Considering switching specialties

[EM1Advice]

I'm currently an intern at an EM residency (inner city, high volume). I'm having serious thoughts about switching specialties. I'm not sure I fully understood what EM would be like through my medical school rotations. The things that I feel are a poor fit for me are the fast pace and acuity. I know, it would seem this would be an obvious component to emergency medicine, but I think I underestimated those things as a med student. I remember thinking to myself that although the volumes are high and acuity is high, the main goal was just to stabilize the patients and get them to their disposition where all the real work was going to be done (ICU, OR, etc). But now, the thought of being presented with a difficult airway or a code is terrifying. I'm at a program where the expectations for interns are generally low, and there is a huge jump up in the second year (like most programs). I have been struggling with severe insomnia as a result of anxiety over this: being the 2nd year, working in the resuscitation rooms, having to carry all those patients at once with my attention constantly being shifted from one thing to the end. There are so many times where I cannot fathom seeing more than 1 new patient per hour, things just seem to chaotic. Not to mention dealing with angry patients, malingerers, difficult nursing staff..

I know that I'm still just an intern and there is still a lot of time to learn all the skills required to deal with a crashing patient. However, I have also been thinking of switching to psychiatry, the other specialty I had serious consideration for during med school. The other option would be to stick it out, survive residency, and look for a job in EM that would involve lower acuity. In my mind, the only position that almost never deals with those unstable patients would be Urgent Care.

My questions for you guys: Has anyone else felt this way and decided to complete residency? Or does it sound like this is not the right field for me? What are the options for lower stress positions after graduation other than Urgent Care? I would be willing to take a significant pay cut to have a more manageable workload.

Thank you to all of you who took the time to read this.

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[WilcoWorld]

It sounds to me like you are having a normal reaction to the gravity of work in the ED. If you did not feel this way I'd suspect that either a) your program wasn't busy enough to train you well OR b) you weren't taking things seriously enough.

I felt the way you describe several times throughout my PGY 1 and 2 years. I now work in a busy high acuity ED and handle it well (at least I think I do).

 

[Tenk]

Intern year always casts some doubts.

I like to tell my interns that when you start you should really only handle 1-2 patients at a time but handle them well, really well. Then go 2-3, then 3-4. By the end of your intern year/start of your pgy-2 year, you should be able to handle 3-4 patients at a time. The trick is to not stop there, anytime you feel comfortable, pick up another patient. Feel uncomfortable. This will make you stronger.

In terms of procedures, until you do a lot of them you will feel uncomfortable. I still remember my first chest tube, first code, first intubation, etc. All that fades with time.

Just stay positive and always remember: for many people visiting the ER this may be the worst day of their life. For you it is just another day in the grind. Just try to do your best so you can hopefully help another poor soul out when they need it most.

 

[Arcan57]

Training isn't supposed to be comfortable. It's a (somewhat) gradual accumulation of pain until you've developed a tolerance that allows you to be functional in the environment in which you'll practice. Every specialty has hard decisions that need making (even psychiatry) and depending on personality those decisions will weigh more or less heavily on you than on your peers. The ED certainly makes you confront the results of your decisions more quickly than some environments. Once the scales fall from your eyes you need to decide if you can go forward. If you make the decision to stick it out you'll be a successful EP.

 

[Old_Mil]

Before you make the change from EM to psychiatry, consider this: the patients and problems who make life in the ED draining will be your bread and butter, every day, for the rest of your life...you will be the guy you turf them to now...

...you have two real questions to ask yourself: medicine or psych? Once that is answered, so you want to stay in a medical field that handles multiple patients at once with some of them being high acuity? Or do you want to be an internist or specialist or out of hospital medicine altogether?

 

[EM1Advice]

Training isn't supposed to be comfortable. It's a (somewhat) gradual accumulation of pain until you've developed a tolerance that allows you to be functional in the environment in which you'll practice. Every specialty has hard decisions that need making (even psychiatry) and depending on personality those decisions will weigh more or less heavily on you than on your peers. The ED certainly makes you confront the results of your decisions more quickly than some environments. Once the scales fall from your eyes you need to decide if you can go forward. If you make the decision to stick it out you'll be a successful EP.

