Some of my: Inventions | Magazine interviews | Sheds | Favorite ER memories

Information for people contemplating
a career in emergency medicine and
other medical specialties

By Kevin Pezzi, MD


1. Working part-time as an ER doctor
2. Doing the right thing

Q: Hi Dr. Pezzi,
I'm a post-bacc (Ed.D.) interested in becoming an emergency medicine physician. I'd like to know if working fewer shifts (e.g., 8–10 12-hour shifts per month) could dramatically improve my work-life balance. I imagine that I could work night shifts exclusively and indicate in my contract that I'm only available Monday through Thursday and no holidays to avoid having to work weekends and holidays. Is this realistic as a part-timer or even as an independent contractor? What do you think about my plan? Is it viable?


Answer by , MD: Working fewer shifts definitely improves the work-life balance. I began my ER career thinking I'd work one shift per week so I could spend the rest of my time inventing. It is possible to live OK off one ER doc shift per week, although in my case it likely would have led to more insults, such as the putdown I received from a hot car salesperson who chided me for my economy car and nerd shoes. However, working one day per week was my intention; reality was something else.

Gee whiz, where do I begin? While driving home from the dentist yesterday, I spotted a group of four young girls on M-37 holding up signs advertising what appeared to be a lemonade stand. I wouldn't drink lemonade at any time (it's corrosive to dental enamel), but I had to stop. From a split-second of observation, I knew they were eager to make a sale.

Indeed they were, I found out as I pulled up near them. They were jumping with joy, and as soon as my door cracked open, they recounted how all of the other cars flew by and wouldn't stop. I was surprised that on a road that busy, I was the first customer of the day at 4:30 PM.

It turned out they were selling two flavors of Kool-Aid®, not lemonade: something blue and something pink—I think. I didn't care. I wasn't thirsty, and after having my teeth cleaned earlier that afternoon, I wasn't ready to put anything in my mouth. I told them I'd buy Kool-Aid for them, which was of course just an excuse to give them money: a few dollars of change, all I had with me.

I told the girls how happy I was to see entrepreneurial children and that I'd recently wrote about the lack of entrepreneurialism in kids. Offhand, the only entrepreneurial youngster I recall was a little girl with a lemonade stand I saw a few years ago in LochenHeath during the Parade of Homes. I regret not buying from her because I think we should do everything to encourage such kids, but I was in too much of a self-imposed rush that day—that's one of my flaws. I vowed that I wouldn't pass up another chance, so I stopped to do my part in rewarding entrepreneurialism.

What does all this have to do with working as an ER doctor? Years ago, my friend Carol told me that marriage involves a series of sacrifices to make it work. Indeed, in life in general, as well as at work, it is often best to put the needs of others ahead of yourself. Yesterday I had no need for Kool-Aid, no need to risk my life by turning around and then stopping on the side of a busy road, and no need to give money to others, but I dearly wanted to do it because I think this world would be a better place if more people put the needs of others ahead of their own, as I am doing now by answering your questions instead of working on an invention, cleaning my home, mowing my yard, or doing 1001 other things I should be doing.

I was that way years ago when I began working in the ER, thinking I'd do one shift per week, but when others asked me to work for them, I almost always said yes. I knew a doc wouldn't give up a shift unless he or she had good reason for that, so I was happy to help even though it meant working more than I wanted and thus putting my other plans aside.

If you work part-time, you're going to be the doc others ask first to fill in for them, so you may end up working full-time or more, as I did.

Regarding what you said about your contract stipulating that you're only available Monday through Thursday and no holidays. You asked if that is realistic.

No, it isn't (with an exception I'll discuss later). By saying you won't work Friday, Saturday, Sunday, or holidays, you're effectively making other doctors work more of those unpopular shifts. Trust me, that's going to make you very unpopular. Sharing the burden is one of the central sacrifices all ER doctors—and good partners in general, à la Carol—make. True, you're contemplating night shift work as part of your sacrifice, but as a newcomer, you're expected to sacrifice more than others to (for example) help the older docs who are running out of steam or have health problems (e.g., diabetes mellitus) exacerbated by working night shifts.

My ER residency director taught me to introduce myself to patients by saying, “Hi, I'm Dr. Pezzi. How may I help you?” Similarly, you will be valued more by your boss and co-workers if you show up for work thinking more about how you can help them than yourself. It's sacrifice, as wise Carol figured out long ago.

