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Life in Emergistan

What Would It Take for You to Quit EM?

Leap, Edwin, MD

doi: 10.1097/01.EEM.0000554846.95540.a0
Life in Emergistan

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Emergency medicine is a wonderful, fulfilling job, but it is also complex and often difficult. It has never been easy, but you must believe me when I say that it was once easier.

I'm 26 years into practice, so I can be a reflective curmudgeon if I want. It occurred to me that many physicians might find the current regulations, metrics, time-stamps, administrative harassment, satisfaction scores, pain scales, protocols, and all the rest to be discouraging. I certainly do.

It may be that some physicians in early or mid-career would simply love to walk away, but they typically don't. Why is that? What keeps intelligent, well-trained, capable physicians coming back to hopelessly overwhelmed, understaffed, and micromanaged emergency departments, day after day, year after year?

For one, they're dedicated. They believe in the importance of their work. Lives are saved, pain is eased, the worried and dying are comforted. That's part of it, to be sure. Not only that, it's also exciting and validating! It feels good to be heroic.

And the money is good. Emergency physicians reason that they work hard and want to reap the benefits of all that intense labor. Exciting trips, nice things, and good colleges for their kids entice physicians back to the salt mines, even as the roof threatens to collapse.

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What if It's a Bubble?

I fear, though, that there's another issue here, and that is simply the weight of debt. Medical school debt in particular. It's now almost axiomatic that physicians will graduate owing a vast amount of money. I heard a pre-med advisor in a university say to his gathered students, “Yes, you may owe a lot of money, but you'll make plenty so don't worry about it.”

The thing is I'd worry about it. Debt is a kind of indentured servitude that doesn't end after seven years. Medical students now carry an average of $193,000 in debt. That's a number our parents and grandparents would have considered staggering.

The result of this king's ransom of debt? It's impossible to quit. No matter how weird or difficult the specialty might be, physicians with that burden have to make money and lots of it simply to make loan payments. That doesn't even take into account house or car payments or the costs of raising a child.

But what if a physician decided to give up his lifestyle? What if he decided to downsize in every way? He could sell his house, cars, and boat. Kids do fine in state schools or trades. They could live for less. Except that those pesky student loans don't go away. Ever. As everyone knows, you can't escape them if you declare bankruptcy. Like herpes or chicken pox, they're the friends that never leave.

Fortunately, the money is good now. But what if all of this is a bubble? What if physician salaries dropped significantly in the near future? It seems unlikely, but if physician salaries were abruptly cut by a third or half, where would physicians go? If all hospitals or insurers did this, would all emergency physicians simply quit? Hardly. They'd press on, complain, and then scramble for more shifts to make up for the hourly loss. That's a possibility that haunts me, and my student loans are paid off!

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Could You Quit?

So I want to ask the wise reader, could you quit emergency medicine? Are you in a position to do so from a loan or debt standpoint? Maybe not. It may be financially impossible.

And if you could, how hard would you have to be pushed to leave the profession you struggled so hard to attain? How many new time-stamps? How many new nursing directives? Which new responsibilities? What new documentation requirement? How much understaffing? What new memorandum from the latest company to purchase your contract, your hospital, your labor would make you leave the emergency department?

Would it take a personal crisis? Depression? Anxiety? PTSD? Would any of those be the last straw? Or would it take a moral insult? If you were compelled to violate your own ethics, your own faith tradition, your own guiding principles, would that be the thing that led you to walk out the double doors at last and not look back?

The future is bright. But things change. I don't know how long we'll be as valued as we currently are. I do fear, however, that the system is gamed.

We had a joke in my first group. We said once a new doctor purchased his lake house, he was yours for life. There was a dark truth there. It may be restated as once a young person is in sufficient debt, which cannot be defaulted, he will be a physician for life. Do with them as you will.

We should probably start thinking about this, individually and collectively. Because the combination of debt and unhappiness is already taking a heavy toll on physicians in a high-pressure, numbers-driven, corporatized world. And I don't see it getting better anytime soon.

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What's Your Limit?

What would it take for you to quit emergency medicine? Vote in our poll pinned at the top of the @EMNews Twitter page at https://twitter.com/EMNews! (And find out what your colleagues have to say too.)

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Dr. Leap practices emergency medicine in rural South Carolina, is a member of the board of directors for the South Carolina College of Emergency Physicians and an op-ed columnist for the Greenville News. He is also the author of four books, Life in Emergistan, available at www.nursingcenter.com, and Working Knights, Cats Don't Hike, and The Practice Test, all available at www.booklocker.com, and of a blog, http://edwinleap.com/. Follow him on Twitter @edwinleap, and read his past columns at http://bit.ly/EMN-Emergistan.

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