Are academic and non-academic emergency medicine (EM) really two completely different worlds?
With this post I want to start a short series on this topic, hopefully with a little twist in the approach.
Why even question?
How and why do you question a distinction that is on the one hand very apparent and real, and on the other is very customary and traditional and may be true for all medical specialties?
Part of the answer is that in order to plan a fulfilling life in EM (not everyone believes in a “career”), it is best to understand the entire landscape – not only regionally and nationally, but also globally. To this end, perhaps more innovation, ingenuity and out-of-the-box thinking is needed to benefit future EM trainees than what habitual teachings on the subject offer.
Are we really committed for life to whatever we pick out of residency? Is the decision regarding a fellowship for a senior registrar a now-or-never decision? Is there such an age as “too late” for academics and vice versa? Is the connection between academic and non-academic EM a one-way street? Is it true that once in EM you cannot do anything else because “you don’t know how to do anything else”, according to some?
Today we will begin by looking at a few labels and presuppositions that may be cemented in the collective EM subconscious. It is my intuitive suspicion that only by uncorking, uncovering or by altogether removing some of these, will we be able to get to the real deal underneath.
As they say, the devil is in the details.
Discussion One: Smoke and Mirrors
Where will you work at and who will you work for?
First, academic vs. non-academic EM identity can to a large extent be affected by how your nation’s overall healthcare system is set up.
In countries with predominantly socialized medicine, “community practice” – very possibly a US-driven term – may simply indicate not being employed at one of the largest tertiary urban centers available, which carry all the prestige and concentrate all of research efforts. In such nations a classically proposed counterpart to academic medicine, a business-driven private EM enterprise, may be lacking completely.
If everyone works for the government, be it local or federal, then becoming “academic”, equally or more so than due to one’s personal talents and inclinations, may be the outcome of having urbanization, luck, connections or some other ability to find a bigger place to work. At one point or another one simply wins the lucky lottery ticket to move and “move up”. In essence, the EM physician is a large capital city’s teaching hospital worker first, and an academician largely by default. Such career aiming of course succumbs to the philosophy that urban and central is always better than rural and peripheral.
Second, let’s consider “community practice” as a kind of a weird term: if you are in academic EM, who else are you serving if not some community or communities? These may be communities of colleagues, trainees, organizations and researchers in addition to patients, but they are communities nonetheless.
Equally, if an EM physician is truly and solely in non-academic practice, does she really envision and lead her professional life without any engagement in research, publications, teaching, administration, local and international networking? What would the website “Life in non-academic EM” look like – a steady picture of a work mule without links or content?
Both terms academic and non-academic EM may be infused and muddied with other meanings like institutional- or government-affiliated practice, private practice, non-teaching, and so on.
In real life, both type of endeavors (if the distinction between academic and non-academic is genuine) can be conducted in very urban or in rather rural environments; and either practice type may be institutionally affiliated or tied to NGOs, governments or businesses. In the United States some recent criticism has sprung related to the so-called inbred residencies – EM training programs created and operated by large corporate entities.
More importantly for a future trainee: both types of EM practices may or may not involve exclusive night shifts, overtime, faraway travel, being underpaid, unfair seniority, feeling unappreciated and cogwheelish (new word for you), without a clear sense of direction or belonging.
Don’t get ridiculous with cliches.
Now to some cliches, most of which are from the trainees themselves.
One: the sigh “I love teaching, but I hate research” from those choosing non-academics.
Let me ask a provocative question: are all of the globally famous EM research superstars you and I know necessarily brilliant teachers? It appears that “I love research, but I hate teaching” never stopped anyone from an academic road. This, of course, is poor logic either way.
Teaching is a hard thing to do well, and there is a distinction between bedside and classroom teaching, but so is research! Just like the so-called charisma of say a journalist, perhaps some abilities one can be born with (in the words of Professor Snape, “possess the predisposition”). Yet, vast majority of skills can be and have to be acquired.
So instead of anguishing over your inborn leanings and phobias, think rather of what you would prefer to be doing, once you learn it, during any typical week of the next five or more years after residency. Now, how can you realistically translate that into life, given the types of attainable EM jobs out there in your current or anticipated environment?
