Miserable in ortho, thinking of switching to EM

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We are different. But so are you and emergent, who likes to talk about the positives of his career 10 years in. And you and whitecoat investor are different, as he likes to focus on the positives.

I'm just more like them than you. So we are all different from you.
TwoGuys is right. No one cares about our personality differences. But as it relates to EM: I've made many posts about the positives of my EM career 10+ years in, and it just so happens I found the most career satisfaction after a fellowship, and now practicing an EM subspecialty. It's not a big deal. It's not even remotely controversial. Different strokes for different folks. It's all good.

But as it relates to this thread: Is my version of EM better than Ortho? I'll repeat what I posted above: "I don't know." The most relevant thing I can say to the guy/gal is that I understand that it's a tough, complicated and very individual decision. Everyone needs to decide for themselves. I wish the OP well. I've been through these career dilemmas, more than once, and it's never easy. I empathize.

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TwoGuys is right. No one cares about our personality differences. But as it relates to EM: I've made many posts about the positives of my EM career 10+ years in, and it just so happens I found the most career satisfaction after a fellowship, and now practicing an EM subspecialty. It's not a big deal. It's not even remotely controversial. Different strokes for different folks. It's all good.

But as it relates to this thread: Is my version of EM better than Ortho? I'll repeat what I posted above: "I don't know." The most relevant thing I can say to the guy/gal is that I understand that it's a tough, complicated and very individual decision. Everyone needs to decide for themselves. I wish the OP well. I've been through these career dilemmas, more than once, and it's never easy. I empathize.

I've read your posts for years - probably even before starting med school. They are almost always a negative slant (i.e. >80%). I've also got to meet with people who feel incredibly grateful to be doing this job even with all the challenges. Our "differences" are simply different philosophies. I will continue to find the hundreds of positives and things that bring me joy/make me excited about the career I'm going into. You can say it's just being naive and that I'm not an attending yet, but I know many with more years experience than you who share my same philosophy. Your posts aren't positive in general, although you may like to think they are. I don't think the negatives you focus on are false, just your own cup of tea.

I never got into this thread to argue against the simple reality that this is an individual decision, completely subjective, and people derive satisfaction from different things. Why I did start dishing out my beliefs is when people try to act like EM sucks, like the only burned out physicians are in EM (quite the contrary, 50% of orthopods are burnt out too), that EM isn't a good field, "don't do it", etc. If people get to $h!t on the field then I will be there to share the positives and all we have to be grateful for. When you posted that post of Emergent who was having a down time in life and momentarily burned out / frustrated - which he explained to you in a previous thread, that was odd. It's like you have it bookmarked or something.

So yes - to the OP. The grass isn't always greener, ortho is challenging, EM is challenging. But I happen to strongly believe, with many other physicians, that this is the greatest specialty in medicine with the greatest people in medicine. I would rather quit medicine then go be a surgeon. EM can be awesome, you just need to find your proper work situation. Many people do and have - unfortunately some don't. But don't blame our specialty for the lack of finding the right situation.

Good luck OP!
 
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How about trying to help the OP or letting this thread die. Somehow you've had 9 posts on this thread without a single one devoted to actually directed toward the OP and all of them directed towards your agenda of "offense."

I guarantee the guy didn't start this thread to hear your opinion on burnout. I'm not trying to pick a fight but c'mon man - move on. You can start a rah-rah EM thread all on its own. I'll even post on it but I can't belive this thread has devolved into the exact same pro-EM vs EM-has cons thread.

That's fine if that's your opinion. I didn't post what I did for you or for the Birds of the world.

I wanted to share with the OP what I think are the best parts of the field and also debunk the idea that everyone is burned out or miserable. Posts like, "Don't do it" are much less helpful than me attempting to articulate why this specialty is great and why it doesn't suck. I think we would be doing him a disservice to have grumpy people sharing their perspectives and not others.

If the OP prefers I not post and not try to articulate the positives of the career, then I will gladly stop and this will be my last post. But I certainly am not writing to entertain the grumpy burnt out physicians who are telling people to run away from EM. That's laughable. It's a great career in medicine, and in America.
 
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I've read your posts for years - probably even before starting med school. They are almost always a negative slant (i.e. >80%). I've also got to meet with people who feel incredibly grateful to be doing this job even with all the challenges. Our "differences" are simply different philosophies. I will continue to find the hundreds of positives and things that bring me joy/make me excited about the career I'm going into. You can say it's just being naive and that I'm not an attending yet, but I know many with more years experience than you who share my same philosophy. Your posts aren't positive in general, although you may like to think they are. I don't think the negatives you focus on are false, just your own cup of tea.

I never got into this thread to argue against the simple reality that this is an individual decision, completely subjective, and people derive satisfaction from different things. Why I did start dishing out my beliefs is when people try to act like EM sucks, like the only burned out physicians are in EM (quite the contrary, 50% of orthopods are burnt out too), that EM isn't a good field, "don't do it", etc. If people get to $h!t on the field then I will be there to share the positives and all we have to be grateful for. When you posted that post of Emergent who was having a down time in life and momentarily burned out / frustrated - which he explained to you in a previous thread, that was odd. It's like you have it bookmarked or something.

So yes - to the OP. The grass isn't always greener, ortho is challenging, EM is challenging. But I happen to strongly believe, with many other physicians, that this is the greatest specialty in medicine with the greatest people in medicine. I would rather quit medicine then go be a surgeon. EM can be awesome, you just need to find your proper work situation. Many people do and have - unfortunately some don't. But don't blame our specialty for the lack of finding the right situation.

Good luck OP!
I'm glad to have you on board, Robinson EM. I mean that. Stick around.
 
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I've read your posts for years - probably even before starting med school. They are almost always a negative slant (i.e. >80%...

This may be more of a sociological post, than medical, but here's an observation related to your comment above and the slant on forums like this one:

A very large amount of this is due to audience reaction and demand. As much as people like to say they want positivity and don't like negative posts or rants, they actually do by a drastic margin and I have proof. For example, a positive post I wrote about a touching "thank you" from a family member (first as an OP on this forums) titled, "A simple thank you makes all the frustration worth it" got 3 comments (all positive) and 162 shares when reposted on KevinMD.com. All in all, not bad.

http://www.kevinmd.com/blog/2014/03/simple-frustration-worth.html

But it's nothing in comparison to when this frustrated rant (also an OP and thread starter here) was cross posted there, "The focus on patient satisfaction is enough to make you sick," which was a much more negative-slanted post, it blew up 80-fold with thirteen THOUSAND ****ing shares and dozens of comments even with the comments closing after only a few days.

http://www.kevinmd.com/blog/2013/11/focus-patient-satisfaction-sick.html

Though a much more "negative slanted" post (actually a watered-down version of a much more unhinged one from two years ago), the comments were almost uniformly positive, and shared 80 times more. This trend follows for nearly all of the posts I've written (I won't bore you with all the links and comment/share numbers) and for nearly all of the other authors on these and other blogs.

