Wanted: A Better Lit Path
Samantha S. Strickler, DO
Navigating the employment path for an emergency medicine/critical care medicine (EM/CCM) physician is a trailblazing experience. There are no beckoning signs with bright lights advertising perfect jobs. For most, the path is dimly lit, with an occasional spark guiding the way to an unexpected opportunity. In an effort to better understand the dynamic forces influencing employment of EM/CCM physicians, ACEP launched the Emergency Medicine/Critical Care Medicine Employment Task Force during the fall of 2016.
Since its inception, the task force has been exploring the employment experiences of EM/CCM physicians and devising strategies to address barriers. Through interviews with employment stakeholders, including attending physicians in both academic and community medicine, fellows engaged in a multitude of training pathways, employers, and recruiters, it is abundantly clear that there are multiple complex forces influencing the employment experience of EM/CCM physicians. Most of the issues identified were expected, however, a few were unforeseen and multifaceted.
Among the forces identified by employment stakeholders, board certification for EM/CCM physicians in the United States has been and continues to be a crux for employment. Employers and recruiters both state that board certification significantly facilitates employment, meeting one of the fundamental requirements for hospital credentialing. Possessing board certification through ABIM, ASA, or ABA checks a box that validates training and opens a symbolic gate to employment opportunities. For EM/CCM physicians who trained prior to board certification (2011), many have been able to navigate this issue through grandfathering, the EDIC examination, or adaptation in hospital by-laws. Yet, there remains a subset of physicians who are ineligible for certification and are still restricted in their employment opportunities.
Universally, EM/CCM fellows and physicians describe incredible variability in their desired employment environment and career goals. For those seeking a single discipline career in either emergency medicine or critical care, employment opportunities are plentiful and relatively easy to secure. However, for fellows and physicians wanting a practice encompassing both emergency medicine and critical care, especially in a single institution, the logistics become significantly more complicated.
Previously established critical care practice models are one of the numerous factors identified by stakeholders that are influencing dual employment opportunities for EM/CCM physicians. Among the various critical care practice models, such as pulmonary/critical care, anesthesia/critical care, and surgical or trauma/critical care, providers traditionally divide their time between the ICU and either the operating room or outpatient clinic. When seeking employment in these practice models, EM/CCM physicians may not be considered for certain critical care positions due to their inability to fulfill a group’s non-ICU responsibilities (ie, call).
Oftentimes, there are also hospital politics and competition for financial reimbursement for critical care that drive established practice models and consequently limit employment opportunities for EM/CCM physicians. Despite such complex and multifaceted barriers, EM/CCM physicians are finding ways to assimilate into these models and challenge traditional practices. A few have even completely circumnavigated defined practice models, creating ED-ICUs to achieve their career goals.
Finding and securing a dual appointment in a single institution also hinges upon a productive and reciprocating relationship between emergency medicine and critical care administration. As noted by employers and physicians, each party must be committed to sharing and creating a vision of dual practice that benefits both departments and the EM/CCM physician involved. This is of the utmost importance, as coordinating schedules, salary, benefits, etc., carries an increased burden for all parties. Dual credentialing is also more complex and costly for an institution. For these reasons, some stakeholders suggest that a dual appointment is best supported in an academic institution.
Further complicating employment of EM/CCM physicians is their relative newness in the medical community. Beyond the epicenters of critical care training, EM/CCM physicians are oftentimes initially perceived as a curiosity. Many employers, hospital administrators, and recruiters still admit to having limited familiarity with the training and skill set of these physicians. Consequently, most EM/CCM physicians are tasked with the challenges associated with being a self-ambassador and self-advocate for employment.
Considering the multifaceted and complex forces influencing dual employment of EM/CCM physicians, it is no surprise that the path to employment is far from being well defined. Rather, it more closely resembles an ever-changing maze with vague endpoints. Consequently, most physicians are initiating their employment search based upon desired location and setting (academic versus community). They are then utilizing multiple resources, including cold calls, networking through professional relationships, recruiters, etc. to create their own employment opportunities. Interestingly, physicians seeking a dual appointment in a single institution appear to be most successful when first approaching and establishing rapport with emergency medicine administration.
To help guide physicians through this process, many fellow and physician stakeholders expressed a need for increased mentorship. Mentorship was felt to be needed not only for securing employment but also for assisting junior physicians in career development. Among those currently practicing in community settings, these physicians further expressed a paucity of mentorship to guide them in their career goals. Increased mentorship between junior and senior EM/CCM physicians would undeniably prove beneficial in navigating the multiple challenges associated with dual employment in all settings
Employment for EM/CCM physicians is a complex beast, influenced by multiple dynamic forces as described by interviewed stakeholders. In the year ahead, ACEP’s Emergency Medicine/Critical Care Medicine Employment Task Force will be fervently examining these issues, as well as many others, to devise strategies to improve the employment experience of dually trained physicians. Undeniably, it will be an exciting year of inquiry and innovation that will aim to cast more light onto the dimly lit path of EM/CCM physician employment.
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