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M4 debating specialty switch to EM, not sure I'm cut out for shift work

Home The Lounge M4 debating specialty switch to EM, not sure I'm cut out for shift work

  • Avatar Charlie Munger 
    Participant
    Status: Student
    Posts: 5
    Joined: 12/27/2018

    Hi everyone,

     

    I started a thread looking for advice about pursuing internal medicine a few months back (https://www.whitecoatinvestor.com/forums/topic/thoughts-on-pursuing-im-residency-to-become-hospitalist-m3-specialty-question/). To summarize, I was really attracted to the flexibility of a generalist specialty with so many options.  After completing my 3rd year of medical school along with my internal medicine sub-internship, I’m having some second thoughts. Here are a few:

    • I don’t really care much for continuity of care.  This was a term I heard get thrown around a lot that I figured I would begin to appreciate more the further along I went in training, but I’ve realized that just isn’t going to be the case.  For me, the exciting part of medicine is diagnosis, or at most treating acute problems.  I don’t enjoy juggling several non-acute medical issues for long periods of time.  It’s not that the next patient may be the nth UTI/AMS or CAP/COPD exacerbation that day that bothers me, but how long it takes to get them off the list and move on to something new.  A really telling sign was when I was looking forward to call on my sub-I because it meant I would be going to the ED and doing H&P’s on new admits one after another.
    • To be brutally honest I do not care about getting to know my patients personal lives or following them for years.
    • I don’t think I have it in me to commit to 6 additional years of training to become sub-specialized. Even if I did, as naive as it sounds, I only recently realized that the majority of time someone like an oncologist or rheumatologist spends is in the clinic optimizing medications, not pouring over interesting/difficult consults.

    I know some of this makes me sound like a terrible student, which may be true. I recently started my EM rotation which I’m hoping provides me with all the answers I need by the end of it, but due to the unique/time sensitive application requirements of EM (video interview, SLOEs) I think I need to decide whether to pursue it further in the next week or so, prompting this thread.

    EM was actually one of the first specialties that I heavily considered but basically wrote it off due to one problem; shift work.  I am not a strong sleeper and have a very fragile circadian rhythm.  For example, even after years of disciplined sleep hygiene and nightly dose of melatonin, I fell asleep close to 4 hours after intended just last night for reasons I don’t think I’ll ever know. I’m worried that even 10 years of a typical EM schedule may be too much for me.  My question is one that I think has been asked probably by thousands of medical students, but how feasible is it to avoid overnight shifts as an attending.  I would be happy working extra evening/swing shifts, weekends, and holidays if it meant I could keep a relatively normal schedule.  I used to think an option would be to take a pay cut for less nights, but after some reading it seems like that would still be problematic because people don’t want to hire a part-timer that requires the same overhead for the group (malpractice, certification, etc).  I don’t want to be a burden for my colleagues.  Is there hope for me in this field, or should I just stick to something more stable even if it may not be the absolute perfect specialty for me? (if such a thing exists)

    Thanks again for any advice, I know this is a bit long-winded.  All of the responses from my previous thread were extremely helpful and greatly appreciated.

    #235610 Reply
    MPMD MPMD 
    Participant
    Status: Physician
    Posts: 2509
    Joined: 05/01/2017

    I would be very nervous about this if I were you. I actually had a VERY talented student switch from EM to IM for exactly this reason and I think she made the exact right call.

    I think you need to really consider if this is the right field for you and I suspect it isn’t if your sleep schedule is this fragile. Keep in mind that this aspect of your life will almost certainly get worse and worse as you get older. Nights are harder on me now than ever (38 years old).

    I think it would be highly inadvisable for you to go into EM with the plan to attempt to trade weekend shifts for nights. If nothing else your life is going to intrude. Your partner/kids may not find your plan to work weekend swing shifts very cool at all. Evening/swing shifts are the most disruptive to my family life not nights. I have only ever met one doc who basically traded weekend availability to be off nights, it’s not a common thing at all. You don’t want to embark on a career plan that only works if someone follows your plan because no one is under any obligation to do that.

