This commentary is an open letter of advice for emergency medicine residents who will eventually be looking for a job. Those who recently began their careers as emergency department (ED) attending physicians may find the advice beneficial as well. There is tons of generic advice lurking about, and I won’t bore you with the common stuff. I will, however, give my own personal take on some pertinent issues that I think many graduating residents either ignore or are dangerously unaware of.

I speak only from personal experience (approaching 10 years functioning in the ED), working solely in community hospitals (no research). I am a residency-trained and board-certified emergency medicine (EM) physician.

Know your value. Demand for ED physicians is higher than supply, and with Obamacare coming into full effect this year, I forecast that demand will go much higher despite the stable number of ED physicians. What this means is that you have increasing power and leverage to choose where, when, and how you want to work. There are always job opportunities out there, and especially for a residency-trained, board-certified EM physician, the choice is yours.

The two distinct advantages that you have over other physician specialties are your portability and seasonability.

Excluding the obligations that would restrict you to a certain geographical area, you have the uncanny ability to pick up and move about the country (and even internationally) to work in different locales. Even within a particular locale, shift work gives you the flexibility to work at many different hospitals, thus maximizing your scheduling preferences. Moreover, being an emergency physician does not mean you have to work in an emergency department. You have the option (and demand does exist) to mix things up in areas like urgent care and occupational health, just to cite a few examples. If you choose to work all over the country, the main impediment on the domestic side is state licensure, but many locum companies can have you up and running in a new state in as little as two weeks; the said companies also are able to provide housing and travel at no cost.

Seasonability refers to your ability to stop and then restart working as you deem appropriate. For instance, if you choose to take every June and July off for vacation, then there’s an arrangement that will accommodate you.

Always keep in mind that hospitals are always looking for someone to cover nights and weekends, so if you don’t mind operating when the rest of the world is at leisure or sleeping, you will find that many groups will welcome you with open arms. Being the “night doc” also gives you a certain pull with others at your site since your work allows them to adhere to a (somewhat) normal schedule.

Obviously, if you have a desire to do academic work and make a name for yourself at a renowned institution, then the above paragraphs do not apply. The renowned institution existed long before you did, and it will take some time to distinguish yourself.

Residents should also be cognizant of an often-overlooked fact of EM: your productivity, as gauged by your wage, is often a false representation of the billings that you actually generate. This certainly isn’t new information, and several voices in the field have been proclaiming this issue for some time, yet many residents either are unaware or are indifferent to the current paradigm. To illustrate, in a group I used to work for, the average physician at one site would generate charges of approximately $1,500 per patient. So if you saw an average of two patients per hour, you would bill (the patient or an insurance company) for $3,000. Granted, as it is with most large physician groups, you would not be doing the billing yourself. Rather, a division within the organization does it for you. As far as you’re concerned, you would just see the patient, complete the chart, sign it, and that’s it. Assuming this bill goes through insurance, at this site, the group would collect about 35% of the billed total, or $1,050.

At the time, I was making anywhere between $130 and $150 per hour, regardless of the number of patients I saw. Take note, the hourly rate did go up based on all the physicians at the site billing more, but my individual efforts were diluted based on the cumulative whole. The math was quite unnerving: I was billing (on average for two patients per hour) $3,000 per hour worked, the group was thus receiving $1,050 per hour, and I was paid only $150 per hour. And by the way, that figure was then taxed on the federal and state levels. In essence, for what I billed, I was paid 5% of the total, and for what was received by the group, I was paid 14% of the total.

This produces a psychological dilemma. On one hand, you will still be doing well by far and earning well in the six figures. With this salary, many groups will also offer you a CME stipend (free trip to Aruba for that toxicology “conference”) and the all-important malpractice coverage for when you do get sued. On the other hand, the majority of the fruits of my labor were being usurped by the organization that allegedly was working in my best interest, and no matter how lucrative the incentives may seem, giving the ED physician, who is generating the lion’s share of all the company’s revenue, a mere fraction of the profits is an abysmal deal for the doctor and a dream for the group or corporation. This is the way the game is played, and many can live and prosper (quite handsomely) under this system.

