Direct accession civilian vs military Emergency Medicine

[ERDRFL]

I’ll try to be brief. I’m a very experienced (read “old”) ER doc in civilian practice for 25 years. I have always wanted to join the military (tried USUHS for medical school) but was declined due to eyesight impaired in one eye and was refused a waiver. Now EM is apparently in demand and waivers are possible.

The thing that drives me crazy about civilian EM is the constant demand from administration to meet throughput metrics (to make sure they maximize their reimbursement) while they demand high patient satisfaction scores with decreasing resources, “but don’t you dare sacrifice quality” simultaneously. They are competing metrics that cannot be all met simultaneously.

Is this a thing in military emergency medicine? I have no problem with paperwork/ administrative responsibilities. It goes with the job. And I understand military medicine does that in spades. But the civilian clinical environment is just littered with figurative mines everywhere. I’m considering Navy and Air Force. Would I be dealing with the same issues?

Also, I understand that hours worked depends on staffing/ etc but how many hours per month can I expect to work on active duty? Don’t mind hard work, just curious.

Thank you!

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[DrMetal]

Is this a thing in military emergency medicine?

No, but what is a 'thing' in military emergency medicine is sheer and utter boredom. Our ER's are not accessible to most regular emergency traffic, we have no trauma, we hardly have any interesting medical/surgical cases. It's glorified urgent care.

You're trading once set of problems for another.

Be a reservist if you want. I'd avoid coming on active duty.

 

[ERDRFL]

No, but was is a 'thing' in military emergency medicine is sheer and utter boredom. Our ER's are not accessible to most regular emergency traffic, we have no trauma, we hardly have any interesting medical/surgical cases. It's glorified urgent care.

You're trading once set of problems for another.

Be a reservist if you want. I'd avoid coming on active duty.

I appreciate your insight and I get that there are problems everywhere. No matter what direction I go, I’m going to have problems. But over 25 years, I’ve had my share of trauma and critical patients such that I don’t really mind a glorified urgent care. I just want to take care of patients. I’m sick of trying to make specialists actually do their job, especially with the critical patients that they don’t want to manage. Orthopedists who can’t manage anything other than routine hip fractures. (I get responses from the tertiary care center such as “so the orthopedist that I trained in residency can’t repair a fracture?”). Vascular surgeons and nephrologists that don’t want to do dialysis catheters (because it doesn’t pay enough). Surgeons that actually have refused to even see a patient that they are consulted on because it’s too complicated for them (whatever the hell that means).

I’m nearing the last years of my career. I truly think that I would find it rewarding to take care of our nations warriors and their families. Yes, I could do it in the reserves. It’s not out of the question. Maybe a 4 year active duty commitment would make me miss my current practice. But my conscience (and sanity) will not allow me to stay where I’m at. And from talking to other colleagues in civilian EM, my experience is not at all unusual.

 

[DrMetal]

I appreciate your insight and I get that there are problems everywhere. No matter what direction I go, I’m going to have problems. But over 25 years, I’ve had my share of trauma and critical patients such that I don’t really mind a glorified urgent care. I just want to take care of patients. I’m sick of trying to make specialists actually do their job, especially with the critical patients that they don’t want to manage. Orthopedists who can’t manage anything other than routine hip fractures. (I get responses from the tertiary care center such as “so the orthopedist that I trained in residency can’t repair a fracture?”). Vascular surgeons and nephrologists that don’t want to do dialysis catheters (because it doesn’t pay enough). Surgeons that actually have refused to even see a patient that they are consulted on because it’s too complicated for them (whatever the hell that means).

I’m nearing the last years of my career. I truly think that I would find it rewarding to take care of our nations warriors and their families. Yes, I could do it in the reserves. It’s not out of the question. Maybe a 4 year active duty commitment would make me miss my current practice. But my conscience (and sanity) will not allow me to stay where I’m at. And from talking to other colleagues in civilian EM, my experience is not at all unusual.

Well, in my opinion, much of these problems stem from the very nature of 'Emergency' Medicine, a specialty that we created out of nothing. How does one create a specialty out of an acuity level? Why not then specialties for 'Urgent Care Medicine', or 'Primary Care Medicine'. It's just as dumb as creating specialties out of symptoms, 'Pain Medicine'. I can't wait for a 'Nausea and vomiting' fellowship.

