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As our specialty matures, we must enter an open dialogue about career progression and the aging physician.     

“Laborare est orare”
-Horace/St. Benedict

This famous quote from Horace can loosely be translated as, “To work is to pray.” St. Benedict, in his grail-like quest for Western monasticism, used it to point out to his devotees the value of work. They were right; working is like praying. It is how we identify ourselves. It is, to a very great degree, who we are. The reasons for labor, apart from the obvious monetary compensations, are many: self-pride, self-worth, self-reliance. This is what humans are all about, and unless you take a Marxist view of the distribution of goods and services, we understand that individual work is the hallmark of the free and the strong. The problem with emergency medicine as a career choice, and its initial residency training, is that we refuse to admit that the nature of work must change with the health and age of each doctor.

Having been involved with ACEP and emergency medicine almost from its inception, I have seen the maturation of a specialty. At each stage of development we have had different dragons to slay. We lived through the, “You’ve got to be kidding. No one would do ER for a living,” phase. Next, we went through the land-on-the-beachhead residency-building phase. In the late 70s, we all got together and gave $150 apiece in order to form a board, which no one else recognized at the time.

Finally, we got recognition for our specialty from the American Board of Medical Specialties.
But time moves on. We are established, admired – even envied – by many of our colleagues in the broader house of medicine. We are slowly losing our defensiveness about being second-class medical citizens. But the new monster waits and is about to rear its ugly visage. First, we need to come to grips with the reality that our chosen profession is not dermatology. Wrestling drunks at 2 o’clock in the morning loses its appeal quickly, and the physical demands of the job can take their toll. Second, we have to be honest about the current economic crisis and the realities of retirement. You are not going to be able to retire at age 55 or 60. The deficit reduction commission said recently that we will need to be 69 to retire on Social Security in the future. Every major economist knows that this is a joke; the number will be closer to 72 if you expect eight years of support from your government near the end of life.

I propose that we start now with a frank discussion about the new demon in our midst: the maturation of the emergency medicine career. Let’s keep it simple. Not simple as in “no problem,” but in the way physicists use the term: profound simplicity. Not simple-mindedness, rather the simplicity to which scientific reductionism leads us. In training, very few residents are ever asked to picture their lives at age 50. The flawless harmony of a properly matured career should be in conformity with sublime reason. It should never come as a surprise to an emergency physician that they will need to change and refocus their career. Life should be a great thought, not an endless machine.

I have, over the years, worked with sophisticated emergency medicine groups to consider how to extend the work life of the physician. Everything from scribes to urgent care shifts to travel and industrial medicine have been debated. To begin with, shift lengths need to be shortened as we age if we are to be long-distance runners. Also, we need to seriously consider the transition from emergency medicine to administrative duties. No specialty prepares us for broad administrative responsibility in running the healthcare system like emergency medicine. After all, we make a broken, almost non-existent system work. We are so good at doing more and more with less and less that I expect to start seeing us do everything with nothing.  We need to consider and take action on these issues, at both the ACEP level and through our journals.

From the moment men and women enter the specialty, we need to start talking about what the specialty will look like for us down the road. Let’s carry on an open forum on the maturation dilemma. After all, put enough days together and you have an entire life. For emergency physicians, a long time may be two hours, not 20 years, but let’s talk about what the life can be . . . and how we can still be productive at age 72.

Every emergency doctor has had moments where they wonder what lies ahead, and what the end of their career will look like. But the only way to predict the future is to make it. And the only way to make it is to come out of the intellectual closet and admit we need to start realistically discussing all the directions the practice can take us. Many physicians in their mid-60s (hello) and 70s not only want to work, but need to work. Not just for the money, but for the thrill of being creative and productive. Shuffleboard is not the proper ending for a life which as been built on the thrill and joy of saving other people’s lives.

Remember the grand unification theory in physics? It combines the fundamental forces of the universe (strong, weak, electromagnetic) to posit symmetries that involve rotation in abstract space and time for more complex dimensions. It unites and finds a collective name for these forces, suggesting that they are, perhaps, manifestations of a single, underlying force. I propose that the emergency medicine career needs its own grand unification theory. We need to take the strong elements of our practice, such as training, systems management, firsthand knowledge of disease and a perspective of its societal implications and blend them into a unified theory of what a career should look like. We need to move towards raising our young with minds of infinite profundity and infinite simplicity. From all quarters – academic, private practice, government service – please join me in this dialogue. Write back. The only things we have to lose are our intellectual shackles.



 

 

Comments   

# Chief Medical Officer, Southern Maryland Hospital CenterJ. Andrew Sumner, MD 2010-12-26 15:26
Hi, Greg. I always enjoy reading your articles and hearing your talks. This one is no exception. Emergency physicians need to develop broader skills than just taking care of patients in the ED if they want to have long and rewarding careers. Our specialty is uniquely qualified to serve as Vice-President for Medical Affairs or Chief Medical Officer. What other doctor understands the system better than we? We understand how a hospital works or fails to work. We have to start going to committee meetings and taking an active role in the life of the hospital to develop the skills that are needed later in our careers. Just doing shifts in the ED is not enough. Working with EMS or serving on committees outside the local hospital will build knowledge and skills that will be marketable later. I am down to two shifts per month in the ED now and still enjoy it. My main job is so busy that I just do not have the time to do more in the ED.
Keep up the good fight and tell us what we should be doing to prepare for the years ahead. All the best, Andy Sumner
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# Director of Physician RecruitmentGary Roth 2010-12-28 10:22
Reading these articles is an excellent way for me to gain knowledge and insight about the Emergency Medicine field. Having been an Army Recruiter for 6 years prior didn't prepare me for the intricacies of the Physician Recruitment world.

