3rd yr med student trying to decide between em vs im, input is much appreciated!

[DO???]

Third-year med student still a bit torn between EM vs IM.

The first month of IM I loved it. I was getting to use my knowledge of pathophysiology to build differentials and I especially loved the cerebral aspect of it. The second month was much more difficult. I did not like rounding and writing the same things over and over in the notes every day. My tolerance could have been lower because I was pretty drained.

Did a month in the ED and loved the pace and team atmosphere, the mixture of acuity and procedures. I fit in well with the team. It felt like I found my people. Time flew, and the month was fantastic. I was always looking forward to my next shift. The big problem that keeps nagging me is that I did not feel the cerebral aspect that I did on IM. Is it because I am a third year and do not know as much? I definitely don't want to sit and mull over the minutia, but I'd like to be able to work the patients up as much as possible/necessary before shipping them upstairs. I do like to know what is causing a thrombocytopenia for example. Another example, for me, if I see a pt with metabolic alkalosis I would want to order a urinary chloride to see what is the cause.

EM folks: What are your thoughts on this? Is there a place in the ED for people like myself and want to work up different things or am I internal medicine and just do not know it yet?

Thank you very much in advance for any wisdom you provide.
Warm Regards

Edit: when working in the ED I felt like I was really helping people, I felt like this was the reason I came back to medical school. However, at the end of the ED rotation, I felt like I just ruling out the major stuff and then figuring out the dispo.

---

Members don't see this ad.

 

[enalli]

There can be a place for you in EM. There's no rule that says you can't send less-common tests from the ED if they are clinically indicated, the issue is you likely won't be the guy following up on those tests and acting on them. No one is stopping you from learning all the rheumatology, endocrinology, medical genetics, etc. that you want and applying them to your practice within reasonable limits, but if those things are your passion then you will get more of it if you go into an IM subspecialty. Can you handle not being seen as an authority on these topics by other physicians and patients?

Do note that if you're in the community, efficiency is the name of the game. Academics may be better suited for you if you want more leeway in not being super efficient. It may also allow you the opportunity to catch more rare diseases both by virtue of being at a tertiary care center and by having a lore more patients due to working with residents.

 

[DO???]

There can be a place for you in EM. There's no rule that says you can't send less-common tests from the ED if they are clinically indicated, the issue is you likely won't be the guy following up on those tests and acting on them. No one is stopping you from learning all the rheumatology, endocrinology, medical genetics, etc. that you want and applying them to your practice within reasonable limits, but if those things are your passion then you will get more of it if you go into an IM subspecialty. Can you handle not being seen as an authority on these topics by other physicians and patients?

Do note that if you're in the community, efficiency is the name of the game. Academics may be better suited for you if you want more leeway in not being super efficient. It may also allow you the opportunity to catch more rare diseases both by virtue of being at a tertiary care center and by having a lore more patients due to working with residents.

Thank you for the response, I am definitely debating em vs hospitalist at the moment. I wasn't planning on doing a subspecialty, I will be pushing 40 when done with residency.

 

[TheComebacKid]

IMO, roughly 80-90% of diagnoses are made in the ED. Emergency physicians, contrary to what the IM folks want to believe, are great diagnosticians. Yes it's true, most of our diagnoses are bread and butter stuff (acute MI, acute heart failure exacerbation, PE, abscess etc) . When it comes to some weird esoteric diagnoses we leave those workups to be completed by the IM folks who have more experience with some of the zebras. In addition, we are hands down the experts when it comes to making the life threatening diagnoses which is what mattered the most to me.

One of the major reasons I chose EM was because when I was on IM and we would get a new admission, the majority of the basic workup was already complete. Often times (though not always), the general diagnoses was sort of apparent. Things were set in motion in the ED in terms of treatment, imaging etc. I could essentially read the HPI from the ED resident and had a good "big picture" sense of what was going on. And when the patient truly had a sick diagnosis, the ED packaged them up and brought them back to life prior to sending them to the floor or the ICU. The patient was intubated, the lines were in, pressors were initiated. If they had a simple abscess the ED I&D'd it, they fixed the lac.