I am not suggesting we all start a revolution now, but always be aware that for any group, without you, the industrious physician, the group would not exist, and blind submission to this business model is the fuel that keeps the machine running.

Don’t assume the advice from consultants will always be good. When I was a naive resident, I used to think that whatever the consultants said had to be words that were divinely inspired. It didn’t matter what was said, as long as the consultant said it was OK, then I was OK.

Nothing could be further from the truth.

At the end of the day, we as physicians are all human and are being influenced by many external variables that are separate and distinct from the by-the-book medicine that we know is right. Further, there are even circumstances when the book will tell you to do one thing, but common sense would suggest otherwise. Consultants may have had a long day and don’t want to come back to the hospital: they may have just had a baby and want to catch up on some sleep, or they simply would prefer not to get involved in the care of a complicated patient who normally goes to another hospital and sees a different set of doctors. In particular, after working several years of strictly night shifts, I find that rules are always negotiable once the clock passes the red line of 11:00 p.m. After that magical hour, emergencies aren’t as emergent, and things always seem to be able to wait until the morning.

My point is this: don’t be simple-minded and think that just because you’ve spoken to Dr. X and documented it that you’re doing the patient justice and practicing good defensive legal medicine. In particular, when you are the one that has actually seen the patient, compared with just a voice on the phone, you are the most qualified to make medical decisions. Always ask yourself this one question: If my patient was a member of my family, would I be happy with their care and disposition? If the answer is yes, then you can sleep comfortably; if the answer is no, then it looks like you’ll have to wake up a few more people up at 3:00 a.m.

Consult your own team. If you are anything like me, I couldn’t wait to become an attending. After three years of residency training, I felt confident (and cocky) enough to release myself from the “shackles” of residency bondage and finally start making decisions on my own instead of doing what my attending wanted. I am a person who highly values independent decision making and control, and I felt the aching sensation that being forced to do someone else’s bidding was cramping my style.

That way of thinking was immature on many levels.

If you think you are the smartest person in the ED, you will run the risk of dismissing the input of many well-intentioned authority figures and others on your medical care delivery team who will often have valuable pieces of information that will assist you in executing better patient care and making the correct diagnosis. Even if you are the smartest, brightest, most competent, and most skilled person in the entire hospital, the best doctor in the world can only be right some of the time—one of the downsides of being human. It has been proven that human cooperation yields better results than a lone operator, and you owe it to yourself not to limit your options.

I can remember starting my internship at the tender age of 24, and then my first attending job at 27 years old, only to quickly meet people who have been working in medicine longer than I had been alive. They had certainly been around the block more than a few times, and the sooner I embraced their experience and perspective (even if I didn’t necessarily agree at times), the more efficient and seamless my ED experience became. At the end of the day, even the superstar studs can’t even come close to matching the multiplicity of knowledge and experience that an ED staff equates to. It still amazes me how many times a nurse saved me or was able to provide a small yet perfectly priceless piece of information that made me look better and allowed me to provide better care for my patients. Further, when the ED staff views you as an approachable, welcoming person who is open to input, they will feel much more comfortable in lending a helping hand and volunteering information that can help. If the team views you as an abrasive, high-handed, and arrogant dud, then you’re on your own. No man is an island, and you should allow yourself to be persuaded.

In the end, as the ED attending physician, the final responsibility rests on your shoulders, and you will quickly develop a filter for information that will actually help, information that is just junk, or someone (who often will not bear ultimate responsibility) who thought it would be a good idea to give their two cents. All groupthink ends with you—just make sure you haven’t dismissed the group in the process.

Be wary of partnership “buy-ins.” Whenever you buy into anything, you must always know what you’re giving up and what you will receive in return. Buying equity and/or stock or becoming a partner of a physician group is not inherently a bad thing, but in many cases, it can serve as a deceptive tool to lure you into giving money away to a group without receiving much in return. As a case in point, I worked for a group where you become eligible to become a partner of the organization after a certain time. This election entitled you to several benefits, but the primary one was financial. In addition to your annual salary, you also receive a check at the end of the year based on the number of shares that you owned. In order for a partner to be fully invested, they would have to dish out about approximately $200K.

