Anyone here deciding between EM and Pulm/Crit? What's your pros/cons list so far?

[Doctor_Strange]

M3 here -- have liked my experience so far in both specialties. I'm interested in hearing the thought process or pros/cons of why one would pursue EM versus Pulm/Crit!

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[AnatomyGrey12]

Well one is heavy ICU medicine based, and the other is essentially acute triage.

 

[Dr. Anonymouss]

Don't do emergency medicine. Acute triage is an understatement... 90% of the patients that come into the ED don't need to be there. Some of these patients make you roll your eyes (cough, sore throat, flu-like symptoms, head ache) because they should be going to primary care, and then the other patients that come in with issues that could be deemed serious (chest pain, shortness of breath, abdominal pain) cause you to downplay possible future emergencies due to the fact 95% of these patients either have chronic issues, which are outside the scope of the ED, or they don't have a problem at all. This field could be enjoyable to some, but it is truly all about perspective. I have a hard time overcoming my predisposition to believe the emergency department is utilized for EMERGENCIES and thus it has became a nightmare for me to work here. Luckily I am only an ED tech so the possibility for happiness in my future is still achievable. If you are okay with 95% of your patients being either the poor or elderly who abuse the emergency department because it is funded by taxpayer dollars for them then becoming an Emergency Physician may not be a bad career as the pay and lifestyle are great, but having that mindset is tough for some and impossible for me which is why I am getting out and never looking back.

 

[sab3156]

Don't do emergency medicine. Acute triage is an understatement... 90% of the patients that come into the ED don't need to be there. Some of these patients make you roll your eyes (cough, sore throat, flu-like symptoms, head ache) and then the other patients that come in with issues that could be deemed serious (chest pain, shortness of breath, abdominal pain) cause you to downplay possible future emergencies due to the fact 95% of these patients either have chronic issues which are outside the scope of the ED or they don't have a problem at all. This field could be enjoyable to some, but it is truly all about perspective. I have a hard time overcoming my predisposition to believe the emergency department is utilized for EMERGENCIES and thus it has became a nightmare for me to work here. Luckily I am only an ED tech so the possibility for happiness in my future is still achievable. If you are okay with 95% of your patients being either the poor or elderly who abuse the emergency department because it is funded by taxpayer dollars for them then becoming an Emergency Physician may not be a bad career as the pay and lifestyle are great, but having that mindset is tough for some and impossible for me which is why I am getting out and never looking back.

You should have a bit more mercy on people who cannot afford healthcare. Some of these people have no choice but to "abuse" the emergency department. It's the only hope for some of the poor and elderly who have slipped through the cracks and were left behind by society. One of my friends who is an EM physician in Baltimore says he takes great pride in being the primary care doctor for an entire population of people who are desperate and cannot afford traditional medical care. He often bends the rules a bit to get people the care they need even if its not his duty. He's a hero for those people.

Since you feel the way you do, I hope you will be lobbying for socialized healthcare in the future when you become a physician.

 

[Dr. Anonymouss]

You should have a bit more mercy on people who cannot afford healthcare. Some of these people have no choice but to "abuse" the emergency department. It's the only hope for some of the poor and elderly who have slipped through the cracks and were left behind by society. One of my friends who is an EM physician in Baltimore says he takes great pride in being the primary care doctor for an entire population of people who are desperate and cannot afford traditional medical care. He often bends the rules a bit to get people the care they need even if its not his duty. He's a hero for those people.

Since you feel the way you do, I hope you will be lobbying for socialized healthcare in the future when you become a physician.

I wouldn't say I am being merciless, I would say I am being honest based on my subjective experiences. I want everyone to be able to receive healthcare, but our emergency departments in the U.S. are being abused when primary care is most definitely available. It is being abused because one can be seen in a matter of hours rather than days when there are no financial repercussions to these actions; patience really is a virtue that is lacking in our society. The middle class do not have this same luxury when an emergency department bill can be crippling compared to a primary care bill. As I said earlier, what it boils down to is perspective... If one accepts the fact that the emergency department isn't utilized primarily for emergencies, but rather quick medical attention for the poor and elderly, than this career could be luxurious and prosperous for those who are interested. I merely want those who are interested to understand the realities behind emergency medicine and this broken system.

 

[InternistDO]

I'd try and decide if you like internal medicine vs emergency medicine before diving into pulmcrit. Do you like rounding? Do you like longer term relationships with patients and having closure when it comes to diagnoses or do you like short term acute issues? Do you care about being trained to see kids?

