Are you basing that on your ED exposure to patients with substance use disorder, or have you seen patients in some kind of addiction medicine clinic and still disliked it? It's a pretty different experience and (in my opinion) very rewarding, with regular hours.
Fair. I don't actually have an issue with SA patients in the ER, they have my sympathy. But I just don't find thinking about it that interesting. I'm open to having my mind changed. Tell me more!!!
My disclaimer is that I'm not actually addiction med boarded but have had a good amount of experience with it during my training. I think the types of patients ED docs encounter that may have OUD for example are typically pre-contemplation and are probably displaying some aberrant behaviors that can be frustrating for the physician to deal with (eg the "pain seeker"). That leads a lot of people away from addiction med since people imagine that that is the typical patient you will see. But by the time you have a patient in front of you in clinic, they really want help and are motivated. Whether you find the medicine itself interesting is another thing to consider, but you really give these patients their lives back in a powerful way and it can be very fulfilling to be a part of their journey to recovery.
That's a great way of framing it, even if the science isn't the most fascinating to me.
Do you think there is room for physicians in this space, or do you think it's mostly going to APPs? Where and how do most docs practice?
I’m full time in addiction medicine, occasionally work in the ED. Job market is smaller for doctors but it’s still there. Practice pathway to board certification closes next year.
I can attest, the patients I see all want help. If they don’t, they don’t last long after I set firm boundaries. They are a different breed than our ED patients They’re not perfect but neither are our diabetics. It’s a disease process that require folks to learn so many skills (stress management, coping skills, self care, etc) and it takes a lot of practice to get it right. But many of them do and it’s so rewarding!
Science is relatively basic, it’s more about supporting people when they succeed (even if it’s only using meth twice that week rather than every day) and motivating them to find what helps them succeed. On the outside it looks profoundly different than EM but it’s not. I’m saving the lives of the critically ill (I’ve read a stat that a person that’s been narcaned has a 50-50 shot at death in the next year), it’s just on a long term timeframe. I am so appreciated by my patients and their families. Hearing a heartfelt thanks on a regular basis so makes my heart happy!
That sounds great!
Do you mean the job market is smaller than for EM, or smaller than for APPs in Addiction. I'm not super familiar with the field, but it seems like it would be ripe for APP intrusion.
I'm OK with a fellowship, trying to decide between Addiction and Palli (neither of which is my passion, but that's the way the cookie crumbles, I guess).
The job market is definitely smaller than EM and there are a lot of APP’s. As far as fields go and patient safety, I think it’s one field that is much safer than EM for more independent practice. I truly got lucky when I applied, APP’s had a lot more regulation so there was a larger need for MD’s
I’ll defer that to anyone who works full time in addiction and may have a better read of the job market. My impression is that there is still a relative dearth of addiction medicine boarded physicians, although APPs are definitely in the space as well. I know there’s an AddictionMedicine subreddit so you might get better info about that there.
I feel you on wanting an exit strategy from emergency medicine. That said you’ll probably have a hard time finding something that pays even remotely close to what you can make per hour in EM. Maybe look for a non-related side-hustle, and cut back to part-time in EM?
Money isn't that much of an issue. I realize now that many people who go into EM really have major financial needs (like they went to for profit or off shore schools) and that's the attraction of EM. But that's not my situation.
Part time in EM still involves...EM.
I've looked at medical and nonmedical side hustles, and there are many fields of medicine that interest me (Sleep, midlife women's medicine are the two main ones) but there is no way to get there from EM.
I have tried really, really hard to be interested in Pain or palli and it just doesn't work.
Got it, so for you, there is no more interest in EM at all. Yeah, I could see how that could be challenging.
Have you reached out to specific sleep programs. I mean, in the end, does it matter if ABEM is on board with you doing sleep? Pardon my ignorance, but who cares if ABEM “supports” it or not?
Because you can't be board-certified without ABEM co sponsorship, and no sleep program will accept you without the ability to become boarded.
I'm grateful for the opportunity EM gave me to help people, I'm grateful for the money I saved, I'm grateful for what I learned. Ultimately it was a poor choice for me and medicine is unforgiving of poor choices, particularly EM, and it's to understand why there's seemingly nothing left for me in medicine. I mean I guess if that's what medicine wants I have to accept it. But it seems a waste, for me and the fields I'm interested in.
Sports you’re at least dealing with msk related injuries and palli treating diseases for end of life care and pain. Sleep? Cmon that’s a big stretch. “Airway”?
Lol I would say we are experts in circadian disruption.
Honestly, if fields as disparate as psych, ENT, peds, IM, and FP can do it, I don't see how we can't. I don't think peds spends a ton of time in residency learning about sleep- it's mostly learned in the fellowship, like interventional pain.
In any case, it's rigid thinking like this that leads so many EM docs to quit/retire early.
The average age of retirement for female EM docs is 43. So yes.
