Intern regretting specialty choice

[iwannabehappyMD]

I am an intern currently regretting my specialty choice in EM.

After submitting ERAS last year and going on to complete required 4th year electives, I found myself enjoying a few other specialties more and realized I may have made a mistake in choosing EM. I thought about reaching out to people to figure out how to switch but I told myself it was too late and there was a reason I chose EM, so decided to go through with the process.

Now that I've done a good amount of EM in residency, I just can't see myself doing this long-term. During my sub-i's, I thought I got a good feel for it and really enjoyed it but my experience in residency has been so much different. I think part of it may be being in a different hospital environment than my sub-i's, but I am also realizing things inherent to EM that make it hard for me to have a long career in this specialty. I focused so much on how I would get to become a jack of all trades who could handle anything that I ignored when people talked about the high stress, constant chaos, burnout, inconsistent schedules, having to work many holidays/weekends, and most of your shifts being when others in society are off of work. As an eager-for-anything medical student it was hard to get this through my head until now that I have signed up for this life. In these almost 6 months, I can already see how its gonna take a toll on those around me including my partner.

My co-residents talk about how they love the chaos but for me it just makes me anxious going to work or thinking ahead to an EM block. I find myself dreading the ED after an off-service rotation compared to others who are glad to be back. Some of the things I don't like are traumas because I wish I could just focus on the patients in front of me or how frequently my attendings hit me with the lets just reach out to so and so service for things that I've seen managed by EM docs in the community. I am in a 4-year ivory/academic program, so I think the volumes are just heavy and our attendings are trying to manage a bunch of residents/patients/traumas and its easier to defer to consulting for some management decisions. In off-service rotations I often see the attendings working one-on-one with their residents to get them to be really good at what they do. I really wish I had that, but in the ED this has been rare for me because I don't even know where my attendings are most of the time.

I know the grass is greener but its hard to put in the hours for 3.5 more years when I cannot see myself enjoying what I'll be doing at the end of the road. If I continue down this path I would only be trying to escape EM and it makes me sad that after all these years of grinding/delaying my life I chose a career I am not happy in. I do like clinical medicine and love being there for patients, but I think I realized EM isn't for me and I don't know what to do at this point. My evals have been really good in EM and off-service but its already past ERAS and am unsure of my options even if I did want to switch into something else and if i'd get any credit for what i've done. Things that I am interested in are: Psych, PM&R, Anesthesia, FM.

Its also the holidays and maybe i'm just down because I'll be missing time with family, but regardless I would appreciate any advice.

If it makes any difference in my options: T25 MD, Step 1 - pass, Step 2 - 250, decent amount of extra-curricular work

TLDR; EM intern currently realizing they made a mistake in their specialty choice

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[Porfirio]

If you want out, the earlier you do it the better. They will only get rid of you if you find another program (as long as you meet your requirements). There is no down side for you to explore getting out now, if you want out. It will be hard, but it only gets harder the longer you go.

 

[valianteffort]

Depending on where you are at, if you make this swap early enough and stay at the same institution they may help you consider your first year as a TY year depending on how many outside of the ED rotations you have. Given you are at a 4 year hopefully more than most. Talk to your PD and have a discussion about transitioning, then interview for FM/Anesthesia/Psych - best case they consider this TY and you start as PGY 2 . Its a long shot but if you do it now theres a chance.

 

[RustedFox]

Ding.

 

[sylvanthus]

Did the med student in the thread above read this?

 

[doctoroxygen]

If you're interested in anesthesia, PM&R, and psych, have you consider a pain fellowship? I felt the same way you do at this point in intern year of a 4-year program but knew coming into residency that I would be doing a pain fellowship. Knowing that I had an exit strategy ready to go helped me get through residency, which I actually ended up really enjoying by the end (especially knowing that I would only ever have to work in an ED again by choice).

 

[GonnaBeADoc2222]

If you're interested in anesthesia, PM&R, and psych, have you consider a pain fellowship? I felt the same way you do at this point in intern year of a 4-year program but knew coming into residency that I would be doing a pain fellowship. Knowing that I had an exit strategy ready to go helped me get through residency, which I actually ended up really enjoying by the end (especially knowing that I would only ever have to work in an ED again by choice).

I second this. Don't waste 2 years of training if you don't have to. Do pain, unless you absolutely can't see doing it

 

[TrailRun]

I think up to 20% of residents switch. First step would be to narrow down to one of the three you're interested in (each offers a better lifestyle than EM in my opinion). Hopefully your PD will be supportive! And then try to meet with the PD from your desired specialty at your home institution to see if you can make a lateral move, ideally as a PGY2 using your EM year as the prelim year. I'm not sure if you're geographically limited, but could potentially soap this coming year. If you know for a fact you don't want to do EM I wouldn't complete a 4! year program just to try to get into Pain. Would be better to do one of your other 3 specialities. Sorry, tough spot to be in! Good luck!

 

[petomed]

Did the med student in the thread above read this?

Yup.