Putting others first may come more natural to me because I'm not egotistical (contrary to what some people think), thus putting a big strike against me in a culture in which the most success often goes not to the greatest, but those most in love with themselves—folks who think they're so great.

I've had some very smart bosses in emergency medicine, but also a couple who proved that the cream doesn't always rise to the top. One made well over $200 million (off the backs of suckers like me who slaved away for less than we were worth) even though he wrote so poorly I sincerely wondered if he had brain damage. Some doctors throw a conniption fit when they encounter healthcare workers who communicate poorly, so I wonder how Dr. MegaBucks slipped past the Admissions Committee when he applied to medical school.

Another boss became the ER director even though I saw him botch cases that even rookie ER doctors should be able to easily handle. He wasn't just bereft of clinical skills, but judgment, too. He told me about a local physician who moonlighted in the ER—his ER!—even though he had bizarre habits that should have disqualified him from being less than 500 feet from patients, such as how he would get an erection and then “press himself” against women during pelvic examinations, apparently trying to impress them with the size of his penis. Kooky. He also had sex with a patient in the hospital chapel and videotaped it, according to the ER director, who seemed amused by the antics of this pervert. Why not fire him and turn him in to the State Board of Medicine?

I wondered for years how such a nitwit could become ER director, but then I learned that he'd married the daughter of one of the richest men in town. The elite take care of their own.

While shopping recently, I saw a big shot in a big weight loss company and was shocked by how big she is. If America were a meritocracy, I'd be filling her shoes because I am in much better shape than she is even though breaking my neck made me unable to do many physical activities. However, America is less of a meritocracy than it is an old boys' club in which Ivy League grads and other well-connected people help their buddies with third-rate ideas and products instead of the best ones. Americans are so enamored with appearance that attractive people are given breaks, thereby creating an ingrained system of discrimination that is recognized by everyone who is awake.

I once was naïve enough to think this wouldn't apply in the medical world, but I forgot to consider the fact that it is still largely run by men who are largely run by hormones. Some—certainly not all—medical and surgical leaders use their power to screw over female doctors who won't screw them (a version of the Hollywood casting couch), as neurosurgeon Frances K. Conley found out; read her book Walking Out On The Boys to see how big shot leaders at even prestigious hospitals can behave like adolescents with testosterone bubbling out their ears.

On the other end of the discrimination spectrum are doctors such as my aforementioned nitwit boss who look the other way when, for example, a beautiful woman working for him so impressed me with her ignorance that I bet Boy and Girl Scouts could do a more thorough neurological exam than she could, even after I prompted her to fill in the many missing blanks (to read about that, see the topics that begin with Treated by a Physician Assistant (PA) in an ER; where is the ER doc?). But hey, when you're really cute and the boss hinted that he wasn't getting enough at home … well, perhaps that's why he gave a pass to a clinician who I would have given the boot.

With this as a long preface, I'll come back as I promised above to the topic of whether it is realistic for your contract to stipulate that you will only work Monday through Thursday and no holidays. Generally no, as I previously said, but if you're hot and your boss values that more than he should, then there is no telling what you might get away with.

Anyone who reads everything I wrote (not just isolated snippets of it distorted by people with an axe to grind) knows that I am a big fan of fairness: treating everyone equally. I bought a present for my mail lady who has an absolutely gorgeous smile, but the motivation for that present had nothing to do with her movie-star appearance; I just love her upbeat attitude that is a welcome oasis in a sea of sourpusses (yes, I know I appear to be that way online, but in real life I'm Mister—or Doctor!—Happy). I've also given presents to my garbage men, and when I give away firewood, I give preference to disabled people and elderly folks.

With this affinity for fairness, it rubs me the wrong way when I see discrimination, whether it is blacks being murdered by healthcare professionals because they're black or beautiful patients being raped by healthcare workers with a screw loose. I'm also peeved when I see a double standard applied to doctors. For example, the most beautiful ER physician I've ever seen was sued and big shots—including a major corporation—came to her defense as if she were royalty and it is a mortal sin to insinuate that such a princess were less than perfect.

Of course, the medical world is just a microcosm of the larger world that is so screwed up there are people in it who rape patients, discriminate against women by thwarting their medical careers, or give hotties breaks others never get. All of this is antithetical to the Golden Rule ethic of reciprocity and the rule of law—the basic principles of fairness.

