Win a Scholarship to 2018 PEM Fellows Conference in DC

We are excited to announce an opportunity for two 3rd year fellows to return to fellow’s conference (February 24-26, 2018) in Washington, DC on scholarship. The cost of travel (with a per diem cap) and hotel will be paid for by the PEM Fellowship Conference for two 3rd year fellows with an interest and career intention that involves advocacy.

Fellows must submit a 350 word abstract describing why he/she believes he/she should be selected for this scholarship. Please include a CV with the submission that includes pertinent contact information.

Third year fellows selected for this scholarship will be required to attend the pre/post conference events. Please forward any questions to Dr. Charles Macias at cgmacias@texaschildrens.org.

Abstracts and CVs should be submitted to cjsmith@bcm.edu by November 30, 2017.

MD Cents: I know how much (history says) you need to retire!

Many people spend inordinate amounts of time planning for their retirement. I applaud people who take time to plan for the future, but wondering how much money you need to retire is something that you can know reasonably well. Of course, no one can predict exactly how much you need in retirement, but history gives us a great guide.

Bill Bengen originally suggested that someone could withdraw 4% of an investment portfolio, adjusted for inflation, per year and not run out of money for 30 years. This means that if you want a 30-year retirement (i.e. 65-95 years old) you must do two things:

  1. Determine what your annual expenses are
  2. Determine what number your expenses are 4% of

Here is an example:

Ann has annual expenses of $80,000, what amount does she need to fund a 30 year retirement?

$80,000=0.04(X)

=$2,000,000

This means that Ann needs 2 million dollars in her retirement accounts in order to withdraw $80k each year adjusted for inflation. What does adjusted for inflation mean? It mean that she will actually take out more than 80k each year because the price of things goes up each year. This can’t be true you say—what if you retire and the great Financial Crises or the Great Depression happens where stocks (and people’s retirement accounts) lose over half of their values? The important thing about this number is that it held true over every 30 year period since the advent of the stock market. Meaning no matter what, you could follow this strategy and still be okay.

People will likely say that past performance is no indicator of future return. This is completely true, but if this formula holds true in the worst economic conditions our country has ever faced, I am willing to bet that it will be okay no matter what comes our way. If our stock market goes to zero, we have much larger problems than how much money one can withdraw for retirement.

The devil is always in the details in financial formulas. In order to replicate the portfolio in this study you would need 60% large stocks and 40% intermediate term government bonds. Today many people hold a much more diversified portfolio. In an earlier post, I told you about index funds and the ability to hold every stock/bond sold in the U.S., every stock/bond in the developed world and safer emerging markets with just 4 mutual funds. The yearly return of this portfolio is expected to be higher than one made up of only U.S. based assets. This portfolio would be expected to make it more likely that you could withdraw your 4% yearly without trouble.

As you see, you can know how much money you need to retire for 30 years, but what if you want to retire for an even longer time, i.e. you want to retire early? The same work determined that if you want to retire for 40-45 years you could withdraw 3.2% of your portfolio each year, adjusted for inflation and not run out of money.

 

So using Ann again:

80,000=0.032(X)

=$2,500,000

 

You can see that if Ann wants to retire at 55 years old she needs to have $2.5 million in her accounts to fund this length of time. This also assumes that Ann never decreases her withdrawals but this is not what rational people do. We all flex our spending based on our budget (i.e. if we don’t work as much one year, we don’t take as nice a vacation, or we put off a home renovation, a big purchase, etc…). These numbers assume you never change your spending no matter what. This means that even if your accounts lose half their value due to changes in the stock market, you keep on spending the same amount and don’t cut back like most of us would do!

As you can see, based on history, you can know with as much certainty as possible how much you need to retire and fund a certain level of spending in retirement. This assumes, you have your budget down and know how much you actually spend each year!

What do you think? Do you feel comfortable knowing your “dollar number” needed in retirement?

As always this post is for educational purposes only and you should always consult a professional regarding your personal situation for specific, tax, investment, legal, or other advice.

PEM Pro Dishes on Getting a Job

Jeff Bullard-Berent, MD

Is the end of fellowship creeping up quickly? Are you looking for a new PEM job? I recently talked to Dr. Jeff Bullard-Berent—who has been practicing PEM since 1990 about tips for getting a job in PEM. Dr. Bullard-Berent has worked in academic and community settings, established PEM divisions and started several PEM programs. He’s the immediate past chair of the ACEP Section on Pediatric Emergency Medicine and is currently working at the University of New Mexico as Vice Chair of Emergency Medicine, Medical Director of Child Ready Virtual Pediatric Emergency Department, and Professor of Emergency Medicine and Pediatrics.

What’s the your take on the state of jobs in PEM at the moment? The great news is that PEM docs are in demand so you’ll be able to find a job. But know that it may not be THE job. For example, by going into PEM you’ve already made some choices about location that you may not have realized. You’re not likely to get a rural or small town job. It’s going to be urban. Most community PEM jobs are in population centers of at least 300,00. If you’re looking for a freestanding children’s hospital, most are found in communities near 1 million.

What advice do you give junior PEM faculty who are looking for jobs? The advice I was given long ago–that still rings true today–was to think about the Location (the city, proximity to family), the Job (your hours, colleagues, opportunities) and the Money ($$). Then pick two because that’s probably the best you’ll get.

