What the F*** should I do with my life?

[The Knife & Gun Club]

So the world has changed a lot in the last 2 years. When I started Med school and decided on EM my original goal was to do EM residency, maybe Med-Ed fellowship, and enter the world of academic EM. Debt burden between myself and my physician spouse is around $400k, so manageable for a double-doc household.

But the world of EM has changed drastically. Academic jobs are virtually non-existent, and jobs in general are getting harder to come by. In the current market it’ll be difficult to impossible to find work in the same location as my spouse, making the whole situation quite hairy. I’ve thought of a few options and wanted to hear takes from the SDN hive-mind.

1) Do crit. I love crit, have the CV to get a spot if I want (maybe not in my preferred location but whatever). Pros: Will give me a better chance of being able to teach/do academic something either in CCM or EM. Cons: BRUTAL 2 year fellowship, 2 years long distance from the SO while she finishes training. 2 years lost wages. CCM job market isn’t headed in the best direction either.

2) Pick up a rural job, fly to and from wherever I live to wherever I work. Pros: geographic flexibility for the SO’s career, some hospitals in the boonies still treat their ED docs well. Cons: crummy work life balance and long term outlook is poor as the job market squeezes further and doing runs of flight+nights at 40 is a lot harder than it is at 28. Won’t be able to re-enter academics later.

3) Yolo and apply to every pain fellowship in the country. Pros: Pain is cool, I love procedures, will have a bit more control over my life and work environment. Cons: 1 year of long distance from the SO, and while I’d enjoy pain my passion is teaching and that’d be off the table for the most part.

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[curiousneuro]

Is telemedicine an option for EM graduates? I'll be doing pure teleneuro/telestroke starting July, and it has a great work life balance, and can be pretty lucrative. If that exists in EM, maybe that could be an option as well? Cons would be that you wouldn't have any procedures...

 

[deleted941485]

So the world has changed a lot in the last 2 years. When I started Med school and decided on EM my original goal was to do EM residency, maybe Med-Ed fellowship, and enter the world of academic EM. Debt burden between myself and my physician spouse is around $400k, so manageable for a double-doc household.

But the world of EM has changed drastically. Academic jobs are virtually non-existent, and jobs in general are getting harder to come by. In the current market it’ll be difficult to impossible to find work in the same location as my spouse, making the whole situation quite hairy. I’ve thought of a few options and wanted to hear takes from the SDN hive-mind.

1) Do crit. I love crit, have the CV to get a spot if I want (maybe not in my preferred location but whatever). Pros: Will give me a better chance of being able to teach/do academic something either in CCM or EM. Cons: BRUTAL 2 year fellowship, 2 years long distance from the SO while she finishes training. 2 years lost wages. CCM job market isn’t headed in the best direction either.

2) Pick up a rural job, fly to and from wherever I live to wherever I work. Pros: geographic flexibility for the SO’s career, some hospitals in the boonies still treat their ED docs well. Cons: crummy work life balance and long term outlook is poor as the job market squeezes further and doing runs of flight+nights at 40 is a lot harder than it is at 28. Won’t be able to re-enter academics later.

3) Yolo and apply to every pain fellowship in the country. Pros: Pain is cool, I love procedures, will have a bit more control over my life and work environment. Cons: 1 year of long distance from the SO, and while I’d enjoy pain my passion is teaching and that’d be off the table for the most part.

I used to think teaching was in the cards for me. Now that I'm out in practice I don't care to share my thoughts with students. In this environment, why teach at all. We have all the EMs were ever gonna need. Why teach more of them?

Why don't you just do pain...at least its still a steady stream of patients and does not necessarily need to beholden to a hospital.

 

[The Knife & Gun Club]

I used to think teaching was in the cards for me. Now that I'm out in practice I don't care to share my thoughts with students. In this environment, why teach at all. We have all the EMs were ever gonna need. Why teach more of them?

Why don't you just do pain...at least its still a steady stream of patients and does not necessarily need to beholden to a hospital.

I agree that we could never train another EM evident for the next decade and the field would be more than full.

