RAMS Administration Roadmap

Administration “ED Administration” is often used as a catch-all term for a wide variety of careers dealing with the management of an emergency department or EM physician group.

This includes management at any level, ranging from day-to-day clinical operations to long-term strategic planning for an entire institution or healthcare system.

MED STUDENT (MS3/4)

JUNIOR RESIDENT

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Senior RESIDENT

Resources

AUTHORS: Jean Sun Scofi, MD; Adam Nevel, MD, MBA; and Kaushal Shah, MD Contributors: Rebecca Donohoe, MD; Jason Theiling, MD; and Amanda Ventura, MD Welcome to the Administration Roadmap, your definitive step-by-step guide on how to succeed in Administration at every training level. Don’t know where to start? Click on “Background” or select your training level above. A full list of fellowships, conferences, and podcasts can be found in “Resources.”

For pearls of wisdom from faculty and residents in the trenches, click on “Insider Advice.”

insider Advice

1 - SENIOR MEDICAL STUDENT If you developed an interest in ED administration as a medical student, then you’re already ahead of the game! During your last two years of medical school, you should identify the residencies that will best prepare you for an ED administration career and work on strengthening your candidacy for those residency programs. Here’s what we recommend you focus on. Keep in mind that this is only a guideline. Your preferred timeline may be different depending on your specific career goals and the opportunities available at your institution.

TIMELINE During MS3 Year: • Seek out leadership roles to see if you enjoy working on team projects. ED administration is all about team-based management, so it’s important to find out if this is something that you like, love, or hate. Some options include: – Leading an interest group or club, or starting one yourself.

– Running for a position in student government.

– Organizing an event or fundraiser for your medical school.

– Participating in a QI project or initiative in your ED. Keep in mind that you will have plenty of chances to do this in residency!

• Research what ED administration is all about.

– Sit down with an ED administrator at your institution and chat about their career. Ask if you can attend some meetings with them or assist on projects to get a better sense of their work.

– Join a local or national interest group. If your medical school offers one, great! If not, look to SAEM, ACEP, CORD or other national professional societies.

– Explore the ED administration literature. Look for operations, patient safety, risk management, or process improvement articles in major peer-reviewed EM journals and gauge whether you find the discussion interesting.

Beginning of MS4 Year: • W hen you explore residency programs, look for the qualities that support a ED administration career. These include: – A high level of resident involvement and engagement in administrative projects and committees in the ED or hospital.

– E D or hospital committees have decision-making power to affect ED policies and practices on a timescale compatible with residency training (residents can see the real impact of their involvement within a 3-4 year timeframe).

– A core group of ED administration faculty has experience working with residents pursuing ED administration careers and can act as mentors.

– The existence of an ED administration fellowship and/or a good track record of graduates with successful ED administration careers.

FAQ Are there particular residency programs for which I should apply?

Since ED administration is still a relatively new academic track, there’s no venerable “top 10” list of residency programs that specialize in training ED administrators.

Keep in mind that you can become a successful ED administrator no matter which residency program you attend. Don’t be too anxious about getting into one residency versus another based solely on their ED administration opportunities. There are numerous other factors to consider, including the faculty mix, location, and 3 versus 4 year training, just to name a few. For an in-depth guide on how to choose EM residency programs, please see the “Foundations of EM” section here.

That being said, if you already developed an interest in ED administration in medical school, it makes sense to look at residency programs that can continue to support and nurture that interest.

When you’re on the residency interview trail, ask programs about the qualities listed above, and take their answers into consideration when you’re making your residency rank list.

2 - JUNIOR RESIDENT TIMELINE NOTE: If you are coming from a 3-year residency program, shift everything back by 1 year. For instance, the recommended preparation in the PGY3 year in this table would apply to you as a PGY2, and the recommended preparation in the PGY2 year would apply to you as a PGY1. In this scenario, much of the administrative project work and publication will likely spill heavily into the senior (PGY-3) year.

Early PGY1 Year: • Just focus on being an intern. It’s hard enough without worrying about careers and life goals!

Middle of PGY1 Year: • Join some national interest groups or listservs.

– Sign up for the administration, quality, patient safety, or operations interest groups in national professional organizations. Some will have listservs that periodically send out projects or articles. Start to get a feel for the trending topics in ED administration.

End of PGY1 Year: • Start getting involved with administration at your institution.