 

[RustedFox]

Yup.

Good.

 

[GonnaBeADoc2222]

You should regret it. It's turned into a terrible specialty, corrupted by hospital systems and CMGs.

In it's pure form, EM is likely one of the best specialities. High acuity, fast paced, appreciated by society. We practice a bastardized form of it in the US though with low mid acuity, grinding pace (work faster cuz the "customer" wants it, not cause there's a medical necessity). We don't practice "primary care" as other people sometimes say. That might actually be enjoyable. I stead we practice what I call "on demand care," aka "I want what I want, when I want it, how I want it."

The logistical problems to solve on each shift are vast, intellectual stimulation is low.

This is how I've survived:

1) Work at a place with no nights (this is key, can't express this enough)

2) work at a place where admissions are easy. Admit whomever you think needs it. Disregard the current census of the hospital. Order lots of CTs. Cover yourself. You'll be massacred for discharging or not imaging a sick patient.

3) Almost completely dissociate from anything that's not directly related to the medical care of the patient. I don't get involved with social or behavioral nonsense. I hand patient standard resources and discharge. When anyone comes to me with any of this I shrug my shoulders and make them solve it.

4) I don't get involved with ED operations on shift. You'll find that no one cares about your input on things that actually matter, but want you to solve every other issue that you don't care about. I ignore all of it. I used to get involved; the gaslighting will kill you.

5) avoid nurses as much as possible beyond addressing the pressing medical needs of the patient and simple tasks. No I will not update patient 5x, explain why CT is delayed or any other nonsense that is a nursing task. No I won't take that call from a random pharmacy or lab, let the midlevel do it.

6) Avoid patients / situations that have a high likelihood of being a disaster.

7) avoid tangential tasks: EMS medical direction, acutely combative psych patients. I work with people who make way more than me for less production, let them do it.

8) Take the wins. Relate as a human to a mom or dad worried about their kid. Connect with the normal patient / family. Shoot the **** about sports with them.

9) leave on time. Every shift. No reason not to. If it's "culture" to stay late you better be getting paid for it. If not, leave or change the culture.

10) all documentation done on shift

 

[Emapp20177]

6) Avoid patients / situations that have a high likelihood of being a disaster.

Agree with 99%, but don't be the person who cherry picks all the easy patients and avoids difficult patients. All patients have to be seen. Do your part.

 

[nVictus]

If you don't like it as a resident... I assure you it's many many times worse as an attending. Get a plan together and get out.

 

[GonnaBeADoc2222]

Agree with 99%, but don't be the person who cherry picks all the easy patients and avoids difficult patients. All patients have to be seen. Do your part.

Why should I when the person next to me is being paid 1.5x more than I am?

 

[EthylMethylMan]

It’s good that you have come to terms with this now. There are options for you. I almost successfully switched to anesthesia in PGY-2 (ultimately fell through because I didn’t have enough ICU rotations at that time), in the end I did a hyperbaric fellowship and haven’t looked back. I found the anesthesia position through the residentswap website. So that’s worth looking into for sure. If you decide on pursuing a swap, read up a little bit on the specialty first so you can write a convincing letter to the receiving PD about your interest in the field. It’ll look better than just saying “I’m diving head-first off the sinking Titanic of EM into your specialty.”

Fellowships are a sound option too. Ultrasound, sim, peds, and a lot of other won’t get you out of the ER. But pain, critical care, hyperbaric, and sports med can get you out of EM 100%, or allow you to go down to part time. There’s also someone on this forum trying to get sleep med to be approved for us.

Whatever you choose, start taking the required steps today. If there are docs at your hospital in the field of your choice, try to schedule a meet and greet. If you could get a rotation in their specialty, it would be good for your application. They could also provide advice for how to get in to their field, and possibly dispel any misconceptions you have about the field.

Good luck, I’m praying for you.

 

[Franzd'Epinay]

in the end I did a hyperbaric fellowship and haven’t looked back.

Fellowships are a sound option too. Ultrasound, sim, peds, and a lot of other won’t get you out of the ER. But pain, critical care, hyperbaric, and sports med can get you out of EM 100%, or allow you to go down to part time. There’s also someone on this forum trying to get sleep med to be approved for us.

Can you comment more about your set up in hyperbarics? Every attending I knew who trained in hyperbarics just worked full-time in the ED.

 

[EthylMethylMan]

Can you comment more about your set up in hyperbarics? Every attending I knew who trained in hyperbarics just worked full-time in the ED.

I’m 100% HBO. A lot of EM-trained HBO docs do a split. Most of my colleagues doing this say they want to keep the EM door open at least a little bit. There also exist some places where you are required to do some EM, either contractually, or because they only have space to schedule you for like 0.4 FTE HBO. But there are a decent amount of jobs that allow you to do just do HBO. This is mostly at busier academic places, which is the kind of job I’m at now.

 

[Arcan57]

Why should I when the person next to me is being paid 1.5x more than I am?

