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By embracing appropriate mid-career shifts, we can re-infuse maturing EPs with the excitement that once drew them to the specialty     

I have just returned from my annual sojourn to the peripatetic holy shrine of emergency medicine, the ACEP Scientific Assembly. It is, for people in emergency medicine, the greatest show on the planet: vendors hawking dubious wares, unspeakable displays of marketing opulence mixed with the wide-eyed stares of first-time resident attendees. This is the place where you would think the marketplace of ideas would prevail – economic openness from Marxist deconstructionism vying with the rules of Milton Friedman. And by the way, Uncle Miltie wins.

In this sea of intellectual biodiversity, you would think that no subject would be taboo. But in my self-proclaimed role as Arbiter Bibendi – encouraging both thought and a little irreverence in confronting the problems of our specialty – I’ve found an area which begs addressing: the mid-life crisis of emergency medicine. Gone are the days of young medical radicals trying to build a board and a profession. The “long hair” – mine was down to my shoulders – and tacky sport coats have faded into legend. Political correctness along with Armani suits and Bulgari ties have now become the order of the day. But there are humanistic values which we once held close that are becoming museum pieces.

What value is being lost with almost no fight? What is slipping away in silence with little being said? It is emergency medicine’s youthful sense of adventure, the spirit that wonders what lies over the next horizon. It is my opinion that we as a specialty do not know how to re-infuse our “maturing” members with the excitement and joy that once brought them into emergency medicine. We need new vistas to explore. In short, we do not know how to mature the emergency medicine career.

Orthopods start out doing trauma and end up replacing hips. OBGYNs start out delivering babies and end up delivering uteruses. But what is the expected maturation of the emergency medicine career? It’s a lot harder to wrestle drunks when you are 65. Night shifts get tougher and tougher. If you think I jest about this situation, you are either very young or very numb.

A note to my almost infantile resident colleagues: I render to you that you shall age and have exactly the same questions with regard to your life and job situation. And lest you think I have joined the Grub Street hacks, turning out copy to fill throw-away journal pages, do me a favor: At your next group meeting start the discussion of maturing the emergency medicine career and watch what happens. They all want to talk about it. The veil of silence will be lifted. The xenial relationship between doctor and profession is not ephemeral but real. And career maturation, like death, awaits us all.

I’m a First Amendment guy all the way. We should be able to express ourselves and talk about real issues. As I spoke at the ACEP convention to my more mature compatriots, it was clear that there is a lugubrious malaise abroad in the land. And they are looking for leadership to cure this ubiquitous nosocomial depression. They are looking for a way to mitigate the effects of time. I can see opportunity in this now that I missed when I served as President of ACEP. Seventeen years ago I proposed we study fast-track and off-site urgent care centers as a mid-career pathway for our members. The tenaciously negative response I got was unbelievable: how could I even suggest that there was a life to be had outside the hallowed halls of our hospitals, wallowing in depravity and cold pizza? 

Listen up troops. Here’s the plan – and I will need your help on this one. I’ve already spoken with the Executive Director of ACEP to add to the 2013 ACEP Scientific Assembly a mid-career job fair. We hold such events for medical students. We have the entire tract devoted for residents looking for their first jobs – and well we should. So why not have a place where seasoned physicians can go to learn what it takes to advance their careers? Did you even know the Navy takes physicians up to age 53?

Did you know that the most sought after physicians by headhunters for the role of Vice President of Medical Affairs are experienced emergency physicians? Why? Because we’re the doctors who must interact with all other doctors every day, and, more importantly, every night. Not to mention that our sense of when we’re being lied to has been honed to a fine degree.
I think our professional societies should care about us throughout our entire career. They should be the vehicle for lifelong learning and change. We need to have a place where we can talk together about what we want and how to get there. A life of experience in emergency medicine and board certification should be a springboard – not an anchor. Emergency physicians should be the ideal group to organize and lead. Doing ten things at once and having to be pretty much right all the time is just our norm. No big deal. Yes, it is a big deal; most people don’t have those skills.