– Be proactive and volunteer to assist with any QI projects in your ED. Don’t be turned off if you’re doing a lot of chart review or spreadsheet analysis. Remember that you’re paying it forward by earning the trust of ED administrators, and you need this trust to open up opportunities to participate at a higher level in the future.

– Join ED or hospital committees focusing on patient safety, quality, operations, or general administration.

– Ask ED faculty if you can attend some administrative meetings as an observer or participant.

Middle of PGY2 Year: • Decide if you want to pursue a career in ED administration.

– During your PGY2 year, you should have a pretty good idea of whether you want to pursue administration further. Keep in mind that individual institutions can have vastly different management structures, so if you don’t feel that your own institution is a good fit, explore elsewhere (or at the national level) before you write off administration completely as a potential career pathway.

During PGY2 Year: • Identify your mentor(s).

– By the middle of residency, you should be familiar with the core ED administration faculty at your institution. Select one or two faculty members who are doing work that you find interesting and whose leadership style you admire. Approach them with your interest in ED administration, and ask to assist with their projects or start your own under their mentorship. Be direct and emphasize that you are considering ED administration as a career. This will improve your chances of getting the best opportunities for project involvement.

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• P osition yourself for leadership roles.

– Time is your most precious commodity in residency, so choose your involvement strategically. Pick projects that result in tangible outcomes or gains. Show up to committee meetings where resident representation is valuable or appreciated. Volunteer to take on additional responsibility when appropriate. If you consistently show up, deliver on tasks, and maintain good working relationships, you will naturally fall into leadership roles.

– Identify an interesting operational problem or challenge at your institution and take the initiative to help solve it. When appropriate, start discussions with ED administrators and offer to create an order set, go to a committee meeting, or draft a policy.

During PGY3 Year: • Seek leadership roles at both the local and national levels.

– Find or create an administrative project that you love and take ownership of all or part of it under faculty mentorship. This is very high yield! No matter which pathway you take into ED administration, you will encounter a question about this during your interviews.

– Consider pursuing a significant resident advocacy or leadership role at your institution, such as chief resident or the resident representative on a major hospital committee (Medical Board, Root Cause Analysis, etc). Chief resident is a common choice among aspiring ED physician leaders, but it is NOT a prerequisite for becoming an ED administrator. It is more important that you demonstrate passion and competence in your area of interest in ED administration. If chief duties do not align with your interests, or actually get in the way of other significant administrative work that you’re doing, it may not be entirely beneficial to seek out that role.

– Consider pursuing a significant leadership role at the national level, such as the chair of a committee in a national resident organization such as RAMS, EMRA, or RSA. • Publish and present findings from your administrative projects at both the local and national levels.

– Submit abstracts and posters to major national conferences such as SAEM, ACEP, or CORD or regional/local conferences.

– Consider writing QI articles for resident publications.

– Publish papers in peer-reviewed journals if possible.

• Turn yourself into the “admin person” within your residency.

– Take opportunities to teach junior residents or medical students about ED workflow or patient safety.

– Read up on departmental or institutional policies and guidelines, so you can answer questions from other residents or faculty.

– When you are given a chance to present morning report, M&M, or didactics at resident conference, think of administrative topics or tie in systems-level analysis in your teaching points.

– Try to synergize your clinical, educational and administrative efforts in preparation for a career in ED admin.

• Start to explore the fellowship, degree, and experience pathways into ED administration, described in detail below.

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FAQ What are the main pathways into ED administration? Generally speaking, there are three pathways to launch your ED administration career after residency: 1. ED Administration Fellowship (Non-ACGME Accredited) 2. Master’s Degree in Administration (MBA, MHA, MPA, etc) 3. On-the-Job Administration Experience You can pursue one, two, or all three. While this gives you a lot of flexibility and choice, it can also be very challenging to navigate. There is no standardized curriculum, degree, or certification across the different fellowships. On top of that, different institutions and degree programs have different timelines and requirements. The best advice is to research all your options thoroughly and talk to as many mentors as possible. For more in-depth advice, see “How Do I Become an ED Administrator?” on the Background page of the ED Administration Roadmap.

The Fellowship Pathway As of 2018, there are approximately 30 ED Administration Fellowships and 14 Patient Safety and Quality Improvement Fellowships offered throughout the United States. They are all non-ACGME accredited fellowships, though this may change. They typically last 1-2 years (often depending on concurrent degree paths). ED Administration Fellowships vary widely in their curriculum and scope, and new ones are being formed every year.