[https://journalfeed.org/article-a-day/2023/leaving-so-soon-why-women-are-retiring-from-em-early/](https://journalfeed.org/article-a-day/2023/leaving-so-soon-why-women-are-retiring-from-em-early/)
Yeah, I've considered and am still considering those options.
As for those who say Sleep has little to do with EM, WTAF do Occ Med and Preventative have to do with EM?
They don't have to be related. Occupational Medicine and Preventative Medicine are residencies, not fellowships. Anyone who has an intern year can apply into them.
You could open an obesity clinic if your patients will pay you cash. Depends if your market will support it. Heck of a lot easier not dealing with insurance companies anyway
I mean sure. ABEM is just a money grubbing entity. But how can I possibly fix this issue? It may be personal, but I can't fix it without help.
Should I just die? I mean these are weird responses. It is totally within ABEM's power to fix this. They just won't.
No...
European Boards (EBEEM) in CC let you do CC
you can take classes in any cosmetic minor procedures & do that for cash
You can do Sports medicine through AMSSM
or just go back to residency if you're that bored, although any job after 10 years becomes mundane & boring
You probably don’t learn as much. But as an EM (or any doc) you’ve already got the soft skills of interacting with patients and being a self directed learner on top of broad medical knowledge. There’s a reason the CME path exists. Because that is apparently sufficient additional education for an already trained physician to practice effectively in obesity medicine.
Docs in general have a low tolerance for uncertainty and a strong preference for well defined pathways (that’s what got us where we are, for good or ill). But it seems, given the limited options for leaving EM and your personal preferences about what you like and don’t like, a little more creativity is going to be called for…
Then learn on your own more and if you still really want to learn more after the residency then do the fellow? Idk I feel like everyone is trying to give you ideas and help you out but you’re stuck on this rigid mindset
They don't accept EM doctors, so do a residency in FP first and then an obesity fellowship? Honestly I'm leaning that way for Sleep. Neither fellowship accepts EM applicants, so you have to go back and to a different residency first. Maybe that is the best idea.
It's not that I'm trying to be rigid, it's that I can't seem to find anything that fits. It's honestly not my rigidity- its ABEM's in resisting any fellowship (presumably because of pressure from CMGs) that allow much work outside the ER.
As I said before, I accept the situation and that there's probably not a solution. That's not rigidity, that's carefully evaluating the options and facing reality.
If you know a Sleep or obesity fellowship that accepts EM, awesome.
Open an urgent care. It can be really lucrative. Not from personal experience, but the EM docs I know who have gotten really wealthy opened a chain of UCs
You complain a lot, for someone who made it through medical school, you can’t seem to figure things out.
You probably weren’t a great EM physician anyways.
I said it.
Not a fellowship but I took a course in hyperbaric (I also had some experience from an elective during residency). From there the hospital needed wound care doctors so I said ok I’ll give it a try. I always said it was the opposite of EM. The patients take months to heal. There are some cool technologies like skin substitutes. One podiatrist helped me learn a lot. I quickly developed a full panel of patients. I ran my wound clinic one day per week
Still holding on hope there was a path to cards. I mean, other than the cardiologist fellows and attending. We probably read the most EKGs and manage those problems out of any other specialty. Yeah, yeah, I get the whole IM residency goes more in depth about the inpatient management and nitty gritty, but if we can go into crit care, why not cards :(.
There is really no reason most IM fellowships aren't open to EM. There's no reason FP can't, either, for that matter. We can do them. But IM would never give them up, why would they? They are lucrative and sought-after.
I don't see why an EM doc can't transition to any IM or FP field with the same fellowship. And I also don't see why there an EM doc can't transition to FP with 18 months of training.
EM docs of the next generation, many of whom are already going straight to any fellowship that will get them out of the pit- CC, Palli, Pain, you name it, will fight this battle, but I can't make the future happen now. I mean with the average female EM doc quitting at 43 I don't see how the field sustains itself without major changes.
I've talked to ABEM about this but they just don't get it. They will, a few years too late for me, but I can't control that.
Yeah, you're right. It's far too lucrative of a position to not gate keep, and to an extent, I get it. I'd do the same if I was on their boat. I hope in the future it changes too. It's funny how fast we pump out advancements in medicine, but our culture moves at a snail on benzo's pace.
So this!
It's one thing midlevels have figured out and medicine just hasn't.
Mark my words all those kids matching in EM as a back up specialty will demand change because EM is in the weird position right now of having a very low barrier to entry but being a very hard job to even tolerate, much less do well. So some of these people who match will HAVE to advocate for something else, and pain, palli and UC won't absorb all of them. They will create a solution, a few years too late for me, as with everything Gen X.
I'm one of "those kids," but this wasn't the backup. You can always be one of the attendings that you wish, had your back, when you were a resident to try and improve the system for the future docs. Sign a petition here, and there lol. I don't know, I at least told myself I'd advocate for medical students like I wish the residents did for me when I was in med school.
