Want to Leave EM--Where Next?

[Hope209]

I've been working in Emergency Medicine for a year and a half out of school. I've learned a lot and I love the autonomy and variety of EM, but the hours are crushing my soul. My wife works full time and I have a 3-year-old daughter who goes to daycare most weekdays. If I'm on a 4-day stretch of 1600-0200's, I don't see them at all.

I've been asking friends, I set up filters for sites like Indeed, but I'm not sure where to apply next. I want to have (at least some) autonomy and not feel like I'm just the attending's assistant. But I need more stable hours. I like to work quickly and always have something to do and I love procedures. I'd really appreciate any input/life advice. Thanks!

[SoCal_PA]

Look into wound care. You are autonomous and do procedures daily. Pay is great too. Most companies let you make your own schedule from what I've seen. 

 

You can also pick up an extra 2 ER shifts/month if you want in order to keep your general medicine skills (+$15-20k is always good)

[Cideous]

The wound care jobs I have seen have been terrible.  No benefits, paid 1099 etc.  Am I missing something?

[MediMike]

IR. Have a buddy who works it, fast paced, almost all procedures, if you've got a production based mind set then it's a great field.

I'd rather sit around pondering AST:ALT ratios...

[EMEDPA]

There are better em jobs out there. Don't give up on the specialty just because of one bad job. Look into Team health positions. There you would be full time with benefits starting at ten 12 hr shifts/month. Overall, pretty nice docs with good teaching and reasonable workflow expectations.

[thinkertdm]

28 minutes ago, EMEDPA said:

There are better em jobs out there. Don't give up on the specialty just because of one bad job. Look into Team health positions. There you would be full time with benefits starting at ten 12 hr shifts/month. Overall, pretty nice docs with good teaching and reasonable workflow expectations.

Would you say those docs and positions are stable or decreasing with the push to make medicine a retail industry?  I can see metrics taking the humanness out of caring for people in the drive to answer to stockholders and Amazon, etc.  And I'm not being facetious, we (society) seem to have lost our way.  Domo Arigato, Mr. Roboto.

[EMEDPA]

decreasing, but still out there. The long-term best bet in emergency medicine jobs is to go rural. pretty much everywhere else PAs are being pushed into high volume fast tracks with 3-4 pts/hr expectations.

[Cideous]

1 hour ago, EMEDPA said:

decreasing, but still out there. The long-term best bet in emergency medicine jobs is to go rural. pretty much everywhere else PAs are being pushed into high volume fast tracks with 3-4 pts/hr expectations.

 

So one thing I will say about this.  EMEDPA has a TON of experience and is obviously very good at his job.  I am however very hesitant to recommend rural ER jobs to anyone but the very VERY most experienced among us.  I'm talking 15 years of hard core high volume, seen it all done it all, ER experience.  In the rural setting you almost never have onsite backup, and you must be incredibly strong and experienced.  There is nothing quite so butt puckering as being all alone in an ER...no matter how rural it is.

[JOhnny888]

15 minutes ago, Cideous said:

 

So one thing I will say about this.  EMEDPA has a TON of experience and is obviously very good at his job.  I am however very hesitant to recommend rural ER jobs to anyone but the very VERY most experienced among us.  I'm talking 15 years of hard core high volume, seen it all done it all, ER experience.  In the rural setting you almost never have onsite backup, and you must be incredibly strong and experienced.  There is nothing quite so butt puckering as being all alone in an ER...no matter how rural it is.

yet ppl are getting mad at AAEM for it's new position statement that it put out? 

[Cideous]

16 minutes ago, JOhnny888 said:

yet ppl are getting mad at AAEM for it's new position statement that it put out? 

You lost me?

 

[ohiovolffemtp]

Each of the major national employers, including TeamHealth, posts lots of open positions on their web sites.  Typically, there are other unadvertized positions at their locations as well.  Team has made less than the 3% 401K match and has eliminated salary reviews over the last 1-2 years, so that may factor into your final choice.