A forum like this, just like KevinMD or any other blog, medical or not, will be much like the nightly news. People like and respond to a certain type of content, yet at the same time like to criticize and complain about the slant of that content. Much like the news cast showing a burning neighborhood will get better ratings than the one showing a neighborhood being built, so go the posts on SDN. It says much more about the people watching (and reading) than it does those controlling the programming (or writing).

So I'm not in the least surprised that, on one hand, you say my posts carry a negative slant, yet at the same time you say not only do you read them, you've been doing so for years.

So I could post some more positive posts, which I will when the spirit moves me to do so, to snoozes and yawns. And I'll post some others slanted the other way when I feel it's indicated. And as expected, people will forget the positive ones, and wonder "Why doesn't he post more of them?" Yet they'll read intently, share virally, and remember the "negative" ones, and wonder, "Why did he post so many?"
 
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Thanks all for the thoughtful and very personal comments.

Fortunately, I do have a lot of time to think about this as I'm not applying this year. I don't want to do anything too drastic just yet. Lifestyle is important, and I think I can have a decent lifestyle as an attending in both (ortho residency is brutal, but at the attending level is fairly sustainable. The hours are longer than EM, but mostly in the day when the wife is working too).

I think I struggle more with the content. I thought I would get a lot of joy being the master of one thing, but I've now realized that's not really true for me; I like to know a little of everything, that's how I keep myself interested and engaged. All this minutiae on hairsplitting orthopedic topics from studies with an N=30 is really just eating my soul. When my patient develops an NSTEMI, I always seem to be the only person in my program excited about reading the EKG, and it makes me sad that I've abandoned so much of medicine. I'm not bitter about ortho, just unhappy and find it not really a good fit for me personally, if I do switch to EM I think my ortho training so far would be incredibly useful in a community ED career.

I plan to ruminate for a couple of months and maybe have a discussion with an ED attending I trust at my hospital when I 95% make up my mind.

In the meantime, I would love to hear more "grass isn't greener on the EM side" posts maybe just to give me more perspective that I'm currently not seeing as a PGY2 ortho consult resident envying the guy who consulted me.
 
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Thanks all for the thoughtful and very personal comments.

Fortunately, I do have a lot of time to think about this as I'm not applying this year. I don't want to do anything too drastic just yet. Lifestyle is important, and I think I can have a decent lifestyle as an attending in both (ortho residency is brutal, but at the attending level is fairly sustainable. The hours are longer than EM, but mostly in the day when the wife is working too).

I think I struggle more with the content. I thought I would get a lot of joy being the master of one thing, but I've now realized that's not really true for me; I like to know a little of everything, that's how I keep myself interested and engaged. All this minutiae on hairsplitting orthopedic topics from studies with an N=30 is really just eating my soul. When my patient develops an NSTEMI, I always seem to be the only person in my program excited about reading the EKG, and it makes me sad that I've abandoned so much of medicine. I'm not bitter about ortho, just unhappy and find it not really a good fit for me personally, if I do switch to EM I think my ortho training so far would be incredibly useful in a community ED career.

I plan to ruminate for a couple of months and maybe have a discussion with an ED attending I trust at my hospital when I 95% make up my mind.

In the meantime, I would love to hear more "grass isn't greener on the EM side" posts maybe just to give me more perspective that I'm currently not seeing as a PGY2 ortho consult resident envying the guy who consulted me.


Oh man, in that case...our grass isn't greener. In fact, we barely have grass. We live at the bottom of the valley where everyone's drainage runs off, so it's mostly just mud down here. Fortunately, a lot of us like mud wrestling.
 
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Thanks all for the thoughtful and very personal comments.

Fortunately, I do have a lot of time to think about this as I'm not applying this year. I don't want to do anything too drastic just yet. Lifestyle is important, and I think I can have a decent lifestyle as an attending in both (ortho residency is brutal, but at the attending level is fairly sustainable. The hours are longer than EM, but mostly in the day when the wife is working too).

I think I struggle more with the content. I thought I would get a lot of joy being the master of one thing, but I've now realized that's not really true for me; I like to know a little of everything, that's how I keep myself interested and engaged. All this minutiae on hairsplitting orthopedic topics from studies with an N=30 is really just eating my soul. When my patient develops an NSTEMI, I always seem to be the only person in my program excited about reading the EKG, and it makes me sad that I've abandoned so much of medicine. I'm not bitter about ortho, just unhappy and find it not really a good fit for me personally, if I do switch to EM I think my ortho training so far would be incredibly useful in a community ED career.

I plan to ruminate for a couple of months and maybe have a discussion with an ED attending I trust at my hospital when I 95% make up my mind.

In the meantime, I would love to hear more "grass isn't greener on the EM side" posts maybe just to give me more perspective that I'm currently not seeing as a PGY2 ortho consult resident envying the guy who consulted me.
 
Oh man, in that case...our grass isn't greener. In fact, we barely have grass. We live at the bottom of the valley where everyone's drainage runs off, so it's mostly just mud down here. Fortunately, a lot of us like mud wrestling.

Locum Tenens
 
This may be more of a sociological post, than medical, but here's an observation related to your comment above and the slant on forums like this one:

A very large amount of this is due to audience reaction and demand. As much as people like to say they want positivity and don't like negative posts or rants, they actually do by a drastic margin and I have proof. For example, a positive post I wrote about a touching "thank you" from a family member (first as an OP on this forums) titled, "A simple thank you makes all the frustration worth it" got 3 comments (all positive) and 162 shares when reposted on KevinMD.com. All in all, not bad.

http://www.kevinmd.com/blog/2014/03/simple-frustration-worth.html

But it's nothing in comparison to when this frustrated rant (also an OP and thread starter here) was cross posted there, "The focus on patient satisfaction is enough to make you sick," which was a much more negative-slanted post, it blew up 80-fold with thirteen THOUSAND ****ing shares and dozens of comments even with the comments closing after only a few days.

http://www.kevinmd.com/blog/2013/11/focus-patient-satisfaction-sick.html

Though a much more "negative slanted" post (actually a watered-down version of a much more unhinged one from two years ago), the comments were almost uniformly positive, and shared 80 times more. This trend follows for nearly all of the posts I've written (I won't bore you with all the links and comment/share numbers) and for nearly all of the other authors on these and other blogs.

A forum like this, just like KevinMD or any other blog, medical or not, will be much like the nightly news. People like and respond to a certain type of content, yet at the same time like to criticize and complain about the slant of that content. Much like the news cast showing a burning neighborhood will get better ratings than the one showing a neighborhood being built, so go the posts on SDN. It says much more about the people watching (and reading) than it does those controlling the programming (or writing).