Two: “get in, get out (of the ED), and enjoy the rest of your life!”
Often the EM backpack mentality, as bumper-stickered above, is sold as the prime appeal of non-academic work.
All true – academicians, when not at work, do not enjoy their lives to any significant extent. They spend most of their free time in dusky library dungeons and at other EM-bound noble activities, while those outside of academics enjoy hundreds of free hours sailing the high seas or YouTube.
As a very weak truism, non-academic EM may sometimes open up more free time for non-EM related activities of one’s life. But is wastage of time laying on a couch an activity, and are you susceptible?
On the contrary, it may be plausible that academicians may enjoy fewer and shorter shifts, more diverse practices, more immediate access to cutting edge innovations and articles, fuller specialist call panels and fewer unfinished charts to review and sign at home.
Three: “One should only do a fellowship if planning an academic career…in which case, you better get into one!”
No, you should probably do a fellowship primarily because you are very interested in what the fellowship is about. Everything else is an extra, albeit a welcome one – like perhaps natural entry into an academic institution or a network of contacts for expanded career options.
It is also completely legitimate to consider the burden and the years of your medical training so far. In some countries just getting to a recognized EM residency (which may be abroad!) has already cost you several years post medical graduation. In such cases, ambivalent feelings towards adding even more years via a fellowship to the perpetual student status are fully valid.
On the other hand, it may very well be that in the near future (if not already), all EM docs without a fellowship, whether entrepreneurial or in public service, academic or not, will become non-competitive for best jobs.
Is doing a fellowship straight off the bat after residency the only option? What if you are not interested in any during training, but become interested later?
To be fair, right after residency makes not only intuitive sense, but typically the system is set up that way, especially fellowship funding. Still, one has to be careful, as not all of fellowships are funded, nor are all fellowships accredited. Viewed in a constructive light, this creates not only constraints but also degrees of freedom for making choices.
True, if years pass, an entire family’s lifestyle dependent on attending level salary may not be very compatible with the salary of a fellow even with all the moonlighting in the world. But is the latter income difference profound in your country, or are the main barriers to a delayed fellowship of a different sort – e.g., government rules written in stone, the mass competition from the youngsters or some unspoken negative culture towards old-timers in their forties among fellowship directors?
Overall, nothing is insurmountable if given enough will, persistence and preparation. Otherwise, there would have been no people in their forties in my medical school class or residency.
Which professional currency would you rather deal in?
All mentioned above is not to be construed to say that some harsh realities do not exist. One problem with cliches is that they are very zonal, while proclaiming to be universals.
The simple overhanging truth is that every field has its own currency, and both academic and non-academic EM are no exceptions.
For future EM trainees this is pertinent and applicable not only because of the obvious choices you will have to make after formal training, but also because of the need to gear and adjust your preferences while still in training.
Grant funding and publications are absolutely the ubiquitous currency in academics. Productivity, billing and people management (aka “leadership”) skills are the hardcore coinage in business-driven EM. Advancement and promotion within socialized medicine systems may call for yet another set of valuables altogether.
Still, thinking in terms of such hard constraints will tend to corner you in at least two ways.
First, it is not to be implied that ability to generate grants or publications never helps or is not useful in non-academics, or that no academician has to keep track of her billing and productivity metrics.
Second, if cornered, you will be liable to forget the correct reasons for choosing a certain path – the ones that spring from your deep interests and curiosities. These reasons miraculously happen to be the same ones to keep you out of burnout and disappointment years later, no matter what type of practice.
I am proposing a much simpler approach to the above dilemma. Choose currencies that will create the least disdain and subconscious resistance (manifested by nausea and wanting to do what your dog does after it gets wet), and then ones for which you think you already have more inborn propensity if not talent.
Finally, are you really ego-, career- and promotion-driven? How would you define your own future success in EM?
Enough from me for now.
In future discussions and interviews we will try to elicit opinions of other EM physicians to shine different shades of light on the intriguing sub-topics this topic uncovers.