Generally speaking, ED administration fellowships fall into two broad categories: those affiliated with an academic or training institution (e.g., Yale, NYU, Stanford), and those affiliated with an independent physician-owned organization or group (e.g., Vituity, formerly CEP America). Some offer a master’s degree in business or hospital administration as either an option or requirement, while others offer to sponsor an external degree, and the rest offer no degree option. The type of degree is also highly variable, with MBA, MPA, MHA, MPH, and MS degrees being offered at different programs, sometimes in combination.

While the variety may seem somewhat overwhelming, keep in mind that it also allows you to find a program that caters to your goals, instead of forcing you to conform to a universal standard. Since most ED Administration Fellowships are relatively new and have no ACGME requirements, there is tremendous potential to tailor them to your individual needs. On the flip side, because they lack a standardized curriculum or degree, there is some risk that you may not receive what you feel to be adequate administrative training or experience if clear expectations are not set in advance. Because of this, it is critically important that you have a clear idea of what you want out of the fellowship before starting the interview process or committing to a program. Research the fellowships thoroughly, talk to former or current fellows, and don’t be shy to compare notes with other applicants during the interview trail.

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While an increasing number of institutions are offering structured fellowship or degree programs for ED administration, keep in mind that graduating from these programs does not guarantee you a management position right out the gate. On-the-job experience still matters tremendously. That being said, academic institutions often view administrative fellowships very favorably, and give preference to candidates who can join the Emergency Department with pre-existing administrative training and skills. This can often lead to an expedited pathway to an administrative leadership position.

For more information about ED Administration and Patient Safety/Quality Improvement Fellowships, please check out the EMRA Fellowship Guide, Chapter 2. To see a listing of SAEM approved fellowships, please check out the SAEM Fellowship Directory.

The SAEM Fellowship Directory was developed in order to promote standardization of fellowship training. Eligible fellowship programs earn the endorsement of “SAEM-Approved Fellowship” in order to be included in the directory. SAEM has developed guidelines for training programs that address milestones in curricular elements, faculty support recommendations, and career development opportunities.

The Degree Pathway Many ED physicians successfully advance their careers by obtaining a master’s degree in administration independent of a fellowship program.

The most popular options are MBA, MHA, or MPH. There are also many other degrees and certifications available. This is a great mid-career option several years out of residency, especially if an institution is willing to sponsor your degree or it is included as part of a promotion track. It’s also a great alternative for residents who don’t want to pursue fellowship but are still looking for formal administrative training. Medical schools are also increasingly offer dual MD/MBA degrees, which is a great opportunity for those who develop an early interest in administration.

The Experience Pathway It is entirely possible to become a successful ED administrator through on-the-job experience alone, without any fellowship training or additional degree. However, accomplishing this immediately after residency is becoming increasingly difficult as more and more aspiring physician leaders are acquiring formal administrative training with the support of their institutions. That being said, a strong track record of effective leadership and successful administrative projects has tremendous weight. Simply completing a fellowship program is no substitute for real proven experience.

If you are fortunate enough to have both an administrative fellowship offer and an administrative job opportunity, you should consider both options very seriously. Make certain the fellowship offers you value beyond just another line on your CV. Is there also a sponsored or subsidized degree that is valued by the administration community? Will you participate in an interesting project or publication that directly aligns with your career goals? Is there opportunity to interface with hospital leadership that you otherwise would not have access to? How will this advance your short-term and longterm career goals? If you’re stumped, reach out to as many people and mentors as you can for advice, both inside and outside your institution.

Keep in mind that there is no “right” path in ED administration. It all depends on your individual career goals. Because ED administration training is so individualized, it’s important to explore the different areas of ED administration early in residency and clearly identify your interests before your senior year.

What if I can’t find any good ED administration mentors for me at my institution?

This is where your regional and national involvement comes in. See if anything on your SAEM or ACEP interest group listservs sounds interesting, and be proactive about volunteering for projects. You can easily connect with faculty at other institutions this way. Try to attend a regional SAEM meeting, or go to the SAEM Annual Meeting in May of your intern year. Consider attending the Speed Mentoring event at the SAEM Annual Meeting, which matches you with a faculty member that shares your interests. The more national involvement you have, the bigger your network of potential mentors.