This is not in any shape or form to take away any credit from the incredible work that IM docs do everyday. Ultimately I resuscitate and stabilize (usually with a working diagnosis) but the IM docs really initiate a well orchestrated treatment plan that they see out to completion. They do everything in their power to make sure the patient gets better which is no easy feat. They bring tremendous knowledge to the table.

Emergency medicine can be cerebral if you want it to be. As the person above alluded, one option is to pursue a career in academics. While I think EM does not offer much time to be cerebral on shift given the pace, being in academics allows you to mentally masturbate all you want when it comes to research, journal clubs and so forth.

Another option is to consider doing an EM-critical care fellowship which allows you to embrace the "fun, team aspects of EM" while you work in the department but still get continuity of care in the ICU and round extensively with patients and forge potentially closer long term relationships with families and so forth.

On a side note, ruling out bad stuff and determining dispo is HIGHLY underrated. While it may seem sexier to you to tell a patient, "You have Sezary syndrome!" that you diagnosed by looking at a smear, I get to tell a patient, "I did a thorough work-up, I don't think you are having a life threatening illness and I don't think you are going to die. I don't know the exact diagnosis but maybe your primary doctor or the doctors upstairs can help you more with that." You can't underestimate how much patients appreciate that.

 

[Apollyon]

IMO, roughly 80-90% of diagnoses are made in the ED. Emergency physicians, contrary to what the IM folks want to believe, are great diagnosticians. Yes it's true, most of our diagnoses are bread and butter stuff (acute MI, acute heart failure exacerbation, PE, abscess etc) . When it comes to some weird esoteric diagnoses we leave those workups to be completed by the IM folks who have more experience with some of the zebras. In addition, we are hands down the experts when it comes to making the life threatening diagnoses which is what mattered the most to me.

One of the major reasons I chose EM was because when I was on IM and we would get a new admission, the majority of the workup was already complete. Often times (though not always), the general diagnoses was sort of apparent. Things were set in motion in the ED in terms of treatment, imaging etc. I could essentially read the HPI from the ED resident and had a good "big picture" sense of what was going on. And when the patient truly had a sick diagnosis, the ED packaged them up and brought them back to life prior to sending them to the floor or the ICU. The patient was intubated, the lines were in, pressors were initiated. If they had a simple abscess the ED I&D'd it, they fixed the lac.

This is not in any shape or form to take away any credit from the incredible work that IM docs do everyday. Ultimately I resuscitate and stabilize (usually with a working diagnosis) but the IM docs really initiate a well orchestrated treatment plan that they see out to completion. They do everything in their power to make sure the patient gets better which is no easy feat. They bring tremendous knowledge to the table.

Emergency medicine can be cerebral if you want it to be. As the person above alluded, one option is to pursue a career in academics. While I think EM does not offer much time to be cerebral on shift given the pace, being in academics allows you to mentally masturbate all you want when it comes to research, journal clubs and so forth.

Another option is to consider doing an EM-critical care fellowship which allows you to embrace the "fun, team aspects of EM" while you work in the department but still get continuity of care in the ICU and round extensively with patients and forge potentially closer long term relationships with families and so forth.

I was in a new program (second class of residents). In my EM-2 year, the IM PD talked to our PD, asking us to not be SO thorough with our workups, because it was making the IM residents into "note writing machines", without anything about which to think. Of course, bitchy Duke IM residents would still complain, even after we told them that we were directed to give them something intellectual to do.

 

[mw18]

If you really love the differential of the undiagnosed (and also like the stabilization/acuity/emergencies); then do EM.
If you really love the management, particularly complexities involving acute issues in those with chronic conditions; then do IM.

There's crossover, but this is one of the main differences to me.

 

[DO???]