That’s a little cynical but at the same time, it’s realistic. Say you want to live in a place like San Francisco. It’s great city, maybe the job is great, but it’s expensive and you won’t have as much money available even if the pay is a little higher. Or in another job, the pay and location are ideal but you’re the only junior member of your division and everyone is 10 years older than you and in different places in their careers and have little in common.

Speaking of the job itself, many PEM fellows and junior faculty have been exposed only to academic jobs. Since you’ve worked in a number of community settings, what’s your perspective on community PEM jobs. Community might be right for you if you want to develop complete confidence in your own clinical practice. Just as in academics, community practices vary considerably. But you’ll likely be practicing without residents and completely responsible for the clinical decision-making.

There’s an adage in the community ED that says “The later the hour, the smarter the ED doc.” This means that in the middle of the night, the PEM attending gets to make the call and perform the procedures because consultant attendings don’t have residents to buffer them, and suddenly they trust your judgement! This means you’ll have more of an opportunity to practice to the full extent of your training. You may drain PTAs, perform fracture reductions, and do your own splinting/ casting.

Dr. Bullard-Berent (left)

What are some of the limitations of working in a community pediatric ED? One thing is that being in a community setting means that you may have to transfer a patient even if you know what needs to happen. Your orthopedist on call may not be  peds trained and may not be comfortable with a Type III supracondylar necessitating transfer. You may not have a PICU for intubated patients, or a PICU that is not prepared to care for congenital hearts.

In the community, your contract will likely include a productivity incentive,  like an RVU/hour model. It’s a meritocracy but that means if you’re not seeing enough patients or things are slow, that hurts your bottom line.  You are also unlikely to be credited for education or research.

Since you’re talking about the bottom line, what’s the money like in community jobs compared to academic jobs? In general, community jobs pay more. But like I said, it’s often productivity based. If you only see 10 patients on a shift in a community job, that’s probably not enough. In most community settings full time work is 12-16 shift per month, which isn’t so different from most academic jobs.  University gigs pay less  but you get some credit for non clinical work, and the retirement plans typically include matching, making the total packages not that much different.

In our next posts, Dr. Bullard-Berent will share his perspectives on academic jobs, interviewing, and the negotiations. The PEMNetwork blog also has a job board where employers post available jobs. Click on the “Find PEM Jobs” tab above.

 

Predicting TBI: Prediction rules or judgment?

Andrea Cruz (Texas Children’s) and Michelle Macy (Michigan) presented the best PEM-related articles of 2016 at AAP this past October. If you weren’t in the room that day, we’re going to be counting them down over here.

Comparison of Prediction Rules and Clinician Suspicion for Identifying Children with Clinically Important Brain Injuries After Blunt Head Trauma

Atabaki SM, et al. Academic Emergency Medicine 2016.

Unmet Needs Addressed

CT imaging has been overused to evaluate children with blunt head trauma despite associated risks to patients and costs. PECARN developed prediction rules to determine which children are at very low risk for clinically important traumatic brain injury (ciTBI). But how do these rules compare to clinical suspicion? In cases when the clinician had a low suspicion for ciTBI but ordered a CT anyway, this study determined reasoning for obtaining the CT.

Methods

  • Secondary analysis of data collected at 24 PECARN centers that derived and validated the original prediction rules.
  • The validation sample was used for analysis to minimize potential bias that would come with using the derivation sample.
  • The clinician suspicion of ciTBI was recorded on a scale. Less than 1%, 1-5%, 6-10%, 11-50%, and greater than 50%. Clinician suspicion did not have the benefit of the prediction rules since these were still being developed.
  • The study also asked for indications for CT when the suspicioin for ciTBI was less than 1%.

Main Results

  • For children under 2 years old, the sensitivity of the prediction rule for predicting ciTBI was 100% while the sensitivity of the clinician was 60%. The specificity of the rule was 54% while the specificity of clinical suspicion was 92%.
  • In children over 2 years old the sensitivity and specificity were similar to the under 2 group.
  • There were 7,688 children in which the clinical suspicion of ciTBI was less than 1%. Over a quarter of these patients (2,099) had a CT and these CTs identified 32 instances of ciTBI. The following is a table of the rationale for obtaining a CT in these children.

Why Did This Make Our Top 10?

  • Clinical decision rules were more sensitive than clinical suspicion
  • Clinical suspicion was more specific than clinical decision rules
  • Clinicians still ordered CTs when their suspicion for ciTBI was less than 1%
  • CT rates are likely higher in settings without PEM providers
  • Translating knowledge can address influences of clinician suspicion

Straight from the source: Applying to PEM Fellowship

ALiEM.com recently hosted a Q&A on applying to PEM featuring several PEM fellowship directors from around the country. It covers topics like what exact IS pediatric emergency medicine, various career opportunities, applying from pediatrics or EM, and what makes a good applicant. Since PEM is one of the most competitive pediatric subspecialties out there, the insight might be helpful whether you’re considering applying or in the middle of applying now.

 

PEMNetwork hosted a different discussion on applying to PEM previously that offers some specifics on common questions about the application process.