Not familiar with this expression, can you explain?

Thanks for all the replies. I am getting mostly encouragement and reassurance from people I talk to in person as well. I've also been working on mental tools to deal with stress. Does anyone have any suggestions for moments when things seem too overwhelming? For example, I've been trying to imagine myself in the department and trying to recreate the environment mentally to try to better be prepared for when things are tough. One of my biggest issues is getting easily distracted. I sometimes can't seem to focus on my own work when there is another case being presented right next to me or there are multiple conversations happening at the same time.

 

[shoal]

Not familiar with this expression, can you explain?

Thanks for all the replies. I am getting mostly encouragement and reassurance from people I talk to in person as well. I've also been working on mental tools to deal with stress. Does anyone have any suggestions for moments when things seem too overwhelming? For example, I've been trying to imagine myself in the department and trying to recreate the environment mentally to try to better be prepared for when things are tough. One of my biggest issues is getting easily distracted. I sometimes can't seem to focus on my own work when there is another case being presented right next to me or there are multiple conversations happening at the same time.

Very normal to get distracted, having that third ear out to learn from colleagues, understand the dynamics of the department at a specific time is very important. This part will come during 3rd year. Lots of good advice so far.

Sent from my VS986 using Tapatalk

 

[Doctor4Life1769]

If the conversation does not involve you or your patient, let it go.
If the patient does not involve you, let it go.
Focus on your patients. You have a light load as an intern, as suggested by someone else, focus on doing a good job managing them.
There will be time as you progress when you will be able to focus on several things, including an incoming patient that you'll likely have to take care of.

It seems you have supportive faculty and upper levels. Use them to your advantage. You work with an attending constantly so that is helpful.

 

[Druggernaut]

I'm an intern too, and I went into EM with about as good an understanding of what I was getting myself into as any medical student could. I've definitely often dreaded the first day back after a few off, and wondered if I should've chosen a different specialty a few times this year. Every other intern in my class that I've talked to about it has said the same thing. One, who had been a paramedic for years prior to medical school, said he would actually frequently feel physically ill before a shift. You're not alone, and I wouldn't make a knee jerk reaction just yet. My program also schedules all residents into all areas of our ED, does not limit the patient acuity by year, and pretty much requires that we see more than one patient per hour, so you can survive that too. I still see our second year residents, who have started to transition into the extra "senior" roles like taking EMS medical direction calls, and am terrified, but I'm sure I'll make it through that too. Then we had a recent talk by some graduates of the program talking about community practice and practicing without all the in-house backup of ortho, ophthalmology, and the like, and it seemed overwhelming too. But that's why we do residency.

There are certainly less busy and lower acuity places compared to the typical residency environment that you can choose to work in as an attending. You just have to hang in there and deal with it for the next few years so that the most terrifying patient encounters happen now while you still have someone looking over your shoulder.

Maybe you did choose the wrong specialty, but these things don't sound unusual enough to make me think that's necessarily the case.

 

[gman33]

Common thoughts during intern year.
If you feel overwhelmed, you are at a good training program.

I had similar feelings and I'm very glad I didn't switch.

Get feedback for your upper years and attendings.
Having some role models will help you out.

The more patients you see and the more procedures you attempt, the better off you will be.

Failure is part of learning. Just make sure you learn from your mistakes.

All that being said, em isn't for everyone.

 

[Arcan57]

Not familiar with this expression, can you explain?

Thanks for all the replies. I am getting mostly encouragement and reassurance from people I talk to in person as well. I've also been working on mental tools to deal with stress. Does anyone have any suggestions for moments when things seem too overwhelming? For example, I've been trying to imagine myself in the department and trying to recreate the environment mentally to try to better be prepared for when things are tough. One of my biggest issues is getting easily distracted. I sometimes can't seem to focus on my own work when there is another case being presented right next to me or there are multiple conversations happening at the same time.

Biblical reference, Saul regaining his sight after baptism. In this case referring to understanding the reality of the what it is we do and our initial unsuitability for the task we have assigned ourselves.

