INTRO TO LIFE AFTER RESIDENCY

Jun 18th, 2013

Epidemiology/Intro

• 1961 – Alexandria Plan– 1st ER to have fully staff physician

• 1968 – First national EM meeting– 32 physician from 18 states

• 1971 – 1st EM training program formed– Univ of Southern California– Univ of Louisville

• 1979 – EM became nationally recognized medical specialty

• 1988 – Last year for “grandfather clause”

Epidemiology/Intro

• Currently, the demand for board certified EP is ≥ 20,0000–Probably will not be achieved till next

century–Rural >>> Urban/Suburban

Factors That the Demand for Emergency

Physicians1) Aging of US population2) General in US population3) Greater demand of the public for ambulatory care

services, but insufficient non-ED alternatives4) Demonstration that improved clinical outcomes are

assoc w/ emergency medicine trained EPs5) Expansion of out-of-care hospital services/systems6) Employment of US trained EPs in emergency health

care facilities outside the US

Factors That Demand for Emergency

Physicians1) Closure of hospital EDs2) Use of “physician extenders” in place of EPs3) Refusal of payers to fund nonclinical duties by

EPs4) Transfer of ambulatory care cases currently

managed by EpPs to primary care practitioners outside the ED

What about the quality of life?

QUALITY OF LIFE RATINGS FOR

EMERGENCY PHYSICIANPersonal satisfaction A

Job security A

Future growth B

Benefit to society A

Low stress D

AGE-GROUP DISTRIBUTION FOR EPs

Why do they leave the Field… (1)

• AMA quotes the attrition rate for most medical specialty is about 2-3%– For EM: 1.5 to >12%– Anwar, RAH (1983) reported in his study:• 5% attrition rate 2 years after EM residency

training

Why do they leave the Field… (2)

• Physicians who left the field– Long and irregular work schedule– Financial stability– Academic vs on your own– Single vs married– Board certification– STRESS

NOW THE GOOD STUFF….

HOW MUCH MONEY WILL I MAKE???

US National Avg Salary for EP

$189,002 $212,295 $269,973 $298,769

10th% 25th% 75th% 90th%

Salary for EPs have an avg of 14%

What about the hours?

Length of Shifts

“Length of the shift should depend on the physical and

mental load of the task”- Kanauth and Rutenfranz. J Human Ergol 1982 (11)

What Do We Prefer???8 hours vs 12 hours

8 hrs 12 hrs Other0%

100%

200%

300%

400%

500%

600%

700%

800%

900%

1000%

Series3Series2Preferred Shift

Length of Shifts: 8 hours vs 12 hours

8 hrs 12 hrs 8 & 12 hrs Other 8, 12, and Other

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

35.00%

11%

32%

18%

26%

13%

% of shifts worked

% worked

Length of Shifts (4): 8 hours vs 12 hours

• Advantages of 12 hrs– Fewer shift changes

• Fewer transfer of pt care

– Longer time period for patient care

– Less time working after shift change

– Less commuting time– 1/3 more days

completely off

• Advantages of 8 hrs– More rest– alertness in the last 2-

4 hrs– Ability to participate in

personal activities on workdays

– Ability to apply circadian principles in rotating shifts

WHAT ARE MY OPTIONS…

OPTION A: I WANT TO DO ONLY ER

• ACADEMIC– Love for teaching– Interaction with

residents/medical students

– “Cutting edge” practice– Administrative work– Research funds– See Constantly

expanding knowledge

• COMMUNITY– Higher pay– More hands on

procedures– Less non-clinical hours

OPTION B: I WANT TO DO A FELLOWSHIP

• BOARD CERTIFICATION– EMS *– HOSPICE/PALLIATIVE

CARE– MEDICAL TOXICOLOGY– PEDIATRIC EM– SPORTS MEDICINE– INTERNAL/CRITICAL

CARE*– UNDERSEA/

HYPERBARIC MEDICINE

• CERTIFICATION (NO BOARDS)– Administration– Cardiology– Education– EMS/Pre-hospital Medicine– Environmental Medicine– Disaster Medicine– Geriatric– International EM– Legal– Medical Informatics– Research– Simulation Lab– Trauma/Critical Care– Transport Medicine– Ultrasound– Wilderness Medicine– Women’s Health

OPTION C: ANY OTHER OPTION

• Go abroad– Work at any clinic/urgent care cites

• Be a medical ambassador– Travel to different regions providing care• Disaster zones• Under-priveledged areas

• Involve yourself in politics

LICENSING, FEES, AND TIME FRAME…

ABEM BOARD CERTIFICATION (1)INITIAL CERTIFICATION APPLICATION

Application fee if submitted onlineApril 15 - July 1,

2013

Application fee if submitted online July 2 - August 2,

2013

Application fee if submitted online

August 3 - October 1, 2013

Initial Certification Application

                     

$420* $575*(includes late fee)

$1,295*(includes late fee)

ABEM BOARD CERTIFICATION (2)QUALIFYING EXAMINATION

Examination Name                              

Register and pay onlineMay 1 - November 1, 2013

Register and pay onlineNovember 2 - 7, 2013

Qualifying ExaminationMonday - Sunday,

November 11 - 17, 2013$960* $1,965*

(includes late fee)