[JOhnny888]

17 minutes ago, Cideous said:

You lost me?

 

Ppl have been mad that AAEM basically said EM physicians should lead the team in the ER and APP's should be supervised. But here we have experienced members saying only very experienced PAs should work in rural ERs.

[Cideous]

9 minutes ago, JOhnny888 said:

Ppl have been mad that AAEM basically said EM physicians should lead the team in the ER and APP's should be supervised. But here we have experienced members saying only very experienced PAs should work in rural ERs.

Ahh Ok.  Gotcha.  I was just confused by what you were saying.  I do stand by my comments, but will add this.  I don't believe a new doc with little experience should be in a rural ER either.  Hopefully they would of put in 3 years of residency first in a busy ER.  My point being, I've been in a rural ER, and although the volume is usually less, the acuity seems to be REALLY high.  Having said that, I would defer to EMEDPA's opinion on the matter.

[JOhnny888]

8 minutes ago, Cideous said:

Ahh Ok.  Gotcha.  I was just confused by what you were saying.  I do stand by my comments, but will add this.  I don't believe a new doc with little experience should be in a rural ER either.  Hopefully they would of put in 3 years of residency first in a busy ER.  My point being, I've been in a rural ER, and although the volume is usually less, the acuity seems to be REALLY high.  Having said that, I would defer to EMEDPA's opinion on the matter.

yeah, not a new FP MD. A EM doc should be able to handle any setting, hence the reason for going through residency...

[EMEDPA]

2 hours ago, Cideous said:

 

So one thing I will say about this.  EMEDPA has a TON of experience and is obviously very good at his job.  I am however very hesitant to recommend rural ER jobs to anyone but the very VERY most experienced among us.  I'm talking 15 years of hard core high volume, seen it all done it all, ER experience.  In the rural setting you almost never have onsite backup, and you must be incredibly strong and experienced.  There is nothing quite so butt puckering as being all alone in an ER...no matter how rural it is.

Thanks for the clarification. I agree that solo coverage is not for new grads. There are plenty of double coverage rural positions out there with 1 doc and 1 pa per shift. My oregon per diem job is like this. We alternate cases. Some of the other PAs there, however cherry pick the easy stuff.

[EMEDPA]

1 hour ago, ohiovolffemtp said:

Each of the major national employers, including TeamHealth, posts lots of open positions on their web sites.  Typically, there are other unadvertized positions at their locations as well.  Team has made less than the 3% 401K match and has eliminated salary reviews over the last 1-2 years, so that may factor into your final choice.

this is probably site specific. I work per diem for them, got my 3% match and a raise this year(that being said, the raise was less than 50 cents/hr as they moved me to their top step). .

[MediMike]

TH has eliminated salary steps locally here in WA, straight pay across the board regardless of experience. Reviews 3% contribution yearly.

[sas5814]

I worked solo ER rural for a few years and "butt puckering" is a fair description. I was a generally trained and experienced but retired from the Army so being alone didn't bother me much. I'd been in worse places under worse conditions.

You just never knew. You could go a week seeing mundane things and have some hella trauma or a code or something bad but obscure come in like the guy who literally had gouts of bright red blood coming from his rectum.. It was a lot like being deployed in a combat zone. Days of mind numbing boredom interrupted by minutes of extreme terror.

I enjoyed it while I did it but was never really comfortable and often felt over extended.

If you are procedure driven look at derm. That's where the $$$ is and they keep regular hours...and nobody calls them from the ER at 2 AM.

[cc56]

From ER you may go urgent care.  I was the only provider in the UC when I worked at certain locations. Some places will put you on a fixed schedule.  You know you have every other weekend off and say Tues/Thur....   Not always exciting, but scheduled.  Some have fixed hours like 8-8 and weekend 8-4 when you work.  From my experience you have to like DOT physicals, school physical, sports physicals, Work comp, and cough/runny nose/sprains/cuts.   I see it as an option, probably won't make as much, but might be easier work over all.   A lot of UC want ER experience.