So I'm not in the least surprised that, on one hand, you say my posts carry a negative slant, yet at the same time you say not only do you read them, you've been doing so for years.

So I could post some more positive posts, which I will when the spirit moves me to do so, to snoozes and yawns. And I'll post some others slanted the other way when I feel it's indicated. And as expected, people will forget the positive ones, and wonder "Why doesn't he post more of them?" Yet they'll read intently, share virally, and remember the "negative" ones, and wonder, "Why did he post so many?"

Haha.

So you are tapping into the fact that negativity sells.

So does porn. So does infidelity. Gossip. Back stabbing. Corruption. Theft. Violence. Injustice. Cheating.

How valiant to feed the masses what they yearn for.

Anyway, you're right. My particular slant isn't liked or shared as much. My audience will likely be much much smaller. But I'm fine with that. I'd rather encourage a soul or two than let my words be driven by popularity or acquiring likes. I'll look for the good. Gratitude. Generosity. Selflessness. Encouragement. Honor. Contribution.

Anyway, you win. Congrats. This will be my last post.:thumbup:

Feel free to tell us everything you can find that is negative about this career. Why we should not do it, how bad we have it and how what others are doing is much better. How we have been dealt a bad hand in life and how great life will be when we can stop doing this. Keep up the good fight and don't lose hope pessimism.
 
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Haha.

So you are tapping into the fact that negativity sells.

So does porn. So does infidelity. Gossip. Back stabbing. Corruption. Theft. Violence. Injustice. Cheating.

How valiant to feed the masses what they yearn for.

Keep up the good fight and don't lose hope pessimism.

Did I see earlier in this thread that you're a med student?
 
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Thanks all for the thoughtful and very personal comments.

Fortunately, I do have a lot of time to think about this as I'm not applying this year. I don't want to do anything too drastic just yet. Lifestyle is important, and I think I can have a decent lifestyle as an attending in both (ortho residency is brutal, but at the attending level is fairly sustainable. The hours are longer than EM, but mostly in the day when the wife is working too).

I think I struggle more with the content. I thought I would get a lot of joy being the master of one thing, but I've now realized that's not really true for me; I like to know a little of everything, that's how I keep myself interested and engaged. All this minutiae on hairsplitting orthopedic topics from studies with an N=30 is really just eating my soul. When my patient develops an NSTEMI, I always seem to be the only person in my program excited about reading the EKG, and it makes me sad that I've abandoned so much of medicine. I'm not bitter about ortho, just unhappy and find it not really a good fit for me personally, if I do switch to EM I think my ortho training so far would be incredibly useful in a community ED career.

I plan to ruminate for a couple of months and maybe have a discussion with an ED attending I trust at my hospital when I 95% make up my mind.

In the meantime, I would love to hear more "grass isn't greener on the EM side" posts maybe just to give me more perspective that I'm currently not seeing as a PGY2 ortho consult resident envying the guy who consulted me.

I think I'm like you. I wanted to like Ortho, did a rotation in it and I did like it, but I didn't love it. Just like you, when I was doing Ortho, I missed the rest of medicine. I also really liked Cardiology, and even OBGYN but ultimately chose EM. I Do envy the specialist or surgeon sometimes, but overall I'm very happy. I don't think it's a bad idea to consider the switch. Good luck to you!
 
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Sometimes people need forums like this when they're having a bad day, tough stretch in residency (like the OP), or are stuck in a rut with a job. It can help them to vent, and help others to hear that someone else is going through something similar. It serves a real purpose, and a positive one, for many people. Though it can seem overwhelming to med students and physician hopefuls, and is in no way an objective balance of career pro's and con's, such expression serves a purpose to many. It's not just pointless negativity to everyone. When someone comes to this board and expresses going through a difficult time, often I'm one of the first to try to offer encouraging advice. Though in the eyes of some, even acknowledging someone's difficult time is a "negative" and the only valid response is to discount that there's any reason to have difficulty, dismiss their problem and brush it under the rug by saying, "You don't know how good you have it."

It helps to discuss interesting cases, the things we're thankful for and inspirational patient encounters, for sure. But all the threads on here with their varied themes and degrees of positivity or negativity, serve a purpose. Most, if not all of the people on here, found ourselves on this forum due to a common, shared interest, and dare I say, "love" for certain aspects of Emergency Medicine at some point in our lives. For the most part, for those of us deep in the weeds of this profession of Medicine, those very substantial positives are understood and often go unsaid, even though many of us have different versions of them. Medicine can be a great career. Emergency Medicine has many positives. I think to most of us on here, those statements are obvious and go without saying.

Although it's often as appetizing as watching sausage being made, I think it helps the younger folk to have a forum like this to come to, to hear some of the darker truths that some recruiting mentors don't want to spill in person (for fear that they'll be labeled burned out, negative or Debbie Downers). Yet, at the same time, it helps the jaded, cynical and grizzled veterans amongst us to be reminded by the younger folks on here how far we've come, how good we do have it, and how not to lose touch with the youthful hope and optimism we once had in such abundance.
 
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I think this thread is so popular because many current EM people were in the ortho vs. EM crew back in medical school and perhaps some of you regret your current decision
 
Dont do it. Ortho residency/fellowship is painful for the next 4-5 years. EM will be painful for the rest of your working life.

Thats not even taking into consideration that orthos probably make 3x what an er doc makes.

This.

Ortho - or any sort of surgery - would have been the wrong choice for me but what erdoc has said here is the truth.
 
But I just don't see EM medicine as intense as any other field. I guess I have the personality for EM. I would be burned out doing Gas watching the dam machine all day in a cold bright room. Forget about it.

I just worked a FSED shift and in 12 hrs saw 7 pts with quick care complaints. I would get burned out from sheer boredom

You are confusing boredom and burnout. They aren't the same thing.
 
From a fourth year medical student's perspective, I think it borders on disrespectful to discount the input of attendings that are actually in the trenches. We can all parrot back "I know a guy/attending..." That means zilch to me. I want to hear it straight from attendings. And who's to say that what these attendings are telling you in person is even their candid opinion? Speaking about the realities of any profession especially if it encompasses the negative aspects can be a provocative and taboo topic when talked about in person especially around other health care professionals.
 
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Just an MS3 here, but I agree with the sentiment that birdstrike mentioned-helps us (old and young) appreciate the other side. I feel its the same thing when i mentor premed students-every single one of them is bright-eyed bushy tailed over everything. "OMG! PBL (problem based learning) is like the greatest thing ever! I love PBL! Problems and I get to learn from them! I REALLY HOPE I GET INTO A MED SCHOOL WITH PBL!"...and then most of us in school are like...gah...gotta wake up early to go to PBL discussions...great...why can't i just read at home....blech. sometimes its pretty easy to forget why we're here in the first place.