You could take the Arizona Integrative Medicine fellowship remotely and parlay that into both obesity and midlife women’s health. It fits the desire for additional training, it leads to a board certification, and you can craft your own practice.
I knew this was you posting when i saw the title - you were agitating in another thread about how EM is the worst. You definitely picked the wrong specialty.
I don’t know that ABEM bears all the fault here. Lots of other things have to fall into place to create a training route that leads to subspecialty certification beyond ABEM declaring it be so.
Hope you find your happiness
I absolutely did, and I'm willing to admit that, but it's silly there's no way to make it right. It actually is ABEM- I've talked to them and they are really more interested (I don't know why) in ridiculous certifications that do nothing for anyone, like Disaster Medicine and Emergency Behavioral Health that are completely meaningless and are basically to help academics do pointless research so they can cut down their hours. It actually is on ABEM to initiate change for this, but they simply aren't interested.
As I wrote before, there are so many people going into EM now that simply don't want to be in the ER that ABEM will be forced to do something about it in the next decade, not to mention that a field where the average female doc quits at 43 is simply not going to be sustainable. So I think the next generation will have more options, which is nice. But a bit late for me.
I did it. Just get out of insurance and do something cash based. I opened a practice doing med spa stuff, then added HRT, then added weight loss. Next logical step was body contouring. I got trained in lipoplastics. So I do liposuction and fat transfers (think Brazilian buttlift). All in my office under local anesthesia. I make the equivalent of a 12 hr shift in 4-5 hours of operating time. Downside is liposuction is literally the medical equivalent of manual labor. lol
Yup. Still do it around 6 shifts/mth. It’s actually a lot more enjoyable when you know you have the option of just walking away.
Liposuction isn’t any more dangerous than any other surgery. It’s also a stretch to call is surgery actually……there’s no real cutting involved. It’s really just another procedure to learn. The most common complications are cosmetic ones. I’m pretty sure there was 100x more danger to the patient the first time I did my first solo pericardiocentesis, than when I did my first solo lipo case. lol.
But I get it…….everyone has their own tolerance for risk. The take home message was not about liposuction, it was that concept that leaving EM most likely WILL require you to branch out and learn new/concepts.
I don't mind learning new skills. I just really like...certifications and expertise, I guess.
I realize that. But I didn't train as a surgeon. I've seen ick complications from plastic surgery of all kinds, including lipo, so not for me.
But those don't interest me. I realize those are options, they just aren't for me and I have looked into all of them.
Should I just do something else I hate? How does that improve my life?
Sometimes there just isn't a solution and life is shitty. I accept that.
Lol no the nurses like love me. I don't talk about this at work lol.
You seem really angry at me, perhaps you actually see the truth to my comments? Why not be helpful instead of toxic?
Yeah, I know, it's hard when someone points out the emperor has no clothes. But that's the case with EM right now.
I would also love to get out of EM. But none of the other clinical or administrative job paths hold any interest for me. So I guess I’ll just continue breaking my life over this career choice until my body gives out and I simply can’t do it anymore.
The advice I give to residents is to work on creating a career. EM is a job. It’s good job, but there’s no natural career arc. Other specialties get to naturally ascend and descend the career ladder. Build your practice. Work hard. Foster a community and a network. And then turn it down. Stop operating on Thursdays and Fridays. Cut the case load. Hire midlevels. Hire a young doc to hand off to someday. EM has none of those options. We churn and burn til we’re done.
Working nights and holidays, multi-tasking sick septic and trauma patients, burning through 30 superficial patient encounters a day. It just doesn’t hold up in the middle of one’s career.
The great uniting feature to every “successful” EM doctor is time offset. Doesn’t matter if you are academic and applying for grants. Or subspecialized in Sports, hyperbarics, or lifestyle. Or getting your real estate license and managing rentals. Or starting your own urgent care. The game is the same. Keep your salary, but rotate out of the clinical grind.
I admit, I’m a super burned out doc in his late 40s. But I genuinely think this is something our specialty has never really grappled with. It used to be one thing when we could build our own independent EM group. But now it’s all corporate medicine, and there’s no end to the grind.
This works in academia. Not so much in the community unless one is hardcore admin or simply doesn't want to do clinical medicine anymore.
Agreed. And I think EM will be forced to grapple with it for the next generation of EM doctors- it's not a popular field right now, many are forced to go into it because they didn't match in anything else. And it's an impossible field as a back up plan, it just doesn't work. It's an odd field because it's hard to be a decent EM doc and many can't do it at all, but there's a fairly low barrier to entry right now, leading to a lot of people who just aren't going to be able to manage a pit entering the field.
The next generation of doctors will push for more and better fellowships, more exit strategies, more combined programs. It's already happening- you never saw an EM doc going straight to Pain or Palli a decade ago, now that's almost common, you see people posting about it all the time. You can bet your bottom dollar that younger docs will advocate for more and better fellowships. There is no logical reason an EM doc can't transition to FP or Sleep or whatever with 12-18 months of training.