40 years ago, when the ERs were staffed with internists, surgeons, anes, peds, orthopods etc . . . those specialists had to see the patients, because they were assigned to the ER for that day, or week, or month. My mentors told me it worked just fine. As soon as they created the 'Emergency Physician' and pulled everyone else out of the ER, I could see how these specialists bailed on the ER, figuratively. And now compounding the problem is the flood of mid-levels into the ER, which the specialists can even more boldly blow off.

Sorry for the tangent.

In any case, you'll likely encounter the same problems in military medicine, where the specialists (unless they moonlight elsewhere) are definitely not comfortable with very sick patients.

If you do reserves, can you come on active duty for short stints . . .sometimes as long as 3 to 6 months. It's really not a bad way to serve.

 

[DMBandFan86]

You are rarely going to find someone one here to encourage you to join the military…

You make a reasonable argument. If you understand what military medicine offers then go for it. It’s only a few years of your life if you do the minimum. If you hate it, then it is a long few years, but eventually it will end.

You could also look into VA jobs. Sometimes the military is hiring civilian contractors (recently saw Navy hiring MEPS doc). Or do reserves and maybe also switch your civilian employer. Only problem with reserves is sometimes hard to get on missions for AD or have to wait a long time. If you want to wear the uniform daily for several years no matter what then only AD would give you that.

I have not been in the Navy or Air Force, but army ER docs can be placed in role 1 care (near fighting) if war breaks out during your service. That’s one thing I didn’t see you mention in your post. Are you okay with wartime medicine and overseas deployments this far long in your career. Maybe someone can post about what ER docs do in the Air Force during combat if you have questions about that.

Finally, and I know I’m all over the place, but you also mentioned admin. Military admin and the civilian supporting staff are the worst. Just know that going in. You will definitely find that worse than civilian.

 

[ERDRFL]

You are rarely going to find someone one here to encourage you to join the military…

You make a reasonable argument. If you understand what military medicine offers then go for it. It’s only a few years of your life if you do the minimum. If you hate it, then it is a long few years, but eventually it will end.

You could also look into VA jobs. Sometimes the military is hiring civilian contractors (recently saw Navy hiring MEPS doc). Or do reserves and maybe also switch your civilian employer. Only problem with reserves is sometimes hard to get on missions for AD or have to wait a long time. If you want to wear the uniform daily for several years no matter what then only AD would give you that.

I have not been in the Navy or Air Force, but army ER docs can be placed in role 1 care (near fighting) if war breaks out during your service. That’s one thing I didn’t see you mention in your post. Are you okay with wartime medicine and overseas deployments this far long in your career. Maybe someone can post about what ER docs do in the Air Force during combat if you have questions about that.

Finally, and I know I’m all over the place, but you also mentioned admin. Military admin and the civilian supporting staff are the worst. Just know that going in. You will definitely find that worse than civilian.

I’m currently in a leadership position at my shop and I don’t have an aversion to administration and paperwork. I don’t love it but it is a necessary evil with bean counters running hospitals/ insurance companies/ CMS. And I get that the military/ government takes paperwork to a whole new level but it’s unavoidable. I doubt that I have it as bad in the civilian world but CMS is continually adding paperwork/ metrics Year over year. I don’t blame Hospital C Suite for pushing metrics since it affects their bottom line and that is the endgame for admin: increase the bottom line.

I have considered the VA and the State Department. Regional Medical Officer is definitely an option. But it’s still paperwork out the a$$ from State rather than Defense. And you still get sent where they need physicians so it’s a lot like the military in many ways.

As for forward deployment and potentially being near the battle, I’m ok with that (or so I think). Of course I’ve never been shot at, but I’m sure it’s a whole new level of misery and fear. I just assume that it comes with the territory. Not fun but expected.

 

[ERDRFL]

I’ve seen posts that mention 160-180 hours per month as a military emergency physician. Is that still about where most ED docs at expected to work (though I have seen a lot more hours mentioned when deployed or short staffed)?

 

[DeadCactus]

Well, in my opinion, much of these problems stem from the very nature of 'Emergency' Medicine, a specialty that we created out of nothing. How does one create a specialty out of an acuity level? Why not then specialties for 'Urgent Care Medicine', or 'Primary Care Medicine'. It's just as dumb as creating specialties out of symptoms, 'Pain Medicine'. I can't wait for a 'Nausea and vomiting' fellowship.

