EM as a career? Yeah, but no……

I have too many jobs!

Amongst other tasks I manage the foundation program for junior docs at my large university teaching hospital. I’m effectively responsible for getting them through the two years of their career with the hope that they will get signed off by the GMC and go on to greater things. I have great trainees, many are high achievers who will go far in whichever career they choose.

I’ve run the program for a few years now and unsurprisingly one of the things I have made everyone do is emergency medicine. All docs do at least 4 months of EM in my hospital. I think it’s good for them, it exposes them to a wide range of clinical problems and tests them to stand by their own decision about diagnosis, treatment and discharge.

So what’s this got to do with recruitment you might ask? Well, at the end of the two years I ask all the trainees which jobs they enjoyed, and as you would expect there are a variety of answers, but it’s perhaps surprising that about a third rate EM as their most interesting and rewarding placement.

So would they consider it is a career I ask?

The responses are consistent and worrying for those of us who are seeking to nurture the next generation of EPs in the UK. Despite their interest in the clinical work, hardly any trainee considers EM as a career choice, and it’s not because of the clinical practice. They love the team working, the unpredictability, the frequent and rapid patient contact. It’s the working conditions, the lifestyle and the career prospects that’s putting them off.

Why they ask should I do EM as opposed to something like medicine or general practice? Fewer weekends, fewer evenings, easier exams……, same pay.

Pay does seem to be a major motivator for todays young medics, but not in the way I originally thought. It’s not so much the amount but the fact that there are no differential pay recognition for those who work the hardest, and at the most socially disruptive times of the week. Why would you do our job for the same pay as your friend who only works every 10th weekend (whilst you do every 2nd). It’s not the absolute amount, rather its the fact that it does not matter which speciality you train in, and indeed practice as a consultant in, the pay and financial reward is the same. So how we find a way of valuing the extra effort and disruption that a trainee embarking on a career in EM takes on? I’m not sure that I can think of many that are not financially orientated. Perhaps time off? More holidays so that we can retain some of our excellent oversees trainees who struggle to find time on busy rotas to travel home to see their families? Ideas please.

But is this not the case with many there specialities? Are there others where personal sacrifice is required as a junior in order to get to the top? Of courses there are. Plastic surgery is a good example where competition is fierce and additional effort is expected with a long and challenging training program…but the rewards at the end are potentially enormous. Not so in EM, there is little or no private practice to rival that of the plastic surgeons nor the prospect of leisurely on calls as a consultant as increasingly EM consultants are moving towards the very same 24-hour rotas that is putting off the juniors.

We are already in a staffing crisis in EM. Consultant posts remain unfilled, Middle grade rotas have been decimated in many departments and trainees in our early training programs are leaving EM for the less onerous and disruptive specialities such as anaesthetics.

What then can we do? A starting point would be to recognise the additional disruption that training in EM causes to the individual and their family. The UK Government is consulting on the idea of differential pay depending on where you work. Perhaps the time is now for us to give additional reward to the hard working trainees in emergency medicine. Perhaps that might convert some of my enthusiastic and brilliant trainees to stay in a speciality where they love to work, and one in which they feel rewarded for doing so.

Simon Carley

6 responses to “EM as a career? Yeah, but no……

  1. In terms of pay, while we all know (at least in EM) that there’s a certain intensity and work that only exists in ED it’s hard to persuade others that this is the case. Do we have good evidence to say out job is harder and more intense (barring the literature on interruptions etc…)

    Otherwise agree with all you say. Personally I don’t find the pay thing persuasive as I love the job and would do it for half the money (and yes you can quote me on that!) but I do struggle with the relentless intensity to see the patients and getting through the queues of pts. So far I’ve had a lack of off-floor training and chances to do audit/research. Everything is squeezed in on your own time when you frequently haven’t the motivation for it.

    I also struggle a little with the hours, i like doing nights, evenings and weekends but would like a little more compensatory time off during the week – a recognition that nights and evenings are worth a bit more – i’d get paid the same but obviously someone would have to pay for the extra cover needed.

    Lastly we need more consultants to lead the way and make us feel a little bit more inspired and supported – a 2 or 3 consultant department isn’t what most of us want to end up working in!

  2. Yes it’s annoying being paid the same as the med reg for grottier hours, but I’m not sure the trainees can be bought. I know that patients get ill at night and weekends, I don’t object to working them, but as a specialty we are asking potential trainees to sign up for 5+ years of working fixed rotas with no more than a week’s leave at once (don’t say you can swap, it doesn’t work), being unable to book a break in the school summer holidays as you never know where you’ll be in August till the end of May…..and that’s before the year in purdah for the exam.

    Your middle grades aren’t single 25-year-olds who will put their lives on hold for 4 or 6 months without moaning too much, we have lives and responsibilities.