IM gives you far more career flexibility--you can do primary care or hospitalist medicine right out of the gate, or any of the zillion subspecialties. EM you can mostly just do EM or urgent care, but that will pay more than unspecialized IM (for now, anyway).

Don't forget you can do crit care (but not pulm) from EM too--though I think the advantage of pulm is you have a different specialty to break up the ICU shifts with more relaxing outpatient work and consults.

As for primary care in the ED, yes, you will have lots of patients who should have gone to their PCP but won't or can't (usually can't, yay American healthcare). Personally I like primary care, but doing it in the ED is frustrating because you can only do ****ty primary care in the emergency department. You have no follow up and no patient relationships. Sure, you can start a hypertensive patient on an ACE inhibitor, but all you're doing is passing the buck until an actual PCP can see them, titrate meds, etc. So I totally understand the frustration people talk about when it comes to "inappropriate" ED use--it's very hard to give subpar care every day. Not subpar because ED doctors are stupid, just subpar because you can't really do primary care in an ER and everyone (except the patient) knows it.


Personally I chose IM, despite my username. I didn't like the transient nature of EM patients, I wanted to see what the final diagnosis was and I hated when the MICU or the medicine service came and swept the patient away. I also wanted the flexibility to do a variety of things when I came out of residency. I will miss being able to see kids though.

 

[Doctor_Strange]

Well one is heavy ICU medicine based, and the other is essentially acute triage.

Yeah, I mean like both of it to be honest. I guess my anxiety is trying to figure out which specialty may cause the most burnout. Seems in EM most of it is due to certain patients, and in the ICU it is from patient outcomes.

 

[InternistDO]

Yeah, I mean like both of it to be honest. I guess my anxiety is trying to figure out which specialty may cause the most burnout. Seems in EM most of it is due to certain patients, and in the ICU it is from patient outcomes.

People get burned out on different things--I have friends who'd get burned out doing primary care 4 days a week who'd gladly spend all week in the ICU surrounded by dying patients (and vise versa). I realize that's not very helpful, but maybe it would help to try and think of what you'd like your career to look like in the future. Would you be ok with working night shifts (ICU often does overnights at bigger places, but pulm doesn't, and on EM it's a guarantee)? Is it important that you're an expert in your specific field or a generalist?

Which do you think would be more frustrating? Never getting to see the final outcome of your patients, or coming in to work and having to see the same patients as yesterday AGAIN? What about babysitting patients who don't really need medical care anymore (whether because they should be allowed to die or because they're waiting on a nursing home placement), vs dealing with endless minor complaints in the ED?

What if you don't match pulm/cc? Would you be ok with being a hospitalist or a primary care doctor?

 

[Lexdiamondz]

I'd try and decide if you like internal medicine vs emergency medicine before diving into pulmcrit. Do you like rounding? Do you like longer term relationships with patients and having closure when it comes to diagnoses or do you like short term acute issues? Do you care about being trained to see kids?

IM gives you far more career flexibility--you can do primary care or hospitalist medicine right out of the gate, or any of the zillion subspecialties. EM you can mostly just do EM or urgent care, but that will pay more than unspecialized IM (for now, anyway).

Don't forget you can do crit care (but not pulm) from EM too--though I think the advantage of pulm is you have a different specialty to break up the ICU shifts with more relaxing outpatient work and consults.

As for primary care in the ED, yes, you will have lots of patients who should have gone to their PCP but won't or can't (usually can't, yay American healthcare). Personally I like primary care, but doing it in the ED is frustrating because you can only do ****ty primary care in the emergency department. You have no follow up and no patient relationships. Sure, you can start a hypertensive patient on an ACE inhibitor, but all you're doing is passing the buck until an actual PCP can see them, titrate meds, etc. So I totally understand the frustration people talk about when it comes to "inappropriate" ED use--it's very hard to give subpar care every day. Not subpar because ED doctors are stupid, just subpar because you can't really do primary care in an ER and everyone (except the patient) knows it.


Personally I chose IM, despite my username. I didn't like the transient nature of EM patients, I wanted to see what the final diagnosis was and I hated when the MICU or the medicine service came and swept the patient away. I also wanted the flexibility to do a variety of things when I came out of residency. I will miss being able to see kids though.

