Evaluating practice opportunities can be challenging, especially for residents just entering the emergency medicine job market. With many diverse practice settings across the country, there are many options to consider, and knowing which opportunity is right for you can be difficult. We spoke with several of our emergency physicians – from newly board-certified ER doctors to seasoned medical directors – and asked them what matters most when searching for an emergency medicine job.

Our panel of physicians outlined the questions below to help guide your job search. Some of these questions can be answered with a simple Google search as you’re researching job opportunities. Others need to be answered by the recruiter or medical director.

Patient Mix

The nature of emergency medicine leads to a diverse mix of patients and medical conditions. Understanding the types of patients and acuity of their conditions or illnesses is a key component to determine whether a position and the facility would be a good fit. . Do you enjoy treating pediatric patients? Are you passionate about treating complex cases in high-volume trauma centers? You have a unique set of skills, passions, and strengths, so choosing a job where those features can shine and improve the lives around is imperative.

1.   What is the annual patient volume?

Annual patient volume paints the picture of the size and scale of the department. This will help you calculate an estimated number of patients per day. Coupled with the coverage model, answered later in this post, you will have a better idea of how many patients you will see individually in the ED.

2. How many beds are in the ED and the hospital? Is there a fast track? How many fast track beds?

Again, this shows size and scale of the department and hospital but also operational structure. For example, does a physician cover the whole department or is it structured in pods? Also, is everyone coming through the main ED or are minor conditions or concerns seen in the fast track area?

3.   What is the patient population?

Understanding the community and surrounding areas the department serves can help with knowing what the patient population will be like. Is the patient population even across the board in type of patients from a demographic or socioeconomic viewpoint? Or, is it skewed in one direction more than another? For example, are there more elderly or nursing home patients vs. behavioral health or psychiatric patients? Also, are you practicing in an underserved community or socioeconomically challenged area vs. a well-insured, bedroom community?

4.  Is the hospital a trauma center? If so, which level?

Trauma center designation criteria can vary from state to state. However, trauma center levels are used to categorize the national standards for trauma care. Levels range from Level I to Level V and define the resources available in the center. The following provides a brief description of each level:

• Level V: This is the lowest level of trauma centers and is primarily used for diagnostic, stabilization, and initial evaluations before being transferred for higher levels of trauma care. More services may be available, but not required for a Level V trauma center.
• Level IV: This center should provide advanced trauma life support (ATLS) before moving patients to higher level trauma centers. The Level IV centers focus on evaluation, diagnostics and stabilization.
• Level III: These centers provide quick assessment, surgery, intensive care and stabilization, and resuscitation. This is the first level of trauma units that requires full 24-hour coverage by emergency physicians and rapid availability for surgeons and anesthesiologists.
• Level II: This trauma center is able to provide immediate care for all patients. A broad coverage of anesthesiology, critical care, emergency medicine, neurosurgery, orthopedics and radiology must be provided on a 24-hour schedule.
• Level I: To be labeled a Level I trauma center, the center must provide total care for every part of an injury from prevention to rehabilitation. It also requires 24-hour coverage, continuing education for clinicians, comprehensive quality assessments and to be a referral source for all nearby regions.

5.    What is the ratio of trauma v. medical cases?

Depending on what sort of situation you thrive in, knowing the balance between trauma cases and medical can be a deciding factor in pursuing a position. If you are more inclined to a position in a trauma center, a hospital with a low volume of these cases may leave you feeling unsatisfied regardless of the other benefits of the job.

6.   What is the admission rate?

Admission rates help paint the picture of the severity of cases treated in the department. Higher patient acuity can equal higher admission rates. Meaning, the patients are sicker or present with challenging medical conditions, which require significant clinical intervention and more intensive care. For new graduates, high-acuity facilities can provide a valuable opportunity for development of skills and continued learning while treating a wide variety of challenging medical conditions and illnesses.

Documentation Systems

As you know, correct and complete documentation is critical to physician reimbursement. As increasing numbers of hospitals move away from traditional “pen and paper” charting toward electronic health record (EHR) systems, physicians must adapt their practices. As you evaluate a practice opportunity, ask questions regarding the documentation system and any training or support their physician staff receives.

7. What charting system or electronic medical record (EMR)  is used?

As hospitals and health systems continue to advance EMR functionalities, you need to make sure you are up to date on new or improved EMR features, workflow changes and system integrations. Familiarize yourself with the EMR the facility uses and any specific features available for the department. For example, is diction offered within the system or is it available in another system? Are labs or other diagnostics tests ordered in the EHR or is there a different system for these orders?

Being comfortable with the EMR is vital in creating an efficient workflow, providing appropriate documentation and minimizing mistakes or issues with care. Make sure you are either familiar with or willing to be trained on a new system.

