophtho and ENT residencies- there are shortages of all of them- so people can go into actually functional, interesting fields, and also in expanding EM fellowships so that people can escape EM ASAP and do something they actually like an have some control over their lives and the patient care they provide.

 

[BoardingDoc]

I'm so much less concerned with EM itself, which is an utterly lost cause, and with expanding plastics and derm and ophtho and ENT residencies- there are shortages of all of them- so people can go into actually functional, interesting fields, and also in expanding EM fellowships so that people can escape EM ASAP and do something they actually like an have some control over their lives and the patient care they provide.

To play devil's advocate here: this is precisely the logic that was used to justify the massive EM residency expansion that is actively destroying the specialty. I can tell you that if I were in any of the specialties you mentioned, I would be lobbying quite vociferously against what you're suggesting.

 

[ToastyEM80s]

I'm curious what you think of this as someone who I think is pretty bright and thoughtful about this stuff -- the one thing that I intuitively believe will protect our job is the lack of a desire on most reasonable humans' part to be The Person Responsible when a limp / seizing / pulseless child gets carried into an ER or a baby is half out or a GSW to the chest gets dropped off at a non-trauma center. Perhaps I underestimate how protective this will be, but it seems like there's a lot of things that you can't use a LLM for where you need someone who is more or less ready to act right away and also to act as a liability and emotional trauma sponge for these very high-risk scenarios. There's probably some PAs and NPs out there who are eager to do this for $120k/year, but I don't think there's enough to staff the CMS-mandated ERs of all the hospitals out there.

I think that AI/LLMs are probably the biggest blindspot that most physicians are overlooking.

Let's take emergency medicine, we are losing autonomy and much of our work is now mandated algorithmic protocols. We are highly discouraged from deviating from said protocols, and if we do - we usually have a come-to-Jesus meeting with take your pick coordinator (Trauma, Sepsis, Stroke, STEMI, Admissions).

Project this forward, essentially, an AI - can make 100% adherence to said protocols, paired with a trained midlevel in critical care procedures, will probably be enticing for large hospital systems. It will be advertised as reducing "waste" and optimize efficient use of resources.

AI/LLM's will eventually be a no-brainer for specialities that are not patient-facing: radiology/pathology.

I don't have an answer on how to prevent AI disruption, but I think relying on regulatory and legal barriers to protect physician job prospects is a mistake. At a certain point, it may be that the cost-savings of relying on AI/physician salaries outweigh the legal costs of just assuming liability for midlevels/AI decisions. Not to mention, healthcare systems have powerful lobbies that can advocate for tort reform if they assume above liability.

----

On a side note, I've been getting numerous locums SPAM, that now include PPH in the job description? Has this always been the case? Wondering if pph are increasing and burning out more physicians?

 

[miacomet]

To play devil's advocate here: this is precisely the logic that was used to justify the massive EM residency expansion that is actively destroying the specialty. I can tell you that if I were in any of the specialties you mentioned, I would be lobbying quite vociferously against what you're suggesting.

Exactly. They are. And it's hard to expand these because unlike EM there are actual standards for these residencies so they can't be expanded like EM. EM has minimal to no standards these days- any hospital can open a residency. But these fields have stuck to having standards so the probably won't expand.

 

[bky3c]

On a side note, I've been getting numerous locums SPAM, that now include PPH in the job description? Has this always been the case? Wondering if pph are increasing and burning out more physicians?

I've been getting locums spam for years (even now, nearly 5 years post retirement), and in my experience, many of them have listed PPH. Whether that number is true (or current) is a whole other question...