advice from the elders

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Sanchik

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Hi everyone, i am hoping some of you could offer some advice to a very confused intern. it seems that EM people, more so than others LOVE EM and know that's what they want to do. I never really found something that i HAD to do. In med school, i always enjoyed every rotation, and i am generally one of those people that really enjoyes medicine. In med school, i mostly considered medicine and PM&R, medicine because i was always intersted in the intellectual part of it, the making the diagnosis and all, and PM&R for the lifestyle b/c i have a baby. I did a required EM rotation, and like most things didn't love it, but enjoyed it. A part of me was afraid of medicine b/c i was afraid that i din't have what it taked to make big decisions. i ended up matching into PM&R.
Fast forward to now, i am an intern in a transitional year and i discovered that i do like medicine and that i am good at it and the whole year everyone is telling that's that i should do it. i finally decided that PM&R is not for me. one of the fields that interest me the most is cardiology and this is where i started to think about EM. i am 29, I would probably be 36 before i could do cardio, and my favorite part of cardiology (or any other field) has always been the diagnosis. so someone floated the idea that since i like diagnosing, cardiology, critical care medicine, i should do em. i would be done sooner, the lifestyle would be better, and i like the idea of not having to "run my own business". here are some things that concern me:

1. i don't like trauma/procedures that much and all the EM people love it. i would rather just do the "medical emergencies"
2. i have a terrible memmory, and am afraid that EM, being the broadest specialy, that i would miss something
3. i always found my ER shifts to be exhausting, meaning not like on medicine, where u sit and write notes, but then again in IM private practice, you are running from room to room all day.

anywho, i cannot believe how long this post is, any ideas?

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hard to do em if you don't like procedures or trauma(that's about 1/2 of the job...)...stick it out and do cardiology, sounds like that would be a better fit for you.
 
Sounds like your most pressing issue is time. You want a specialty that will allow you to spend more time with family. I personally love EM and the time off is just a bonus, but if you don't love it it will be hard on you. Family Medicine may be a good choice.
 
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The amount of trauma will depend on where you are. Some places have a lot of penetrating trauma (So called gun and knife clubs) and others have mostly blunt trauma (MVAs).

That being said, I guess I am in the club of individuals in (or going into) EM who love it and cannot see doing anything else. I love the pace and rounding for even an hour is excrucriating for me.

As far as you age goes, I am a 31 year old third year medical student and will be 35 when I finish my EM residency. Do what you love. If cardiology speaks to you and you enjoy being deliberate, it sounds like you could be a good match.
 
I'm actually a humble 4th-year student, but I'll try to offer some advice, notwithstanding my youth and inexperience. There are a lot of issues in your post -- I'll try to address them individually.

it seems that EM people, more so than others LOVE EM and know that's what they want to do.

EM people are often extroverted and enthusiastic, but I don't think EM has a monopoly on career satisfaction (PM&R has a very high rate of job satisfaction, if memory serves), nor do I think that people who are not "gung ho" are doomed to not enjoy EM as much as the next guy.

A part of me was afraid of medicine b/c i was afraid that i din't have what it taked to make big decisions.

As a physician, whether you're a pathologist, radiologist, dermatologist, or neurosurgeon, you have to make decisions that impact patient care and can affect whether a given patient lives or dies. That's why we get paid the big bucks and carry malpractice insurance. Two caveats: 1. Not everyone has to constantly make potentially patient-life-altering decisions at 4am with no past medical history and very limited information -- that's the specialty of the EP. 2. Over the course of residency/fellowship in any field, you'll get pretty competent at making the requisite "big decisions."

someone floated the idea that since i like diagnosing, cardiology, critical care medicine, i should do em. i would be done sooner, the lifestyle would be better, and i like the idea of not having to "run my own business".

Two other alternatives that would also largely satisfy these criteria, aside from cardiology and EM, would be doing an IM (or FM) residency and working as a hospitalist, or doing a 1-year critical care fellowship after IM and being an intensivist.

1. i don't like trauma/procedures that much and all the EM people love it. i would rather just do the "medical emergencies"

I think hospitalist/intensivist would satisfy these criteria. Alternatively, as was mentioned, you don't need to do EM at a trauma center, but it really is a core competency, certainly during training.

2. i have a terrible memory, and am afraid that EM, being the broadest specialy, that i would miss something

I'm going to risk flaming here, and say that as an EP you don't always have to know everything. If someone has surgical disease, you admit to surgery, etc. The main thing to figure out is who is sick and who isn't. You also need to not miss, and be able to provide initial management for, a fairly small group of diagnoses that will be drilled into you during EM training (MI, PE, aortic dissection, meningicoccemia, SAH, ectopic pregnancy, etc.).

3. i always found my ER shifts to be exhausting, meaning not like on medicine, where u sit and write notes, but then again in IM private practice, you are running from room to room all day.

I think that largely varies by location and how much money you want to make. There are low-volume ED's that see under 26K patients/year, which is <500 patients/week, which is <3 patients/hour. There are internists/FPs who see 32 patients in an 8-hour office day = 4/hour. A lot of that depends on your payer mix, overhead, and salary requirements.
 
There are low-volume ED's that see under 26K patients/year, which is <500 patients/week, which is <3 patients/hour.

I don't care what the volume is - busiest in the world, or 26K - if you are seeing 3 patients per hour in the ED (except in peds), you are getting royally screwed.

My group adds doctors on when the PPH average exceeds 2.2.
 
If you really like internal medicine, do internal medicine. If you want cards, do cards. Critical care is a two year fellowship, btw. If EM drains you, then it probably isn't for you. Also, you don't always see the "final" diagnosis in ED.