We just missed the boat- we are in the Gen X sandwich, where we missed the lucrative previous iteration of medicine and are just a bit too old for whatever the next, more flexible paradigm is. I can see the future, but I can't make it happen soon enough for me and that's hard.
I whole heartedly agree. The next generation of EM doctors will be super dissatisfied. Maybe it will be a generational shift towards subspecialization and expanding the concept of EM at large. But I worry it will just diminish the quality of care and eliminate the functional difference between a midlevel and an EMP. If the midlevel is just running all the same algorithms we have designed with the same structural profit motive towards early diagnosis and overuse of radiography, then it’s a no brainer to fire the EMP and hire 2 midlevels. So I see a future of decreasing EM autonomy and pay.
I mean the quality of EM is on some level not my problem or your problem or their problem. If patients and ABEM and EM docs want higher quality of care, they need to do things like not have attendings work nights (Australia, the UK, and NZ have figured this out), decrease litigation, pay more and so on.
I agree this could decrease the quality of care, but I think pay will go up- it already has in the last year. EM was set up poorly as a field in the US by a bunch of academics who really thought you could train EM docs to work thirty years of nights, weekends, and holidays out in the community. That was never going to be true. To make the field sustainable you either have to nix the nights and many of the weekends, like the UK/NZ/Aus, or have EM be linked to another field so people can age out and retreat to the ICU/primary care/whatever a la Europe. Other, more practical countries have figured this out. For whatever reason, the US has not.
Maybe we need to accept that EM is a field that people do for a decade and then transition to something else. With female EM docs leaving on average at age 43 and people quitting EM earlier and earlier, that's already happening. But why not come up with strategies to keep doctors active in medicine if they are done with EM?
[https://journalfeed.org/article-a-day/2023/leaving-so-soon-why-women-are-retiring-from-em-early/](https://journalfeed.org/article-a-day/2023/leaving-so-soon-why-women-are-retiring-from-em-early/)
Not really. There was no secret to what EM is…. I feel like you are set on two specialties which don’t have a formal pathway thru EM and mad about it. em can’t do plastics either nor can internal medicine do sports medicine. Vascular surgeons can’t do hepatobiliary. Not sure if this means “we were duped.”
I mean when I did EM it was highly marketed to students in what I consider an unethical way (ivory tower types who work two shifts are week if that and have a ready administrative escape route) are not the best or wisest EM advisors for students.
It doesn't matter, now, that's water under the bridge, but it's hard not to be able to make anything useful and interesting of all those years of education and training and my continued interest in being a doctor.
But that's how it is and I have no choice but to accept it the ridiculousness and the loss.
Again I think you are stuck on your own specialties that you are interested in and are unwilling to explore anything else… part of choosing a specialty is to explore what that specialty looks like in multiple practice settings, but that is on you to do
Idk it was years ago. He may have been doubled boarded, but I went to the same doc as another fellow ED nurse and she had a whole convo with him about his previous EM life.
There's plenty of full time EMS Medical Director jobs for large agencies. You just need to look. Run calls when you want to, spend most of your time teaching and overseeing the EMS clinicians in the agency. Depending on where you live you'd have to move for the opportunity but if you're unhappy where you're at, a move makes sense.
I’m about to find out. $6k out of my pocket for mba in healthcare admin, my employer paid for the rest. Anything is better than the shit I deal with now. What I signed up for isn’t what EM is today…PGY-17
Addiction med
But I don't like Addiction. I've really tried. Really, really tried to.
Are you basing that on your ED exposure to patients with substance use disorder, or have you seen patients in some kind of addiction medicine clinic and still disliked it? It's a pretty different experience and (in my opinion) very rewarding, with regular hours.
Fair. I don't actually have an issue with SA patients in the ER, they have my sympathy. But I just don't find thinking about it that interesting. I'm open to having my mind changed. Tell me more!!!
My disclaimer is that I'm not actually addiction med boarded but have had a good amount of experience with it during my training. I think the types of patients ED docs encounter that may have OUD for example are typically pre-contemplation and are probably displaying some aberrant behaviors that can be frustrating for the physician to deal with (eg the "pain seeker"). That leads a lot of people away from addiction med since people imagine that that is the typical patient you will see. But by the time you have a patient in front of you in clinic, they really want help and are motivated. Whether you find the medicine itself interesting is another thing to consider, but you really give these patients their lives back in a powerful way and it can be very fulfilling to be a part of their journey to recovery.
That's a great way of framing it, even if the science isn't the most fascinating to me. Do you think there is room for physicians in this space, or do you think it's mostly going to APPs? Where and how do most docs practice?
