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Potential ER Position, currently in Family Practice

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So…. After months of searching for a job (currently in FP w/ 1 yr total experience), I had an initial phone interview today with the Lead APP at a Level 1 Trauma Center ER. I know my description is a bit lengthy but I hope it provides some details and leads to some feedback from all of you on this position and things I should ask at the next stage of the interview (by phone with HR and shadowing on-site in 1 week). Red Flags? Good, bad, ugly?

Potential Offer: Metropolitan Area Level 1 Trauma Center, 70k annual volume, 38 bed ED (also addtl psych ED, peds ED, and 9-bed OBS unit), Attending, Resident and PA/NP coverage all day/night w/ residency program.

Base Pay: Unsure. I do know that it’s SALARIED at “40hrs” per week, 36hrs actually schedule. If you work an extra shift, you get your salary rate turned to an hourly rate and paid that per hour. I should have more on this soon…. Note: A friend of mine has worked the Psych ER side for 1 year and is at $107K. So I’m guessing 100k-110K. Bonus is unknown.

Shifts: 12 hr shifts, Required 12 shift per month, combination of 7a-7p, 11a-11p, and 7p-7a. (NP I spoke to there said they are typically in the department 36-39hrs, rarely more unless you picked up more shifts) Scheduling done by the Lead APP approx. 6 weeks in advance according to provider preference for days that everyone submits on a shared spreadsheet by the deadline. Typically able to accommodate requests for front loading/back loading weeks or specific days off without dipping into PTO)

There are 2 FT night PAs that cover 6 nights per week (3/3), the remaining 1 night per week is split amongst the rest of the team. Typically I’d work 2-3 night shifts per month. No night differential that I’ve heard of thus far (I’ll ask)

Acuity: Typically high (safety net hospital in state capitol). 50% of time in OBS unit/ 50% of time in main ED seeing Level 1-3’s. All the Level 4 & 5s go to the Adult Walk In Clinic which is a separate job title and department entirely (note: I also applied for an open position with that dept but haven’t heard back yet from that team). No peds ER coverage. No psych ER coverage. No Fast Track.

Pts per shift: Average 15. Range 15-20. APP Lead states it’s not higher because of high acuity pts and not working fast track.

The Day to Day:

50% Obs Unit inside the ED (7a-7p and 7p-7a shifts): Solo w/ RNs and Techs, attending SP and Senior Resident backup from the main ED. Sick/tricky complex pts, intoxicated pts, and actual obs of pts just being monitored until able to be discharged.

50% Main ED incl. trauma (11a-11p shifts): Attending coverage, working side by side with residents, PAs take Level 1-3 pts, Not involved in resuscitations or most “advanced” procedures (chest tubes, intubations) due to the residency program. Will suture, LP, paracentesis, the like.

CME: “Money and time allowances” per job listing, however my friend in the psych ER states NO CME time off but CME $2,000 annually. Required to attend 1 M&M per month. Allowed and encouraged to attend all resident lectures etc.

Training/transition: Limited. 6-12 shifts double coverage with another PA/NP, then you’re on your own. It sounded like this isn’t really flexible. (Will be asking LOTS more questions about this)

PTO: 160 hours/year, accrued per pay period. (Essentially 4 wks PTO)

Medical/Dental/Vision: 3 plans ranging from $66/mo in-house plan up to $177/mo for Highpoint HMO w/ Cofinity network for individual only. $0-$500 deductible. Max out of pocket 5k per individual/10k per family. Dental is Delta PPO (3 different plans. The option I’d chose to keep my same dentist is $2/mo individual and $4/mo for me+1. Sweet.) Vision available, I don’t need it. FSA available.

Retirement: 401(a) Defined Contribution Plan (all employees contribute 6.2% of each paycheck (up to IRS limits) to an individual 401(a) plan instead of paying into Social Security. In addition, employer contributes a total of 3% (up to Social Security limits) of each paycheck on the employee’s behalf. In addition to the 3% contribution for the Social Security Replacement Plan, Denver Health contributes an additional 3% (up to IRS limits) on behalf of all benefit-eligible employees) 100% vested after 3 years. Also, an alternative 457b Deferred Compensation Plan w/ 3.5% match but higher dollar amount limits. (I’m not very familiar with either of these plan types…thoughts?)