8. Does on-boarding include EMR training?

No two EMR systems, workflows or features are identical from hospital to hospital. Often, the EMR system is designed and built with the intention of catering to the unique needs of a facility. While you may be familiar with, or even well-versed in several different EMR systems, it is likely you will experience variances in a new interface. Learning a new system can take up a considerable amount of time, so find out if on-boarding includes EMR training and if there are additional training opportunities available if needed.

9. Are scribes available to support physician documentation?

Scribes can be a valuable addition to the emergency department team, especially in high volume facilities. Understanding what scribe coverage resources are available to you, if any at all is important. If scribe coverage is available, ask for more information about the department’s process for requesting coverage and the hours these coverages are available. If scribe coverage is not available, find out if other documentation support is available or how others in the department are successfully and efficiently completing documentation requirements.

Clinical Support for Emergency Teams

Providing outstanding emergency care requires an entire team of dedicated personnel. Both clinical and administrative staff members play an important role in the patient experience. As you consider practicing at a facility, ask questions regarding the support team, both within the emergency department and across the hospital.

10. Does the team include advanced practice clinicians (PAs/NPs)?

States and facilities have different bylaws and regulations to define how advanced practice clinicians can support the emergency department. One of the most important questions to understand is what role you will play in supervising APCs. For example, are you required to sign off on every chart? Do you need to see every patient the APC treats?

In addition, you should ask what the operational structure of the APC role is. Will you work side-by-side the APC team in the main ED, or are they managing front-end flow and fast-track area?

11. What is the coverage model and the nursing ratio?

Understanding the coverage in the ED with respect to the number of hours of physician and advanced practice clinician coverage should give you a comfort level in ensuring you can provide the best clinical care for the number of patients that come through the ED during your shift. Shift length, start and end times of shifts and any single coverage hours are also important. While outside of our control, a good nurse-to-patient ratio contributes greatly to the overall flow in the ED and is something you should ask about as well.

12. What sub-specialties are available and how do they support the ED?

Sub-specialty support is your back up call in a specific service line. Knowing the ins and outs of who is available, when they are available and how to get in contact with someone on call is critical. However, sometimes it is simpler to ask what sub-specialty support the hospital does not have before navigating through the details.

Once you know what is or isn’t available, make note of which specialties are available in-house versus consultants. Regardless of being in-house or a consultant, you need to know what hours sub-specialty support is available. In addition, if a consultant is used, you need to know what group and who makes the call for support.

Transfers are also important. Make sure to ask what gets transferred out, who makes the transfers and where the transfers go.

Sub-specialty support varies from hospital to hospital. Common examples include:

• Anesthesia
• Behavioral Health/Psychiatry or Telepsychiatry
• Cardiology
• ENT
• General Surgery
• Neurology
• OB/GYN
• Ophthalmology
• Orthopedics
• Pediatrics
• Rheumatology
• Urology

13. What is the average turnaround time for lab results/radiology reads? Is the lab or  radiologists on site?

Average turnaround times for lab or radiology results are out of an ED physician’s direct control but can directly impact individual efficiency. If the radiology department and lab is on site, you need to know the hours of availability. Are both available 24/7? If not, what is the process outside of operational hours?

14. Who is responsible for responding to floor codes?

Your primary responsibility is to the ED, but it is important to know what is expected of you. If it is single coverage, is the ED physician responsible for covering the code on another floor? Does the hospitalist team respond to floor codes?

15. Who is responsible for writing admission orders?

Is it the ER physician or is there a hospitalist on-site there to write the admission or bridge order? This will also vary from hospital to hospital but give you an idea of the hospital medicine and emergency department alignment.

Moving Forward

Before you leave or end the interview, make sure to ask for a sample contract and review it in detail with your attorney. Knowing the patient mix, documentation system, and types of clinical support offered by the facility is important, but having a straightforward contract not riddled with jargon and complicated clauses is even more important. Always make sure non-compete language is not included in your contract, as it can hinder your ability to practice outside of group you are currently with or prevent you from working elsewhere if the group changes.

Remember every job can come with a different type of physician compensation or employment model. Compare the benefits of working as an independent contractor versus an employed physician or partner.

If you are offered the job, know that your contract can come with a little negotiation. Prioritize your non-negotiables first and remember to get all changes down in writing.

These questions and methods can provide great insight within the emergency medicine job search, giving you an idea of how the department operates and whether the opportunity is the right fit for you.

If you have any questions or concerns with selecting your next emergency medicine position, don’t hesitate to reach out. At ApolloMD, we are committed to training and empowering our future medical directors and professionals.