    There is also the issue of being the root of all evil within the hospital (only partially tongue-in-cheek) – we need to be able to say to our ologist colleagues that actually we are the experts at what we do, and that not every referral represents a dump on our part(!). This needs commitment from our seniors and a willingness to rock the consultoid boat and defend our juniors (only appropriately of course).

    And what would really make my day…..? Positive feedback. Does anyone else recognise the thought pattern of “oh no, the boss is initiating a conversation with me, I must have screwed up”? Not universal, but a wider habit of saying thanks and well done at the end of a shift would go a very long way!

    We work in a great specialty, it has huge potential, let’s not put off a great proportion of our future colleagues by letting the system grind them down.

  3. Kath W @lanafeld

    Interesting post. Not sure how things in Oz translate to those of the UK, however some positives from here:
    Where I work, some years back they created a transitional post for those keen on emergency for PGY3, our provisional training year. Three years ago there were 9 applicants for 8 jobs. There are now 24 applicants for the 8 jobs for next year. The trainee SHO post is being expanded to other emergency departments in the area. It did take a about 8 years to get to this point but EM is becoming more and more popular while internal medicine is struggling to fill medical registrar positions (here they are pre-exam).
    I get 6 weeks annual leave as opposed to 5 of my peers as recognition that I won’t get any public holidays. And I am able to take several weeks’ leave as well. I don’t know about pay on completion of training yet but I do get a bit more because of loading on weekends, evenings and nights.
    My thoughts as to why it has become more popular where I am (aside from the work obv): the department is cohesive and friendly. Trainees are valued and get feedback regularly. We have a weekly education program – 4 hours , which is paid about 50% of the time. And although we are still considered by every other specialty (bar those who deal with the critically ill) to be incompetent, we are very well supported by our consultants. Any of my consultants will pick up the phone to call an inpatient registrar or consultant if there is a problem.
    Create a good program and the trainees will come…

  4. “……. we need more consultants to lead the way and make us feel a little bit more inspired and supported – a 2 or 3 consultant department isn’t what most of us want to end up working in!”

    I completely agree @AndyNeill…. But to get to and then beyond this point we need to recruit otherwise we’re never going to get past this point and we’re never going to recruit, then we’ll never get past this point and then we’ll never recruit and we’ll never…. (I think its a white hole.. Red Dwarf quote – remember that??)…….etc etc etc.

    As @lanafeld points out “……take a about 8 years to get to this point but EM is becoming more and more popular….” it takes a long time to get to a state where ED is popular and there must be a tipping point… and it will come in the UK (hopefully)…But keen enthusiastic people currently in ED have to stick with it and motivate each other and keep motivating the next generation….

    Can we all manage this without getting burnt out and gnarled in the process??

  5. Marc G @emergencylocum

    This is a very interesting post. I’ve worked as an emergency physician in NZ & Australia and am shortly moving to the UK.

    Pay is important but I think not in isolation – as it is only one way of communicating value. The feeling of being valued as an individual – to the patients, the team & the organization – is immensely important to maintain morale and trainee numbers.

    So the solution might be more pay, but it might be increased staffing to protect teaching time, allowing good meal breaks, rostering well, and being collegial and supportive in dealing with junior staff.

    Value is also communicated by acknowledging the individuality of Emergency doctors within the system. The flow chart at the top is funny because it is largely true! Emergency doctors are invariably active outside work with multiple interests, not to mention their families. To facilitate rather than impede this is crucial.

    Finally doctors must feel respected as clinicians, and this is affected by the standing of the ED within the hospital. We will always suffer from giving work to others, but the best departments I have seen are respected for working autonomously within certain boundaries. Often this is not just about whether they conduct their own resuscitations, sedations and airway management, but whether they make their own rosters and manage their own staff.

    We are lucky in having a very interesting speciality as the patients provide that. I don’t think we can take the rest for granted.

  6. Thanks so much for the comments here, offline and on twitter. I really appreciate it as I am genuinely worried about the future recruitment of our workforce. I suppose I talked about pay as that is what had been a feature of the conversations I’ve had with the most junior trainees who are ‘considering’ EM as a speciality. At that very first step they see the balance of life disruption to reward as unbalanced so they never take their first step into the speciality. This is a disaster as we are losing some great docs at the very first hurdle.

    The question for EM trainees who have jumped into the speciality is different. What comes out here is a feeling of professional value, rather than financial and I have to agree. Those of us in the speciality are here because we love it, but there is perhaps a lack of role modelling from consultants and a lack of intellectual reward in the form of positive feedback.

    Sadly, although I would like to argue against this I think it is the case in many departments. As a senior doc I think a bit of reflection is in order and I guess I like others could do more in both these regards. So, thanks for all the comments. I will do my best to set a good example and to praise more often than I criticise. In the past I have always quoted a 3:1 ratio of praise to criticism. Greg Henry said 10:1 at ICEM, so there is something I can role model on and aspire to. I implore us all to do the same.

    S

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