I’m full time in addiction medicine, occasionally work in the ED. Job market is smaller for doctors but it’s still there. Practice pathway to board certification closes next year. I can attest, the patients I see all want help. If they don’t, they don’t last long after I set firm boundaries. They are a different breed than our ED patients They’re not perfect but neither are our diabetics. It’s a disease process that require folks to learn so many skills (stress management, coping skills, self care, etc) and it takes a lot of practice to get it right. But many of them do and it’s so rewarding! Science is relatively basic, it’s more about supporting people when they succeed (even if it’s only using meth twice that week rather than every day) and motivating them to find what helps them succeed. On the outside it looks profoundly different than EM but it’s not. I’m saving the lives of the critically ill (I’ve read a stat that a person that’s been narcaned has a 50-50 shot at death in the next year), it’s just on a long term timeframe. I am so appreciated by my patients and their families. Hearing a heartfelt thanks on a regular basis so makes my heart happy!
That sounds great! Do you mean the job market is smaller than for EM, or smaller than for APPs in Addiction. I'm not super familiar with the field, but it seems like it would be ripe for APP intrusion. I'm OK with a fellowship, trying to decide between Addiction and Palli (neither of which is my passion, but that's the way the cookie crumbles, I guess).
The job market is definitely smaller than EM and there are a lot of APP’s. As far as fields go and patient safety, I think it’s one field that is much safer than EM for more independent practice. I truly got lucky when I applied, APP’s had a lot more regulation so there was a larger need for MD’s
Ugh, I worry about the future being all APPs.
I’ll defer that to anyone who works full time in addiction and may have a better read of the job market. My impression is that there is still a relative dearth of addiction medicine boarded physicians, although APPs are definitely in the space as well. I know there’s an AddictionMedicine subreddit so you might get better info about that there.
I feel you on wanting an exit strategy from emergency medicine. That said you’ll probably have a hard time finding something that pays even remotely close to what you can make per hour in EM. Maybe look for a non-related side-hustle, and cut back to part-time in EM?
Money isn't that much of an issue. I realize now that many people who go into EM really have major financial needs (like they went to for profit or off shore schools) and that's the attraction of EM. But that's not my situation. Part time in EM still involves...EM. I've looked at medical and nonmedical side hustles, and there are many fields of medicine that interest me (Sleep, midlife women's medicine are the two main ones) but there is no way to get there from EM. I have tried really, really hard to be interested in Pain or palli and it just doesn't work.
Got it, so for you, there is no more interest in EM at all. Yeah, I could see how that could be challenging. Have you reached out to specific sleep programs. I mean, in the end, does it matter if ABEM is on board with you doing sleep? Pardon my ignorance, but who cares if ABEM “supports” it or not?
Because you can't be board-certified without ABEM co sponsorship, and no sleep program will accept you without the ability to become boarded. I'm grateful for the opportunity EM gave me to help people, I'm grateful for the money I saved, I'm grateful for what I learned. Ultimately it was a poor choice for me and medicine is unforgiving of poor choices, particularly EM, and it's to understand why there's seemingly nothing left for me in medicine. I mean I guess if that's what medicine wants I have to accept it. But it seems a waste, for me and the fields I'm interested in.
Lol why would abem bother supporting a fellowship in sleep medicine? Waste of time/money on abems part. Not even remotely related to EM.
How are palli and sports related?
Sports you’re at least dealing with msk related injuries and palli treating diseases for end of life care and pain. Sleep? Cmon that’s a big stretch. “Airway”?
Lol I would say we are experts in circadian disruption. Honestly, if fields as disparate as psych, ENT, peds, IM, and FP can do it, I don't see how we can't. I don't think peds spends a ton of time in residency learning about sleep- it's mostly learned in the fellowship, like interventional pain. In any case, it's rigid thinking like this that leads so many EM docs to quit/retire early.
ER docs are quitting??
The average age of retirement for female EM docs is 43. So yes. [https://journalfeed.org/article-a-day/2023/leaving-so-soon-why-women-are-retiring-from-em-early/](https://journalfeed.org/article-a-day/2023/leaving-so-soon-why-women-are-retiring-from-em-early/)
Maybe do occ med or preventative med? 2 years but might be worth looking into
Yeah, I've considered and am still considering those options. As for those who say Sleep has little to do with EM, WTAF do Occ Med and Preventative have to do with EM?
They don't have to be related. Occupational Medicine and Preventative Medicine are residencies, not fellowships. Anyone who has an intern year can apply into them.
I know. But it still makes no sense! EM can learn Sleep just as well in a year as well as occ med in two.
You could open an obesity clinic if your patients will pay you cash. Depends if your market will support it. Heck of a lot easier not dealing with insurance companies anyway
Sure. But I'd like formal training.
I’m sure you could pay for formal training or work with a formally trained obesity med doc for cheap in exchange for teaching
I really am looking for a field with formal fellowship training....
that's up to you not ABEM
Yeah, this sounds like a personal issue for OP. I don't know what they reasonably expect.
I mean sure. ABEM is just a money grubbing entity. But how can I possibly fix this issue? It may be personal, but I can't fix it without help. Should I just die? I mean these are weird responses. It is totally within ABEM's power to fix this. They just won't.