Malpractice: Uncertain. Possible FTCA coverage. (More questions to ask)

Non-compete: None.

Loan Repayment: None offered by the hospital. ER does not qualify for loan repayment. Per the NHSC and state program websites, the Adult Walk In Urgent Care there DOES qualify (I also have an application in with them, but haven’t heard back yet)


-It’s a foot into the door of Emergency Medicine, and at a Level 1 Center in the main ED to boot.

-I can continue to live at my current home and not have to move in order to get my feet wet in Emed

-I will still be working with under served population (Important to me)

-Pay will be at least a 30% increase over my current salary. It’ll take me another 5 yrs at my current position to make that.

-Being in the main ED and out of fast track

- 4 day weekends!? IF I can stack my days together. (I currently have 3 day weekends Fri-Sun in FP but I work 10-10-10-12 to earn it)

-Daily RT commute is 1h20m. Might be able to make the bus system/bike work (free bus pass by employer) which is shorter than my current 2 hours/100 miles RT commute that’s killing my Subaru. This ER position would save me 4 hrs commute time, 220 miles driving, and 6-11 hrs of work time per week. Combined time savings: 10-15 hours a week & nearly 11k miles a year. As well as an potential $20-30k more per year in base pay)


-OBS unit sounds like a potential Bermuda Triangle of the department. Will need to stay on my toes out there.

-Pay not as great as other EDs may be able to offer, but then again our whole market here is below average in all specialties.

-Salaried, not hourly. I swore after my current job that I’d never work salary again because although I’m scheduled 40 hrs per week, I never work less than 45-50.

-No loan repayment

-VERY limited training/run-in time. Due to volume and residency program, I’ll probably have to learn to swim fast. This is probably my biggest CON to this position at the moment (other than lack of participation in resuscitations and certain procedures). I have 5 yrs EMS/ER tech, my PA clinical training (included ER time at a similar Trauma center, CICU, trauma team SICU/Surgery, and the standard rotations), and 1 year FP in rural FQHC underserved population. I worry about getting stuck in FP if I don’t expand back out and start using my clinical skills on higher acuity patients and my procedural skills beyond IUDs, basic suturing/I&D, and skin bx.

-I feel some guilt about leaving my current SP/patients/clinic. I finally feel supported by my current (new) SP and (new) clinic manager and I actually like some parts of FP but I’m still not super touchy feely like most of my colleagues. I kinda worry that my new colleagues and direct supervisors may not be as supportive or worse, it be a hostile work environment. Higher up in my current Admin, I feel fairly supported but they’ve specifically told us that there will be no significant pay raises for the foreseeable next few years. Limited 5k/year base salary increase and a bonus structure which will never be attainable for my position/pt volume due to rural location. (I started at 75k/yr, now at 80k/yr)


OKAYYYYY....GO! Good, bad, ugly? Things I didn't think about that I should ask?

Edited by Colorado
forgot to add a pro list item
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I would definitely clarify on the potential for an overnight differential, 10-12/hr seems to be standard at least in my neck of the woods. Overall I think the higher acuity patients sounds great if you're looking to avoid the fast track and get some good experience. The short training period sucks but if its a teaching environment (with residents it hopefully is) it sounds like it could work out.

Sounds like a personal decision on the career move but good luck on the potential change!

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not perfect, but not terrible. and from a work/life balance perspective it sounds good. try it. give it a year or 2, then you can always move somewhere else to do EM with the experience under your belt. 

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Thank you to both of you who took the time to read this and reply! I am definately taking this interview process seriously and am likely to take the offer. It is so very difficult to break into Emed locally in my region and this would definately be my best opportunity right now. A follow-up question:

How do you deal with the feelings of guilt in leaving your current job?

(My job isn't toxic, but it pays terribly and the commute is horrendous. Not to mention I don't think I can ever live in the same tiny rural town where most of the residents are my patients. I feel supported by my SP and clinic manager (theyre new additions over past 6mo) and the place has turned a new leaf in part thanks to my contributions and theirs )

I'm sure its normal to have feelings of guilt about leaving. But, I've also been told to never quit on a bad day, only on a good day. (ie: if things still are not what you ideally want even on a good day, then its a better informed decision than leaving when things are at their worse and you're in a rut)

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