IMO, roughly 80-90% of diagnoses are made in the ED. Emergency physicians, contrary to what the IM folks want to believe, are great diagnosticians. Yes it's true, most of our diagnoses are bread and butter stuff (acute MI, acute heart failure exacerbation, PE, abscess etc) . When it comes to some weird esoteric diagnoses we leave those workups to be completed by the IM folks who have more experience with some of the zebras. In addition, we are hands down the experts when it comes to making the life threatening diagnoses which is what mattered the most to me.

One of the major reasons I chose EM was because when I was on IM and we would get a new admission, the majority of the basic workup was already complete. Often times (though not always), the general diagnoses was sort of apparent. Things were set in motion in the ED in terms of treatment, imaging etc. I could essentially read the HPI from the ED resident and had a good "big picture" sense of what was going on. And when the patient truly had a sick diagnosis, the ED packaged them up and brought them back to life prior to sending them to the floor or the ICU. The patient was intubated, the lines were in, pressors were initiated. If they had a simple abscess the ED I&D'd it, they fixed the lac.

This is not in any shape or form to take away any credit from the incredible work that IM docs do everyday. Ultimately I resuscitate and stabilize (usually with a working diagnosis) but the IM docs really initiate a well orchestrated treatment plan that they see out to completion. They do everything in their power to make sure the patient gets better which is no easy feat. They bring tremendous knowledge to the table.

Emergency medicine can be cerebral if you want it to be. As the person above alluded, one option is to pursue a career in academics. While I think EM does not offer much time to be cerebral on shift given the pace, being in academics allows you to mentally masturbate all you want when it comes to research, journal clubs and so forth.

Another option is to consider doing an EM-critical care fellowship which allows you to embrace the "fun, team aspects of EM" while you work in the department but still get continuity of care in the ICU and round extensively with patients and forge potentially closer long term relationships with families and so forth.

On a side note, ruling out bad stuff and determining dispo is HIGHLY underrated. While it may seem sexier to you to tell a patient, "You have Sezary syndrome!" that you diagnosed by looking at a smear, I get to tell a patient, "I did a thorough work-up, I don't think you are having a life threatening illness and I don't think you are going to die. I don't know the exact diagnosis but maybe your primary doctor or the doctors upstairs can help you more with that." You can't underestimate how much patients appreciate that.

Thank you for this well thought out and thorough response. My wife who is an ER nurse was also suggesting the EM-CC fellowship.

 

[DO???]

I was in a new program (second class of residents). In my EM-2 year, the IM PD talked to our PD, asking us to not be SO thorough with our workups, because it was making the IM residents into "note writing machines", without anything about which to think. Of course, bitchy Duke IM residents would still complain, even after we told them that we were directed to give them something intellectual to do.

Wow, this is pretty interesting to hear. Do you think this is a function of going to Duke or an academic center like the previous posters mentioned? I am at a community hospital and IM complains that the ED did not do enough of the workup. So two completely different experiences for sure.

 

[Apollyon]

Wow, this is pretty interesting to hear. Do you think this is a function of going to Duke or an academic center like the previous posters mentioned? I am at a community hospital and IM complains that the ED did not do enough of the workup. So two completely different experiences for sure.

This was, what, 14 years ago? Growing pains. It's a push/pull, and, sometimes, difficult to find the even ground.

 

[NITRAS]

IMO, roughly 80-90% of diagnoses are made in the ED. Emergency physicians, contrary to what the IM folks want to believe, are great diagnosticians. Yes it's true, most of our diagnoses are bread and butter stuff (acute MI, acute heart failure exacerbation, PE, abscess etc) . When it comes to some weird esoteric diagnoses we leave those workups to be completed by the IM folks who have more experience with some of the zebras. In addition, we are hands down the experts when it comes to making the life threatening diagnoses which is what mattered the most to me.