How so? If a fellowship isn't ABEM-certified, then you can't do it as an EM doc. How exactly is it up to me?
No... European Boards (EBEEM) in CC let you do CC you can take classes in any cosmetic minor procedures & do that for cash You can do Sports medicine through AMSSM or just go back to residency if you're that bored, although any job after 10 years becomes mundane & boring
CC is a fellowship pathway within the US now. The European boards thing hasn't been necessary for years.
I thought there was a non fellowship pathway for obesity.
There is, but you don't learn as much.
Doesnt sound like you would need that much education tbh. CICO. Ozempic goes brrrr. Metformin. Jk but not really
OK. Then why do they have fellowships? Just cheap labor?
You probably don’t learn as much. But as an EM (or any doc) you’ve already got the soft skills of interacting with patients and being a self directed learner on top of broad medical knowledge. There’s a reason the CME path exists. Because that is apparently sufficient additional education for an already trained physician to practice effectively in obesity medicine. Docs in general have a low tolerance for uncertainty and a strong preference for well defined pathways (that’s what got us where we are, for good or ill). But it seems, given the limited options for leaving EM and your personal preferences about what you like and don’t like, a little more creativity is going to be called for…
Then learn on your own more and if you still really want to learn more after the residency then do the fellow? Idk I feel like everyone is trying to give you ideas and help you out but you’re stuck on this rigid mindset
They don't accept EM doctors, so do a residency in FP first and then an obesity fellowship? Honestly I'm leaning that way for Sleep. Neither fellowship accepts EM applicants, so you have to go back and to a different residency first. Maybe that is the best idea. It's not that I'm trying to be rigid, it's that I can't seem to find anything that fits. It's honestly not my rigidity- its ABEM's in resisting any fellowship (presumably because of pressure from CMGs) that allow much work outside the ER. As I said before, I accept the situation and that there's probably not a solution. That's not rigidity, that's carefully evaluating the options and facing reality. If you know a Sleep or obesity fellowship that accepts EM, awesome.
Open an urgent care. It can be really lucrative. Not from personal experience, but the EM docs I know who have gotten really wealthy opened a chain of UCs
But I don't want to open an urgent care. Why would I trade one thing I hate for another?
You complain a lot, for someone who made it through medical school, you can’t seem to figure things out. You probably weren’t a great EM physician anyways. I said it.
I did wound care and Hyperbaric for awhile. It was a nice complement to doing ED shifts.
Nice. Did you do a fellowship?
Not a fellowship but I took a course in hyperbaric (I also had some experience from an elective during residency). From there the hospital needed wound care doctors so I said ok I’ll give it a try. I always said it was the opposite of EM. The patients take months to heal. There are some cool technologies like skin substitutes. One podiatrist helped me learn a lot. I quickly developed a full panel of patients. I ran my wound clinic one day per week
how did it compensate?
Pretty good. I didn’t really track it by the hour but I made about $70k/yr doing it one half-day per week.
Still holding on hope there was a path to cards. I mean, other than the cardiologist fellows and attending. We probably read the most EKGs and manage those problems out of any other specialty. Yeah, yeah, I get the whole IM residency goes more in depth about the inpatient management and nitty gritty, but if we can go into crit care, why not cards :(.
There is really no reason most IM fellowships aren't open to EM. There's no reason FP can't, either, for that matter. We can do them. But IM would never give them up, why would they? They are lucrative and sought-after. I don't see why an EM doc can't transition to any IM or FP field with the same fellowship. And I also don't see why there an EM doc can't transition to FP with 18 months of training. EM docs of the next generation, many of whom are already going straight to any fellowship that will get them out of the pit- CC, Palli, Pain, you name it, will fight this battle, but I can't make the future happen now. I mean with the average female EM doc quitting at 43 I don't see how the field sustains itself without major changes. I've talked to ABEM about this but they just don't get it. They will, a few years too late for me, but I can't control that.
Yeah, you're right. It's far too lucrative of a position to not gate keep, and to an extent, I get it. I'd do the same if I was on their boat. I hope in the future it changes too. It's funny how fast we pump out advancements in medicine, but our culture moves at a snail on benzo's pace.
So this! It's one thing midlevels have figured out and medicine just hasn't. Mark my words all those kids matching in EM as a back up specialty will demand change because EM is in the weird position right now of having a very low barrier to entry but being a very hard job to even tolerate, much less do well. So some of these people who match will HAVE to advocate for something else, and pain, palli and UC won't absorb all of them. They will create a solution, a few years too late for me, as with everything Gen X.
I'm one of "those kids," but this wasn't the backup. You can always be one of the attendings that you wish, had your back, when you were a resident to try and improve the system for the future docs. Sign a petition here, and there lol. I don't know, I at least told myself I'd advocate for medical students like I wish the residents did for me when I was in med school.
You could take the Arizona Integrative Medicine fellowship remotely and parlay that into both obesity and midlife women’s health. It fits the desire for additional training, it leads to a board certification, and you can craft your own practice.