So what can you do? Three things. First, write to your specialty society and tell them this is an idea whose time has come. It is an appropriate venue for our specialty society and we need to get with it. This is why we pay dues dollars. And for what it’s worth, we need to try something new. Second: Send me your thoughts and ideas about what you would like to see, learn and get from such an experience. If you have had a great second career and want to share, by all means do so. Make a comment online, or email This email address is being protected from spambots. You need JavaScript enabled to view it. . We want to hear what you’ve done, and your colleagues want to hear from you. You will see endless possibilities only when you believe in yourself. Remember there were 169 people at the first ACEP Scientific Assembly forty years ago. How did that turn out? Lastly: Come out of the intellectual closet. Talk openly about what you want your work life and personal life to contain. You will not be fulfilled until you have been honest with what you want. “Most men lead lives of quiet desperation” does not need to be your sentence.

Why am I on this kick? Simple. As I looked around during the Scientific Assembly, I saw a total spectrum of ages. We didn’t have this in the past. We must learn to extend the working life of a physician well into their 60s and 70s. But you need to add more than just years to your working life. We need to add life to those working years. I have had a great life in emergency medicine. I do not intend to be marginalized by a few gray hairs. I am in no need of cerebral Viagra. Let’s do this together for our generation and for all those that will come after us. We will be thanked by our progeny.

Finis Coronat Opus
‘The end crowns the work’

Greg Henry, MD
Founder and CEO of Medical Practice Risk Assessment, Inc.; past president of ACEP.

 

 

Comments   

# Med StudentDan 2012-11-27 16:01
Amen. This is something I've been thinking about and asking EM docs about as I consider my future career choices. Great post.
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# 59 years old, just left clinical EMGeorge Hossfeld MD 2012-11-28 07:45
Partly as aresult of health issues, I have left EM after 32 years. I just recertified for the 3rd time, just to keep future options open. I have found a calling in writing, 2 columns previously, none now. Photography is my "baby", and would like to couple that with my EM history if I can find a way. As usual, you are right on about the need.
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# EPHeidi 2012-11-28 09:39
Here. Here. I've been an EM physician for 15 years and am the mother of 2 young boys.
I just moved and changed jobs to go from 12h shifts to 8h shifts and a much shorter commute. What a huge improvement that made in our lives and in my ability to care for my patients with less fatigue at the end of the shift! Would love more conversation about this as I ponder what I will when I get to my next transition.
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# Great Idea Hoyt Childs Jr 2012-11-28 09:50
(I love to read Greg Henry's works: it's like William F Buckley is alive and well and still writing. I have to use my English and Latin dictionaries with every one.)
Here is a good idea. At 67, the night shifts are too onerous, the drunks too malignant, the elderly too numerous with unsolvable problems. And the ACA looms.
It is time to quit. But I feel that my 30 years of experience should count for something. Perhaps there is life outside the ED. A job fair should help. Let's do it! Carpe diem!
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# Emergency Physician past 14 years & Family Physician 21 years before thatCharles J. Neilson MD 2012-11-28 15:36
When will the medical profession give the older seasoned physician (who is not boarded in EM) some semblance of honor by recognizing the fact that circumstances have occurred over their entire long career that led to their not getting board-certified (and certainly not residency trained)? There will always be such a situation in the future with regard to an individual physician who develops competency over many years in an area not part of his original residency training. When these physicians mature, by current standards, they will also be cast aside by the medical profession as unworthy and "incompetent". But, for now, we have the EM-certified residency-train ed youngsters protecting the urban and suburban ER's as their sole turf while rural areas are teeming with non-certified primary practice trained physicians who have stepped up over the years to heavy or full time ED work there. And many of these covering rural venues are commuting more than an hour to their work sites as they are locked out of their home towns by this group of ever-growing young EM residency-train ed docs (who acknowledge that it is impossible to ever train enough of their kind for all EDs. Now they appear to be locking up the free standing and off-site urgent care centers all for themselves too. I would think that the medical profession would not simply allow all of those seasoned mature non-boarded non-residency-train ed emergency physicians with more than a decade of full time ER work (plus a couple of decades of primary care before that) to be cast aside as "incompetent" when it has yet to be proven who is necessarily more competent. Such individuals should be given a practice track opportunity to take boards......mak e the hours required 10 years if need be. But just as it takes more effort on the part of medical staffs to judge each non-boarded EP individual's credentials from A to Z for privileges, it takes no effort to casually accept a young boarded EP who has just worked in a tertiary hospital for 3 years and has had the luxury of calling the neurosurgeon to the ER for serious head trauma rather than treating the patient until he can be transferred. Many youngsters just out of residency find that they incur a lot more responsibility when they start practicing in smaller hospitals. I consider this disparity a real "turf war" where the favored minority is nesting in the urban and suburban areas to make their commute short and their salaries big. Now that they are becoming "mature", they still wish to have little to do with rural EDs. Perhaps, by allowing a practice track basis for mature physicians to become boarded, these older more experienced physicians will then force a goodly number of the residency trained docs out into the rural practices for the first time.
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# Replyalexander kuehl 2012-11-30 20:28
As a member of the first EM residency class at hopkins(1975)I helped define the speciality ; but we quickly grew into department heads, Deans and VPs, The Faustian trade off results in $200/hr drones working nights and weekends omtp old age. Frankly. experienced now PAs staff EDs in my hospitals.
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# Asphyxiated by the agedPgy10 2012-12-03 19:50
Dear Dr. Henry,
As a still early career community physician I am coming to terms with the oranate structure that various groups apply to the beginning EP. There are numerous algorithms that have multivariate weighted-scheme s to determine the manner in which a young physician can be 'fairly' compensated. It's as if every older EP has become a John Nash calculating and justifying why the older physician deserves the subsidized compensation for less work, easier hours, and (forgive me) lesser procedural skill. There is then a strange dichotomy in that the same aged EP is completely democratic about costs, share and share alike, no need for an ornate formula to divide the costs by all who are present. This ubiquitous financial and group structure seeds a resentment between us whereby I want you the older physician to vacate. I therefore posit that the plan for the aging EP begins with the structure in which we value each other. Plan a group structure in which the reimbursement decreases as you slow down, and actively explore methods of career extension via PAs/NPs/scribes , SIM training/proced ural skill assessment, and perhaps not look at the equity share of your contract as a retirement package. I too can envision when my skills will diminish and realize that being in a high-paced, high acuity environment will weigh on me more and that expecting a nurturing workplace is up to me to extend that to the young physician so that the culture is established. These complex group and reimbursement structures are where we should begin to plan for the beginning and retiring physician alike.
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# important stuffjohn dunn 2012-12-05 07:43
Everyone wants to feel good--right, so overwork and stress and energy levels are the issue. Reducing the stress, whatever it might be, is important for the young and the old.