 

[goodoldalky]

To be honest these thoughts sound pretty normal. You are currently an incompetent intern. Just like we all were. You will come to find that in some ways the sickest patients are the easiest, there's no way you can hurt a patient who is already dead, and ACLS is just an algorithm. Beyond that the variety of jobs in EM are as varied as anyone could desire. My .02 stick it out.

 

[da8s0859q]

EM third year in a three-year program, contract signed for that first attending job out in 4.5 months.

Agree with "it's normal, it's common, stick it out" sentiment in multiple posts above. Normal and common is exactly what it is. Was there too. Still occasionally "wonder" as many of us do. There are bad days in any specialty.

The better we are at things, the more we enjoy them.

 

[Daiphon]

All the above advice, on both sides of the coin, is golden & spot on.

In many ways it gets better, in some harder... but this happens in all specialties & be wary of "grass is greener" syndrome.

I really resonated with the idea of feeling uncomfortable; unless the department is dead, you should never feel truly relaxed before the end of your shift. Pushing boundaries is how you learn & develop those practice patterns & algorithms on which you can fall back when the **** hits the fan and you need to buy some time to think.

Have you a trusted mentor/physician from med school with whom you can talk through these thoughts, without your program getting wind of it? Sounds like you need to hash things out, but I'd caution against doing anything that could cast you in a negative light with your PD...

Good luck.
-d

Semper Brunneis Pallium

 

[BklynWill]

Is it possible you have something going on in your life outside internship that is feeding into your anxiety? Yes, it is normal to feel overwhelmed in the ED. I often feel it as an attending but you have to trust in your ability to develop the tools necessary to help you focus on the most important issues of your patients. Stick with it and believe that, in time, this skill will come to you. Referring to my original question, if you unconsciously bring issues of your personal life into the shift with you then it becomes much more difficult to focus on your patients and can add to the feeling that things are getting out of control in the ED.

 

[gamerEMdoc]

One of the things that attracted me to EM was watching how cool EM docs were in critical situations. Go to the cath lab sometime and see what happens when a code occurs there. Its a goddamn disaster. Or god forbid when a code occurs on the L+D floor. We are the masters at dealing with complete disasters and dealing with it without losing our mind. Noone expects you to be able to deal with this as a PGY1. If you could, they'd pay you 400K/year and wouldn't make you do 3 years of residency. Understand that. Residency is 3-4 years for a reason. I went into EM because I wanted to be that guy. I was scared of crazy sick patients as a student, and I didn't want to be scared of anything. I wanted to be the doc that people looked too when all else was melting down; I wasn't that as a medical student, and I knew that doing EM would get me there.

So if you're scared of those patients now, great. Remember that in two years, if you stick it out, you won't be. And people will look up to you because of it. And then you can sit a scared PGY1 down who will look up to you as the fearless attending, and tell them exactly what I'm telling you now.

 

[gman33]

Rich Levitan is one of the true masters of airway management.
He has said that his interest grew out of fear.

Constantly try to learn about your weak points and you will be fine.

 

[Angry Birds]

I think your concerns are normal, as others have stated.

However, the question is: has your PD or other faculty singled you out as much weaker than your colleagues? If so, then in that case you may have been fortunate enough to realize you need to change specialties at an early part of your career.

If not--and if your evals are just fine--then this is probably just your inner voice that may even lead you to success. Being a bit scared is important to succeed in EM.

 

[gutonc]

I'm not in EM but would add that this is normal, especially for this time of intern year. And that it's the people who don't feel this way (a little scared, a little uncertain) that are the problem, especially at this point in your training. If you already knew and could handle everything, you wouldn't need residency. But you don't...so you do.

Not saying that you're absolutely in the right field, just that, it's more likely that you're an intern in February...just like all the rest of them.

 

[RustedFox]

Rich Levitan is one of the true masters of airway management.
He has said that his interest grew out of fear.

Constantly try to learn about your weak points and you will be fine.

This. Quoted for truth. I need to do some of this these days, too. I might spin this off into its own thread.