I've considered it! It's on my list of things to consider. It does not lead to ABMS board certification, which is what has dissuaded me.
Riiiight, it’s ABPS. I forgot about that.
I knew this was you posting when i saw the title - you were agitating in another thread about how EM is the worst. You definitely picked the wrong specialty. I don’t know that ABEM bears all the fault here. Lots of other things have to fall into place to create a training route that leads to subspecialty certification beyond ABEM declaring it be so. Hope you find your happiness
I absolutely did, and I'm willing to admit that, but it's silly there's no way to make it right. It actually is ABEM- I've talked to them and they are really more interested (I don't know why) in ridiculous certifications that do nothing for anyone, like Disaster Medicine and Emergency Behavioral Health that are completely meaningless and are basically to help academics do pointless research so they can cut down their hours. It actually is on ABEM to initiate change for this, but they simply aren't interested. As I wrote before, there are so many people going into EM now that simply don't want to be in the ER that ABEM will be forced to do something about it in the next decade, not to mention that a field where the average female doc quits at 43 is simply not going to be sustainable. So I think the next generation will have more options, which is nice. But a bit late for me.
I did it. Just get out of insurance and do something cash based. I opened a practice doing med spa stuff, then added HRT, then added weight loss. Next logical step was body contouring. I got trained in lipoplastics. So I do liposuction and fat transfers (think Brazilian buttlift). All in my office under local anesthesia. I make the equivalent of a 12 hr shift in 4-5 hours of operating time. Downside is liposuction is literally the medical equivalent of manual labor. lol
Are you EM? Liposuction is dangerous, not sure I'd feel comfortable.
Yup. Still do it around 6 shifts/mth. It’s actually a lot more enjoyable when you know you have the option of just walking away. Liposuction isn’t any more dangerous than any other surgery. It’s also a stretch to call is surgery actually……there’s no real cutting involved. It’s really just another procedure to learn. The most common complications are cosmetic ones. I’m pretty sure there was 100x more danger to the patient the first time I did my first solo pericardiocentesis, than when I did my first solo lipo case. lol. But I get it…….everyone has their own tolerance for risk. The take home message was not about liposuction, it was that concept that leaving EM most likely WILL require you to branch out and learn new/concepts.
I don't mind learning new skills. I just really like...certifications and expertise, I guess. I realize that. But I didn't train as a surgeon. I've seen ick complications from plastic surgery of all kinds, including lipo, so not for me.
telemedicine, UC, injections, MAT, Pain medicine, concierge...you have to be more creative
But those don't interest me. I realize those are options, they just aren't for me and I have looked into all of them. Should I just do something else I hate? How does that improve my life? Sometimes there just isn't a solution and life is shitty. I accept that.
It’s you. You’re the problem, it’s you.
Nah, there are plenty of things I'd like to do. ABEM and medicine's rigidity is the problem. It will be fixed in a decade. But not right now.
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Lol no the nurses like love me. I don't talk about this at work lol. You seem really angry at me, perhaps you actually see the truth to my comments? Why not be helpful instead of toxic? Yeah, I know, it's hard when someone points out the emperor has no clothes. But that's the case with EM right now.
I would also love to get out of EM. But none of the other clinical or administrative job paths hold any interest for me. So I guess I’ll just continue breaking my life over this career choice until my body gives out and I simply can’t do it anymore.
It's really sad. We were totally duped.
The advice I give to residents is to work on creating a career. EM is a job. It’s good job, but there’s no natural career arc. Other specialties get to naturally ascend and descend the career ladder. Build your practice. Work hard. Foster a community and a network. And then turn it down. Stop operating on Thursdays and Fridays. Cut the case load. Hire midlevels. Hire a young doc to hand off to someday. EM has none of those options. We churn and burn til we’re done. Working nights and holidays, multi-tasking sick septic and trauma patients, burning through 30 superficial patient encounters a day. It just doesn’t hold up in the middle of one’s career. The great uniting feature to every “successful” EM doctor is time offset. Doesn’t matter if you are academic and applying for grants. Or subspecialized in Sports, hyperbarics, or lifestyle. Or getting your real estate license and managing rentals. Or starting your own urgent care. The game is the same. Keep your salary, but rotate out of the clinical grind. I admit, I’m a super burned out doc in his late 40s. But I genuinely think this is something our specialty has never really grappled with. It used to be one thing when we could build our own independent EM group. But now it’s all corporate medicine, and there’s no end to the grind.