[LT_Oneal_PAC]

On 2/9/2019 at 3:27 PM, JOhnny888 said:

Ppl have been mad that AAEM basically said EM physicians should lead the team in the ER and APP's should be supervised. But here we have experienced members saying only very experienced PAs should work in rural ERs.

 

I hate to derail the thread, but this can't go uncorrected.

It was more than that. First they said that the physician should be meaningfully involved in each case. My rural job and my level one trauma center would come to a grinding halt if the attending's even had to spend 5 minutes with each patient all the PAs see.  So this is unrealistic. Honestly, what is the point of PA if a physician has to see EVERY patient for every encounter. Nonsense.

They also said that every PA working in the ED should have a BC EM physician as their supervisor. So many EDs don't have a EM BC physician because there is not enough to staff every ED, they can't get them to move to BFE where the dating pool is small or kids don't have access to big city extracurriculars or maybe even a decent school. Most can't afford one even if they could. CAHs around the country would shut their doors if they weren't staffing PAs in the ED. 

Lastly, they "took a stand" on APP practice. An unnecessarily confrontational tone. They dropped membership for PAs just to show they meant business.They literally say in their position they are worried about jobs, and that is what this is about. Not safety, because there is no data showing poor patient outcomes. If they were, then they should have come out against FM physicians running rural EDs. There is a ED in Iowa staffed by a MFing radiologist. I'll take the new grad PA that was a paramedic before I have a radiologist coming at me with a laryngoscope or chest tube.

They offered a lot of problems, and no solutions. Even my residency director was fuming about this because he is a pragmatist. Even you are capable of doing the job, then you can do the job. Sure, we see your point about having a BC EM physician, but what are you going to do about it? How are you going to make it where there are sufficient numbers without over supply or decreasing training, and get them to go to these rural centers. Crickets. No answer. The position statement also doesn't allow room for people who have been doing this forever like EMEDPA, who I will take any day over a physician who isn't BC EM, and probably over many that I know of that are and do not practice at standard. They would make him report back to the attending as much as a new grad. The statement certainly doesn't account for people like me, that are residency trained to specifically provide this kind of care at rural EDs. ACEP has the same position, but says it with a much less arrogant tone.

So, no, there wasn't a problem with the position that BC EM should lead, but that they MUST with a very much "You suck and we hate you" vibe.

[surgblumm]

If your main area of concentration is a family life and you desire to use your EM experience, you can try Urgent Care. You have enougfh experience at eighteen months in an ER to do Urgent Care and you will get more experience in medicine. Urgent care is for those that NEED TO HAVE A SLOWER PACE, FOR PAs who are at your level of experience and for those who are preparing for retirement. Rural EF experience is definitley out of the question without five years of solid ER and Cardiac and Trauma experience.

[EMEDPA]

21 hours ago, MediMike said:

TH has eliminated salary steps locally here in WA, straight pay across the board regardless of experience. Reviews 3% contribution yearly.

I work for them in OR.

[EMEDPA]

5 hours ago, surgblumm said:

 Urgent care is for those that NEED TO HAVE A SLOWER PACE, FOR PAs who are at your level of experience and for those who are preparing for retirement. Rural EF experience is definitley out of the question without five years of solid ER and Cardiac and Trauma experience.

I found rural EM to be a slower pace than urgent care. 12 interesting pts in 24 hrs instead of 30 very low acuity, often demanding pts in 12 hrs.

[LT_Oneal_PAC]

7 minutes ago, EMEDPA said:

I found rural EM to be a slower pace than urgent care. 12 interesting pts in 24 hrs instead of 30 very low acuity, often demanding pts in 12 hrs.

Agreed! Having done some urgent care when I was in FM, would do rural ED with only a glucometer before I do UC again.

[surgblumm]

I agree in terms of volume but it is an unusual day to get a very esoteric case and there is no major trauma. When I formally work in the ER in the late evening I hated a trauma case at 10 PM because it took me two hours after getting home to think about the outcome for the patient.