 

[RustedFox]

Intern year always casts some doubts.

I like to tell my interns that when you start you should really only handle 1-2 patients at a time but handle them well, really well. Then go 2-3, then 3-4. By the end of your intern year/start of your pgy-2 year, you should be able to handle 3-4 patients at a time. The trick is to not stop there, anytime you feel comfortable, pick up another patient. Feel uncomfortable. This will make you stronger.

In terms of procedures, until you do a lot of them you will feel uncomfortable. I still remember my first chest tube, first code, first intubation, etc. All that fades with time.

Just stay positive and always remember: for many people visiting the ER this may be the worst day of their life. For you it is just another day in the grind. Just try to do your best so you can hopefully help another poor soul out when they need it most.

Wow.

Tenk was a MS-4 at my program when I was a PGY-3. We've had many meaningful interactions in real life.

Dude. You make me so proud to write this.


"QUOTED FOR TRUTH".

 

[gamerEMdoc]

Wow.

Tenk was a MS-4 at my program when I was a PGY-3. We've had many meaningful interactions in real life.

Dude. You make me so proud to write this.


"QUOTED FOR TRUTH".

Always awesome to watch them grow up, right!

 

[TooMuchResearch]

Wow.

Tenk was a MS-4 at my program when I was a PGY-3. We've had many meaningful interactions in real life.

Dude. You make me so proud to write this.


"QUOTED FOR TRUTH".

I finally understand qft.

 

[BJJVP]

I would like to offer a different perspective to the OP.

While it is certainly possible that this is completely normal for an intern in February, it may also be a sign that the ED isn't for you. I know I felt almost the exact same way at the midpoint of my intern year. However, I have to be honest and say that the fear, anxiety, insomnia NEVER completely went away for me and I recertify with ABEM within the next several years! Now, this doesn't mean EM was not right for me. If I think long and hard about it, AND I am truly honest with myself, I would not have chosen any other specialty. BUT, the only reason is that no other medical field would allow me the time off I have with my kids while making the amount of money I do. The big price I pay for this is that I have a baseline low level of anxiety and frustration that never completely goes away. In addition, after residency, I found even more frustrating things about the job that didn't affect me during residency (press ganey, irrational patient complaints, inadequate specialist back-up, trauma and stroke certifying bodies negatively impacting my practice, etc). You, on the other hand, have a second specialty that actually interests you and you may want to explore that a little more.

I also want to add that I don't believe that anyone who knows me in the ED would guess that I feel this way (at least any more than the average emergency physician). I actually move the meat quite well in the ED and sick patients don't scare me. In my group, I receive less than the average number of complaints from patients and staff. In fact, ironically, I tend to do well in patient satisfaction surveys.

It could just be that I have the grass is greener syndrome and I fully realize this...which is a big reason why I haven't actually switched fields. But if another field actually excited you before residency, I think you should give it a second look.

Having said that, I still think you should finish the EM residency unless there is a very good reason not to. It would still be very valuable training no matter what you ended up doing. In addition, whatever you do, whether it is a second residency or fellowship, I highly recommend you do it before you work a single day as an attending. It is just too hard to go back to training once you've left. It was a big regret of mine that I didn't even consider a second residency or fellowship until I was several years out of residency. Also, I have no idea about how the funding issue works and so my advice does not consider that aspect at all.

I know I didn't give you any definite answers either way but it is just too hard to do so without knowing you or your situation better. However, I don't want you to blow off these feelings as completely normal. There's a more senior physician in my group that always says, "It's the norm, but it's definitely not normal." He's referring to the general dysfunction of the emergency department and the lives of emergency physicians.

 

[gamerEMdoc]

I would like to offer a different perspective to the OP.