That said, my thoughts on the ortho/em situation--I think you need to find what you like the most.
Ortho: OR time. woo hoo. A little more of a controlled environment (unless trauma), likely "cleaner"
(tbh, don't know much about ortho. that said, never really cared for it much anyway...)
EM: Ability to be the first to treat/diagnose/differentiate. Fast paced, gogogogogogo, and resuscitations.


An attending told me that work-life balance is what you make of it. I think most would probably(?) agree. I've seen plenty of EM attendings work nonstop all week/month/year long, and then you have others who take a week of vacay each month. To each their own. I think for the OP, what needs to be done is to have an idea of what you envision your future to be, and to pursue it? Obviously this changes a lot over time, but you really can't make a decision until you have a good idea of what you envision your future to be. Residency is not forever, and tbh, i don't think its that big of a difference in terms of length, esp that a fair number of EM grads go into fellowship these days...
 
uhhh...what just happened? Is this attention-seeking behavior?
 
For the pre-meds and med students who need affirmation, here's the best I can do:

I personally (just one person!) think the future of Medicine actually is bright. Though Obamacare has created some adjustments and tough changes, and despite all the talk otherwise, it has and will largely preserve the fee-for-service system that has benefitted, and will continue to benefit doctors greatly. I personally think the brightest pathway is this:

1-Keep medical school debt as low as possible and,

2-Choose the highest paying, lowest-stress, most lifestyle-oriented specialty that you think you'll like.

You can argue amongst yourselves as to what is high paying enough, low enough stress for you, and what is a "lifestyle oriented" specialty to you, individually. But in my single, measly opinion of one, to the extent that anyone cares, that's the best formula. I don't doubt there are other pathways to find success and fulfillment for many people. But after nearly 20 years of first being a volunteer, pre-med, medical student, resident, attending, fellow, then attending again in an EM subspecialty, that's my personal opinion as seen through my own personal filter. It hasn't always been perfect. There's been bumps along the road (which I do yes, disproportionally write more about). But I personally, do see it working out very well for me, for the remaining 20-25 years of my career. I don't regret becoming a doctor. I'm quite happy I did. If the outlook changes, and all of a sudden, things look more dim, I won't hesitate to come here and say that. But as of right now, and into the forseable future, that's my honest opinion.
 
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From a fourth year medical student's perspective, I think it borders on disrespectful to discount the input of attendings that are actually in the trenches. We can all parrot back "I know a guy/attending..." That means zilch to me. I want to hear it straight from attendings. And who's to say that what these attendings are telling you in person is even their candid opinion? Speaking about the realities of any profession especially if it encompasses the negative aspects can be a provocative and taboo topic when talked about in person especially around other health care professionals.
"Like" times 1,000
 
From a fourth year medical student's perspective, I think it borders on disrespectful to discount the input of attendings that are actually in the trenches. We can all parrot back "I know a guy/attending..." That means zilch to me. I want to hear it straight from attendings.

Wise.

"Human beings, who are almost unique in having the ability to learn from the experience of others, are also remarkable for their apparent disinclination to do so."
 
Don't over think this, people:

http://t.co/5rhSUjHIWm

to dovetail off of that...

https://www.garyvaynerchuk.com/on-having-too-many-choices-870135108.html

"Here is my advice: at some point, you have to put your big boy pants on and say “I’ve made this decision” and you move on. The “buyers regret”, or remorse, or thinking “Did I do the right thing” is never going to be helpful. Because guess what? Every option will get you SOMETHING. That something could be a return on an investment, or it could be a lesson learned. Doesn’t matter. You’re never going to be left with zero results. That is my advice to you. Suck it up. Make the call."
 
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Well I made the switch from orthopaedics to EM.... shoot me a PM

Orthopaedic residency decimated my family relationships (my wife is still bitter), gained 30 lbs, the call was ridiculous , and those are just the highlights. Chronic sleep deprivation.

EM residency feels like a vacation and I am beyond grateful that I made the switch. Are there some negatives in EM? Of course, but for me they fall into the non-consequential category. Continue rocking out your current position, talk to a few EM attendings. Choose these wisely, because if it gets out that you are looking to switch it can only hurt you with your current program. Nothing much else riles an attending like explicitly stating that you don't want to do what they have done.

Money isn't everything.

I love what I do; occasionally save a life; my children recognize my face; and I do what I liked best about orthopaedics other than operative fixation, acute fracture management.

It is your life. It is short. Too short to be miserable and be treated miserably no matter what the compensation or prestige.
 
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Well I made the switch from orthopaedics to EM.... shoot me a PM

Orthopaedic residency decimated my family relationships (my wife is still bitter), gained 30 lbs, the call was ridiculous , and those are just the highlights. Chronic sleep deprivation.

EM residency feels like a vacation and I am beyond grateful that I made the switch. Are there some negatives in EM? Of course, but for me they fall into the non-consequential category. Continue rocking out your current position, talk to a few EM attendings. Choose these wisely, because if it gets out that you are looking to switch it can only hurt you with your current program. Nothing much else riles an attending like explicitly stating that you don't want to do what they have done.

Money isn't everything.

I love what I do; occasionally save a life; my children recognize my face; and I do what I liked best about orthopaedics other than operative fixation, acute fracture management.

It is your life. It is short. Too short to be miserable and be treated miserably no matter what the compensation or prestige.

Just curious... are you still a resident or are you now an attending and if so for how long?

My observations as an attending are much different than when I was a resident. As a resident I didn't mind working overnight and switching back and forth. I could even work 6 Twelve-hour shifts straight and not care. As an attending, though, a lot of that changed for me. I started to hate working nights because of the flipping back and forth. And when I worked only nights to avoid this, I started to become really bored because nobody else was up when I was. And as far as working shifts in a row... now I'm burned out if I work anything more than 3 in a row. I also hated missing holidays with my family.

Being out of residency, I'd encourage people to think about your lifestyle 10-15 years out from residency. When we're stuck as underpaid slaves to the residency program, we're all jaded and burned out. I could've easily walked away from medicine completely if I wasn't burdened by my loans. Is EM residency better than orthopedic residency... yes, by a mile... at least for the first few years.

But when you graduate and begin to practice, what will your life be like then?

As an attending in EM, my feelings are that we are treated like the grunts of the hospital. Every day is a challenge of uncontrollable chaos and even "good" days are darkened by the thought (read: previously experienced) that you are only one neonatal code, pregnant MVA, or multi-trauma away from having a terrible day... it can happen at any time. Most days are treating the worried well. Rarely do we do an actual intervention that is meaningful. We are forced to retain a knowledge base that is probably one of the most challenging in medicine... not only is the breadth of knowledge basically the entirety of medicine, but because we rarely encounter these problems clinically, retaining the knowledge is unbelievably more complicated than it should be.