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3 - SENIOR RESIDENT Congrats! You’re almost done with residency! It must feel good to be so close to graduation, but you need to cross the job/fellowship application hurdle first. Here’s our recommended approach. Keep in mind that this is only a rough guideline to give you a sense of what to expect. Your own journey into an ED administrative career may be very different depending on your career goals and personal background. There is no one formula for success. When in doubt, rely on your trusted mentors. Their advice will likely supercede any guide you read.

By the beginning of your last year of residency, you should have a good sense of whether you want to pursue the fellowship, degree, or job experience pathways into ED administration. While these pathways are separated below for clarity, keep in mind that some fellowships offer one or more degree programs, and some jobs can sponsor a degree as well.

Regardless of which pathway you pursue, you should join an Administration, Patient Safety, or Quality Improvement Senior Track or Focus at your residency program if one is available. If one isn’t available, find an elective at an outside institution that either has administrative distinction or houses a fellowship or job position that you desire. Lean on your involvement in national organizations like SAEM, ACEP, CORD, or one of the many ED administration associations to find contacts that can help you set up an elective. If you’re looking to stay within your own institution after residency, consider starting a new ED Administration Senior Track if one doesn’t yet exist. Identify a faculty mentor and a few other interested residents and put together a proposal to present to your Program Director or Department Chair. This will make some waves within your residency and help distinguish you as someone who is truly passionate and capable of starting an ED administration career.

Depending on whether you choose the fellowship, degree, or job experience pathways, your preparation will be different, and is described in detail below.

TIMELINE FOR THE ADMIN FELLOWSHIP PATHWAY During PGY3 Year: • August: Start actively exploring fellowship options. You need to start early for the fellowships that include a degree with a GRE/GMAT requirement, in case you need a few months to study.

• October or May: Attend a fellowship fair. The two biggest are the Resident and Fellowship Fair at the SAEM Annual Meeting in May and the EMRA Job and Fellowship Fair at the ACEP Scientific Assembly in October. If there’s a particular fellowship that you like, email the fellowship director in advance to ask questions and set a time to meet at their booth.

During PGY4 Year: • July-August: Create a list of fellowships that you’re interested in, then reach out to Fellowship Directors or their designated recruiters/ coordinators. Yes, it’s okay to just email them out of the blue. There’s no portal or common electronic application for ED administration fellowships, so you need to reach out to each program individually.

• August: Take the GRE or GMAT if you plan to apply to fellowships that include a degree program. Plan to study for the test over a 1-2 month period.

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• Sept: Begin filling out your fellowship applications. Requirements for applications vary widely, but typically include these elements: – Updated CV – Letter of interest/intent or essay questions – Letter(s) of recommendation – Graduate school application (required for fellowships with degree programs) • October-February: Start interviewing for fellowships. Here’s some tips: –W hen scheduling your interviews, try to cluster them over a 1-2 month period if possible. You want fellowship offers to come at approximately the same time, to avoid a situation where you are forced to respond to an offer before you hear back from other programs.

–B e prepared for long interview days. Remember what it was like to interview for residency? It’s very similar. Expect back-to-back interviews, lunches with applicants, and ED or site tours.

–B e prepared to speak with non-physician interviewers. Remember that ED administration involves nursing and hospital leadership, as well administrators from outside the ED. Don’t be blindsided by an interview with the Director of Nursing, for instance, who asks you about your experience working with nursing on projects.

–L ook up the organizational structure of the institution or organization before you interview.

You should know the people in key positions such as Department Chair, CMO, or President, and the major hospital sites or offices.

–B e prepared to talk about both your clinical and administrative experiences in a meaningful way. Come up with an arsenal of different projects or cases throughout your medical training where you had meaningful involvement. Be able to succinctly describe the nature of your impact or the lessons learned.

–D emonstrate curiosity about the institutions or organization’s administrative challenges or projects. Ask about key initiatives, why they were chosen, who is involved, what the goals are, etc.

The trick is to find a project that both you and the institution are interested in, and start talking about how you might get involved.

• November-April: Get fellowship offers! Accepting and declining offers is a very tricky process.

Every fellowship operates on a different timeline, so you may get an offer and be asked to make a decision within days, well before you hear back from other programs. There’s no good answer about how best to navigate this process, but here’s a few tips and tricks: – Ask for an explicit timeframe to accept or decline the offer. Be ask specific as possible (“5pm EST on January 4th”).