40 years ago, when the ERs were staffed with internists, surgeons, anes, peds, orthopods etc . . . those specialists had to see the patients, because they were assigned to the ER for that day, or week, or month. My mentors told me it worked just fine. As soon as they created the 'Emergency Physician' and pulled everyone else out of the ER, I could see how these specialists bailed on the ER, figuratively. And now compounding the problem is the flood of mid-levels into the ER, which the specialists can even more boldly blow off.

This is just nonsense. The old system was ridiculous, of course your mentors don't want to tell you how badly they mismanaged a bunch of patients through hubris and ignorance. Critical care is just an acuity. Primary care is an acuity. Both are specialties and have developed to the point where there are subspecialists within them for specific patient populations. It's 2023, medicine is specialized now and those specialties can be drawn in sensible ways across organ systems, disease classes, care settings, and subspecialties.

 

[DrMetal]

This is just nonsense. The old system was ridiculous, of course your mentors don't want to tell you how badly they mismanaged a bunch of patients through hubris and ignorance. Critical care is just an acuity. Primary care is an acuity. Both are specialties and have developed to the point where there are subspecialists within them for specific patient populations. It's 2023, medicine is specialized now and those specialties can be drawn in sensible ways across organ systems, disease classes, care settings, and subspecialties.

Why would an internist working an ER mismanage a DKA? A general surgeon doesn't know how to manage an acute cholecystitis/cholelithiasis? Or an OB/gyn an obstetric emergency? (If there is mismanagement, they're bad at their specialty---has nothing to do with it being an 'emergency', per se).

Hell at most of the hospitals I've worked at, we get consulted for admission (and we become the 'attending' of record) within 10 minutes of the patient hitting the ER. That's almost the same as me parking myself in the ER and admitting the medical cases, and the surgeon the surgical cases.

It's 2023, medicine is specialized now and those specialties can be drawn in sensible ways across organ systems, disease classes, care settings, and subspecialties.

Yeah, we're too specialized, maybe that's the problem. With over-specialization, comes over-glorification, over-pricing, then the system finds a way to circumnavigate around you. Hence the plethora of mid-levels now entering 'emergency' medicine (and other specialties too of course).

 

[DeadCactus]

Why would an internist working an ER mismanage a DKA? A general surgeon doesn't know how to manage an acute cholecystitis/cholelithiasis? Or an OB/gyn an obstetric emergency? (If there is mismanagement, they're bad at their specialty---has nothing to do with it being an 'emergency', per se).

Hell at most of the hospitals I've worked at, we get consulted for admission (and we become the 'attending' of record) within 10 minutes of the patient hitting the ER. That's almost the same as me parking myself in the ER and admitting the medical cases, and the surgeon the surgical cases.



Yeah, we're too specialized, maybe that's the problem. With over-specialization, comes over-glorification, over-pricing, then the system finds a way to circumnavigate around you. Hence the plethora of mid-levels now entering 'emergency' medicine (and other specialties too of course).

You appear to be fundamentally ignorant of how emergency departments and emergency medicine work. Somehow you're able to simultaneously ignore the experience and training that lets a physician accurately admit a patient with a "10 minute" evaluation while simultaneously believing everyone else in medicine can do an equivalent job or better job despite doing it as a hobby on the side of their actual specialty. It's baffling that this conversation still happens on forums when it began before the internet existed and the emergency medicine specialty model continues to prove itself across the globe.

 

[DrMetal]

and the emergency medicine specialty model continues to prove itself across the globe.

Yeah, proving itself great, for the current and future generation of mid-levels (and mid-level encroachment is certainly not unique to EM, but EM has been a great proving ground).

We occasionally see good ones (ER docs who places lines, resuscitate, starts fluids, antibiotics, give you a nice packaged patient). I've actually had better experience with the military ones.

The civilian world is a total shtshow (no doubt, b/c of the ridiculous volume). They'll call me for admission just based on age and an elevated troponin (with CKD), that they've obtained having not even seen the patient. What the difference is between them and a glorified triage nurse I don't know.

 

[pgg]

They'll call me for admission just based on age and an elevated troponin (with CKD), that they've obtained having not even seen the patient. What the difference is between them and a glorified triage nurse I don't know.

In the ER's defense, sort of, I think a lot of patients are getting seen by actual glorified triage nurses (aka midlevels) and not physicians ...