What I really like is undergraduate med Ed - like teaching the fundamentals of physiology, physical exams, ultrasound, etc. not necessarily GME. And unlike residency, I still believe EM clerkships as a student are super important so every budding sub specialist knows what it’s really like in the ED when you’re trying to admit for CHF exacerbation but there’s a code and a stroke alert occurring immediately before and after that phone call.

 

[deleted941485]

I agree that we could never train another EM evident for the next decade and the field would be more than full.

What I really like is undergraduate med Ed - like teaching the fundamentals of physiology, physical exams, ultrasound, etc. not necessarily GME. And unlike residency, I still believe EM clerkships as a student are super important so every budding sub specialist knows what it’s really like in the ED when you’re trying to admit for CHF exacerbation but there’s a code and a stroke alert occurring immediately before and after that phone call.

Let the PhDs and the MS Teaching assistants worry about teaching physio etc. I think you're just gonna have to let this teaching thing go unless of course its art history of something.

 

[Birdstrike]

So the world has changed a lot in the last 2 years. When I started Med school and decided on EM my original goal was to do EM residency, maybe Med-Ed fellowship, and enter the world of academic EM. Debt burden between myself and my physician spouse is around $400k, so manageable for a double-doc household.

But the world of EM has changed drastically. Academic jobs are virtually non-existent, and jobs in general are getting harder to come by. In the current market it’ll be difficult to impossible to find work in the same location as my spouse, making the whole situation quite hairy. I’ve thought of a few options and wanted to hear takes from the SDN hive-mind.

1) Do crit. I love crit, have the CV to get a spot if I want (maybe not in my preferred location but whatever). Pros: Will give me a better chance of being able to teach/do academic something either in CCM or EM. Cons: BRUTAL 2 year fellowship, 2 years long distance from the SO while she finishes training. 2 years lost wages. CCM job market isn’t headed in the best direction either.

2) Pick up a rural job, fly to and from wherever I live to wherever I work. Pros: geographic flexibility for the SO’s career, some hospitals in the boonies still treat their ED docs well. Cons: crummy work life balance and long term outlook is poor as the job market squeezes further and doing runs of flight+nights at 40 is a lot harder than it is at 28. Won’t be able to re-enter academics later.

3) Yolo and apply to every pain fellowship in the country. Pros: Pain is cool, I love procedures, will have a bit more control over my life and work environment. Cons: 1 year of long distance from the SO, and while I’d enjoy pain my passion is teaching and that’d be off the table for the most part.

Why is that?

I do Pain and teach a rotation with residents rotating with me regularly.

 

[dchristismi]

I sort of miss teaching, but honestly, I just teach my nurses at this point. It's not quite the same, but it works enough for me.

I'd say go the pain route. One year will go fast.

 

[Test Boy]

I sort of miss teaching, but honestly, I just teach my nurses at this point. It's not quite the same, but it works enough for me.

I'd say go the pain route. One year will go fast.

Easier said than done. It’s competitive even if you did anesthesia or PMR.

 

[Dr Mantis Toboggan]

So the world has changed a lot in the last 2 years. When I started Med school and decided on EM my original goal was to do EM residency, maybe Med-Ed fellowship, and enter the world of academic EM. Debt burden between myself and my physician spouse is around $400k, so manageable for a double-doc household.

But the world of EM has changed drastically. Academic jobs are virtually non-existent, and jobs in general are getting harder to come by. In the current market it’ll be difficult to impossible to find work in the same location as my spouse, making the whole situation quite hairy. I’ve thought of a few options and wanted to hear takes from the SDN hive-mind.

1) Do crit. I love crit, have the CV to get a spot if I want (maybe not in my preferred location but whatever). Pros: Will give me a better chance of being able to teach/do academic something either in CCM or EM. Cons: BRUTAL 2 year fellowship, 2 years long distance from the SO while she finishes training. 2 years lost wages. CCM job market isn’t headed in the best direction either.