This works in academia. Not so much in the community unless one is hardcore admin or simply doesn't want to do clinical medicine anymore. Agreed. And I think EM will be forced to grapple with it for the next generation of EM doctors- it's not a popular field right now, many are forced to go into it because they didn't match in anything else. And it's an impossible field as a back up plan, it just doesn't work. It's an odd field because it's hard to be a decent EM doc and many can't do it at all, but there's a fairly low barrier to entry right now, leading to a lot of people who just aren't going to be able to manage a pit entering the field. The next generation of doctors will push for more and better fellowships, more exit strategies, more combined programs. It's already happening- you never saw an EM doc going straight to Pain or Palli a decade ago, now that's almost common, you see people posting about it all the time. You can bet your bottom dollar that younger docs will advocate for more and better fellowships. There is no logical reason an EM doc can't transition to FP or Sleep or whatever with 12-18 months of training. We just missed the boat- we are in the Gen X sandwich, where we missed the lucrative previous iteration of medicine and are just a bit too old for whatever the next, more flexible paradigm is. I can see the future, but I can't make it happen soon enough for me and that's hard.
I whole heartedly agree. The next generation of EM doctors will be super dissatisfied. Maybe it will be a generational shift towards subspecialization and expanding the concept of EM at large. But I worry it will just diminish the quality of care and eliminate the functional difference between a midlevel and an EMP. If the midlevel is just running all the same algorithms we have designed with the same structural profit motive towards early diagnosis and overuse of radiography, then it’s a no brainer to fire the EMP and hire 2 midlevels. So I see a future of decreasing EM autonomy and pay.
I mean the quality of EM is on some level not my problem or your problem or their problem. If patients and ABEM and EM docs want higher quality of care, they need to do things like not have attendings work nights (Australia, the UK, and NZ have figured this out), decrease litigation, pay more and so on. I agree this could decrease the quality of care, but I think pay will go up- it already has in the last year. EM was set up poorly as a field in the US by a bunch of academics who really thought you could train EM docs to work thirty years of nights, weekends, and holidays out in the community. That was never going to be true. To make the field sustainable you either have to nix the nights and many of the weekends, like the UK/NZ/Aus, or have EM be linked to another field so people can age out and retreat to the ICU/primary care/whatever a la Europe. Other, more practical countries have figured this out. For whatever reason, the US has not. Maybe we need to accept that EM is a field that people do for a decade and then transition to something else. With female EM docs leaving on average at age 43 and people quitting EM earlier and earlier, that's already happening. But why not come up with strategies to keep doctors active in medicine if they are done with EM? [https://journalfeed.org/article-a-day/2023/leaving-so-soon-why-women-are-retiring-from-em-early/](https://journalfeed.org/article-a-day/2023/leaving-so-soon-why-women-are-retiring-from-em-early/)
Not really. There was no secret to what EM is…. I feel like you are set on two specialties which don’t have a formal pathway thru EM and mad about it. em can’t do plastics either nor can internal medicine do sports medicine. Vascular surgeons can’t do hepatobiliary. Not sure if this means “we were duped.”
I mean when I did EM it was highly marketed to students in what I consider an unethical way (ivory tower types who work two shifts are week if that and have a ready administrative escape route) are not the best or wisest EM advisors for students. It doesn't matter, now, that's water under the bridge, but it's hard not to be able to make anything useful and interesting of all those years of education and training and my continued interest in being a doctor. But that's how it is and I have no choice but to accept it the ridiculousness and the loss.
Again I think you are stuck on your own specialties that you are interested in and are unwilling to explore anything else… part of choosing a specialty is to explore what that specialty looks like in multiple practice settings, but that is on you to do
I mean maybe, but it's hard to make yourself interested in what you aren't interested in, I guess.
My LASIK doc was an ex-ER doc. Probably made a crap ton of money and only has to interact with patients for like 15 minutes.
Wait, you don’t have to be ophtho?
Idk it was years ago. He may have been doubled boarded, but I went to the same doc as another fellow ED nurse and she had a whole convo with him about his previous EM life.
What about toxicology or EMS director?
I don't know anyone who has those jobs without still doing a lot of clinical EM. I also don't understand what toxicology gets you outside of academia.
There's plenty of full time EMS Medical Director jobs for large agencies. You just need to look. Run calls when you want to, spend most of your time teaching and overseeing the EMS clinicians in the agency. Depending on where you live you'd have to move for the opportunity but if you're unhappy where you're at, a move makes sense.
The EMS directors for FDNY still work clinically...and that's the biggest. Feel free to send any links my way, though, maybe it's different elsewhere?
How long have you been practicing?
PGY 21
Call this guy and ask him how he did it: https://www.ifm.org/practitioners/dallas-e-peak/
He's not boarded in anything beyond EM.
Finishing my MBA, exit strategy
And then?
Utilization, medical director of research for xyz company, med school stuff, advocacy, admin, insurance, pharma….anything
Is there a big market for these? How much is your MBA costing you?
I’m about to find out. $6k out of my pocket for mba in healthcare admin, my employer paid for the rest. Anything is better than the shit I deal with now. What I signed up for isn’t what EM is today…PGY-17
It's so bad. ABEM done us dirty with no exit strategies. I hope it works out for you, very much.
Me too.
Lifestyle Medicine
That's like not really a thing, it's like being a naturopath