– If you accept an offer, ask for a written confirmation. This doesn’t need to be a formal contract; a simple email from the Fellowship Director is sufficient. This gives you a definite “yes” that allows you to start closing your other applications and offers.

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• F ebruary-June: Once you’ve accepted a fellowship offer, start preparing for your new life. You will need to get credentialed as a fellow, obtain a medical license (if you don’t have one already), and complete pre-work if you’re also enrolling in a degree program. Most fellowships have a July start date, and credentialing can take anywhere from 2-6 months depending on the state, so don’t fall behind on the paperwork!

TIMELINE FOR THE ADMIN DEGREE PATHWAY During PGY3 Year: • Start actively exploring degree options. You need to start early in case the degree has a GRE/GMAT requirement, and you need time to study. Focus on executive or extended degree programs that will allow you to hold an attending job at the same time. A traditional on-campus degree program is not recommended.

During PGY4 Year: • August: Start actively exploring job options. Look at institutions that may sponsor your degree, or count it towards a promotion track. At bare minimum, find institutions that will accommodate your class schedule. If you’re coming straight out of residency, focus on part-time positions. It won’t be possible for you to work full time as junior faculty and obtain a degree at the same time.

• A ugust: Take the GRE or GMAT if required by your graduate school(s). Plan to study for the test for 1-2 months.

• O ctober-February: Fill out degree applications and looking for an EM job at the same time.

Most executive MBA, MPA, and MPH programs having multiple rounds of admissions or rolling admissions, so there’s some flexibility in when you apply. Pay close attention to the deadlines and offer dates for each round. You want to pick the round that works best for you. For instance, some degree programs have start dates in both the spring and fall. Make sure pick the one that lines up best with your job start date.

• O ctober-February: Start interviewing for your degree and job. Here’s some tips: – Discuss sponsorship as early as possible.

–A sk how your degree and job can fit together. Some Department Chairs may offer to have you sign a two-year contract as junior faculty and work for a year full-time before sponsoring or subsidizing your degree. Remember that everything is negotiable.

– Be prepared to interview with non-physicians. You probably haven’t done this for a while, since all medical school and residency interviews are with MDs. If you’re applying for a MBA, be prepared for the possibility of a group interview.

• N ovember-April: Start getting degree and job offers!

This is an even trickier process than dealing with fellowship offers.

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– While your negotiating power with regard to hours or salary as a first-year attending may be limited depending on external factors (location, demand, etc), you may have the ability to negotiate sponsorship for your degree and how the degree might fit into a promotion track, and possibly pick among different part-time attending packages. Don’t be turned off, however, if you aren’t able to change the total number of clinical hours, base salary, or your benefits. This is frequently standardized for new residency graduates, regardless of background.

– Wait until you’re actually accepted into a degree program before signing a job offer built around the assumption that you’re pursuing a degree.

Most degree programs will give you a window of time to accept or reject their enrollment offer, so you’ll have some flexibility and time to maneuver your job offers after your initial acceptance letter.

TIMELINE FOR THE JOB EXPERIENCE PATHWAY For an excellent primer on how to apply for any academic ED attending position, and what to expect during your first year as an attending, please see the “Foundations of EM” section. Here’s some more specific tips about how to find a first-year attending job that can launch a career in ED administration: • Look for job opportunities that include options to lead an interesting administrative project or initiative, or even offer a fast track leadership position (e.g., Assistant Medical Director) straight out of residency. This is where all your preparation and experience during residency and medical school comes in. If you were able to follow the recommendations above, you should be in a good position to seek this level of responsibility.

You should have participated or led one or more significant QI/QA projects, held one or more leadership positions, been involved in committee or interest group work at both the institutional and national levels, and published some of your work or findings as abstracts, posters, or papers. You should also have identified one or two areas of administration that you would like to focus on, such as Quality Improvement, Patient Safety, or Risk Management. With this level of experience, you should be well prepared to participate in hospital or departmental administrative projects without difficulty as junior faculty, and the hiring institution will likely recognize this and assign you responsibilities accordingly.

• Look for institutions or organizations with well-defined ED administration promotion tracks. You want a job where administrative work by ED physicians is valued by the Department Chair or leadership. Talk to ED administrators within the institution and get a sense of their career path.