2) Pick up a rural job, fly to and from wherever I live to wherever I work. Pros: geographic flexibility for the SO’s career, some hospitals in the boonies still treat their ED docs well. Cons: crummy work life balance and long term outlook is poor as the job market squeezes further and doing runs of flight+nights at 40 is a lot harder than it is at 28. Won’t be able to re-enter academics later.

3) Yolo and apply to every pain fellowship in the country. Pros: Pain is cool, I love procedures, will have a bit more control over my life and work environment. Cons: 1 year of long distance from the SO, and while I’d enjoy pain my passion is teaching and that’d be off the table for the most part.

One of my partners applied to be an owner/operator of a Chik Fil A. He was willing to give up emergency medicine if he got a franchise location. He didn’t get one.

 

[betamale]

Welcome to the YOLO Economy (Published 2021)

Burned out and flush with savings, some workers are quitting stable jobs in search of postpandemic adventure.

www.nytimes.com

This.

 

[WilcoWorld]

It sounds like option #3 is what you expect will make you happiest.

Do what makes you happy, and be open to the possibility that what that is may change with time.

 

[Birdstrike]

Easier said than done. It’s competitive even if you did anesthesia or PMR.

Most things worth attaining are easier said than done.

 

[Birdstrike]

Patient population may also not be appealing. May just be me but I cannot stand thinking of the idea of treating pain patients long term. A lot of people with MSK pain bark for oxycodone/controlled substances like it's candy.

They don't do this in your current line of work?

 

[Test Boy]

Patient population may also not be appealing. May just be me but I cannot stand thinking of the idea of treating pain patients long term. A lot of people with MSK pain bark for oxycodone/controlled substances like it's candy.

The vast majority of physicians don’t like dealing with these patients either! Lol, I’m sure most pain docs dread their clinic days and would rather just do their injections and be done with it.

 

[Mr. Vandemar]

My impression was jobs in the pain market are not easy to come by either, particularly in desirable locations. Worth considering if you are viewing this as a means to have more control over where you find work.

 

[sloh]

Pain is feeling the squeeze as well. I know a lot of colleagues coming out of pain fellowship and their job offers are either slim or pitiful. You’re honestly probably better off doing urgent care. Probably a more tolerable patient population as well. Have you looked into palliative care?

Chronic Pain Management and Midlevel Encroachment

Resident here- So I'm having a discussion a few months ago with a chronic pain doc about my future plans as a generalist, and she opined that current residents need to 'strongly consider' doing a fellowship for "job security" with all the common arguments we've heard before. She mentioned her...

forums.studentdoctor.net

“I practice anesthesia and interventional pain management, fellowship trained. Training was very heavily interventional but in a university true multidisciplinary treatment program.

CRNAs independently practicing interventional pain has been going on for a while now.

A lot of non fellowship trained anesthesiologists and physiatrists practicing only interventional pain. Some family doctors and emergency room physicians attend weekend courses and conferences for fluoro and ultrasound guided blocks then call themselves pain specialists. Some of these courses are physician only. Some are not. I remember as a resident attending a very large name national annual pain conference and attending a few of the cadaver lab courses. Side by side with PAs/NPs who after speaking with them, want interventional only practices in rural areas.

Even chiropractors and naturopaths are out practicing interventional pain with ultrasound and fluoroscopy, especially the regenerative medicine cash only stuff. Even know of someone who had left residency without finishing and just opened a pain clinic, state specific.

Not hard to buy or lease a c arm and ultrasound machine.

No they are not only doing minor blocks. Some are out doing radiofrequency ablations and spinal cord stimulators.

I have worked in private practice with non fellowship trained physicians with a background in emergency medicine, family medicine, anesthesia, physiatry, and psychiatry. From my experience, the most knowledgeable and multidisciplinary focused are the psychiatrists.
The joke that pain management is really just interventional psychiatry is mostly true.

