The transition from residency to your first job or fellowship is an exciting time in any career. New opportunities for professional growth appear, but with them come a new and unique set of challenges. Transitioning from a structured clinical environment to more independent work and self-driven projects can be a difficult transition. For this reason, we wanted to share a few lessons we’ve learned. Although this advice is derived from our experience in EMS fellowship, we expect that it will apply and be helpful to other upcoming fellows and all people stepping away from residency to enter the workforce.
1. You may not have signed up to be an engineer, but you will be building a lot of bridges.
The double-edged sword of being a new subspecialty is that many are unexposed to your role and purpose. This allows you to control the narrative and set the tone of your future interactions. This is true on both the prehospital and hospital side. However, be aware that when you are accompanying a patient and show up to an ED that is not affiliated with your program, heads will likely turn when you say you are a physician. Similarly, from the moment you arrive at an EMS station or firehouse, you’ll probably repeat the same spiel about who you are a few times per day. Do not let these repeated conversations dim your enthusiasm. Most, if not all, of these interactions will be overwhelmingly positive moments because both prehospital providers and frontline ED providers will be glad you are seeing things from their perspective. They, much like you, have the same goal of improving the care delivered to prehospital patients in the region and delivering the right care to the right patient at the right time. The insights you gain and share with them will ultimately lead to quality improvement and innovation in your EMS system.
2. Become a well-recognized face.
You should not meet a crew for the first time during a quality improvement (QI) review or a mass casualty incident. A lot of providers, especially the ones that are strong advocates of EMS, are excited to see an involved and approachable physician. It takes time to create deep ties, but this is arguably the most rewarding aspect of our fellowship. You can not treat every patient who calls 9-1-1, but you can influence every patient’s care if the paramedics follow what you believe is the right philosophy. This is more likely to happen when they see how you provide care, how you teach, and how you just show up and support them at the Fire vs Police softball game. The key here is showing up and being present even when no one has told you it is required.
3. While you’re accustomed to being hands-on, you’ll need to recognize the benefits of being hands-off.
Imagine someone coming to your place of practice and saying things to your patients–sometimes aligned with what you had already told them and other times at odds. For field providers who may be accustomed to a certain degree of independence, an EMS fellow may be perceived as more intrusive than he or she means to be. Take careful consideration when providing on-scene medical care and strive to provide value. If providers are looking to you for clarification and help, provide it—sometimes that means simply letting them know that they are correct in their assessment of a complicated patient. If there is nothing to add, then find a way to make yourself useful: help move the patient, gather equipment, place leads, or obtain a blood glucose. Be cautious not to overstep; paramedics frequently note that some physicians will start treating a patient like they would in the emergency department, instead of streamlining the care of a patient, especially when they are uncomplicated. Remember, this is the paramedic’s care space and we should respect their practice style. It is not the right time or location to change the EMS system’s culture and operational procedures.
4. Look out for your brethren.
As a future EMS fellow you will be joining a first responder community that potentially thinks, feels, and reacts differently from the care community you have engaged with during residency. Part of the assimilation into this new tribe will be how you treat them in their time of need. Our advice is to treat them as you would a relative. And always make time, even if it means taking some time from your busy ED shift to check on them. They are very cognizant of how stretched thin we are in the ED as providers, so it means a great deal to the crew for a physician to carve out time for them. If they did something well, praise them publicly for it. This sort of behavior-modeling also reinforces how to positively engage with first responders for your ED staff and colleagues.
5. Explore all the opportunities available. You might be surprised by what niche you stumble upon!
Some EMS fellowships may be more focused on research or quality improvement. Some may be more operational. Some may have you hiking in the wilderness doing search and rescue in austere conditions. Each EMS fellowship will be unique: they are based on the local, regional, and institutional practices and resources. Think about the role you would like to play in EMS and what components would help advance your future career. For some, that may be spending more time in the field to learn operational medical direction and learn about the challenges your first responders face. For others, it may be evaluating data, developing a QI intervention and seeing its effectiveness. In order to get the most from your fellowship, take a hard look at the things that are difficult for you and consider opportunities that allow for mentored growth.
6. Connect with the emergency medicine department.
You will be joining a cadre of fellows and faculty that will have many of their own projects in progress. Use this community to help develop your EMS fellowship experience and give back when your colleagues need a helping hand. Your fellowship will depend not only on the relationships you have with your first responders but also with the emergency medicine community you become a part of. Be proactive about seeking out opportunities your colleagues present and, while everyone is busy, remember that kind or helpful emails do not cost much and show you are interested in what they have to say.
7. Watch out for the clinical hour creep and protect your time.
Do not bite off too many clinical hours in the ED while your fellowship duties lag behind. It is tempting to take extra shifts, but do not forget that your primary responsibility is to contribute and participate in the accredited EMS fellowship you are affiliated with. Working in the ED an additional shift per month might not seem like much at first–after all it might be as little as an extra 8 hours out of the month. However, if this continues, your total clinical hours will creep up and before you know it, the EMS fellowship will take a back seat during the short time you have for fellowship. Twelve months pass by quickly! Make sure your schedule requests protect your EMS responsibilities. Remember that your EMS program director and section chief are on your side and your greatest educational advocates. If the ED scheduler is increasing your clinical workload, reach out to your mentors and enlist their help in keeping your hours in check. On a related note, for the operationally oriented fellows, make sure to keep a portion of your time allocated to your office-based and administrative activities.
8. Plan ahead: NAEMSP deadlines come fast.
A substantial part of any fellowship is some type of scholarly activity and if you are hoping to get your work out to the EMS community at large, be mindful of the National Association of EMS Physicians (NAEMSP) deadlines. The deadline for the 2020 NAEMSP meeting was just over 1 month after the fellowship start date. Obtaining institutional review board (IRB) approval, collecting data, analyzing, and formulating an abstract can be a significant challenge while adjusting to a new city or emergency department. We recommend starting early. Specifically, tackle the IRB issue as soon as possible to prevent subsequent delays. Also, consider wrapping up residency projects that pertain to EMS and submitting them for abstract proposals.
9. Keep your next job in mind: Job hunt early.
A few months after starting fellowship you’ll be having to consider the next move for post-EMS fellowship job opportunities. While it may be difficult to secure employment until after most academic and community emergency departments have settled on a budget for the upcoming fiscal year, get your name and interest out early so that there can be time for interviews, negotiations, licensure and credentialing. Do not hesitate to use your networks from residency and fellowship along with your co-fellows and faculty members! Emergency medicine is a small world and chances are if you are interested in a region or city, there is someone in your network who knows someone. Do not forget to check out emCareers from ACEP/EMRA, the SAEM EM Job Link, and the NAEMSP Job Postings often.
10. Your field has broadened. Significantly.
Anything and everything ranging from public health, current events, disaster medicine, advocacy, mass gathering event management, municipal budgets, pediatrics, wilderness and austere medicine, rural EMS, critical care transport, regional systems of care and flow of patients, emergency preparedness, tactical EMS, and oh so much more is now connected to your subspecialty. Do not forget to always check the weather and dress accordingly before going out into the jungle known as…the field. Welcome to EMS!
Want to hear from a EMS fellowship director? Not going to do an EMS fellowship? ALiEM has you covered:
Pediatric Emergency medicine Fellowship
Simulation, Toxicology or Ultrasound Fellowship
Acknowledgements
We would like to recognize Dr. Heather de Anda, Dr. Erin Kane, and Dr. Maria Maldonado for their contributions to this article.
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