I appreciate the fact that you are sufficiently ethical to suggest a quid pro quo exchanging night shift work for restricted hours otherwise, but you probably won't get what you want and even if you could, you shouldn't even try unless you're lucky enough to find an ER group willing to give a newcomer breaks that veterans usually don't get.

My suggestion is that you consider working Urgent Care, as I've discussed in other articles, but even with that, you're bound to work Fridays, weekends, and holidays. Patients are #1, and they need help 24 hours per day, 365 days per year. In my opinion, doctors and other healthcare providers should do more to expand patient access hours.

People who become licensed doctors have immense power (in some cases exceeding what the President of the United States can legally do), but ultimately all that power is to help patients and society. If doctors wanted to be as ruthless as many politicians and business leaders, we could justify our actions by saying that we live in a capitalistic society in which the value of any good or service equals whatever people are willing to pay for it.

“Oh, Mr. Gates, you just entered what will likely be a fatal arrhythmia (abnormal heart rhythm). I can correct that, but I have a special price just for you: $50 billion, to thank you for the crappy software you've foisted upon the world. Microsoft is so pathetically inept that it drove even you bonkers. So how about it, Mr. Gates? $50 billion for me, or a casket for you?”

That isn't ethically acceptable because the profession of medicine is based on an ideal that others come first. That's why I chose to work Fridays, weekends, holidays, and nights even when I wasn't a rookie. A determination to do the right thing is why I said “no” to a beautiful ER patient who offered to sleep with me in exchange for a narcotic prescription, and an even more gorgeous one who offered to pay me in addition to the sex! (I described that case in my blog.)

Doing the right thing is why I paid a programmer in India twice what our contract specified at a time I desperately needed the money. It's also why I didn't take thousands of dollars I found stuffed in the clothing of a dead patient, and why I turned down the chance to date a gorgeous young brainiac who wanted a relationship with me. I am related to some famous people, but the one I admire most is Chester Arthur, the 21st President of the United States, because he was so ethical he confounded his erstwhile political allies, as I described in a blog article. His lack of partisanship is exactly what the USA needs now.

Doing the right thing is also why I told an orthopedic surgery resident working in the ER as part of his training to go home one night, saying, “Dan, it's Christmas Eve. You should be home with your wife. Go on, get out of here. I won't tell anyone.” By saying the latter, I indicated I wouldn't flunk him, as I did others who skipped their shifts without permission. While doctors need more training, not less, I think medical students and residents should spend as much time as possible with their families on holidays; they'll have years in the future to sacrifice those precious days.

medical students and residents should spend holidays with their families
Medical students and residents should spend holidays with their families

In answering your question, I hope that you will pardon my avuncular advice on doing what is best for others, but that is what medicine is all about. Incidentally, it is a lesson that medical educators should do a better job of instilling. Now that I no longer work in direct patient care, and now that I've seen friends and family members receive inept and brutally insensitive care, I'm on a mission to point out flaws that need correction, stat.

Response from Joi:

Dr. Pezzi,
I'm so THRILLED that you answered my e-mail. It was definitely the highlight of my day!!! I couldn't stop smiling and told everyone I spoke to about your kindness. What a thoughtful, candid and detailed response you have provided! Thank you so much for taking the time to offer your insights. I REALLY appreciate the time that you spent. I will continue to read more on emergency medicine as well as other specialties. I was a bit disappointed to hear that my plan may not be viable but I feel blessed to have been able to gain such feedback early on in my journey to medicine. I can tell that you're a kind and giving person, thanks for sharing a piece of yourself with me and the world :-).

Thanks Again!!!

Reply from Dr. Pezzi: I had a few more thoughts: If you opened your own Urgent Care center, you could set your own hours, and other docs and PAs (thrilled to have a job) could work the other hours.

You could do much the same if you formed your own ER group. One of my bosses did that straight out of residency, proving that one need not be a seasoned doc to start a group. If you decide to pursue that, I'll give you more tips and arrange for you to meet him because he is a very savvy businessman/doctor.

Another option is to work from home, depending on your specialty. I can't say too much about inventions because I've learned not to blab about them on the Internet, but in the not-too-distant future, some doctors (more than the expected ones, such as radiologists) could work without ever leaving home, which would also give them the flexibility to work whenever and wherever they want. Thus, you could be home, on a picnic, camping, or at the beach and squeeze in work when it is convenient for you, such as when your son was swimming.

This article continues in this topic:

1. Sleep (& fun) deprivation in medical education: contrary to Maslow's hierarchy of needs
2. Starting an ER group or Urgent Care Center

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