Overgeneralizing but many of the nonacademic anesthesia and physiatry guys just wanna go out after training and run a block shop. Again overgeneralizing, many of the family med and emergency medicine guys have little to no foundational understanding of the very basics of chronic pain or management. Many frequently tout disproven theories and treatments or experimental treatments on a cash only basis. Nothing is stopping a family doc from buying bone marrow aspiration kits, a centrifuge, and opening up shop. Nothing is stopping a new grad from opening up a ketamine clinic that claims to cure anything under the sun. Some pain docs used to overtest every urine sample with their own lab and found this is far more lucrative than interventional procedures. These "pee mills" really gave insurances a tough time. Now the DEA is cracking down hard on such behaviors. Heck, even dermatologists are pushing PRP and microRFA for many conditions. All real examples. Not trying to start a flame war, just my experience.

I'm not writing this to discourage you if you want to pursue this path but know that it's a wide open mostly unregulated market and many people from all sorts of educational backgrounds want a piece of the pain management pie.

The current pain market is saturated. Unless you want to go to the underserved boonies, it will be hard to open something for yourself.

Reimbursement has been dropping. Likely from over utilization. Even one of the biggest names in spinal cord stimulation is says it's way overused and may not be a covered benefit in the future if changes aren't made.

Some insurance companies will only allow you to bill for pain procedures if you are fellowship trained.”

 

[Birdstrike]

The vast majority of physicians don’t like dealing with these patients either! Lol, I’m sure most pain docs dread their clinic days and would rather just do their injections and be done with it.

Not at all. My worst clinic day feels like one of my best days in the ED. The most hardcore, end-of-the-line medication abusers/doctor-manipulators don't come to see me. They have no hope of getting through my screening and referral process. They go to the ED.

What most of my EM colleagues don't seem to understand is that practicing Pain Medicine doesn't equal "seeing EM drug seekers every day." But that is what EM is.

What I do is something entirely different than that.

 

[miacomet]

I just want to say that while our politics may differ in some ways, @Birdstrike has consistently given some of the most levelheaded advice on EM in this forum.
Sadly, Pain is getting pretty packed now, too. The exit strategies for EM are few, and getting fewer. Caveat emptor.

 

[dadaddadaBATMAN]

Not at all. My worst clinic day feels like one of my best days in the ED. The most hardcore, end-of-the-line medication abusers/doctor-manipulators don't come to see me. They have no hope of getting through my screening and referral process. They go to the ED.

What most of my EM colleagues don't seem to understand is that practicing Pain Medicine doesn't equal "seeing EM drug seekers every day." But that is what EM is.

What I do is something entirely different than that.

I’m not pursuing or involved in pain, but the patients I would be more concerned with would be the incurable fibro/back pain/trigeminal neuralgia chronic lyme flavor of folks.

Do you get many of these? I dread them far more than opiate seekers. Obviously we get them in the Ed, but we can do fun things like say “you need a pain specialist (really a psychiatrist and a dog)”

 

[bravotwozero]

I’m not pursuing or involved in pain, but the patients I would be more concerned with would be the incurable fibro/back pain/trigeminal neuralgia chronic lyme flavor of folks.

Do you get many of these? I dread them far more than opiate seekers. Obviously we get them in the Ed, but we can do fun things like say “you need a pain specialist (really a psychiatrist and a dog)”

But as a pain doc, you aren't bound to EMTALA. You don't have to see anyone you don't want to.

As for the market being crowded, that may or may not be true. But I'm sure you could join an existing practice, or or start a new one, because you are no longer restricted to a hospital. There's no shortage of pain patients, even in this saturated market.

 

[miacomet]

Starting a practice is not easy, that's for sure. But yes, anything non hospital-related is the way to go.

 

[Birdstrike]

I’m not pursuing or involved in pain, but the patients I would be more concerned with would be the incurable fibro/back pain/trigeminal neuralgia chronic lyme flavor of folks.

Do you get many of these? I dread them far more than opiate seekers. Obviously we get them in the Ed, but we can do fun things like say “you need a pain specialist (really a psychiatrist and a dog)”

I tend to focus on the interventional pain so I don't get as many of those types patients as you'd think. But yes, the chronic pain population a challenging patient population. It's a matter of your mindset and expectations. You can't expect to cure anyone. You're managing a chronic condition. You learn the treatments options, do or recommend them, and move on. When done, they can be sent back to their PCP or surgeon. If you can lower someone's pain 30% for a while, you're doing great. You're not expected to make everyone 100% cured/dispo'd-for-cure, 100% pain free, and 100% happy, all the time, like in the ED.