In comparison to ortho, I've never been an orthopedic surgeon obviously. But what I see in orthopedics are things that I think are overall much better for one's lifestyle long term. The hours are relatively stable and your day is relatively predictable. Yes obviously when you're on call, that changes this. But on a day to day basis, you likely know what you'll be doing tomorrow and when you show up for work will more often than not have a predictable sequence to your day. I personally never appreciated this until working in the ER where the prospect of walking into a full house with 15 deep in the waiting room or having a "slow" shift turn terrible when an ambulance call goes out for a 4 vehicle MVA is enough of a frequent occurrence that every shift is a PTSD-inducing event. Also, even when you're on-call in ortho, that's a 24 hour circadian "shift"... when it's over you're still back on a day schedule even if you didn't get any sleep. You haven't had enough circadian disruption to be off schedule, to the point where your body can no longer recognize if it should be awake or sleeping; this is something that is frequently encountered when doing night/day shift transitions... and the longer you do it, the worse it gets.

The other major factor, in my personal opinion, is that in ortho, you're dealing with a known problem or a problem with relatively few causes. As an orthopedic surgeon, your role is that of fixing things and much less of solving undifferentiated problems. For me, I greatly underestimated this and how it impacts my sense of well-being... and this brings me to my main point and most important thing I can say:

Overwhelmingly, the biggest cause of dissatisfaction I have in EM, is dealing with the cognitive burden of having to rapidly solve undifferentiated complaints all day (often without any breaks) in a population of patients where it is unlikely they have life threatening problems and in a system that wants to restrict unnecessary cost but will not allow for even low percentage "misses."


The "unknown" of EM is essentially what makes it so much more intolerable. In specialties like Ortho, this is much less of a problem since you're limiting the scope of potential problems and typically your role as a surgeon is not one of "undifferentiated problem solving" but more of "performing a service" or "fixing a known problem." Also, when you are a specialist like ortho, you have a very limited scope of knowledge but very deep understanding of that scope. From a cognitive perspective, this is a much easier task since it's all relatively related information. Can you get "burned out" in ortho? Absolutely... but when I look at my ortho attending colleagues, it doesn't seem their default is a state of unhappiness and burnout. In EM, it seems like the rule is to be jaded and burned out and the exception is the happy ER doc... and they are usually only happy because they have a unicorn job as a partner in a group that works in a hospital where they can call the shots.

From my personal perspective, unless you detest operating, Orthopedics is far and away the better option. You will call your own shots and not be bullied by hospitals or other physicians. You will have a relatively straightforward/predictable daily schedule. It is low cognitive burden compared to EM. You will do some of the greatest quality of life improvement in medicine. You'll also happen to make some of the most money in medicine (least important IMO). Don't make the mistake of judging a specialty by how difficult/unfavorable the residency is.
 
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Just curious... are you still a resident or are you now an attending and if so for how long?

My observations as an attending are much different than when I was a resident. As a resident I didn't mind working overnight and switching back and forth. I could even work 6 Twelve-hour shifts straight and not care. As an attending, though, a lot of that changed for me. I started to hate working nights because of the flipping back and forth. And when I worked only nights to avoid this, I started to become really bored because nobody else was up when I was. And as far as working shifts in a row... now I'm burned out if I work anything more than 3 in a row. I also hated missing holidays with my family.

Being out of residency, I'd encourage people to think about your lifestyle 10-15 years out from residency. When we're stuck as underpaid slaves to the residency program, we're all jaded and burned out. I could've easily walked away from medicine completely if I wasn't burdened by my loans. Is EM residency better than orthopedic residency... yes, by a mile... at least for the first few years.

But when you graduate and begin to practice, what will your life be like then?

As an attending in EM, my feelings are that we are treated like the grunts of the hospital. Every day is a challenge of uncontrollable chaos and even "good" days are darkened by the thought (read: previously experienced) that you are only one neonatal code, pregnant MVA, or multi-trauma away from having a terrible day... it can happen at any time. Most days are treating the worried well. Rarely do we do an actual intervention that is meaningful. We are forced to retain a knowledge base that is probably one of the most challenging in medicine... not only is the breadth of knowledge basically the entirety of medicine, but because we rarely encounter these problems clinically, retaining the knowledge is unbelievably more complicated than it should be.

In comparison to ortho, I've never been an orthopedic surgeon obviously. But what I see in orthopedics are things that I think are overall much better for one's lifestyle long term. The hours are relatively stable and your day is relatively predictable. Yes obviously when you're on call, that changes this. But on a day to day basis, you likely know what you'll be doing tomorrow and when you show up for work will more often than not have a predictable sequence to your day. I personally never appreciated this until working in the ER where the prospect of walking into a full house with 15 deep in the waiting room or having a "slow" shift turn terrible when an ambulance call goes out for a 4 vehicle MVA is enough of a frequent occurrence that every shift is a PTSD-inducing event. Also, even when you're on-call in ortho, that's a 24 hour circadian "shift"... when it's over you're still back on a day schedule even if you didn't get any sleep. You haven't had enough circadian disruption to be off schedule, to the point where your body can no longer recognize if it should be awake or sleeping; this is something that is frequently encountered when doing night/day shift transitions... and the longer you do it, the worse it gets.

The other major factor, in my personal opinion, is that in ortho, you're dealing with a known problem or a problem with relatively few causes. As an orthopedic surgeon, your role is that of fixing things and much less of solving undifferentiated problems. For me, I greatly underestimated this and how it impacts my sense of well-being... and this brings me to my main point and most important thing I can say:

Overwhelmingly, the biggest cause of dissatisfaction I have in EM, is dealing with the cognitive burden of having to rapidly solve undifferentiated complaints all day (often without any breaks) in a population of patients where it is unlikely they have life threatening problems and in a system that wants to restrict unnecessary cost but will not allow for even low percentage "misses."


The "unknown" of EM is essentially what makes it so much more intolerable. In specialties like Ortho, this is much less of a problem since you're limiting the scope of potential problems and typically your role as a surgeon is not one of "undifferentiated problem solving" but more of "performing a service" or "fixing a known problem." Also, when you are a specialist like ortho, you have a very limited scope of knowledge but very deep understanding of that scope. From a cognitive perspective, this is a much easier task since it's all relatively related information. Can you get "burned out" in ortho? Absolutely... but when I look at my ortho attending colleagues, it doesn't seem their default is a state of unhappiness and burnout. In EM, it seems like the rule is to be jaded and burned out and the exception is the happy ER doc... and they are usually only happy because they have a unicorn job as a partner in a group that works in a hospital where they can call the shots.