While it is certainly possible that this is completely normal for an intern in February, it may also be a sign that the ED isn't for you. I know I felt almost the exact same way at the midpoint of my intern year. However, I have to be honest and say that the fear, anxiety, insomnia NEVER completely went away for me and I recertify with ABEM within the next several years! Now, this doesn't mean EM was not right for me. If I think long and hard about it, AND I am truly honest with myself, I would not have chosen any other specialty. BUT, the only reason is that no other medical field would allow me the time off I have with my kids while making the amount of money I do. The big price I pay for this is that I have a baseline low level of anxiety and frustration that never completely goes away. In addition, after residency, I found even more frustrating things about the job that didn't affect me during residency (press ganey, irrational patient complaints, inadequate specialist back-up, trauma and stroke certifying bodies negatively impacting my practice, etc). You, on the other hand, have a second specialty that actually interests you and you may want to explore that a little more.

I also want to add that I don't believe that anyone who knows me in the ED would guess that I feel this way (at least any more than the average emergency physician). I actually move the meat quite well in the ED and sick patients don't scare me. In my group, I receive less than the average number of complaints from patients and staff. In fact, ironically, I tend to do well in patient satisfaction surveys.

It could just be that I have the grass is greener syndrome and I fully realize this...which is a big reason why I haven't actually switched fields. But if another field actually excited you before residency, I think you should give it a second look.

Having said that, I still think you should finish the EM residency unless there is a very good reason not to. It would still be very valuable training no matter what you ended up doing. In addition, whatever you do, whether it is a second residency or fellowship, I highly recommend you do it before you work a single day as an attending. It is just too hard to go back to training once you've left. It was a big regret of mine that I didn't even consider a second residency or fellowship until I was several years out of residency. Also, I have no idea about how the funding issue works and so my advice does not consider that aspect at all.

I know I didn't give you any definite answers either way but it is just too hard to do so without knowing you or your situation better. However, I don't want you to blow off these feelings as completely normal. There's a more senior physician in my group that always says, "It's the norm, but it's definitely not normal." He's referring to the general dysfunction of the emergency department and the lives of emergency physicians.

I'm quite a bit like you as well. I've dealt with anxiety for years, and many of those that work with me would never know. I think WAY MORE emergency med docs are in similar situations, but noone knows. Physicians are generally type A people, and in the ED, you often lose all control, which drives type A people absolutely crazy! Add that to the constant chaos, interruptions, circadian disruption, and probably some level of subclinical PTSD from horrific cases we all deal with, and you have a perfect mixture for people to have trouble just sleeping at night.

The good thing is, as you suggested above, EM provides a work environment that can fit just about anyone. Terrified of sick patients, go work in Urgent Care or a sleepy rural ED. Want to crack a few chests, go work in a crazy volume urban trauma center. There is absolutely a job out there for everyone in our field, and I'm convinced burnout is often times a result of us trying to fit into a job that we just don't fit in. Sometimes, if you are a slower doc who is a control freak, you just have to take a step back and go work in a slower place and maybe make a little less money, but be way happier. Unfortunately, far to many of us go after the job that's going to pay the most, or that is geographically best for our families, and often times that means pounding a square peg into a round hole.

 

[EM1Advice]

Thank you to everyone for your thoughts and advice. I am pretty sure I will be staying in the field, and trying to balance the objective view of my career against the grass-is-greener mentality that I seem to have picked up on lately, especially as I am looking into the realities of different fields/jobs.

It's good to know that there are positions with lower stress levels after graduation, and perhaps that thought will also keep me going.

I'll keep you guys posted, but again, thank you so much for all your comments and experiences.

 

[ERDude]

I'm quite a bit like you as well. I've dealt with anxiety for years, and many of those that work with me would never know. I think WAY MORE emergency med docs are in similar situations, but noone knows. Physicians are generally type A people, and in the ED, you often lose all control, which drives type A people absolutely crazy! Add that to the constant chaos, interruptions, circadian disruption, and probably some level of subclinical PTSD from horrific cases we all deal with, and you have a perfect mixture for people to have trouble just sleeping at night.

The good thing is, as you suggested above, EM provides a work environment that can fit just about anyone. Terrified of sick patients, go work in Urgent Care or a sleepy rural ED. Want to crack a few chests, go work in a crazy volume urban trauma center. There is absolutely a job out there for everyone in our field, and I'm convinced burnout is often times a result of us trying to fit into a job that we just don't fit in. Sometimes, if you are a slower doc who is a control freak, you just have to take a step back and go work in a slower place and maybe make a little less money, but be way happier. Unfortunately, far to many of us go after the job that's going to pay the most, or that is geographically best for our families, and often times that means pounding a square peg into a round hole.