    It’s also very tough to go onto the job hunt asking how you can avoid nights, that will be seen as a red flag by most medical directors. Even if you manage to avoid nights you are going to have to deal with early morning shifts (starting at 6a) and swing shifts (ending at 2a).

    If I were you I would take a hard look at Anesthesiology. Great field, good comp, fun cases. For the most part you work during the day and sleep at night. It’s not boring that’s just what medical students say. It’s boring to watch someone do anesthesiology in the same way that it’s boring to watch someone fly a plane.

    Avatar SValleyMD 
    Participant
    Status: Physician
    Posts: 468
    Joined: 05/12/2016

    Another vote for anesthesia based on your description

    #235617 Reply
    Avatar squirrel 
    Participant
    Status: Physician
    Posts: 78
    Joined: 01/26/2016
    Splash Refinancing Bonus

    Have your follow a hospitalist?  Follow in the hospital only.  Where I work, most hospitalists work days or nights (some some occasional crossover, but not often).  Would keep you in IM but may be a better match given your concerns?

    #235624 Reply
    Avatar artemis 
    Participant
    Status: Physician
    Posts: 593
    Joined: 12/02/2016

    Let’s see:  you enjoy diagnosis, but not continuity of care, and you really don’t care about getting to know your patients as people.  You need a reasonably regular schedule.

    Have you considered pathology?  Diagnosis is the bread and butter of anatomic pathology, we generally only see actual patients when they are lying on an autopsy table, and we generally work very regular hours.  And as a US medical graduate, you’ll have no trouble matching into a good residency and finding a good job later.  The only downside is you’ll need to train for five years (four years in residency, plus most places expect a year of additional fellowship training).

    I agree anesthesia is also a good option, worth checking out.  Maybe radiology as well.

    Avatar hightower 
    Participant
    Status: Physician
    Posts: 1485
    Joined: 12/07/2016

    Hi everyone,

     

    I started a thread looking for advice about pursuing internal medicine a few months back (https://www.whitecoatinvestor.com/forums/topic/thoughts-on-pursuing-im-residency-to-become-hospitalist-m3-specialty-question/). To summarize, I was really attracted to the flexibility of a generalist specialty with so many options.  After completing my 3rd year of medical school along with my internal medicine sub-internship, I’m having some second thoughts. Here are a few:

    • I don’t really care much for continuity of care.  This was a term I heard get thrown around a lot that I figured I would begin to appreciate more the further along I went in training, but I’ve realized that just isn’t going to be the case.  For me, the exciting part of medicine is diagnosis, or at most treating acute problems.  I don’t enjoy juggling several non-acute medical issues for long periods of time.  It’s not that the next patient may be the nth UTI/AMS or CAP/COPD exacerbation that day that bothers me, but how long it takes to get them off the list and move on to something new.  A really telling sign was when I was looking forward to call on my sub-I because it meant I would be going to the ED and doing H&P’s on new admits one after another.
    • To be brutally honest I do not care about getting to know my patients personal lives or following them for years.
    • I don’t think I have it in me to commit to 6 additional years of training to become sub-specialized. Even if I did, as naive as it sounds, I only recently realized that the majority of time someone like an oncologist or rheumatologist spends is in the clinic optimizing medications, not pouring over interesting/difficult consults.

    I know some of this makes me sound like a terrible student, which may be true. I recently started my EM rotation which I’m hoping provides me with all the answers I need by the end of it, but due to the unique/time sensitive application requirements of EM (video interview, SLOEs) I think I need to decide whether to pursue it further in the next week or so, prompting this thread.