One of the major reasons I chose EM was because when I was on IM and we would get a new admission, the majority of the basic workup was already complete. Often times (though not always), the general diagnoses was sort of apparent. Things were set in motion in the ED in terms of treatment, imaging etc. I could essentially read the HPI from the ED resident and had a good "big picture" sense of what was going on. And when the patient truly had a sick diagnosis, the ED packaged them up and brought them back to life prior to sending them to the floor or the ICU. The patient was intubated, the lines were in, pressors were initiated. If they had a simple abscess the ED I&D'd it, they fixed the lac.

This is not in any shape or form to take away any credit from the incredible work that IM docs do everyday. Ultimately I resuscitate and stabilize (usually with a working diagnosis) but the IM docs really initiate a well orchestrated treatment plan that they see out to completion. They do everything in their power to make sure the patient gets better which is no easy feat. They bring tremendous knowledge to the table.

Emergency medicine can be cerebral if you want it to be. As the person above alluded, one option is to pursue a career in academics. While I think EM does not offer much time to be cerebral on shift given the pace, being in academics allows you to mentally masturbate all you want when it comes to research, journal clubs and so forth.
t.

My experience with EDs are different. ERs have to move people, stabilize people, start some kind of treatment and justify the admission.

They have their challenges, I have mine. Being “cerebral” isn’t something I’d worry about. 99% of EM isn’t cerebral and probably 97% of IM isn’t either.

 

[Angry Birds]

My experience with EDs are different. ERs have to move people, stabilize people, start some kind of treatment and justify the admission.

They have their challenges, I have mine. Being “cerebral” isn’t something I’d worry about. 99% of EM isn’t cerebral and probably 97% of IM isn’t either.

This is a very IM sort of explanation of—and soft dig at—EM.

 

[deuist]

If you really want cerebral, try radiology or pathology. Those guys have an incredibly limited amount of information to go on.

 

[emergentmd]

Third-year med student still a bit torn between EM vs IM.

The first month of IM I loved it. I was getting to use my knowledge of pathophysiology to build differentials and I especially loved the cerebral aspect of it. The second month was much more difficult. I did not like rounding and writing the same things over and over in the notes every day. My tolerance could have been lower because I was pretty drained.

Did a month in the ED and loved the pace and team atmosphere, the mixture of acuity and procedures. I fit in well with the team. It felt like I found my people. Time flew, and the month was fantastic. I was always looking forward to my next shift. The big problem that keeps nagging me is that I did not feel the cerebral aspect that I did on IM. Is it because I am a third year and do not know as much? I definitely don't want to sit and mull over the minutia, but I'd like to be able to work the patients up as much as possible/necessary before shipping them upstairs. I do like to know what is causing a thrombocytopenia for example. Another example, for me, if I see a pt with metabolic alkalosis I would want to order a urinary chloride to see what is the cause.

EM folks: What are your thoughts on this? Is there a place in the ED for people like myself and want to work up different things or am I internal medicine and just do not know it yet?

Thank you very much in advance for any wisdom you provide.
Warm Regards

Edit: when working in the ED I felt like I was really helping people, I felt like this was the reason I came back to medical school. However, at the end of the ED rotation, I felt like I just ruling out the major stuff and then figuring out the dispo.

If you think EM is not cerebral, then you have another thing coming to you as a hospitalists. This is my typical conversation with my hospitalist

Me - I have a CP rule out for you
IM - Did you page cardiology?

Me - I have a GI bleed, stable
IM - Can you call GI

Me - Got a sick hypotensive pt here, septic
IM - Admit ICU and call CCU doc

Me - got a ....... pt here
IM - Did you call xxxxx?

 

[emergentmd]

Wow, this is pretty interesting to hear. Do you think this is a function of going to Duke or an academic center like the previous posters mentioned? I am at a community hospital and IM complains that the ED did not do enough of the workup. So two completely different experiences for sure.

IM likes the diagnosis on a silver platter. I have never met an IM doc that I did too much. It is more like, can you call me back when the UA comes back when the pt complains of CP.

 

[DO???]

If you think EM is not cerebral, then you have another thing coming to you as a hospitalists. This is my typical conversation with my hospitalist

Me - I have a CP rule out for you
IM - Did you page cardiology?