From my personal perspective, unless you detest operating, Orthopedics is far and away the better option. You will call your own shots and not be bullied by hospitals or other physicians. You will have a relatively straightforward/predictable daily schedule. It is low cognitive burden compared to EM. You will do some of the greatest quality of life improvement in medicine. You'll also happen to make some of the most money in medicine (least important IMO). Don't make the mistake of judging a specialty by how difficult/unfavorable the residency is.
What is your response to the people that say, "Just change jobs, cut back your hours, pay someone to do your nights, and all will be well"?
 
What is your response to the people that say, "Just change jobs, cut back your hours, pay someone to do your nights, and all will be well"?

My response is that the everyone is different. EM works for some people. For the people that it doesn't work for, some of the solutions are "change jobs" or "cut back hours" or "pay someone to do your nights". But these are only temporizing measures if you really don't enjoy the work.

I personally have cut back to part-time, around 72 hours a month in order to make it work. The only reason this works is because it's a few enough shifts that I can justify getting beaten up at work by enjoying the fact that I have most of the month off to do whatever else in life I like. So in my situation, EM is actually a better lifestyle fit for me than ortho. But people need to realize it's a huge pay cut and that it's not "Doctor money." With that said, there are few other positions in life that you can work so few days and make a very good living. So for that, I'm quite thankful. The caveat, though, is that I don't have kids I need to pay for and I don't get to live a "doctor's lifestyle" from a wealth perspective.

The bottom line for me is that full-time EM is not for me. I think too much and worry too much. I also like to spend time with patient's and look at each encounter as an intellectual challenge. This mentality doesn't fit in emergency medicine. I've worked enough places to know that while certain aspects can change, overall emergency medicine is very similar regardless of where you practice. The common threads in nearly every ER/ED are:

1.) They are understaffed: For as much as everyone wants to get wait times down and patient satisfaction up, the bottom line is that nobody wants to actually pay for it. Not enough techs, not enough nurses, and not enough doctors. Also, in my personal opinion 1.5 pts/hr is the maximum any doctor should see at a busy ER with moderate-to-high acuity. But again, nobody wants to pay for it and doctors don't want to take a pay cut.

2.) You are the grunt of the hospital: From an administrative standpoint, nobody really cares about what you have to think. All the hospital cares about is that you don't piss people off and keep people out of the waiting room. You can be the biggest ***** to ever graduate from medical school, but as long as you get along with staff and pay lip service to all of your patients, they could not care less how poor the quality of medicine you practice. i.e... as long as you don't affect their bottom line and don't rock the boat, you're a golden child.

3.) The patient are the same everywhere: I used to think that maybe different parts of the country would be different, but the patient's are the same everywhere. East coast, west coast, mid west... liberal, conservative... rich, poor... the ER patients don't ever change. Your average patient is entitled, frustrated, and doesn't really care what you think so long as you just do what they want. Many patient's have personality disorders... many patient's have agendas... and just about everyone has a sense of entitlement of what they "deserve" while in the ER. This used to not be such a big issue when physician's were treated as professionals. But in the current consumer/business-driven EM model, it's a nearly intolerable environment to work in. As hospitals continue to kowtow to every single patient and their complaints, it's gotten to the point where you might as well just hand them a menu and let them order whatever they want.

4.) Just about every physician hates the ER and doctors in it: I remember being told in residency "Once you're out in the community, things will be better. Specialists will want the consults because it means more money for them." Well I can tell you that this is false. In the community, in academics, in the county... one universal truth still exists: People don't want to work more than they already are. Every time you call another doctor, it means more work for them. They all hate the ER. The hospitalists hate the ER, the general surgeons hate the ER, the ophthalmologists hate the ER, the ENTs hate the ER, the orthopedists hate the ER... It starts to really get old when every admission or consult becomes an argumentative debate about "appropriateness" or "need" of the admission or consultation. And because this is an essential part of EM practice, it will never go away.

5.) There isn't time to do anything other than see patients: This may sound like whining, but it starts to really get old when you are at work for 12 hours and the "norm" is that you aren't going to be able to take a break to eat, pee, have a BM, drink water, or any other essential life task. In your average ER, you are busy from shift begin to shift end. I am so envious of any job where people aren't nose-to-the-grindstone for every single second of their work day. Yes we get paid good money, but that's because we have literally zero time to do anything else while at work.


These are my personal feeling and observations of EM. I think the people that are most happy in emergency medicine are people that are able to take the work at face value (cog in the machine of modern medicine), don't mind being involved as a businessperson/waiter of medicine, don't mind kowtowing to patients/consultants/administration, and don't mind being wrong or missing diagnoses. Or they work in a unicorn job that is not representative of actual emergency medicine.

At the risk of being inflammatory, I really feel that if you have intellectual tendencies, try to act in a moral and ethical manner, and a generally desire to provide the most exceptional care possible, emergency medicine burns you out very quickly. You can only work in a broken system and deal with *****s for so long before the infrastructure of your sanity starts to self-destruct.

Sorry for the rant, but hopefully this helps somebody trying to make decisions about specialty...
 
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My response is that the everyone is different. EM works for some people. For the people that it doesn't work for, some of the solutions are "change jobs" or "cut back hours" or "pay someone to do your nights". But these are only temporizing measures if you really don't enjoy the work.

I personally have cut back to part-time, around 72 hours a month in order to make it work. The only reason this works is because it's a few enough shifts that I can justify getting beaten up at work by enjoying the fact that I have most of the month off to do whatever else in life I like. So in my situation, EM is actually a better lifestyle fit for me than ortho. But people need to realize it's a huge pay cut and that it's not "Doctor money." With that said, there are few other positions in life that you can work so few days and make a very good living. So for that, I'm quite thankful. The caveat, though, is that I don't have kids I need to pay for and I don't get to live a "doctor's lifestyle" from a wealth perspective.

The bottom line for me is that full-time EM is not for me. I think too much and worry too much. I also like to spend time with patient's and look at each encounter as an intellectual challenge. This mentality doesn't fit in emergency medicine. I've worked enough places to know that while certain aspects can change, overall emergency medicine is very similar regardless of where you practice. The common threads in nearly every ER/ED are:

1.) They are understaffed: For as much as everyone wants to get wait times down and patient satisfaction up, the bottom line is that nobody wants to actually pay for it. Not enough techs, not enough nurses, and not enough doctors. Also, in my personal opinion 1.5 pts/hr is the maximum any doctor should see at a busy ER with moderate-to-high acuity. But again, nobody wants to pay for it and doctors don't want to take a pay cut.

2.) You are the grunt of the hospital: From an administrative standpoint, nobody really cares about what you have to think. All the hospital cares about is that you don't piss people off and keep people out of the waiting room. You can be the biggest ***** to ever graduate from medical school, but as long as you get along with staff and pay lip service to all of your patients, they could not care less how poor the quality of medicine you practice. i.e... as long as you don't affect their bottom line and don't rock the boat, you're a golden child.