The group freely disseminated its particular formula to keep all its partners in the know about how their yearly bonus would be calculated, but they controlled the information and kept secret the exact dollar values that were used to calculate the final figure. This is the first red flag. You may know how your bonus is calculated but have no idea (and therefore have no control over) how much it will be. A second red flag was that as the company expanded, they recruited more doctors, who then became partners and then bought shares. As a result, the pie did get larger, but not in proportion to the number of mouths it fed. In essence, my shares became progressively less valuable and hollow because their expected yield went down as time progressed.

A third potential red flag is the recoupment of your investment. If you put down $200K to buy shares but are getting a bonus of $50K annually, then congratulations, you have a dream job. But if you’re “only” getting $10K to 15K a year, then you must come to terms with the fact that you will not break even for another 13 to 20 years. It’s only after that that you will see a positive return on your buy-in.

The fourth and final red flag is how your accumulated purchase is distributed if you decide to pack up your bags and leave the group in question. Some organizations will not give you all of your funds back at once but instead elect to give it out only over the course of a few years. Imagine going to a bank and saying, “Hey, give me my money,” and the teller informs you that he’ll give you $10 now but the rest will be given back over the next six years. This is a petty attempt at a Ponzi scheme.

Democratic may not mean what you think. I began to interview for jobs during the fall of my last year of residency. I remember all the groups that I looked into proclaim that they were “democratic,” yet the concept of democracy seems to vary depending on how you look at things.

The fact is, nowadays, it is becoming less cost-effective to have a handful of ED physicians micromanaging all aspects of an ED. Where I live in the Northeast, you would be hard-pressed to find a physician group that has less than a handful hospital contracts. The smaller you are, the less leverage and purchasing power you have, and with the remodeling of health care delivery toward efficiency, cost cutting, and centralization, it makes financial sense to expand and maximize a group’s earning potential. This equates to delegating vital core components (e.g., insurance and billing) either in-house or to an outside firm. The specifics are unimportant, but as you can see, the bigger a group gets, the greater its bureaucracy and corporate infrastructure. And with corporatism, democracy gets crushed.

Now don’t get me wrong … I didn’t join a group thinking we would all be voting on whether or not to buy an espresso maker for the ED lounge. But you would be surprised how much decision making goes behind the scenes at many groups, thus leaving the physicians to vote on more trivial matters.

For example, in one democratic group, I was part of a committee that made recommendations for retirement plans and advised the whole group on its investment strategies. This committee had no more than 10 physician members, yet we made decisions that impacted the finances of hundreds of doctors who had millions of dollars at stake. In this specific case, each physician committee member had a quantifiable say, but hundreds of other doctors were none the wiser as far as financial matters were concerned. Hence, as a “regular physician,” you never had a chance to vote on matters that directly affected you, and this paradigm extended throughout several levels within the organization. When the doctors did vote on a company-wide level, the matters tended to be more superficial. When the issues were more complex, we typically had an analyst (paid by the group) or some other figurehead in the company strongly advise what we should be voting for.

Go long. Before you start your working career, always keep the end in mind. I say this because, unfortunately, ED physicians have an exceedingly high burnout rate compared with both the general population and other physicians in general. In fact, according to a study in Annals of Emergency Medicine, a majority of active ED physicians reported signs of burnout—this means most of us are either not satisfied with work or work is getting the best of us. This is not meant to forecast doom and gloom, but you should always pay attention to your own personal preferences on what work sites and cycles work for you, your state of mind, sleep cycles, outlets for catharsis outside of work, and how your job affects your other relationships. Cognizant of all these facts, you should tailor your work around your life and do not tailor your life around your work. Go long, realizing that thinking for the short-term may only serve to diminish your long-term viability and prematurely end your career.