Were they promoted from within or brought in from outside? How many years did it take? What are their obligations to administrative work versus clinical shifts versus research and education, and how much did each one contribute to their promotion? All this will give you a sense of how much they value ED administrative work and the potential for upward mobility.

FAQ Do I need to do an away rotation or administration elective during residency? Unlike the EM-Critical Care or Ultrasound pathways, an away rotation or elective is not necessary for ED administration, regardless of whether you’re pursuing a fellowship or job. If you have your heart set on one particular institution or organization, you may find it rewarding and beneficial to visit there and gain exposure. However, it’s certainly not mandatory.

If your residency program lacks an ED Administration Senior Track or meaningful administration opportunities for residents, however, an away rotation can be a great option to gain experience at another institution. To set this up, all you need to do is contact the Program Director or Medical Director at that institution and inquire if this is possible. You should identify a particular project, committee or event that you want to be involved in; for instance, visiting a hospital triage command center at a large academic institution, or attending a leadership retreat for a physician group.

Is there a fellowship portal for ED Administration Fellowships? Not currently. Remember that all ED administration fellowships are all nonACGME accredited, and there is no standardized curriculum or centralized process for applications. You will need to look up or contact each

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institution individually to obtain their updated application requirements. We highly recommend attending the ACEP and SAEM job and fellowship fairs. Remember that new ED administration fellowships are being created every year, so this is the best way to get the lay of the land.

Which fellowships or degrees require the GRE/GMAT? This varies tremendously, so the best thing to do is research the fellowship or degree program thoroughly before deciding to take the test. ED Admin fellowships will only require the GRE/ GMAT if there is a degree included. Some graduate schools require the GRE/GMAT as part of their admissions process, and your MD does not exempt you in the vast majority of cases.

How do I study for the GRE/GMAT? And which one should I take? If you’re pursuing a MPH, MHA, MPA or any type of master’s degree in administration that is not an MBA, you should take the GRE. Some of these degree programs may actually exempt you from the GRE if you have an MD. Similarly, if you want to keep your options open to apply to any type of administration degree, you should take the GRE. If you’re applying for an MBA, however, it gets a bit tricker. Business schools used to only accept the GMAT, but many now accept the GRE as well (you can check here).

Taking the GRE versus GMAT is an age-old question in the business world. There are large online forums for business school candidates that debate it (see Magoosh and Poets and Quants). In general, the GMAT is more analytical and quantitative, and takes a bit more practice with equations. The GRE has a more extensive verbal section with obscure vocabulary, so it requires a bit more memorization. If you are short on time as a resident, you may find the GRE somewhat easier to study for since you’re not using algebra or statistics in your daily life, but memorization is familiar to anyone who’s been through their fair share of USMLE and SHELF exams. Your best bet is to actually do some GRE vs GMAT questions and decide for yourself.

The Princeton Review, Kaplan, and all the other major testing sites have a few free questions online that you can use.

As for studying, we recommend that you actually do it. Both the GRE and GMAT contain math, verbal logic, and essay questions that you probably haven’t seen in years. This isn’t a test that you’ll be able to walk into cold as a resident. Set aside one or two months and purchase a question bank or prep book. You’re already a pro at studying if you got through medical school, so it’s a matter of diligence, not ability.

As an MD seeking a professional-level graduate program, you probably don’t need to knock this test out of the park. You just need to do well enough to demonstrate proficiency.

5 - BACKGROUND What is ED Administration?

“ED Administration” is often used as a catch-all term for a wide variety of careers dealing with the management of an emergency department and/or EM physician group. This includes management at any level, ranging from day-to-day clinical operations to long-term strategic planning for an entire institution or healthcare system. In addition to developing clinical expertise in Emergency Medicine, ED administrators also need to have effective leadership skills, an understanding of basic business principles, and a working knowledge of institutional and national policies.

Traditionally, these skills were obtained through on-the-job experience, culminating in promotion to an administrative role. However, as the field of Emergency Medicine faces increasingly complex operational challenges, an expanding number of institutions are creating structured pathways to train ED physician administrators.

If you love working with people, enjoy quality improvement projects, and spend a lot of time wondering, “how did this policy come about?” or “how can we improve this at a higher level?,” then you should strongly consider a career in administration. Residents and students who pursue this career path typically enjoy leading projects or teams, and are drawn to the business and operational aspects of Emergency Medicine and how they impact patient care. Those who are particularly interested in implementation science or scholarship in ED administration should consider an academic career in this field.