Henry is writing about something that people should be taking care of all the way through--figure out a way to like the people you see or tolerate their misconduct, how to feel good--don't feel the work is piling up too much--so fewer or shorter shifts or less work load per hour will keep things balanced.

need a jobs fare? sure, but also a better attitude about whether heroic workloads have to be taken on with an eye to being sensible.

if you don't like the patients or the nurses or the consultants, maybe you don't like what you're doing and that level of anger will diminish your skills and your effectivenee--p eople can sense when you're pissed off, maybe not as well as your spouse, but certainly close enough.
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# mark schaffield 2012-12-07 11:32
I am soon to be 64 years old. I am boarded in Peds and EM. I also did a residency in IM but not sit for boards. When I left the ED in 2005 I found the practice that "fit". I started working in prisons and now work in several local jails. This type of practice reminds me of EM in the '70's-no one wanted to do it. I've always been rewarded for doing the job that no one else wants. My days are very manageable, my patients varied, and I have no narcotics on formulary and therefore, few arguments. Life is good. Mark Schaffield MD.
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# Greg Henry...Joe Lex 2012-12-10 07:09
...may be only 65 years old, but he writes at the level of a 68 year-old.
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# It's all about optionsSonny Morton 2012-12-18 16:26
Kids (and I do mean kids, even before they start college) need to be taught that it's all about having options. Everything you can do to open, expand or preserve a viable option is an idea to consider. You don't realize it when you are young, but you will want those options later. An MD/MBA program, a hobby, a funky project that develops a skill, a side business, a new friend, all are potential options for the future.

I found that my best skill is managing relationships. I was fortunate to have an opportunity to work in the new field of retail health care. I still work in the ED about 3 shifts a month, but I'm pretty sure I won't miss it when I stop. My day job is far more interesting.

Never stop exploring. Exploring generates options, and options make you happy.
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