If your practice style is to minimize the use of opiate as much as possible, and have a good screening process, you will see mostly what you choose to see, and what referrals you accept.

Burnout does exist in Pain. But in my personal direct comparison with EM, I find my stress and feelings of burnout are 80-90% lower, because even when you have to deal with someone that slips through, you're not having to juggle codes, criticals and circadian-rhythm depression, on top of it all. It's immeasurably easier for me, simply because I feel rested all the time and I set my own pace, as opposed to it always being 25% faster than what feels sane.

Most of all, I get to have a normal life. Of the many reasons the benefits of doing the fellowships outweighed the drawbacks, this was numbers 1 through 10 on the list. I get to live a normal life now and it's incredibly freeing. At least for me.

 

[Iamnew2]

So the world has changed a lot in the last 2 years. When I started Med school and decided on EM my original goal was to do EM residency, maybe Med-Ed fellowship, and enter the world of academic EM. Debt burden between myself and my physician spouse is around $400k, so manageable for a double-doc household.

But the world of EM has changed drastically. Academic jobs are virtually non-existent, and jobs in general are getting harder to come by. In the current market it’ll be difficult to impossible to find work in the same location as my spouse, making the whole situation quite hairy. I’ve thought of a few options and wanted to hear takes from the SDN hive-mind.

1) Do crit. I love crit, have the CV to get a spot if I want (maybe not in my preferred location but whatever). Pros: Will give me a better chance of being able to teach/do academic something either in CCM or EM. Cons: BRUTAL 2 year fellowship, 2 years long distance from the SO while she finishes training. 2 years lost wages. CCM job market isn’t headed in the best direction either.

2) Pick up a rural job, fly to and from wherever I live to wherever I work. Pros: geographic flexibility for the SO’s career, some hospitals in the boonies still treat their ED docs well. Cons: crummy work life balance and long term outlook is poor as the job market squeezes further and doing runs of flight+nights at 40 is a lot harder than it is at 28. Won’t be able to re-enter academics later.

3) Yolo and apply to every pain fellowship in the country. Pros: Pain is cool, I love procedures, will have a bit more control over my life and work environment. Cons: 1 year of long distance from the SO, and while I’d enjoy pain my passion is teaching and that’d be off the table for the most part.

Pain is competitive. EM is typically not the most competitive specialty for pain. Typically goes to Anesthesia or PM&R. Also Pain has its own world of hurt right now, with declining reimbursements, predatorial groups, midlevels doing procedures, having to do more and more invasive stuff, etc. Uncertain that you'd match. You dont just wake up and say hey! let me do pain.

 

[Birdstrike]

Pain is competitive

All the good specialties are.

EM is typically not the most competitive specialty for pain

So what? Suffice it to say, people with low self esteem, who don't believe in themselves need not apply.

Pain has its own world of hurt right now, with declining reimbursements, predatorial groups, midlevels doing procedures, having to do more and more invasive stuff, etc.

Reimbursements: Over the years, some go down, some go up. They do this in every specialty. If they stop paying you for certain things, you stop doing them and start doing the stuff they reimburse for. Some procedures pay pennies; other pay thousands. But either way, they've been saying this for 10 years and I've managed to do well. You adapt your practice patterns.

"Predatorial groups": I'm not sure specifically whether this refers to groups that try to swallow up other groups or just groups of docs full of jerks, scammers, fraudsters. But both exist in Pain and some other specialties, particularly procedural and surgical based. Talk to surgeons about having to deal cut-throat competing groups. Having to tolerate such meatheads is annoying, but a small price to pay for being able to be a doctor with Derm-hours.

Mid-levels doing procedures: This applies to all specialties, not unique to Pain. But we're used to this, always having had to deal with chiro's, ortho, physical therapists, PCPs, surgeons and others for patients. There's always been enough patients to go around.

"Having to do more invasive stuff" I'm not sure what this specifically refers to, but as an interventionalist, learning new and 'more invasive' procedures is actually what we like to do.