What is It Not? While ED administration draws upon principles from many industries outside of clinical medicine, ED administrators are not synonymous with policy-makers, politicians, or “business people.” Becoming an ED administrator does not mean that you are doomed to become a pencil-pusher or destined to become an entrepreneur. Training in ED administration simply helps you develop a skill set in management. Who and what you manage is up to you. Some ED administrators thrive in the clinical environment, and seek jobs that allow them to work on ED staffing models and clinical policies. Others are interested in managing risk at a hospital level, and become Patient Safety or Quality Improvement Officers.

Still others use their management experience to start their own companies, urgent care centers, or practice groups. The options are diverse and numerous. You do not need a burning passion for reimbursement fee structures or process maps to become an ED administrator. You only need an interest in leading and working with people outside of a purely clinical setting.

How Do Academic vs Non-Academic Careers in ED Administration Compare?

Because every institution, department, and practice group has a different organizational structure, career options in ED Administration can be challenging to navigate and compare. In general, all ED administrators have some type of management role, but the responsibilities, focus area, and stakeholders involved can vary widely from place to place.

At an academic institution, the entry point is usually at the departmental level as an Assistant Medical Director or appointed leader of one or more key projects or committees. From here, you can begin to specialize in Operations, Quality Improvement, Patient Safety,

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Risk Management, Patient Experience, or other focus areas within your organization. As you gain experience, you will shift from the execution of individual ideas or projects to the management of strategy and resources at a higher level. A typical mid-career position is to become the Medical Director of your ED. You can then aspire to a senior departmental leadership position such as Vice Chair or Department Chair, or a senior hospital leadership position such as Chief Medical Officer, Vice President, or President. If you are part of a multi-hospital system, you can also consider a senior leadership position at the systems level.

Outside of academia, you can become the director of a physician group practice, urgent care center, freestanding ED, or community hospital. ED administration also prepares you to pursue other types of management opportunities, such as working as a healthcare consultant or creating health policy, to name just a few.

If you work at an academic institution, you will likely have teaching and/or research responsibilities alongside your administrative ones. While the exact nature of these responsibilities are often flexible as you advance in your career, the core educational mission of an academic institution will always be paramount. This means that you will constantly face the unique challenge of balancing education and service in any administrative role. For instance, an initiative that increases patient throughput may decrease opportunities for bedside teaching or increase burnout among trainees. You will need to think creatively to allocate resources in a complex environment that accounts for education and research alongside pure operational efficiency. Some ED administrators find this challenge highly rewarding, while others prefer a non-academic setting without this added layer of complexity.

That being said, non-academic organizations (such as community hospitals or private group practices) certainly come with their own unique challenges as well. The best approach is to keep an open mind, and try to explore different environments during your training to discover which one suits you the best.

Education and research will also be critical to your career advancement in academia, regardless of your proficiency as an ED administrator. Most academic institutions have specific requirements

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or milestones for promotion tracks that include peer-reviewed publications, involvement in national professional societies, speaking engagements, and other endeavors that advance their educational and research missions. Unlike in community or group practice, you will need to learn to synergize your day-to-day administrative duties with your educational and research pursuits.

With all these challenges in academia, what’s the benefit of pursuing an academic career as an ED administrator? The ultimate benefit is that you will advance the field of Emergency Medicine by carving out a unique area of administrative expertise that you can prove, replicate, disseminate and teach to others. The recognition, scholarship, and trainee education that comes with this brand of expertise is traditionally only possible in academia.

At a more practical level, an academic appointment will often lead to a decrease in clinical responsibilities and an increase administrative reach and compensation.

How Do I Become an ED Administrator?

Before we delve into the specifics of ED administrative training, keep in mind that there is no universal pathway for this career. This is not like EMS or Toxicology, where there’s a one-and-done ACGME-accredited fellowship option. Because physician-led ED administration is an expanding area of expertise, it’s a bit like the Wild West out there when it comes to training. Generally speaking, there are three options: 1.

2.

3.

ED Administration Fellowship (Non-ACGME Accredited) Master’s Degree in Administration (MBA, MHA, MPA, etc) On-the-Job Administration Experience

You can pursue one, two, or all three as part of your training. Keep in mind that any one of these is often sufficient, including option #3, which is simply getting a job straight out of residency and taking on administrative projects without a fellowship or advanced degree. Some institutions also combine options #1 and #2 by offering a fellowship program that includes obtaining a master’s degree.