Here are two sloppy admits from yesterday. I was the anesthesiologist in a hospital endoscopy suite and I canceled both of these cases which were coming from the ER as afternoon add-ons:

1) Patient with chest pain and dyspnea. First troponin was 0.9. Given a diagnosis of "acute nontraumatic myocardial injury" "probably due to [anemia]". Hb was 12. Scheduled for a EGD to look for a GI bleed. Cardiology hadn't been consulted.

2) Patient with abdominal pain, history of Crohn's, rectal fistula. Something about a seton and something gross leaking. Initial lactate was 6.something. Four hours later a repeat lactate was over 11. Scheduled for a colonoscopy that afternoon. Surgery hadn't been consulted.

I don't know who was seeing these patients in the ER but I'm pretty sure it wasn't someone whose vocabulary includes "NSTEMI" or "shock" ...


My brother is an EM doc, so naturally after canceling these cases the first thing I did was give him some **** about what goes on in the ER. I don't know how they stay sane working down there.

 

[DrMetal]

I think a lot of patients are getting seen by actual glorified triage nurses (aka midlevels) and not physicians ...

Yeah, pretty much. How easily mid-levels have penetrated the ER (and some of them barely out of school) is quite startling. It just demonstrates (in my opinion) that the entire specialty of EM should've never come to be. That is, the role of the emergency physician has become a sort of mockery. Sad. I'm glad I wasn't lured into it. I saw way past the '90s-ER-ChicagoHope-GeorgeClooney' effect. I was more of a 'Scrubs' guy.

We're the only profession that makes specialties out of acuity levels. Some now want to create one for 'primary care', and 'urgent care'. Absolutely silly.

When a bridge collapses, do we call an 'emergency' engineer? No, we call a civil engineer who's responds to emergencies. If the dam is broken too, we call the hydro engineer. Each engineer is specialized in her own field; each knows how to respond to their respective emergencies.

 

[armytrainingsir]

Yeah, proving itself great, for the current and future generation of mid-levels (and mid-level encroachment is certainly not unique to EM, but EM has been a great proving ground).

We occasionally see good ones (ER docs who places lines, resuscitate, starts fluids, antibiotics, give you a nice packaged patient). I've actually had better experience with the military ones.

The civilian world is a total shtshow (no doubt, b/c of the ridiculous volume). They'll call me for admission just based on age and an elevated troponin (with CKD), that they've obtained having not even seen the patient. What the difference is between them and a glorified triage nurse I don't know.

The last few hospitals I’ve been at, the ER runs like this:
Pt sees triage nurse
Pt sees mid level who orders a plethora of tests based on CC. Random chance if any physical exam or history has been obtained at this point.
Only when all the results are back will the ER doc review the results, briefly chat with and examine patient, and then: have hospitalist admit, consults every specialist that corresponds with any abnormalities in the labs, scans, ROS, or streets the patient with instruction to f/u with the specialist(s) on call.

To be fair though, outpatient primary care isn’t much different. These days, it’s all about referrals.

The end result is the same regardless of acuity. The specialist ends up being the de facto supervising physician for our current system

 

[ERDRFL]

I guess I’ll have to let my critical care colleagues know that they are not in a real specialty either. After all, it is a specialty just based in acuity, whatever that means. I suppose if you can’t attribute an organ system to it, it’s not a specialty?

I appreciate the information you have provided but this is obviously not the venue to get answers to my questions.

 

[DrMetal]

The last few hospitals I’ve been at, the ER runs like this:

Yeah, that's pretty much the paradigm now in the ER. Even at Level 1's, there's a trauma team run by a surgeon that gets call to the ER to take care of things. The ER physician might do the FAST exam, which the surgeon of course doesn't trust, and he orders the CT CAP anyway.

I guess I’ll have to let my critical care colleagues know that they are not in a real specialty either.

I know you're being sarcastic, but it's an interesting conundrum now in critical care. Most patients in the unit get parsed out to either medical or surgical. And a specialist does end up calling the shots, not the general intensivist. Acute renal failure, the nephrologist decides when to initiate CRRT. Cerebral mass causing effect, Nsgy decides when to operate. Severe heart failure, cardiology runs it. And you can tell this is the case, now by the plethora of fellowship programs that have added on 'critical care' (Nepro CC, Cardiology CC, ID CC, etc etc). Each one of these subspecialists can (and should be) well versed in the critical situations of their own organ system.