STATE LICENSING AND FEE• Illinois License processing fee: $600.00

– California: $1298– Texas: $1002– Florida: $1227– Indiana: $250– Michigan: $150 ($230 w/ Controlled Substance)

• Illinois State Physician-controlled Substance License $5.00 and up to 8 weeks

• DEA application 6 weeks and $551.00

• Apply for NPI number (on line, a few minutes, free)

Expected Time Frame

• Depending on the state:– Arizona: 4 – 6 weeks– Illinois: 6 weeks – 12 weeks– Michigan: 6-8 weeks– Indiana: 6 weeks– Florida: 3 – 4 months– Texas, California: 6-9 months– Wisconsin: 3 months

FCVS

FEDERATION CREDENTIALS VERIFICATION SERVICES (FCVS)

• Permanent repository of primary-source verified credentials for physicians– Lightens the workload of credentialing staff– Reduces duplication of effort from physician– Reduces time period to get a license

• Good: those who wish to work in multiple states

• Bad: Another expense

FCVS

WHAT DO YOUR FELLOW PEERS/

COLLEAGUES HAVE TO SAY?

Advice From Your Fellow Colleagues at ACH (1)

• Get the nurses on your side (D. Girzadas)– “it’s like starting residency all over again…”

• Show up early or on time (H. Zerth)– “or colleagues will resent you forever”

• Things move faster than ACH, have a plan before leaving the patient room (H. Zerth)– “adding on tests after tests will delay disposition

for 2-3 hrs and are generally frowned upon”

Advice From Your Fellow Colleagues at ACH (2)

• Don’t be afraid to ask your senior co-attending a question (D. Strasburger)– “asking for a second opinion is not forbidden”

• It’s not as hard to admit someone (H. Zerth)– “don’t fight tooth and nails, if you aren’t

comfortable discharging someone then admit”• You are going to be nervous (H. Zerth)– “just trust your training and you will do fine ”

Advice From Your Fellow Colleagues at ACH (3)

• Ask for an orientation of your ED (C Kulstad)– “never want to be in a situation where you have to

look around for something in a hurry (central lines, ET tubes, chest tubes, etc)”

• Become a “good citizen” by asking how you could contribute (M.Felder)– “allows you to find a nitche, both security and

longevity”

Advice From Your Fellow Colleagues at ACH (4)

• Say thank you a lot, act like you want the business (S Altman)– “when you are paid full salary, there is no such thing

as an ‘inappropriate’ ED Visit”• Be involved early and as much as possible(PJ

Konicki)– “get to know as many attendings outside the ED”– “attend social and charitable events run by hospital

and medical staff office” – “Make ED consultation friendly ”

Advice From Your Fellow Colleagues at ACH (5)

• Walk in the door calling your fellow attending by their first name (S Altman)– “if you act deferential, you will be treated as a

resident”• Try to accept all requests for shift trades when

possible, even if they don’t seem fair (S Altman)– “you will become known as a team player”– “just keep track of the shifts, beware of anyone who

tries to take advantage of you”

Advice From Your Fellow Colleagues at ACH (6)- Shadow Shifts -

• Do a shadow shift in a place you are not familiar (A. Kiernicki-Sklar)– “important to know how certain processes work before

you start (e.g. transfer, admission, running codes, etc)”– “allows you to be familiar with the kinds of equipment

they have available”• Need to know the competency of the staff around

you (A. Kiernicki-Sklar)– “ancillary staff may not know the medications you are

familiar with”– “will they be able to recognize a sick patient?”

Advice From Your Fellow Colleagues at ACH (7)- Watch your words-

• Listen first, talk last (T. Ross)• Give advice/opinion ONLY when asked (T. Ross)

• Do not get in an argument for any reason – DO NOT raise your voice (T. Ross)– “remember, you are under watch at all times”

• Never engage in any talk complaining about one of your colleagues (T. Ross)– If someone asks, respond back by saying: “you haven’t noticed

that, but how about them Bears”

Advice From Your Fellow Colleagues at ACH (8)- Watch your words-

“I think you will find that if you stop complaining you might not need to do it as much anymore. Once you start, it is hard to stop. Think of complaining like cigarettes and stay away... (Oh, how I would

love to have a smoke!!)” (T. Ross)

Advice From Your Fellow Colleagues at ACH (9)- Financial Help-

• Live like a resident for 2 more years (S Altman)– “a dollars saved today is worth more than one saved

tomorrow”– “put off that temptation of buying that Lexus/Porsche”– “ONLY EXCEPTION IS BUYING A HOUSE”

• Maximize tax deferred opportunities (S. Altman)– “money saved in this account is untouchable in case of

divorce, law suit, or even criminal activity”

• Look for a good team to manage your investments/retirements/disability (A Katiyar)

Advice From Your Fellow Colleagues at ACH (10)

- AND AT LAST…-

• Remember this is your last year of training…– Start forming your “thinking process”• Ask yourself, “what will I do if I were on my own”?

– Get comfortable with as many procedures• EJs, central lines, chest tubes, LP, etc…• What have I not done?

– Challenge yourself everyday with seeing pts• There is no limit, try to see as many pt as you can…

– Learn how to chart efficiently!!!• Don’t lose money!

MOST IMPORTANT NOTE:

DON’T FORGET ABOUT THE EMERGENCY MEDICINE

BOARDS

AND YOUR TAXES!!!