3.) The patient are the same everywhere: I used to think that maybe different parts of the country would be different, but the patient's are the same everywhere. East coast, west coast, mid west... liberal, conservative... rich, poor... the ER patients don't ever change. Your average patient is entitled, frustrated, and doesn't really care what you think so long as you just do what they want. Many patient's have personality disorders... many patient's have agendas... and just about everyone has a sense of entitlement of what they "deserve" while in the ER. This used to not be such a big issue when physician's were treated as professionals. But in the current consumer/business-driven EM model, it's a nearly intolerable environment to work in. As hospitals continue to kowtow to every single patient and their complaints, it's gotten to the point where you might as well just hand them a menu and let them order whatever they want.

4.) Just about every physician hates the ER and doctors in it: I remember being told in residency "Once you're out in the community, things will be better. Specialists will want the consults because it means more money for them." Well I can tell you that this is false. In the community, in academics, in the county... one universal truth still exists: People don't want to work more than they already are. Every time you call another doctor, it means more work for them. They all hate the ER. The hospitalists hate the ER, the general surgeons hate the ER, the ophthalmologists hate the ER, the ENTs hate the ER, the orthopedists hate the ER... It starts to really get old when every admission or consult becomes an argumentative debate about "appropriateness" or "need" of the admission or consultation. And because this is an essential part of EM practice, it will never go away.

5.) There isn't time to do anything other than see patients: This may sound like whining, but it starts to really get old when you are at work for 12 hours and the "norm" is that you aren't going to be able to take a break to eat, pee, have a BM, drink water, or any other essential life task. In your average ER, you are busy from shift begin to shift end. I am so envious of any job where people aren't nose-to-the-grindstone for every single second of their work day. Yes we get paid good money, but that's because we have literally zero time to do anything else while at work.


These are my personal feeling and observations of EM. I think the people that are most happy in emergency medicine are people that are able to take the work at face value (cog in the machine of modern medicine), don't mind being involved as a businessperson/waiter of medicine, don't mind kowtowing to patients/consultants/administration, and don't mind being wrong or missing diagnoses. Or they work in a unicorn job that is not representative of actual emergency medicine.

At the risk of being inflammatory, I really feel that if you have intellectual tendencies, try to act in a moral and ethical manner, and a generally desire to provide the most exceptional care possible, emergency medicine burns you out very quickly. You can only work in a broken system and deal with *****s for so long before the infrastructure of your sanity starts to self-destruct.

Sorry for the rant, but hopefully this helps somebody trying to make decisions about specialty...


I feel sorry that EM has worn your down this much. It is true that EM is not for everyone. It takes a certain personality to like it. But this is true with all medical fields. I would not be happy doing 80% of other fields, be happy in about 5 %, and be OK in the other 15%.

I have been doing this for 15 yrs. I have had times when I was burned out and did not want to go to work. But overall, I am blessed to be able to work 15 days a month and make in the top 1% of income. My job is also super stable and will never need to worry about losing my job. Alot of what you say is true and some I disagree with. But nothing you state really bothers me.

But I am tired after some shift. Some shift worse than others. But I take a step back and my job is better than 90% of what is out there. It is hard for me to complain from this perspective.
 
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My response is that the everyone is different. EM works for some people. For the people that it doesn't work for, some of the solutions are "change jobs" or "cut back hours" or "pay someone to do your nights". But these are only temporizing measures if you really don't enjoy the work.

I personally have cut back to part-time, around 72 hours a month in order to make it work. The only reason this works is because it's a few enough shifts that I can justify getting beaten up at work by enjoying the fact that I have most of the month off to do whatever else in life I like. So in my situation, EM is actually a better lifestyle fit for me than ortho. But people need to realize it's a huge pay cut and that it's not "Doctor money." With that said, there are few other positions in life that you can work so few days and make a very good living. So for that, I'm quite thankful. The caveat, though, is that I don't have kids I need to pay for and I don't get to live a "doctor's lifestyle" from a wealth perspective.

The bottom line for me is that full-time EM is not for me. I think too much and worry too much. I also like to spend time with patient's and look at each encounter as an intellectual challenge. This mentality doesn't fit in emergency medicine. I've worked enough places to know that while certain aspects can change, overall emergency medicine is very similar regardless of where you practice. The common threads in nearly every ER/ED are:

1.) They are understaffed: For as much as everyone wants to get wait times down and patient satisfaction up, the bottom line is that nobody wants to actually pay for it. Not enough techs, not enough nurses, and not enough doctors. Also, in my personal opinion 1.5 pts/hr is the maximum any doctor should see at a busy ER with moderate-to-high acuity. But again, nobody wants to pay for it and doctors don't want to take a pay cut.

2.) You are the grunt of the hospital: From an administrative standpoint, nobody really cares about what you have to think. All the hospital cares about is that you don't piss people off and keep people out of the waiting room. You can be the biggest ***** to ever graduate from medical school, but as long as you get along with staff and pay lip service to all of your patients, they could not care less how poor the quality of medicine you practice. i.e... as long as you don't affect their bottom line and don't rock the boat, you're a golden child.

3.) The patient are the same everywhere: I used to think that maybe different parts of the country would be different, but the patient's are the same everywhere. East coast, west coast, mid west... liberal, conservative... rich, poor... the ER patients don't ever change. Your average patient is entitled, frustrated, and doesn't really care what you think so long as you just do what they want. Many patient's have personality disorders... many patient's have agendas... and just about everyone has a sense of entitlement of what they "deserve" while in the ER. This used to not be such a big issue when physician's were treated as professionals. But in the current consumer/business-driven EM model, it's a nearly intolerable environment to work in. As hospitals continue to kowtow to every single patient and their complaints, it's gotten to the point where you might as well just hand them a menu and let them order whatever they want.

4.) Just about every physician hates the ER and doctors in it: I remember being told in residency "Once you're out in the community, things will be better. Specialists will want the consults because it means more money for them." Well I can tell you that this is false. In the community, in academics, in the county... one universal truth still exists: People don't want to work more than they already are. Every time you call another doctor, it means more work for them. They all hate the ER. The hospitalists hate the ER, the general surgeons hate the ER, the ophthalmologists hate the ER, the ENTs hate the ER, the orthopedists hate the ER... It starts to really get old when every admission or consult becomes an argumentative debate about "appropriateness" or "need" of the admission or consultation. And because this is an essential part of EM practice, it will never go away.