Internal medicine offers a range of practice situations available from specialist to hospitalist to private clinic to research and consulting.


I'm going to risk flaming here, and say that as an EP you don't always have to know everything. If someone has surgical disease, you admit to surgery, etc. The main thing to figure out is who is sick and who isn't. You also need to not miss, and be able to provide initial management for, a fairly small group of diagnoses that will be drilled into you during EM training (MI, PE, aortic dissection, meningicoccemia, SAH, ectopic pregnancy, etc.)

TakayaSue- you won't get flamed. :boom: (I love this avitar!) NO physician needs to know everything- it would be impossible! Also, everyone knows that for a surgical disease, it is admit to medicine, consult surgery! :laugh:
 
I think that largely varies by location and how much money you want to make. There are low-volume ED's that see under 26K patients/year, which is <500 patients/week, which is <3 patients/hour. There are internists/FPs who see 32 patients in an 8-hour office day = 4/hour. A lot of that depends on your payer mix, overhead, and salary requirements.
I'll join in with Apollyon (why can't you use the Roman spelling? I have to look it up every time) and say that 4/hour FP clinic is a lot different than 3/hour in the ED.
In our vascular surgery clinic, we see 49/day, and the day is from 9-4, with an hour for lunch. However, none of these patients are septic, or require any procedures (other than dressing changes, and that is what the nurses at the office do), or anything else that takes time other than "what are we going to cut off" vs "how is the wound from where we cut off xxxx"
There are never any vagueness.
 
thanx everyone for your contribution.
 
so someone floated the idea that since i like diagnosing, cardiology, critical care medicine, i should do em.

Truncated Quote

I'm guessing this 'someone' is not an EP. No person who is actually involved in emergency medicine would EVER make such a suggestion. Especially if they know your aversion to trauma and procedures (by the way, cardiology is a fairly procedure oriented specialty)
 
well, i didn't say that i have an aversion to trauma and procedures, they just don't turn me on.
at the small community hospital where i am doing my internship, there's not much trauma, but there's a lot of chest pain, mis, pe's, sepsis, cardiogenic shock, etc. and i think that it would be fun to be on the diagnosis and stabilizing end, as opposed to being called with "we have a guy with a STEMI". in terms of cards, i am not interested in the interventional part beyond fellowship.
i also often look at our ED attendings and think "these guys are the real doctors". they manage mis, intubate, do central lines, anything- and i find that to be v.cool
 
An emergency physician definitely has to be a "jack of all trades, master of none" and specialists tend to forget this. I get the impression that many of the uber-specialists we see in the ED would crumble under the patient load and acuity that many EP's deal with everyday. There's an internist who admits patients for a big HMO who is always complaining about the ED, yet when he gets more than three admits he comes unglued and looks as if we're going to have to put him in an isolation room for his own good :laugh:
 
An emergency physician definitely has to be a "jack of all trades, master of none" and specialists tend to forget this. I get the impression that many of the uber-specialists we see in the ED would crumble under the patient load and acuity that many EP's deal with everyday. There's an internist who admits patients for a big HMO who is always complaining about the ED, yet when he gets more than three admits he comes unglued and looks as if we're going to have to put him in an isolation room for his own good :laugh:

I wish I could remember who to attribute this quote to, but it is not my line. "A good EM physician is NOT a jack of all trades, master of none, but rather is second best at everything." I know this is sort of off topic, but I think it is an important difference in the choice of verbage and goes to something the OP noted. You have to be ready and willing to deal with everything until the person who is "the best" can help you out. They may not be at the facility you are at and so you represent the best that your hospital has to offer for that patient (until they are transfered). So if there are many aspects of EM that you don't like or feel comfortable with it might not be a good fit.

On a separate note, I think some of the other responses hit on a more important point. That is you have to do what will make you happy. If you are simply choosing a specialty based on the perception that it is a "lifestyle" specialty I think you will lose out. If you aren't happy at work and have "buyer's remorse" it will carry to your life outside of the office.

Good luck with whatever you choose.
 
Sanchick,

I'm probably playing a little devil's advocate, but from what it sounds like, you should not go into EM. Passion must drive someone into the field. Once you are in it, you'll need that passion to get you by. I think EM is one of those fields where being solid about your decision matters. Don't be lukewarm. You'd be better off in IM where option paths are available to you.

No you might just say to yourself, "Screw Aloha Kid," how dare someone tell me what I can and can't do. But remember, it's not about what others think, but what about you feel you should do and whether you can happily live with your decisions thereafter.
 
Sanchick,

I'm probably playing a little devil's advocate, but from what it sounds like, you should not go into EM. Passion must drive someone into the field. Once you are in it, you'll need that passion to get you by. I think EM is one of those fields where being solid about your decision matters. Don't be lukewarm. You'd be better off in IM where option paths are available to you.

No you might just say to yourself, "Screw Aloha Kid," how dare someone tell me what I can and can't do. But remember, it's not about what others think, but what about you feel you should do and whether you can happily live with your decisions thereafter.

Very well said. And the rest of you as well. IF for some odd reason I don't feel the ED is right for me, I'm sure I'll find another specialty that is (but I highly doubt this would happen to me, but at least have kept my mind open to the what ifs).
 
If you like diagnosing and want a lifestyle, perhaps pathology is a good fit. No procedures except for autopsies and maybe biopsies (dermatopath), nothing but medical knowledge required, and little emphasis on short-term memory recall. From what you have suggested, EM is not for you. Just a thought...
 
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