    EM was actually one of the first specialties that I heavily considered but basically wrote it off due to one problem; shift work.  I am not a strong sleeper and have a very fragile circadian rhythm.  For example, even after years of disciplined sleep hygiene and nightly dose of melatonin, I fell asleep close to 4 hours after intended just last night for reasons I don’t think I’ll ever know. I’m worried that even 10 years of a typical EM schedule may be too much for me.  My question is one that I think has been asked probably by thousands of medical students, but how feasible is it to avoid overnight shifts as an attending.  I would be happy working extra evening/swing shifts, weekends, and holidays if it meant I could keep a relatively normal schedule.  I used to think an option would be to take a pay cut for less nights, but after some reading it seems like that would still be problematic because people don’t want to hire a part-timer that requires the same overhead for the group (malpractice, certification, etc).  I don’t want to be a burden for my colleagues.  Is there hope for me in this field, or should I just stick to something more stable even if it may not be the absolute perfect specialty for me? (if such a thing exists)

    Thanks again for any advice, I know this is a bit long-winded.  All of the responses from my previous thread were extremely helpful and greatly appreciated.

    Click to expand…

    I too would look into hospitalist work if you’re not a fan of traditional IM.  I don’t want to do traditional IM for the same reasons you pointed out.  You can also do hospitalist work for awhile while applying to fellowships.  I work as a hospitalist and I don’t have to do nights at all.  There are plenty of opportunities like that if you can’t do nights.  That won’t be the same with EM.  You will have to do nights in EM, especially as a new hire.
    EM can be a very stressful job.  Do you like being bombarded with 10 h&p’s all at once, some of which may be very critically ill?  Do you like being in the middle of seeing a patient and getting called to a code blue to intubate someone and place a central line?  You need to like that kind of environment to do well in EM.  I’m not EM, but I realized very quickly that it wasn’t for me during med school.

    What makes you think you have a “fragile circadian rhythm?”  If you’re referring to having difficulty sleeping as a medical student doing stressful work and trying to figure out what you want to do for the rest of your life, you’re probably just experiencing anxiety and the sleep difficulty is the result of that, not a problem with your body.  A lot of people have insomnia related to anxiety and they are totally unaware of the fact that they are so anxious.  And the lack of sleep and the fear of lack of sleep can make the insomnia worse.  Sleep is important obviously so I would get to the bottom of why you’re having such difficulty at such a young age.  I don’t believe melatonin is generally considered effective and I would caution that it could be screwing you up if it’s causing your levels to peak at the wrong time in the night.  Definitely continue to practice good sleep hygiene, get exercise every day, and go to bed and wake up at the same time each day if possible.

     

    #235629 Reply
    SerrateAndDominate SerrateAndDominate 
    Participant
    Status: Physician
    Posts: 487
    Joined: 02/01/2018

    Agree with Artemis regarding path. This read like a future pathologist. Has many upsides and downsides. It can be shift work and may have some boring aspects, but it checks many of your boxes regarding diagnosis only.

    If you have the right volume and avoid a specialist abusing you for pennies on the dollar, you can do very well in terms of income and lifestyle.

    It’s weird going to the point where you rarely/never see patients, but clinic life wasn’t my thing. I’m glad there are people who enjoy that just as i’m sure they are glad people do path.

    Feel free to PM me if you have questions.

    Earn everything.

    #235631 Reply
    Avatar trebizond 
    Participant
    Status: Resident
    Posts: 131
    Joined: 12/31/2017

    I vote path or rads. Also consider rad onc (very competitive though). Consider IM hospitalist but again some shifts can be chaotic and there are plenty of nights in residency.

