I listened to EMS’s story (hypotension, bradycardia, altered) via the new electronic medical record then looked to head of the bed for my PGY-2, who would already have a GlideScope, bougie, and endotracheal tube ready to go. Instead, there was a nurse at the head of the bed, waiting for me to say something. My eyes then scanned the entire room for familiar sights (interns, residents, onlookers); there were none.

After graduating from the residency program at St. Luke’s-Roosevelt Hospital in New York City, I continued working at the same hospital for several years. I was the assistant program director for two years when I made a huge life change last summer. I willfully stepped off of the academic train, but transitioning to a community hospital has not been the smooth ride that I expected.

Residents Versus No Residents

Getting back to my first shift without residents, in Catch Me If You Can, Leonardo DiCaprio briefly plays an attending. He fakes his way through medicine by asking for one resident’s opinion, then turning to a second resident and asking, “Do you concur?” In some ways, I spent years asking, “Do you concur?” without having to initiate a plan of my own.

While I missed my residents for the complicated patients, I missed them even more during the minute-to-minute ED moments. I felt lonely without someone to share in the excitement of making a rare diagnosis or someone to show a cool X-ray finding.

Education

Surprisingly, the thing I don't miss is teaching. Don’t freak out. I love teaching, and I think it’s something I do well. The reason I don't miss teaching is that I'm still constantly teaching. I work with scribes who are super-eager premed students dying for two minutes of teaching. Have you tried to explain an anion gap to a kid who is taking biochemistry? It requires an understanding of the science well beyond MUDPILES. It’s both fun and challenging to teach to their academic level.

I also work with many nurses who are working on their nurse practitioner degree. Once I know they are interested in education, I’ll take a minute to pull them aside and teach. I made the mistake of waltzing into my new emergency department and assuming that everyone wanted me to teach. Many nurses are receptive, but some are not interested in pausing during their busy day for “learning.” On a few occasions, my two-minute mini-lectures were taken as pejorative instead of well-intentioned. Asking the simple question, “Do you have a minute to discuss that patient?” has gone a long way in figuring out who is interested and who is not.

Patient Satisfaction

While teaching is not one of my job requirements anymore, patient satisfaction is. I like to think that I was nice and respectful to patients as an academician, but I’ve made one major change to my practice since moving to the community: I wear a white coat. For those of you who have never practiced medicine as a youngish female, introducing myself as “Dr. Van Leer” and having “Doctor” in bold on my nametag is not enough. Patients would complain to a nurse that they’ve never seen a doctor. I even had an old woman say to me after my initial introduction, “You’re adorable; now I’d like to see my doctor please.” I now use the white coat as another cue to show, “I’m your doctor.”

Salary

One of the biggest purported differences between academia and the community is compensation. I spent my first years as an attending being told repeatedly by co-workers how little we made. I heard about endless examples of easy money in the community. “I have a friend who works one week a month in rural Minnesota and makes as much as we do,” or, “In Texas, no one works for less than $$$ per hour.”

Physicians often equate job satisfaction with salary, but it is clearly a much more complicated equation—trigonometry as opposed to algebra.

I took a community job that offered a higher salary than my academic job; my weekly clinical hours were similar, with no academic responsibilities. I was finally going to get a taste of this community living that I’d heard so much about. It was somewhere in the middle of my third shift when one of my new co-workers started telling me about how little we make. “You can make $$$ if you go to Hospital X or $$$ if you go to Hospital Y.” How had I moved to the community and still found the lowest-paying hospital?

There will always be a higher salary or a lower patient load or a nicer physician lounge, but at what cost? Academia didn’t pay me well but offered a lot of personal satisfaction and professional growth opportunities; I was happy. Can you quantify how much happiness is worth? My new job is only a few minutes from my house. If I moved to a hospital 40 minutes away, how much more would I have to make to pay for that time difference? Physicians often equate job satisfaction with salary, but it is clearly a much more complicated equation—trigonometry as opposed to algebra.

Career Path

A few weeks ago, I was sitting on the beach in Mexico when I received the text: “Vinny and Chen won CPC!!” It was a message from my old program director. In my old life, I would have been at those Clinical Pathologic Case competitions, cheering them on. Immediately, all of my anxieties came flooding back. Why did I leave a job I loved? I looked up to see my boys playing in the water and felt the warm sand on my toes. I felt like the universe was telling me that I was in the right place.

There will always be negative voices telling you that you’re not making enough money, but as I left academia, I also encountered some negative voices telling me, “You won’t be able to come back.” I guess the main thing I’ve learned this past year is that there is no traditional career path. Don’t let those negative voices or expectations unduly influence your decisions. EM physicians have so many options; make choices that prioritize the things that are important to you.