Me - I have a GI bleed, stable
IM - Can you call GI

Me - Got a sick hypotensive pt here, septic
IM - Admit ICU and call CCU doc

Me - got a ....... pt here
IM - Did you call xxxxx?

this is exactly what I do not want. If I had this experience, EM would be a slam dunk. I loved almost every aspect of EM. I worked in a smaller community hospital where most of the workup was done by the IM doctor and only when he got stuck did we consult which was not often. I did two months of IM, during the second month I had a doc who did this and I was miserable. I am really torn between the two. Union of the two fields would be the ideal fit for me. I certainly appreciate your insight.

 

[DO???]

IM likes the diagnosis on a silver platter. I have never met an IM doc that I did too much. It is more like, can you call me back when the UA comes back when the pt complains of CP.

ha, I am the opposite and I would just want the complaint and I would prefer to do the work up.

 

[emergentmd]

this is exactly what I do not want. If I had this experience, EM would be a slam dunk. I loved almost every aspect of EM. I worked in a smaller community hospital where most of the workup was done by the IM doctor and only when he got stuck did we consult which was not often. I did two months of IM, during the second month I had a doc who did this and I was miserable. I am really torn between the two. Union of the two fields would be the ideal fit for me. I certainly appreciate your insight.

If you want to work in a mid sized or decent sized city, IM would not be for you. If you want to work in a small rural or under-served area, then you can work up as much as you please.

But in a hospital with many specialist, you will be the unicorn doing evaluations before consulting. And you never want to be a unicorn.

 

[NITRAS]

This thread is hilarious.

As a hospitalist, you can consult or not consult based on your comfort level and availability of consults. As the primary, you ultimately have the decision. Different hospital systems work different. Where I trained, I the ED mosly called the appropriate consultant. Where I currently work, the ED only makes emergent calls, or if they might (but usually don't) be primary.

Do you like following patients for more than a few hours? Procedures? Thoughts of specialization into a medical specialty? These will probably help you more than if you like to be "cerebral" about stuff. Everything becomes pretty routine after a while, no matter what you do.

Sorry for the "dig" @Angry Birds , but if EM docs did complete workups on everyone, they would plug of their ER's. Patients ultimately need to have only the basic workup to stabilize them before they should be triage to outpatient workup or to justify the admission. Also realize the medical ward is a lower level of care than the ED.

 

[Redpancreas]

In terms of EM, no one is really stopping you for learning and applying more. EM physicians are really active when it comes to Free Online Access Medical Education (FOAM).

 

[LebronManning]

I think ultimately it comes down to whether you want to diagnose or treat. Sure, EM docs "treat" some patients and send them home but these patients should have been in a PCP office anyway. Yes, hospitalists are frequently given the initial diagnosis on a silver platter but the treatment as you know can be much more complex. Also, I don't think many hospitalists miss out on the diagnosis part because any diagnosis made in the ED is likely a fairly obvious one based on imaging and labs alone. Fun and interesting diagnoses are going to happen upstairs.

EM is a great field if you have the personality for fast paced work and are ok with "moving the meat." I find that ED docs tend to be very passionate about the social implications of our healthcare system as they are on the front lines of it. They get to do procedures and awesome resuscitations. The trade off is less cerebral of a specialty.

If you want more cerebral work I certainly think you should go down the IM route. Day in and day out, your most straightforward patients will be among the sicker patients that the ED doc sees. Based on what you're already saying, it sounds like you're going to miss the opportunity of following up on interesting patients and love the pathophysiology of how the disease develops. Imagine not having the opportunity to look up causes of thrombocytopenia in the patient you worked up. Instead you have to go see back pain in room 6 or maybe an MVC in trauma 1. Will you be OK with that? Are you OK with writing metabolic alkalosis in the impression and then being done with the patient or do you feel like the work starts after that?

I think you should consider IM-> critical care (2 years).