You dont just wake up and say hey! let me do pain [and get accepted]

Why not? I did.

I just applied. No rotation, no research, nothing. Just years of seeing patients in all types of acute and chronic pain, in the ED. Dozens of balls of silly putty thrown up against the wall until one stuck. Fast forward 10 years and here I am. Numerous others on this board did the same, and have gotten in. The only way to know if that would work for others, is to apply. Applying is no guarantee of acceptance. But not applying does guarantee non-acceptance.

 

[miacomet]

I think it's harder now, @Birdstrike. Things have changed a lot in ten years, just as they have in EM.

 

[Birdstrike]

I think it's harder now, @Birdstrike. Things have changed a lot in ten years, just as they have in EM.

Of course it's gotten harder to get in, and it will continue to.

Which restaurant do you want to eat at?

The one that's tough to get a reservation at, or the one where all the tables are empty?

 

[Iamnew2]

I think it's harder now, @Birdstrike. Things have changed a lot in ten years, just as they have in EM.

correct. trying to give op objective view.

 

[Birdstrike]

Disclaimer: My intent is not to convince a bunch of ER docs, or even one, to go into Pain. In fact, it's better for me if I don't.

My intent is,

1) To let EM docs know that this option exists, because a lot of people still don't,

2) Be one person they can talk to that's actually done it, if interested, and

3) Let people know the don't have to be trapped in EM if it's making them miserable.

I know for a fact the culture of EM is for people to gaslight the docs and try to convince them they are crazy for feeling burned out by the whole goat-circus of it all, and not the other way around. It is in fact, the ED that's nuts, not the staff. Never forget that.

 

[southerndoc]

One of my partners applied to be an owner/operator of a Chik Fil A. He was willing to give up emergency medicine if he got a franchise location. He didn’t get one.

It's harder than you think to get a CFA franchise.

 

[Birdstrike]

But as a pain doc, you aren't bound to EMTALA. You don't have to see anyone you don't want to.

As for the market being crowded, that may or may not be true. But I'm sure you could join an existing practice, or or start a new one, because you are no longer restricted to a hospital. There's no shortage of pain patients, even in this saturated market.

Agree on all counts.

 

[Dr Mantis Toboggan]

It's harder than you think to get a CFA franchise.

No I know it’s very very difficult. Easier to get into med school.

 

[miacomet]

No I know it’s very very difficult. Easier to get into med school.

Why is it so hard? What are the qualifications for a franchise?

 

[Apollyon]

Why is it so hard? What are the qualifications for a franchise?

Yeah, that's what I was wondering. Getting a franchise is straightforward - is there a territory? Do you have the money?

There are some franchises you can get for $250K (like Tim Horton's, from YUM Brands). I'm guessing the assets to get CFA might be a LOT higher, like $1mil.

I don't know if they make you notarize a statement that you are a church-going Christian (and no Catholics allowed, thanks).

 

[Dr Mantis Toboggan]

Yeah, that's what I was wondering. Getting a franchise is straightforward - is there a territory? Do you have the money?

There are some franchises you can get for $250K (like Tim Horton's, from YUM Brands). I'm guessing the assets to get CFA might be a LOT higher, like $1mil.

I don't know if they make you notarize a statement that you are a church-going Christian (and no Catholics allowed, thanks).

So CFA is like the opposite of emergency medicine residencies: they are very careful about where they expand and insure that they are not oversaturated (as opposed to like, HCA or Subway sandwich shops).

So the spots are very limited (many applicants per spot) and you the are owner-operator of your store (again the opposite of EM since we love to hire midlevels to do the actual work). So no one can own 10 CFA’s and become a zillionaire you get one and you work there a lot and you just become a millionaire (300 or more a year I’ve been told) and that’s why the quality is good at virtually every one. I believe the CFA corporation has an ownership stake as well, maybe somewhere around 50-50? The exact % I am unsure of. I don’t think you have to bring a ton of $ to the table...