Again, the guy fixing the bridge doesn't have to be the same person fixing the dam. Makes no sense to categorize by acuity level. Makes all the sense in the world to categorize by the problem or task at hand.

I appreciate the information you have provided but this is obviously not the venue to get answers to my questions.

Sorry to have derailed your thread (this happens often here). To answer your original question: Join the reserves. It's a great way to serve, you'll have opportunities to hop on (and off) active duty. You can keep your civilian practice. It really is the best way to go.

 

[armytrainingsir]

I appreciate the information you have provided but this is obviously not the venue to get answers to my questions.

Yeah. I get your frustration. Your thread did get derailed pretty bad.

I’ll second the motion to go reserves to scratch the itch. But AD will kill your soul, lol.

 

[Onefellswoop87]

Yeah, that's pretty much the paradigm now in the ER. Even at Level 1's, there's a trauma team run by a surgeon that gets call to the ER to take care of things. The ER physician might do the FAST exam, which the surgeon of course doesn't trust, and he orders the CT CAP anyway.



I know you're being sarcastic, but it's an interesting conundrum now in critical care. Most patients in the unit get parsed out to either medical or surgical. And a specialist does end up calling the shots, not the general intensivist. Acute renal failure, the nephrologist decides when to initiate CRRT. Cerebral mass causing effect, Nsgy decides when to operate. Severe heart failure, cardiology runs it. And you can tell this is the case, now by the plethora of fellowship programs that have added on 'critical care' (Nepro CC, Cardiology CC, ID CC, etc etc). Each one of these subspecialists can (and should be) well versed in the critical situations of their own organ system.

Again, the guy fixing the bridge doesn't have to be the same person fixing the dam. Makes no sense to categorize by acuity level. Makes all the sense in the world to categorize by the problem or task at hand.



Sorry to have derailed your thread (this happens often here). To answer your original question: Join the reserves. It's a great way to serve, you'll have opportunities to hop on (and off) active duty. You can keep your civilian practice. It really is the best way to go.

You have summarized a huge reason why I didn’t pursue a crit care fellowship after anesthesia residency. I rotated through the MICU and the plum-cc attending made sure that we consulted nephro for any creatinine bump. Not attending dependent, as attendings rotated by the week and it happened for multiple attendings. I didn’t know at the time if that was institution dependent, but as it was a military residency, did another outservice rotation for hearts and SICU. The anesthesia critical care attendings (closed ICU again) deferred to the CT fellows regarding volume status (even when objectively wrong) because “it was their patient” from the surgery.
I’d hate myself to do a CC fellowship and be a consult coordinator but that’s what ICUs across other hospitals implied.
Hope some crit care attendings out there stand on their own knowledge base and privileges/credentials instead of consulting for every organ, but those seemed few and far between in my time as med student, resident, and now few years as attending.

 

[CCM-MD]

Yeah, that's pretty much the paradigm now in the ER. Even at Level 1's, there's a trauma team run by a surgeon that gets call to the ER to take care of things. The ER physician might do the FAST exam, which the surgeon of course doesn't trust, and he orders the CT CAP anyway.



I know you're being sarcastic, but it's an interesting conundrum now in critical care. Most patients in the unit get parsed out to either medical or surgical. And a specialist does end up calling the shots, not the general intensivist. Acute renal failure, the nephrologist decides when to initiate CRRT. Cerebral mass causing effect, Nsgy decides when to operate. Severe heart failure, cardiology runs it. And you can tell this is the case, now by the plethora of fellowship programs that have added on 'critical care' (Nepro CC, Cardiology CC, ID CC, etc etc). Each one of these subspecialists can (and should be) well versed in the critical situations of their own organ system.

Again, the guy fixing the bridge doesn't have to be the same person fixing the dam. Makes no sense to categorize by acuity level. Makes all the sense in the world to categorize by the problem or task at hand.



Sorry to have derailed your thread (this happens often here). To answer your original question: Join the reserves. It's a great way to serve, you'll have opportunities to hop on (and off) active duty. You can keep your civilian practice. It really is the best way to go.

That goes against all of the evidence that shows intensivists improve patient outcomes, reduce mortality, increase ventilator free days, reduce length of stay etc.