I think this is where the biggest difference in EM vs IM minided people lies. I LOVE dispo-ing a patient. While I never hand off a resuscitation, once the pt has been stabilised by all means, get them the f*ck outta here.

 

[Lexdiamondz]

Well one is heavy ICU medicine based, and the other is essentially acute triage.

This is a fairly gross oversimplification of both specialties.

 

[AnatomyGrey12]

This is a fairly gross oversimplification of both specialties.

Simplification? Sure. Gross oversimplification? Not really.

 

[Doctor_Strange]

People get burned out on different things--I have friends who'd get burned out doing primary care 4 days a week who'd gladly spend all week in the ICU surrounded by dying patients (and vise versa). I realize that's not very helpful, but maybe it would help to try and think of what you'd like your career to look like in the future. Would you be ok with working night shifts (ICU often does overnights at bigger places, but pulm doesn't, and on EM it's a guarantee)? Is it important that you're an expert in your specific field or a generalist?

Which do you think would be more frustrating? Never getting to see the final outcome of your patients, or coming in to work and having to see the same patients as yesterday AGAIN? What about babysitting patients who don't really need medical care anymore (whether because they should be allowed to die or because they're waiting on a nursing home placement), vs dealing with endless minor complaints in the ED?

What if you don't match pulm/cc? Would you be ok with being a hospitalist or a primary care doctor?

Yeah, I'll definitely mull these questions over -- some of which I have been asking myself for the last few months.

 

[Lexdiamondz]

Simplification? Sure. Gross oversimplification? Not really.

I'm sure this is coming from your extensive experience in ICU and Emergency medicine, undoubtedly.

 

[AlteredScale]

Longitudinal care seems to be a big thing for anything in medicine. In EM it's def been more of "move the meat" kind of deal, no matter what that means (admit, discharge, transfer, etc). In medicine, you get to see your patients for days to weeks to months. The social aspects of medicine also seem to be pretty prominent (ie discharge planning).

 

[InternistDO]

Yeah, I'll definitely mull these questions over -- some of which I have been asking myself for the last few months.

If it helps, I realized I didn't like EM in the middle of my EM subi in July of 4th year (having set up several EM aways at that point), so you're not alone. Maybe some extra rotations would help you decide--EM is often fun for med students cause you finally get to be useful and do minor procedures, so sometimes it takes a second rotation to carve out your true feelings--or at least that's how it was for me.

I'd also set up EM aways preferentially if you're considering it since they're much more important--IM aways are pretty useless.

 

[Radetzky]

The two are entirely different. In CC I get interested in tracking the sodium, fiddling with ventilators and having goals of care discussions, which ED people mostly don’t care about.

Similarly an ED resident enjoys seeing a breadth of undifferentiated patients and having to pick out the sick patients from them, which I don’t particularly care for.

You have to make a decision based on the bread and butter of each specialty rather than the coolest part. For CCM that’s sepsis, sepsis, sepsis, pneumonia, pneumonia, pneumonia. For ED it’s bronchiolitis, bronchiolitis, elderly fall, elderly fall, drunk, drunk, vague chest pain.

 

[AnatomyGrey12]

I'm sure this is coming from your extensive experience in ICU and Emergency medicine, undoubtedly.

Or you could actually point out what is wrong with those simplifications.

 

[Postictal Raiden]

OP, seems that you’re all over the place with specialty choices. I see your posts on the neuro, EM, gas and now also IM(pulm/crit). Nothing wrong with that but my advice is to narrow your choice to 2 specialties, explore them deeply and then have your choice made by beginning of 4th year to allow yourself time to audition and cater your application for the specialty.

best wishes

 

[Lexdiamondz]

Or you could actually point out what is wrong with those simplifications.

ICU medicine is much more than just thought-provoking critically ill patients, much as EM is much more than simply triage and stabilisation. Much of your time in the unit will be dealing with complex goals of care discussions with families of patients that should be hospice, providing fruitless care for moribund patients because you can't find next of kin who are willing or able to make sound medical decisions or withdraw care, and monitoring patients who are by no means critically ill but need close nursing monitoring so they now become your problem.

I'm the MICU senior at my institution right now and out of our current census of 12 patients, 4-5 of them truly don't belong in an ICU. We have one patient who is here for "airway monitoring" who is literally eating a bag of chips and watching football in front of me.