Debt equals slavery. A graduating resident’s number one economic priority after completing residency is to pay down and eliminate all debts. When you’re making $200K a year in excess, it may be initially tempting to buy a Porsche, but unless monetary obligations are paid off, debt will persistently drain you of your hard-earned money for years (and even decades) to come. Timely (and early) repayment is paramount because the longer the principal on any debt exists, the longer the interest has to accrue value and thus can often exceed the initial amount borrowed. Medical professionals are in a special group because our educational debt often reaches well into the six figures, far above that of the average American. Debt deceptively shackles us all in unbreakable chains since its full effect is diluted over time and displaced far off into the horizon. Many young residents lack the future orientation to fully realize the gravity of this dilemma.

Until debt obligations are fulfilled, I would recommend renting versus buying, saving a lot and spending a little, and certainly not allowing your new six-figure salary to entice living beyond your means. Try not to live shift to shift.

In light of all these things, would living with Mom and Dad again really be that bad?

Do not waste time. The primary purpose of your residency is to train and educate you. This means you’re supposed to not know everything, and your attendings, who are wiser and smarter than you are, are there for backup. Exploit this dynamic to your advantage and don’t waste your own valuable time—use each and every shift to learn more about EM and attempt to perform as many procedures as possible, especially the rare ones. This doesn’t mean you should leave your shift, go up to labor and delivery, and perform an emergent C-section, but it does mean that once you have graduated, there’s no longer a helping hand to watch over you and there’s no backup—you are the backup.

In order to maximize your knowledge and skills in the long term, use your training not as a congratulatory mechanism for all the things you can do, but to focus on all the things you’ve done wrong and how those wrongs can be avoided in the future. You’ll be making a plethora of wrongs, so this should be a very easy task. This allows you to identify and eliminate all weaknesses as soon as possible and not overdevelop those areas in which you already demonstrate proficiency. You’d be surprised how much more efficiently your brain works when you’ve dedicated serious mental energy into what not to do (based on prior error) in the heat of the tense moments. Psychologically, when it comes to our training, our brains are wired to better respond to learn-from-the-errors-based training compared with an emphasis on desired positive outcomes.

Know thyself. I once worked with a man who was an EM machine. He could work two 16-hour shifts back-to-back with a five-minute Mountain Dew break in between, go home, get two hours sleep, and then come back fresh and ready after doing an emergent C-section in the parking lot. Oh, and by the way, since he’s also such a nice guy, he also put in a subclavian central line in that patient with no veins. I am certainly not that guy, and if I work more than three 12-hour shifts in a row, I become frazzled.

All people are built and wired differently, and this certainly impacts where and how you work. After years of residency training, you have a rough idea of your length of shift preference, whether you prefer days, midshifts, or nights or whether you prefer to work in blocks with large gaps in between or even scattered around. So if you like penetrating trauma, don’t move to rural Alaska and think the change will keep you interested. Conversely, if you prefer a more relaxed pace with not-as-complex cases, consider a more suburban setting with lower volumes.

In my opinion, peace of mind at work is the most important factor in determining happiness and longevity. This peace won’t be rooted in one thing, but from the cumulative sum of many small and diverse factors coming together. It may take some time and effort to find it, but once you do, you’ll have a long and fruitful path ahead of you.

Happy job searching.


C. H. E. Sadaphal, MD, FACEP

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  1. Todd L. says:

    this info is the real deal. never thought of it that way before. thanks!

  2. Jaqueline says:

    Down with the corporations!

  3. Jason Pax says:

    This is depressing. Most of us are showing signs of burnout plus our average career span is a decade.

    • The Night Doc says:

      The Annals study is more depressing. Working in the ED by itself means we’re much more likely to burn out. If we did ANYTHING else, we’d be less stressed.

  4. Nathaniel says:

    good stuff. managed to get through it during a not so busy morning shift.

  5. H. Brock says:

    The south has many more opportunities for independent contractors where you pretty much make what u bill or “eat what you kill.”

  6. NP says:

    Enlightening (and revealing) as usual, Dr. S.

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