These posts have been refreshing to read. I too am a chronically anxious person and have always dealt with pretty significant impostor syndrome. I've had some gaffes related to anxiety throughout med school, residency and attendinghood (5 yrs out now) but I guess they have always been pretty minor because I've also uniformly received very positive annual reviews and do well on pt sat.

With that being said - anxiety is fear and fear is weekend by experience and courage. I still recall my first few airways as an attending - my fear had spiked b/c I was worried about f'n up and being judged in front of new people. Struggled my way through those first few months/resuscitations and felt like I had to re-learn my confidence but sure enough with perseverance and repeated exposures things improve pretty quickly.

So for the OP I would agree - keep moving forward and ultimately you'll almost certainly succeed even if your brain and your body try and tell you otherwise.

 

[takeurmeds02]

One of the things that attracted me to EM was watching how cool EM docs were in critical situations. Go to the cath lab sometime and see what happens when a code occurs there. Its a goddamn disaster. Or god forbid when a code occurs on the L+D floor. We are the masters at dealing with complete disasters and dealing with it without losing our mind. Noone expects you to be able to deal with this as a PGY1. If you could, they'd pay you 400K/year and wouldn't make you do 3 years of residency. Understand that. Residency is 3-4 years for a reason. I went into EM because I wanted to be that guy. I was scared of crazy sick patients as a student, and I didn't want to be scared of anything. I wanted to be the doc that people looked too when all else was melting down; I wasn't that as a medical student, and I knew that doing EM would get me there.

So if you're scared of those patients now, great. Remember that in two years, if you stick it out, you won't be. And people will look up to you because of it. And then you can sit a scared PGY1 down who will look up to you as the fearless attending, and tell them exactly what I'm telling you now.

I've been a scribe for almost the last two years in the ED and this is exactly what drew me in too.

You guys are the **** and what I aspire to be.

And good luck to you OP

 

[Ellaellafan]

I'm currently an intern at an EM residency (inner city, high volume). I'm having serious thoughts about switching specialties. I'm not sure I fully understood what EM would be like through my medical school rotations. The things that I feel are a poor fit for me are the fast pace and acuity. I know, it would seem this would be an obvious component to emergency medicine, but I think I underestimated those things as a med student. I remember thinking to myself that although the volumes are high and acuity is high, the main goal was just to stabilize the patients and get them to their disposition where all the real work was going to be done (ICU, OR, etc). But now, the thought of being presented with a difficult airway or a code is terrifying. I'm at a program where the expectations for interns are generally low, and there is a huge jump up in the second year (like most programs). I have been struggling with severe insomnia as a result of anxiety over this: being the 2nd year, working in the resuscitation rooms, having to carry all those patients at once with my attention constantly being shifted from one thing to the end. There are so many times where I cannot fathom seeing more than 1 new patient per hour, things just seem to chaotic. Not to mention dealing with angry patients, malingerers, difficult nursing staff..

I know that I'm still just an intern and there is still a lot of time to learn all the skills required to deal with a crashing patient. However, I have also been thinking of switching to psychiatry, the other specialty I had serious consideration for during med school. The other option would be to stick it out, survive residency, and look for a job in EM that would involve lower acuity. In my mind, the only position that almost never deals with those unstable patients would be Urgent Care.

My questions for you guys: Has anyone else felt this way and decided to complete residency? Or does it sound like this is not the right field for me? What are the options for lower stress positions after graduation other than Urgent Care? I would be willing to take a significant pay cut to have a more manageable workload.

Thank you to all of you who took the time to read this.

Angry patients.. Malingerers.... I'm in psych and welcome to my world.. If anything you'd be facing more of those patients in that field. I was actually thinking of switching to EM but would be nervous about the acuity too... Urgent care sounds good for you for a small city.... I think go through and finish it and see how you like it before switching, unless you're really unhappy... Good luck!