Attending

Now that you've completed decades of schooling, spent countless hours in libraries and hospitals, and worked hours you didn't think were humanly possible, you've finally reached the long-awaited day when you become an attending. But you're still faced with a major decision: in what sort of setting do you want to work?

Picking the Setting That's Best for You

When searching for positions as an emergency medicine (EM) attending physician, one of the first decisions to consider is the type of practice setting. Do you want to work at a teaching hospital and pursue a career in academic medicine? Are you interested in gaining experience at a single-coverage critical access hospital? Or are you seeking something in between? Residents have often considered these questions prior to graduation, and have likely tailored their educational experiences to help answer them. There are always opportunities to move between these different practice environments; therefore, nothing is set in stone. Additionally, working in an emergency department (ED) is not the only option upon graduating. Below are some general descriptions regarding attending positions in varying practice settings.

Attending in a Community Setting

• Attendings in a community setting are primarily responsible for providing direct patient care, and may have additional roles in billing and reimbursement. Community settings can vary widely in terms of volume, patient population, physician coverage and hospital environment (i.e., urban vs. suburban vs. rural). The scope of practice will also vary widely depending on the hospital designation (e.g., tertiary referral center vs trauma center vs critical access hospital), and whether or not there are consultants readily available. Community attendings may be employed by the hospital, a private contracting group, or may even function as independent contractors. There is also the opportunity to take on leadership roles within community EM; for example, serving on a board of directors, or becoming the director of the ED. Additionally, fellowship training could allow an attending to take on a leadership role within a particular niche in a community setting. Examples include serving as an emergency medical services (EMS) medical director or ultrasound director for the community practice group or hospital system.
• Performance is generally evaluated through efficiency and productivity metrics such as relative value units (RVUs), quality metrics (patient satisfaction scores), clinical outcome metrics, and physician citizenship and professionalism that includes meeting attendance and timely chart completion.
• Attendings in community settings often directly or indirectly supervise advanced practice providers (APPs), such as nurse practitioners and physician assistants. Responsibilities may include reviewing and signing APP charts, directly supervising procedures and clinical care, and/or overseeing education and quality improvement initiatives.

Attending in an Academic Setting

• Attendings in an academic setting generally have a combination of clinical, teaching, scholarly, and administrative responsibilities, including clinical service, resident and medical education (including bedside and didactic teaching), departmental/hospital/institutional committee participation, and scholarly activity.
• Regular scholarly activity is typically required of core faculty members; however, it is not limited to original research and can include efforts such as contributions to textbooks, national presentations, and case reports.
• Protected time to satisfy a department’s educational requirements often results in fewer annual hours of clinical service compared to non-academic positions. Non-clinical responsibilities, which are important for faculty progression on their promotion and tenure track, often include didactics, mentoring, departmental improvement initiatives, and scholarly activity.
• While institutionally dependent, protected time may come in the form of clinical shift “buy down,” wherein attendings may reduce their clinical workload through non-clinical activities. Buy down may occur in a number of ways, with one of the most common being the use of external grants to fund the pursuit of clinical research. This can also occur internally through departmental support of administrative positions, such as education leadership, medical direction, or quality improvement roles.
• Attendings who practice in an academic setting may also hold a variety of non-clinical positions, such as clerkship director, program director, or head of a subspecialty division. Departmental chairs, for example, will focus more on the administrative and operational aspects of the ED while program directors will focus on trainee education and career development.
• Clinical practice in an academic setting often differs from that in other settings due to the responsibility to educate and supervise the clinical care provided by resident physicians and other trainees. Attendings in academic settings often see patients as part of a team with residents and medical students, but may also have non-teaching shifts or see patients independently depending on departmental needs and staffing. Academic attendings may perform fewer procedures themselves, as their role emphasizes teaching and prioritizing trainee education. Additionally, academic medical centers typically have a broad range of consultants who may assume responsibility for certain procedures. Because many residency programs incorporate community exposure into residents’ training, some academic attendings will have the opportunity to work in a community setting if staffed by the same group of physicians.

Check out the Society for Academic Emergency Medicine (SAEM) Academic Career Guide and Academic Promotion Toolkit for more information and resources on developing a career in academic EM.

Entrepreneurship and the Private Sector

A subset of emergency physicians pursue careers in the private sector, either in conjunction with their clinical careers or full-time. Consulting positions in a variety of different industries are possible, with physicians increasingly joining startup companies in the biomedical sector. Areas of focus can include patient satisfaction, medical informatics, patient safety and best practices, medico-legal consulting, coding and reimbursement, health insurance, operational management, biomedical and pharmaceutical development and safety, and physician recruitment. Training and experience requirements vary widely and depend on one's specific area of expertise. For example, advanced degrees may be useful for physicians interested in conducting pharmaceutical industry research and development.