You shouldn't go into Pulm/CCM because you're looking for sick patients. Absolutely there are plenty of them here - the MICU has some of the sickest patients in any institution and some of the most complex patients you can find in medicine. But among those patients are plenty of 97 year old "gomers" who should be in hospice, plenty of trach patients who should have been palliatively extubated and are instead condemned to a life of multiple VAPs, MDROs, Urosepsis and bed sores, and noncompliant patients who wake up, pull out their lines and AMA to go smoke crack. Just as how you need to be able to tolerate the bull**** in the ED - the drunks, druggies, violent psychotics and the ever-present Karen-I-Wanna-Speak-To-The-Manager you need to be okay with this bull**** as well.

 

[InternistDO]

Yeah if you don't have a reasonable appreciation and at least take some satisfaction from hospice/palliative care/goals of care stuff then the ICU is not for you.

 

[AnatomyGrey12]

ICU medicine is much more than just thought-provoking critically ill patients, much as EM is much more than simply triage and stabilisation. Much of your time in the unit will be dealing with complex goals of care discussions with families of patients that should be hospice, providing fruitless care for moribund patients because you can't find next of kin who are willing or able to make sound medical decisions or withdraw care, and monitoring patients who are by no means critically ill but need close nursing monitoring so they now become your problem.

I'm the MICU senior at my institution right now and out of our current census of 12 patients, 4-5 of them truly don't belong in an ICU. We have one patient who is here for "airway monitoring" who is literally eating a bag of chips and watching football in front of me.

You shouldn't go into Pulm/CCM because you're looking for sick patients. Absolutely there are plenty of them here - the MICU has some of the sickest patients in any institution and some of the most complex patients you can find in medicine. But among those patients are plenty of 97 year old "gomers" who should be in hospice, plenty of trach patients who should have been palliatively extubated and are instead condemned to a life of multiple VAPs, MDROs, Urosepsis and bed sores, and noncompliant patients who wake up, pull out their lines and AMA to go smoke crack. Just as how you need to be able to tolerate the bull**** in the ED - the drunks, druggies, violent psychotics and the ever-present Karen-I-Wanna-Speak-To-The-Manager you need to be okay with this bull**** as well.

This is a great in depth summation. I don’t understand, however, your issue with the simplifications I gave. Boiled down to the nuts and bolts EM is acute triage, and CCM/Pulm is ICU Medicine.... which are highlighted in your post.

Personally I think they are more fundamentally different than one might think, and OP needs to really decide where they want their career to go.

 

[Doctor_Strange]

If it helps, I realized I didn't like EM in the middle of my EM subi in July of 4th year (having set up several EM aways at that point), so you're not alone. Maybe some extra rotations would help you decide--EM is often fun for med students cause you finally get to be useful and do minor procedures, so sometimes it takes a second rotation to carve out your true feelings--or at least that's how it was for me.

I'd also set up EM aways preferentially if you're considering it since they're much more important--IM aways are pretty useless.

Really appreciate the advice. Agreed -- my 4th years are telling me to set up auditions around EM and if I end up not liking it can more easily find a sub-I for IM.

 

[Doctor_Strange]

OP, seems that you’re all over the place with specialty choices. I see your posts on the neuro, EM, gas and now also IM(pulm/crit). Nothing wrong with that but my advice is to narrow your choice to 2 specialties, explore them deeply and then have your choice made by beginning of 4th year to allow yourself time to audition and cater your application for the specialty.

best wishes

Guilty as charged! Part of it is some of my rotations are really subpar, so unfortunately I am relying on other avenues for an accurate picture. Even many 4th years are not too helpful in regards to advice etc. SDN remains a good outlet in this respect. But yeah, I may just be getting cold feet since VSAS is soon to open. Frankly, another thing is I have classmates you are so passionate about the field they are going into, and I just have not had that "a-ha" moment yet and I am looking for anything at this point lol

 

[zero0]

You should have a bit more mercy on people who cannot afford healthcare. Some of these people have no choice but to "abuse" the emergency department. It's the only hope for some of the poor and elderly who have slipped through the cracks and were left behind by society. One of my friends who is an EM physician in Baltimore says he takes great pride in being the primary care doctor for an entire population of people who are desperate and cannot afford traditional medical care. He often bends the rules a bit to get people the care they need even if its not his duty. He's a hero for those people.

Since you feel the way you do, I hope you will be lobbying for socialized healthcare in the future when you become a physician.