In addition, most patients in the ICU don’t have single organ system failure. Pulmonologist managing ARDS, cardiologist managing the heart failure, nephrologist manage the renal failure, ID manage the bacteremia, Heme managing platelets… on the same patient, it doesn’t work well. The “specialist” calling the shots in these situations is the intensivist. The cardiologists are happier in the cath lab and the surgeons are happier in the OR, they don’t want to deal with these patients. You need a point person. Who the best person to do that can be argued but there definitely needs to be someone who ties it all together. Hence the hot market and rising compensation over the past 5-10 years.

ID and nephrology fellowships are adding on CCM to attract candidates because they have been going unfilled for a number of years. It’s a way for those programs to fill. The graduates don’t just care for critically ill ID or nephrology patients… they are trained intensivists to care for all. And that’s what most of the graduates do - they work as intensivists because the job market is better and it also pays significantly more.

 

[DrMetal]

on the same patient, it doesn’t work well. The “specialist” calling the shots in these situations is the intensivist.

Really? You tell the cardiologist when to cath? the nephrologist when to dialyze? you (not ID) manages the antibiotics in a complex bacteremia? You (not the surgeon) decides when a patient has to go back to the OR? There's no doubt that the general intestivist plays an important role, watching over everyone in the unit, playing traffic cop, doing procedures (although more are going to IR now), having family meetings, etc. But the major shots are still called by the sub specialists.

I still have hope for critical care, as a specialty. Despite it being predicated on a acuity level like Emergency Medicine, I still think CC is better defined, especially when it's done by someone previously trained in medicine and surgery. The thought of a neurologist-CC managing DKA is pretty scary.

ID and nephrology fellowships are adding on CCM to attract candidates because they have been going unfilled for a number of years. It’s a way for those programs to fill. The graduates don’t just care for critically ill ID or nephrology patients…

So what does that say about CC, that it can just be added on like that for an extra year? "Hey you want to be an intensivist, lets tack on a year of training, and boom, now you manage everything in the ICU!" You can't just add on a year and become a pediatrician, or a CT surgeon. So what does the Nephro-CC do when he sees complex HF in the ICU? He consults cardiology.

 

[CCM-MD]

Really? You tell the cardiologist when to cath? the nephrologist when to dialyze? you (not ID) manages the antibiotics in a complex bacteremia? You (not the surgeon) decides when a patient has to go back to the OR? There's no doubt that the general intestivist plays an important role, watching over everyone in the unit, playing traffic cop, doing procedures (although more are going to IR now), having family meetings, etc. But the major shots are still called by the sub specialists.

I still have hope for critical care, as a specialty. Despite it being predicated on a acuity level like Emergency Medicine, I still think CC is better defined, especially when it's done by someone previously trained in medicine and surgery. The thought of a neurologist-CC managing DKA is pretty scary.



So what does that say about CC, that it can just be added on like that for an extra year? "Hey you want to be an intensivist, lets tack on a year of training, and boom, now you manage everything in the ICU!" You can't just add on a year and become a pediatrician, or a CT surgeon. So what does the Nephro-CC do when he sees complex HF in the ICU? He consults cardiology.

I never expected one of my own physician colleagues to question the very existence of critical care medicine as a specialty, especially after going through the COVID-19 pandemic. Its actually pretty sad. I’m not going to try to convince you that intensivists make multiple major life altering decisions on critical patients, sometimes on an hourly basis. The data on improved patient outcomes speaks for itself. These data are not because of playing “traffic cop” or moving critical ventilated patients to the IR suite to have them do procedures that can be done at the bedside. You have a flawed view of ICU medicine. Regardless, I hope that in the unfortunate event you or a loved one suffers from critical illness, there is an intensivist involved in their care. One can hope that maybe you will have some more respect then.

 

[DrMetal]

I never expected one of my own physician colleagues to question the very existence of critical care medicine as a specialty,

What's wrong with asking some provocative and objective questions? Look: I personally still regard and think the world of my fellow medicine-CC colleagues, especially those who have good family meetings and convince them to stop of futility of care (that is, if they don't consult Palliative Care to do so).

But there's a lot of people, hospital administrators and bean counters in particular, that are asking these questions, and trying to replace us generalists with mid-levels. In my own field, general hospital medicine, I think these questions are even harder to answer (at least the general intensivist does procedures, can manage some things before consulting). Us hospitalists are forced do to almost do nothing and consult the world. We could just as easily be replaced by good mid-level or even AI. [so the thinking goes, of course I don't agree with it. In my own practice, I try to not consult and take care of things on my own, sometimes I get chastised because I didn't consult Neurology for a BS TIA, before starting ASA/statin.]