 

[Iamnew2]

Why is it so hard? What are the qualifications for a franchise?

for chik fila, since it's a christian organization, you have to be a christian, christ based beliefs, also can only work as a franchise owner. they have hundreds of applications yearly so very select

 

[RustedFox]

I know for a fact the culture of EM is for people to gaslight the docs and try to convince them they are crazy for feeling burned out by the whole goat-circus of it all, and not the other way around. It is in fact, the ED that's nuts, not the staff. Never forget that.

Dear God, this.

I wound up on SSRI/BZD meds for the first time after 8 years doing this job. Awful side effects. Thought I was developing multiple sclerosis.

Bird said it first and said it best: "This job is bad for you."

 

[Apollyon]

So CFA is like the opposite of emergency medicine residencies: they are very careful about where they expand and insure that they are not oversaturated (as opposed to like, HCA or Subway sandwich shops).

So the spots are very limited (many applicants per spot) and you the are owner-operator of your store (again the opposite of EM since we love to hire midlevels to do the actual work). So no one can own 10 CFA’s and become a zillionaire you get one and you work there a lot and you just become a millionaire (300 or more a year I’ve been told) and that’s why the quality is good at virtually every one. I believe the CFA corporation has an ownership stake as well, maybe somewhere around 50-50? The exact % I am unsure of. I don’t think you have to bring a ton of $ to the table...

Well, that's about any business, as far as saturation. I use Tim's, because that is the one with which I am most familiar. Even though, in our area, it seems as if there are too many Tim's, actually, each business is doing crazy business. I had heard (but can't locate now) of a corner in Newfoundland, if I recall, where, on 3 of 4, there was a Tim's, and they all had their very loyal customer base, and all were doing wonderfully. They map out heat maps, and that's where they determine if there is an area that can bear one.

But, also, what is the hallmark of business? Know your audience. We have a CFA opening (or maybe opened already) which is the second one in the area. Me? I rarely went when I lived in NC and SC, and I wasn't all that impressed. I won't be going out of my way to go there.

I wonder how they evaluate if you are Christian enough.

 

[miacomet]

Well, that's about any business, as far as saturation. I use Tim's, because that is the one with which I am most familiar. Even though, in our area, it seems as if there are too many Tim's, actually, each business is doing crazy business. I had heard (but can't locate now) of a corner in Newfoundland, if I recall, where, on 3 of 4, there was a Tim's, and they all had their very loyal customer base, and all were doing wonderfully. They map out heat maps, and that's where they determine if there is an area that can bear one.

But, also, what is the hallmark of business? Know your audience. We have a CFA opening (or maybe opened already) which is the second one in the area. Me? I rarely went when I lived in NC and SC, and I wasn't all that impressed. I won't be going out of my way to go there.

I wonder how they evaluate if you are Christian enough.

Probably not in the way Jesus did....

 

[The Knife & Gun Club]

Dear God, this.

I wound up on SSRI/BZD meds for the first time after 8 years doing this job. Awful side effects. Thought I was developing multiple sclerosis.

Bird said it first and said it best: "This job is bad for you."

It’s so sad, because it doesn’t need to be bad. You can staff an ED appropriately, support it appropriately, make plenty of money, and have providers that don’t hate their lives.

But it’s cheaper to push everyone to their breaking point so someone at Blackrock can get new leather seats in their secondary private jet.

 

[southerndoc]

Why is it so hard? What are the qualifications for a franchise?

CFA is very selective because of the number of applications they have. You have to sign a NDA just to get the requirements. You do not have to be a Christian, but it does help. Previous management of a CFA is desired. You also need to show financial stewardship. Doesn't mean you need $5 million in capital, but you have to show that you know how to manage your money. CFA receives over 40,000 applications/year and has a <0.5% selection rate. Average cost to establish a restaurant is about a 1/2 mil to $2 mil depending on location. CFA maintains purchasing decisions and gets 15% of the sales.

The average CFA makes more than a McDonald's restaurant. Most places pull in more than $7 million in sales annually. The highest pull in close to $15 million. Most McDonald's restaurants generate about $1.5-2 million in sales.