That's nice of him and all but those people are costing taxpayers thousands of dollars to be treated for a cold when they should be going to the free clinic like everyone else. It's very hard to be sympathetic to these selfish human parasites who make hard-working people pay for their healthcare. Unfortunately, EMTALA makes it all too easy for them to get away with it and American EDs see no problem with it. Rather they encourage this behavior for a profit and drive up healthcare costs. The current ED model is the biggest fiscal black hole in modern medicine, even worse than the cancer that is growing administrative costs.

On a related note, some of the most burned out and cynical doctors I have ever met worked in the ED. I can see why too. Being surrounded by this crap every day is enough to make you want to pull your hair out.

Please let's not start on socialized medicine. ED medicine basically is socialized medicine 90% of the time and look how great that's working.

 

[InternistDO]

That's nice of him and all but those people are costing taxpayers thousands of dollars to be treated for a cold when they should be going to the free clinic like everyone else. It's very hard to be sympathetic to these selfish human parasites who make hard-working people pay for their healthcare. Unfortunately, EMTALA makes it all too easy for them to get away with it and American EDs see no problem with it. Rather they encourage this behavior for a profit and drive up healthcare costs. The current ED model is the biggest fiscal black hole in modern medicine, even worse than the cancer that is growing administrative costs.

On a related note, some of the most burned out and cynical doctors I have ever met worked in the ED. I can see why too. Being surrounded by this crap every day is enough to make you want to pull your hair out.

Please let's not start on socialized medicine. ED medicine basically is socialized medicine 90% of the time and look how great that's working.

The best part of every SDN thread is the moment when someone decides to take a charged political stance in response to a question that has nothing to do with politics

 

[Dr. Anonymouss]

That's nice of him and all but those people are costing taxpayers thousands of dollars to be treated for a cold when they should be going to the free clinic like everyone else. It's very hard to be sympathetic to these selfish human parasites who make hard-working people pay for their healthcare. Unfortunately, EMTALA makes it all too easy for them to get away with it and American EDs see no problem with it. Rather they encourage this behavior for a profit and drive up healthcare costs. The current ED model is the biggest fiscal black hole in modern medicine, even worse than the cancer that is growing administrative costs.

On a related note, some of the most burned out and cynical doctors I have ever met worked in the ED. I can see why too. Being surrounded by this crap every day is enough to make you want to pull your hair out.

Please let's not start on socialized medicine. ED medicine basically is socialized medicine 90% of the time and look how great that's working.

EMTALA is ridiculous and it's the reason emergency departments are abused the way they are. But the real question that we need to be asking ourselves is: How do we incentivize the use of primary care and decentivize the use of emergency care? The way the current system is set up there are no financial or legal repercussions to continuous emergency department visits. It allows for tremendous amounts of tax payers dollars to be wasted without any true benefit. The emergency department isn't equipped to care for patients long term so we need to stop acting like we are doing a service to these patients because we aren't.

 

[Lexdiamondz]

EMTALA is ridiculous and it's the reason emergency departments are abused the way they are. But the real question that we need to be asking ourselves is: How do we incentivize the use of primary care and decentivize the use of emergency care? The way the current system is set up there are no financial or legal repercussions to continuous emergency department visits. It allows for tremendous amounts of tax payers dollars to be wasted without any true benefit. The emergency department isn't equipped to care for patients long term so we need to stop acting like we are doing a service to these patients because we aren't.

Not quite true.

There are huge financial repercussions for abuse of the ED if you are a middle class, insured individual. Those people pay huge copays for utilisation of the ED.

The self-pays, medicaid, medicare pts - they have no real repercussions so good luck getting them to wait for their PCP.

 

[Dr. Anonymouss]

Not quite true.

There are huge financial repercussions for abuse of the ED if you are a middle class, insured individual. Those people pay huge copays for utilisation of the ED.

The self-pays, medicaid, medicare pts - they have no real repercussions so good luck getting them to wait for their PCP.

I was referring to those who abuse the emergency department with taxpayer funds i.e the poor and the elderly. This is why we need to find a way to incenticize the use of primary care and decentivize the use of emergency care.

 

[EMikate]

I didn't read this thread in detail, so I am sure someone already brought this up....but you know critical care can be a fellowship from EM right? That way you can go with EM (which is clearly the best specialty in my opinion lol) and if you don't want to stay in it, do a CC fellowship. Very common. If I was trying to decide between the two that is what I would do because that way you don't have to choose just one. Best of luck!