The data? I've learned to regard most studies in clinical medicine as religious texts; setup, collected, and reported with pre-conceived conclusions. The critical care community is very family with this, circa the debacle of Rivers et al EGDT etc, and other debunked studies like it, that were first boasted as gospel.

I hope that in the unfortunate event you or a loved one suffers from critical illness,

No way, everyone in my immediate family will be DNR DNI and Comfort Care only, especially the mother-in-law.

 

[the_world_has_gone_mad]

So - although this is not going to add anything at all to the OP's question ... I do think some of the posts here have a very 'tertiary care/large (academic) medical center' "bubble" flavour to it ... as someone who has worked almost a decade as the sole nocturnist in small 'isolated' community hospitals (70 beds) [with 7 ICU beds and no intensivist on staff] I can definitely say that having 'ER docs' is absolutely critical for 'small places' to function at all ... because at night (and do not forget this means 50% of the time a hospital has to 'function' in the end...) it was the ED physician and myself in house (anesthesia is asleep 20 minutes away...) ... it's the ED doc that e.g. "allows" the sometimes 'sole surgeon' who is on call for a one-week stretch or the pediatrician to get at least some rest as (thanks to the ED physician) they are only 'called in' for the really 'severe' things (not all the 2 am head lacerations requiring a couple of stitches or all the 'fuzzy babies' ....) - having them (with their much more extensive procedural training) also allowed me personally to feel somewhat more comfortable (as a 'general internist only' and non-critical-care fellowship trained person - sorry these small places just do not have the volume/budget to employ fellowship trained intensivists....) to 'run' the ICU at night as at least there was someone in-house to call when I had trouble with getting that tube into the patient....

Of course 'big places' are all about consults ... - well because you actually have the sub specialists there.... - if you are (perhaps a little bit frustrated??) by that 'care model' - just call a locum agency and moonlight in a 'small place' for some time ... trust me - they are desperately looking for people all the time ... ;-)

 

[ERDRFL]

If you can’t beat ‘em, join ’em. Might as well comment.

Without ED docs, the ED would have to be staffed by a pediatrician, an internist, a surgeon, a cardiologist, and on OB/gyn at a minimum. A pediatrician can see pediatric patients but doesn’t know how to manage a NSTEMI. An internist or cardiologist can manage an NSTEMI but doesn’t know how to manage a pediatric DKA. Orthopedists typically don’t even own a stethoscope and are great at their field but typically not much else. The specialists are busy enough that they don’t have time to deal with all the BS in the ED. And the old days when a moonlighting internist or cardiologist staffed the ED was of no benefit to pediatric or trauma patients. I’ve taken out an appendix in medical school and spent hours in the OR during trauma rotations, but I have no business in an operating room. Most specialists, quite honestly, have no business in the ED. That is not to say that they can’t expertly manage the patients in their wheel-house but it is too diverse a patient population for any one specialist to manage. I could have kissed my Army-trained surgeon who rushed in to help me when I had a young man slash his own neck, transecting arteries and much of the trachea. He was my hero that day. But he’s really useless with many of my other non-surgical patients. That does not diminish his importance. But the fact that I need him to manage his surgical cases doesn’t diminish my role in the team either.

As mentioned in a post above regarding community EDs, my surgeons on call often get to sleep in their warm beds more often than not unless I have to wake them up for an emergency surgery (which is rare). More often, I’m trying to delay the hospitalist’s request to call the surgeon at 2am for the diverticulitis patient with the microperf who doesn’t have an acute abdomen and that doesn’t need urgent surgery. Why the hell should I wake up the surgeon in the middle of the night for something that he can manage in the morning? We never even talk to the pediatricians except to the pediatric hospitalists at the regional children’s hospital. OB never gets to sleep because, well, they’re OB doctors and that just goes with the territory. My hospitalists are extremely busy with admitting patients plus all the floor BS they have to deal with that we in the ED do our best to not overload them with more BS.

I am a s^&t strainer in the ED. Discharge the s&%t and admit what has to be admitted. None of my specialists want my job and I don’t want theirs. Medicine is a team effort and those who are not team players are the ones who are making medicine so damn miserable. 25 years ago we all looked out for each other. We had each others six. Now, it‘s a quite frequently a free-for-all and it sucks.

And sounds like many of you need new ED groups if they are, in fact, as bad as some of you say they are.