Despite what the rumor is, you can have multiple units but it's rare to have more than one. More than two is unheard of. Operators have very little turnover (<1% per year). If you want to buy a CFA from another operator, you have to go through the approval process of CFA.

The rumor that you can only operate a CFA isn't true. You can have other adventures, but they don't want serial entrepreneurs. However, a CFA can still work in the ER as an emergency physician part-time.

 

[CajunMedic]

Telemedicine enables DO to pursue dual careers as doctor and Boeing 747 pilot - The DO

As I read this thread, I keep thinking about this guy. Guess it's a good thing I kept my steel-toed boots and life jacket. Wonder how many more days I need for my inland vessel Master's License? I can ride for 28 days and pick up a few shifts at Podunk General on my 14-28 days off. Hard part will be convincing someone to hire a dam near 50 year old semi-experienced deckhand/ER Doc.

 

[RoyBasch]

CFA is very selective because of the number of applications they have. You have to sign a NDA just to get the requirements. You do not have to be a Christian, but it does help. Previous management of a CFA is desired. You also need to show financial stewardship. Doesn't mean you need $5 million in capital, but you have to show that you know how to manage your money. CFA receives over 40,000 applications/year and has a <0.5% selection rate. Average cost to establish a restaurant is about a 1/2 mil to $2 mil depending on location. CFA maintains purchasing decisions and gets 15% of the sales.

The average CFA makes more than a McDonald's restaurant. Most places pull in more than $7 million in sales annually. The highest pull in close to $15 million. Most McDonald's restaurants generate about $1.5-2 million in sales.

Despite what the rumor is, you can have multiple units but it's rare to have more than one. More than two is unheard of. Operators have very little turnover (<1% per year). If you want to buy a CFA from another operator, you have to go through the approval process of CFA.

The rumor that you can only operate a CFA isn't true. You can have other adventures, but they don't want serial entrepreneurs. However, a CFA can still work in the ER as an emergency physician part-time.

How are you so knowledgeable about the CFA franchise system?

Anyways, very interesting.

 

[Gastrapathy]

If you are still a PGY1 and you don’t want to be an Emergency physician anymore, do something else.

 

[southerndoc]

How are you so knowledgeable about the CFA franchise system?

Anyways, very interesting.

I just know a ton of useless facts.

 

[Birdstrike]

I just know a ton of useless facts.

Try Jeopardy

 

[Apollyon]

I just know a ton of useless facts.

It's like Batman's utility belt - only useless until you need it, then, not useless. And Birdstrike's throwaway comment belies the fact that it is monumentally difficult to get on Jeopardy! as a contestant.

 

[southerndoc]

It's like Batman's utility belt - only useless until you need it, then, not useless. And Birdstrike's throwaway comment belies the fact that it is monumentally difficult to get on Jeopardy! as a contestant.

My high school best friend won a lot of money on Jeopardy. He tries to get me to go on all the time.

J! Archive - Eric Floyd

www.j-archive.com

J! Archive - Eric Floyd

www.j-archive.com

Maybe I'll follow in his footsteps one day. His comment during the show about his mother getting drunk and hanging out by the pool all day was priceless.

 

[BoardingDoc]

My high school best friend won a lot of money on Jeopardy. He tries to get me to go on all the time.

J! Archive - Eric Floyd

www.j-archive.com

J! Archive - Eric Floyd

www.j-archive.com

Maybe I'll follow in his footsteps one day. His comment during the show about his mother getting drunk and hanging out by the pool all day was priceless.

"What left the strongest impression?
Uh, I couldn't believe I was standing that close to Alex Trebek. I could reach out and bite him if I wanted to. That was kinda neat."

You've got some interesting friends.

 

[southerndoc]

"What left the strongest impression?
Uh, I couldn't believe I was standing that close to Alex Trebek. I could reach out and bite him if I wanted to. That was kinda neat."

You've got some interesting friends.

You don't know the half of it. I hang out with some that are more "interesting" than me.

 

[Sushirolls]

One EM alternative could be to become a bee keeper and then have a sideline niche practice of doing bee sting therapy. No idea what its for or what the evidence is.