However, time does continue to travel on, and my knowledge increases each day. Thanks again for all the articles, and keep them coming!

Gary Roth
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# Dr. J 2010-12-29 09:38
This is a really important article. There is no doubt that the career we have chosen has some impact on our health and for many is not sustainable into the late fourth quarter of our careers. There are a few ways I see to address this:

1) Smart departments will pay their young-guns a premium to work more nights. Young guys (like me) have mortgages, student loans, and with young kids can make nights shifts fit in our lives. We bounce back from nights faster and easier. Smart departments will not make this a policy, but instead will make it a culture; 'When we hire you on we're hiring you for a career. At first your shift mix will favor nights and you'll pay off your loans quickly with the extra money that will provide. As you get older your shift mix will get easier an easier and you'll pay that extra money back to the new young-guns who will be doing the nights.'

2) Transitioning into admin is a great idea, but there are more ED docs than admin jobs, especially in non-academic hospitals. Nurses have also gotten a huge lead on us in taking on admin roles (in my hospital almost all the leadership roles are staffed by nurses). If you want to eventually transition to admin, take on some admin early in your career.

3) There are non-traditional admin options such as becoming the chief medical officer of a company. If a company staffs paramedics or nurses it likely needs someone who does medical oversight. Initially pick a small company, but ask for a big title, then grow with the company or outgrow the company and move on to something bigger. Again this needs to be done early in the career, not as a last ditch throw of the dice.

4) As a Canadian emerg doc I (like the majority of my colleagues) am cross trained in family medicine. I have not done any family medicine for years, but if I ever find the grind of shifts too much it will provide me an easy transition out of the emerg. I find it hilarious to watch the squabbling in the US about cross-trained doctors as this provides the easiest options of all near to retirement. Working in a family practice office, a jail, an occupational therapy clinic or a sports medicine clinic can provide an income with no work at all outside of business hours.

5) A great option near to retirement is to fly in to remote communities to work for a brief period of time. I used to work in the arctic and we always had a need for more doctors. We had lots of docs near to retirement fly in for 2 to 4 weeks, once or twice a year. For them it was a brief period of work that was often very challenging and exhilarating, but with a very limited time frame. The money was good too. I think this is a great option, it provides remote places with much needed docs, and keeps the older docs in the game a little longer.

My 2 cents...
Dr. J
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# How about helping our country / fellow citizensShant Garabedian 2011-01-04 07:16
Dr. Henry,
It's a pleasure as usual reading your articles, which usually make me see things a different way.
How nice would it be to put some of our older docs to good use in the public sector, in urgent care clinics that are supported by the government, where the docs would mainly do voluntary work, but the great demon of malpractice is exempted/covere d by the government. ED physicians have the capacity to manage everything!! So why not we be tasked for even some chronic illnesses like HTN and Diabetes management and preventative care. With minimal involvement we can effectively and efficiently do a better job at preventative care. There are not enough physicians to take care of all the basic healthcare needs of the 300 million Americans. I for one would enjoy providing acute care in government clinics like health departments on a voluntary basis. This would take some of the load off the Emergency Departments, allowing them to care for the sicker patients; hopefully improving the efficincy of this healthcare system. I guess it's always nice to dream a bit.
Shant
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# staff physicianThomas Faulhaber MD 2011-01-10 10:40
Great article. One more option is to go rural. In our Level 4 trauma center we see 10-15 patients per 24hr. We have recurited an experienced ED doc who had retired from a Level 1 trauma center in his early 60's. He has now started his 3rd year. We benefit from a wealth of experience and he gets to continue working.
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# MDStaci Chamberlain 2011-01-10 15:36
I agree with Dr. Faulhaber that going rural is a great option for some. Especially in desirable "vacation" areas (like the NC mountains where I work), docs can find a much slower pace, with a great quality of life.
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# Switching Departments Doesn't Change ThingsDO 2011-01-21 07:39
Generally agree with the sentiments echoed in the original article, with one exception: there is no reason for a physician, or any employee, to have to be productive - or even in the workforce - as they approach age 72. Working till you die is no way to live. If that is where we are as a society, we must completely re-evaluate what we have done in the past 30 years to get here and change it.

As I step away from the Trauma center at the end of residency, I look back on how residency has changed me. Foremost among those changes is that I like people a hell of a lot less now than before I started. Taking care of your 45th meth deal gone bad for free does that to you. Children, the elderly, and dogs are probably the only groups I have any compassion for anymore and so while they may envy me, I envy Pediatricians, Geriatricians, and veterinarians. I guess, as they say, the grass is always greener.

I cannot possibly imagine practicing medicine, let alone Emergency Medicine, into my 60s or 70s. Inmates are running the asylum and watching them scurry around the prison yard from outside its walls - yes, while perhaps playing shuffleboard - sounds like the perfect ending to a successful career.

Dying with my boots on does not.
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# PhysicianPB MD 2011-01-29 08:21
Oooo. Sounds like DO is in burnout mode already, just out of residency!
I have transitioned to urgent care after 28 years of ER pit doc, and one has to remove the vaunted title of ER doc and don the title of regular doc. That is not insignificant. ER docs have prided themselves in being ready for life threatening problems, anything, anytime and urgent care is more the sinusitis thing.
But your patients are not self abusive, want to get better, do not need triple rule-outs, and you can spend a few moments chatting. Chatting in a busy ER with patients garners universal scowls from everyone around.
So definitely some good things to be found in urgent care.
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