To make sense of it all, you should begin with a clear goal in mind and work backwards. For instance, if your dream is to own a network of urgent care centers, option #2 makes sense because a MBA would help you obtain necessary business skills like accounting that are not taught in medical school. You might also favor on-the-job experience at an urgent care center over 1-2 years of fellowship after residency. On the other hand, if your dream is to be the Emergency Medicine Department Chair at a large tertiary care center, pursuing a fellowship at an academic institution likely makes the most sense. Comparing different fellowships, the ones that offer a master’s degree might be more practical, since prominent Department Chair positions are competitive and training in business administration would give you an edge over other candidates. If your dream is to work at a particular institution, then you may benefit the most from taking a position there right out of residency, especially if an interesting administrative project or role is already waiting for you. Regardless of your path, forming relationships with mentors who can help you fine-tune your career development from a variety of perspectives is critical. This can be formal mentorship in a fellowship program, or an informal relationship through work experience and connections. However you attain it, good mentorship will be a critical component to success.

If you’re not sure what your goal is, try to leave your options open. It can be difficult (although not impossible) to return to academics once you leave it for an extended period of time. Because of this, you may want to consider pursuing a fellowship at an academic institution that also allows you to moonlight at community hospitals or other non-academic settings, so you can experience multiple settings while you choose a specific career pathway. Alternatively, consider getting a job in a hospital system that has both a large academic center and community affiliates.

For a detailed explanation of each of these pathways, please visit the Junior Resident page on the ED Admin Roadmap.

6 - RESOURCES Professional Societies • • • • •

S AEM Academy of Administrators in Academic Emergency Medicine (AAAEM) E mergency Department Practice Management Association (EDPMA) A merican Association for Physician Leadership A merican College of Healthcare Executives A merican College of Medical Quality

Interest Groups & Committees • S AEM’s Patient Safety Interest Group • A CEP’s Quality and Patien Safety Section

Journals and Publications • • • •

A cademic Emergency Medicine Th e American Journal of Medical Quality H ealth Affairs J ournal for Healthcare Quality

Recommended Conferences & Certification Programs • • • •

S AEM Certificate in Academic Emergency Medicine Administration (CAEMA) A CEP ED Directors Academy (EDDA) A CEP Leadership and Advocacy Conference E DPMA Solutions Summit

Scholarships & Grants for Residents

• E MRA’s ED Directors Academy (EDDA) Travel Scholarship • N ew York ACEP’s Young Physician/Resident Leadership & Advocacy Award

7 - INSIDER ADVICE Dr. Rebecca Donohoe, Assistant Director for Patient Experience, Duke University: “[For residents and students] interested in Operations, I would recommend seeking opportunities within your department. There are usually many committees that meet regularly within a department, as well as leadership meetings, operations meetings, safety/ quality review meetings, patient satisfaction committees...”

Dr. Jason Theiling, Medical Director, Duke University: “...when I was hired in my current position I was told that a significant portion of success especially early on is showing up and doing what you say you will do. Sometimes this is simply initiating and carrying out chart review or quality improvement programs. This gives you an opportunity to interact with various groups within the hospital. These types of activities will eventually lend themselves to more operationally-driven opportunities.”

“Often I hear that residents feel like they must be a chief resident to have the hope of being an administrator. This is simply not true...I know many medical directors that were never chief residents.”

Dr. Adam Nevel, Assistant Professor, Icahn School of Medicine: “I would highly recommend residents at least consider some sort of formalized education or training in administration. The teambased, analytical approach that is taught in these programs, forums, academies, etc. is SO different than the more individualized aspects of medical education and training. Getting early exposure to this approach can often offer huge payoffs in terms of career trajectory and timeline.”

Dr. Kaushal Shah, Vice Chair of Education, Residency Director and Associate Professor, Icahn School of Medicine: “You don’t have to be the smartest or fastest resident, but you do need to stand out from everyone else. How do you do that?

Follow your passion vigorously! Take on projects in your department or on a national committee that you love and don’t just do what is asked of you -- leave your mark by taking it to the next level. Your hard work will get noticed... and then you’ll be asked to participate in bigger projects. It won’t be long before the Chairman of the department or the President of the national society knows your name and wants you on their team.”