Because having a fear based mindset is damaging and it doesn't take very long for "I don't pick up complex patients because I feel my compensation is unfair" to turn into " I've been avoiding them so long that I don't feel comfortable with them anymore". If your compensation model is such that half-assing it seems like the only viable option, find a new job. Also, if this is a pre-partner thing, being the doc that sucks to work with means that your chances of making it to partner are pretty low.

 

[GonnaBeADoc2222]

Because having a fear based mindset is damaging and it doesn't take very long for "I don't pick up complex patients because I feel my compensation is unfair" to turn into " I've been avoiding them so long that I don't feel comfortable with them anymore". If your compensation model is such that half-assing it seems like the only viable option, find a new job. Also, if this is a pre-partner thing, being the doc that sucks to work with means that your chances of making it to partner are pretty low.

Nope, not fear based. I love medically complex sick patients. Infact, i do all my own procedures while the boomers are farming their hip reductions to Ortho and vascular access to interns.

No reason to pick up a difficult, impossible to disposition, or violent patient when the person next to me earning 100k more. Earn your money old timer.

This isn't pre partner track either. It's an employed pyramid scheme. And there's no better jobs.

 

[Birdstrike]

I am an intern currently regretting my specialty choice in EM.

This was me, intern year. The EM-hive minds kept telling me, "but it'll get better when..." I was foolish enough to make the choice to believe it.

It didn't.

Finally, eight years after graduation from residency, I did a fellowship that the EM-hive minds told me was, "Awful-terrible omg worst-thing-in-the world there-is-nothing-worse OMG-I'd rather-RaThEr kill-myself than do that."

And it turned out to be great. I sleep when its dark out, work when the sunlight is out. I no longer have to live in upside-down world where I'm going to work/family is going to bed, the neighbors are winding down the dinner party, I'm just getting off work. I always feel rested. I never feel jet lagged.

Why do all that? For what?!

Just to get treated like dirt?

In private practice, when you actually have relationship with patients, you're everything to them. In the gigantic ocean of the system which is Emergency Medicine, we as single doctors are a mere microscopic plantkon drifting in the current of 1 billion gallons of water.

I can tell you @iwannabehappyMD : EM is not going to change. If you can be one of these people that somehow adapts and changes your mindset about it, great. It might work for you. But if you're like most people, you'll just regret the decision to stay in it, more and more every year, until one day, you decide it's too late.

I'm not telling you what to do, whether to stay in residency, switch, do an EM fellowship so you can work fewer (or zero) EM shifts.

The only thing I can tell you for certain, is I felt just like you did, 20+ years ago and EM never got any easier. It just got harder as the cumulative weight built up, and even more so, when I started to have a family for whom the lifestyle was a very bad fit.

But I'm just one person, who wasn't put here to spend 35 years in EM. I'm happy I did my 10-year tour of duty. But I thank God it wasn't a single day longer.

Come shadow me for a couple days doing Interventional Pain and you'll be shocked at how the other have live. It's like night and day.

 

[GonnaBeADoc2222]

This was me, intern year. The EM-hive minds kept telling me, "but it'll get better when..." I was foolish enough to make the choice to believe it.

It didn't.

Finally, eight years after graduation from residency, I did a fellowship that the EM-hive minds told me was, "Awful-terrible omg worst-thing-in-the world there-is-nothing-worse OMG-I'd rather-RaThEr kill-myself than do that."

And it turned out to be great. I sleep when its dark out, work when the sunlight is out. I no longer have to live in upside-down world where I'm going to work/family is going to bed, the neighbors are winding down the dinner party, I'm just getting off work. I always feel rested. I never feel jet lagged.

Why do all that? For what?!

Just to get treated like dirt?

In private practice, when you actually have relationship with patients, you're everything to them. In the gigantic ocean of the system which is Emergency Medicine, we as single doctors are a mere microscopic plantkon drifting in the current of 1 billion gallons of water.

I can tell you @iwannabehappyMD : EM is not going to change. If you can be one of these people that somehow adapts and changes your mindset about it, great. It might work for you. But if you're like most people, you'll just regret the decision to stay in it, more and more every year, until one day, you decide it's too late.

I'm not telling you what to do, whether to stay in residency, switch, do an EM fellowship so you can work fewer (or zero) EM shifts.

The only thing I can tell you for certain, is I felt just like you did, 20+ years ago and EM never got any easier. It just got harder as the cumulative weight built up, and even more so, when I started to have a family for whom the lifestyle was a very bad fit.

But I'm just one person, who wasn't put here to spend 35 years in EM. I'm happy I did my 10-year tour of duty. But I thank God it wasn't a single day longer.

Come shadow me for a couple days doing Interventional Pain and you'll be shocked at how the other have live. It's like night and day.

Listen to this man.

I'm one of the ones who adapted their mindsets. Working no nights certainly helps me.

In a different life, I would have course corrected early and done pain.

 

[Birdstrike]

You have no idea how strong the EM-hive mind is. Its persuasive. It's hypnotic.