    #235670 Reply
    Avatar DCdoc 
    Participant
    Status: Physician
    Posts: 562
    Joined: 06/14/2016

    A vote for rad onc if you’re smart enough. I was probably smart enough but didn’t realize it’s potential as a MS. Anesthesia will be tough if you don’t want to do nights/calls. I actually stopped both those 1.5 years ago but it came with a huge pay cut I couldn’t have handled if I were early career or weren’t an agressive saver the first decade. If you start out on that path in anesthesia, your career mobility and salary will be severely restricted. You would have a hard time as a fresh anesthesia resident finding a non-call Job and those that exist are 200k+ less than partners, especially in an environment shifting to CMGs and CRNAs.  ED likely some way.  Both anesthesia and ED are 24/7 shift work where new hires do a disproportionate share of nights/weekends/holidays.  Path is 100% diagnosis, 0% continuity, and can have great hours if that’s what you seek. I always was just staring at my eyelashes when looking in the microscope, but I have immense respect for pathologists and it would be on my short list if I could rewind time.

    #235675 Reply
    Dreamgiver Dreamgiver 
    Participant
    Status: Physician
    Posts: 871
    Joined: 03/09/2017

    Anesthesia can be very tough especially in a tertiary care center. Don’t ask me how I know. I am still recovering from a brutal weekend 5 days ago. However, in a smaller hospital or such anesthesia can be much better, even though income will usually be lower and cases not as challenging. I don’t enjoy nights at all but I have learned to adapt. Residency trains you for that.

    #235716 Reply
    Avatar Allixi 
    Participant
    Status: Physician
    Posts: 112
    Joined: 03/16/2016

    I wouldn’t give up on “hospitality” (being a hospitalist) just yet. A lot of programs, including mine, have shifts where you only see new admits, then hand off all these pts the next day, and don’t have to maintain continuity. These typically are evening/swing shifts – you come in around mid-day and leave at 8-10 PM. The only major downside is that you have to eat dinner in the hospital.

    Other programs might even have these during the daytime.

    #235717 Reply
    Avatar jacoavlu 
    Moderator
    Status: Physician, Small Business Owner
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    Joined: 03/01/2018

    In almost any field you can find a job that suits what you want. Maybe you won’t make as much money as you could working some other way, but whatever hours you want can be had, somewhere. Everything is negotiable.

    The Finance Buff's solo 401k contribution spreadsheet: https://goo.gl/6cZKVA

    #235721 Reply
    Avatar G 
    Participant
    Status: Physician, Small Business Owner
    Posts: 1800
    Joined: 01/08/2016

    Ugh, dont have much advice for you, but I feel for you. These decisions have a way of working out, it just seems impossible to believe this where you are at now.

    EM can be crafted to get on bankers hours, but this is after a couple decades of sweat and banking $. And apparently even then it is a unicorn job, based on the commentary here. You’re going to be flipping from mostly evenings/afternoons to nights to days for the foreseeable future.

    I see shift work becoming more prevalent vs traditional call in many call panels at my hospital(cards. Ortho, hospitalist, anesth, ICU, peds, even discussion now for surgery) . FWIW I find this easier to adjust to than being awakened all night every fourth night. Anchor sleep is good for me.

    Maybe you should find an NP job and just switch careers every couple years? (Sorry…couldn’t resist.)

    Good luck, you’ll look back on this time 20 years from now and smile.

    #235725 Reply
    Liked by Tim, 02Sats
    Avatar Outdoors 
    Participant
    Status: Resident
    Posts: 27
    Joined: 08/12/2017

    As someone who went through the match this year, I just wanted to point out from above that Rad Onc is significantly less competitive now, with quite a few unfilled spots and unmatched programs this year (see SDN if you want a full discussion of reasons why).  I agree it can be a great field, but it seems like OP is pretty close to needing to decide with it being August of fourth year.

    I obviously can’t provide an attending perspective on specialty choice, but feel free to PM me if you have questions about the match.  I switched my specialty pretty late (not EM or IM), and I’m very happy I did.  After years of back and forth, I decided I needed to keep it simple and pick the field that I enjoyed most.

    #235732 Reply
    Liked by Roentgen
    Avatar G 
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    Status: Physician, Small Business Owner
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    Joined: 01/08/2016

    p.s. next year when you are bumming and hating your decision, remember that intern year stinks for everybody in pretty much all specialties.

    #235735 Reply

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