5.) There isn't time to do anything other than see patients: This may sound like whining, but it starts to really get old when you are at work for 12 hours and the "norm" is that you aren't going to be able to take a break to eat, pee, have a BM, drink water, or any other essential life task. In your average ER, you are busy from shift begin to shift end. I am so envious of any job where people aren't nose-to-the-grindstone for every single second of their work day. Yes we get paid good money, but that's because we have literally zero time to do anything else while at work.


These are my personal feeling and observations of EM. I think the people that are most happy in emergency medicine are people that are able to take the work at face value (cog in the machine of modern medicine), don't mind being involved as a businessperson/waiter of medicine, don't mind kowtowing to patients/consultants/administration, and don't mind being wrong or missing diagnoses. Or they work in a unicorn job that is not representative of actual emergency medicine.

At the risk of being inflammatory, I really feel that if you have intellectual tendencies, try to act in a moral and ethical manner, and a generally desire to provide the most exceptional care possible, emergency medicine burns you out very quickly. You can only work in a broken system and deal with *****s for so long before the infrastructure of your sanity starts to self-destruct.

Sorry for the rant, but hopefully this helps somebody trying to make decisions about specialty...
Edwin Leap posted an interesting post yesterday, echoing your thoughts in his own way. He writes essentially that all specialties of Medicine have gotten burned out and to the greatest extent they're able, have opted out of anything that doesn't fit into the 8-5 Mon-Friday mold, including jettisoning as much night-call duties as possible, leaving ER physicians in the lurch:

http://www.kevinmd.com/blog/2014/12/american-hospital-know-peril.html
 
Very grateful for the opinions and perspectives posted.

Not to hijack, and because I think it's somewhat relevant: is it overly naive to hope to find places near decently-sized cities -- maybe a couple hundred of thousand people, not millions -- where it's not so breakneck that you'll actually have time to keep caught up on charts? To stay well south of our own ACEP's recommendation on patients per hour without ridiculous acuity and still have it be an otherwise solid job?

Feel like expectation versus reality shapes much about whether we are happy with what we do and quality of life -- including jobs within a specialty, not just across specialties.
 
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My response is that the everyone is different. EM works for some people. For the people that it doesn't work for, some of the solutions are "change jobs" or "cut back hours" or "pay someone to do your nights". But these are only temporizing measures if you really don't enjoy the work.

I personally have cut back to part-time, around 72 hours a month in order to make it work. The only reason this works is because it's a few enough shifts that I can justify getting beaten up at work by enjoying the fact that I have most of the month off to do whatever else in life I like. So in my situation, EM is actually a better lifestyle fit for me than ortho. But people need to realize it's a huge pay cut and that it's not "Doctor money." With that said, there are few other positions in life that you can work so few days and make a very good living. So for that, I'm quite thankful. The caveat, though, is that I don't have kids I need to pay for and I don't get to live a "doctor's lifestyle" from a wealth perspective.

The bottom line for me is that full-time EM is not for me. I think too much and worry too much. I also like to spend time with patient's and look at each encounter as an intellectual challenge. This mentality doesn't fit in emergency medicine. I've worked enough places to know that while certain aspects can change, overall emergency medicine is very similar regardless of where you practice. The common threads in nearly every ER/ED are:

1.) They are understaffed: For as much as everyone wants to get wait times down and patient satisfaction up, the bottom line is that nobody wants to actually pay for it. Not enough techs, not enough nurses, and not enough doctors. Also, in my personal opinion 1.5 pts/hr is the maximum any doctor should see at a busy ER with moderate-to-high acuity. But again, nobody wants to pay for it and doctors don't want to take a pay cut.

2.) You are the grunt of the hospital: From an administrative standpoint, nobody really cares about what you have to think. All the hospital cares about is that you don't piss people off and keep people out of the waiting room. You can be the biggest ***** to ever graduate from medical school, but as long as you get along with staff and pay lip service to all of your patients, they could not care less how poor the quality of medicine you practice. i.e... as long as you don't affect their bottom line and don't rock the boat, you're a golden child.

3.) The patient are the same everywhere: I used to think that maybe different parts of the country would be different, but the patient's are the same everywhere. East coast, west coast, mid west... liberal, conservative... rich, poor... the ER patients don't ever change. Your average patient is entitled, frustrated, and doesn't really care what you think so long as you just do what they want. Many patient's have personality disorders... many patient's have agendas... and just about everyone has a sense of entitlement of what they "deserve" while in the ER. This used to not be such a big issue when physician's were treated as professionals. But in the current consumer/business-driven EM model, it's a nearly intolerable environment to work in. As hospitals continue to kowtow to every single patient and their complaints, it's gotten to the point where you might as well just hand them a menu and let them order whatever they want.

4.) Just about every physician hates the ER and doctors in it: I remember being told in residency "Once you're out in the community, things will be better. Specialists will want the consults because it means more money for them." Well I can tell you that this is false. In the community, in academics, in the county... one universal truth still exists: People don't want to work more than they already are. Every time you call another doctor, it means more work for them. They all hate the ER. The hospitalists hate the ER, the general surgeons hate the ER, the ophthalmologists hate the ER, the ENTs hate the ER, the orthopedists hate the ER... It starts to really get old when every admission or consult becomes an argumentative debate about "appropriateness" or "need" of the admission or consultation. And because this is an essential part of EM practice, it will never go away.

5.) There isn't time to do anything other than see patients: This may sound like whining, but it starts to really get old when you are at work for 12 hours and the "norm" is that you aren't going to be able to take a break to eat, pee, have a BM, drink water, or any other essential life task. In your average ER, you are busy from shift begin to shift end. I am so envious of any job where people aren't nose-to-the-grindstone for every single second of their work day. Yes we get paid good money, but that's because we have literally zero time to do anything else while at work.


These are my personal feeling and observations of EM. I think the people that are most happy in emergency medicine are people that are able to take the work at face value (cog in the machine of modern medicine), don't mind being involved as a businessperson/waiter of medicine, don't mind kowtowing to patients/consultants/administration, and don't mind being wrong or missing diagnoses. Or they work in a unicorn job that is not representative of actual emergency medicine.

At the risk of being inflammatory, I really feel that if you have intellectual tendencies, try to act in a moral and ethical manner, and a generally desire to provide the most exceptional care possible, emergency medicine burns you out very quickly. You can only work in a broken system and deal with *****s for so long before the infrastructure of your sanity starts to self-destruct.

Sorry for the rant, but hopefully this helps somebody trying to make decisions about specialty...
Where It All Went Wrong (And The Solution)


First, the founding fathers of EM decided EM must be a single pathway specialty, with no fellowship and only a residency, therefore eliminating all attachment to primary specialties. This was done to strengthen the specialty and to gain respect and prevent untrained people from passing themselves off as EPs. While this may have been a noble goal initially, I think it was a mistake (though not likely foreseeable) considering what changes have come along since. Along came EMTALA as part of COBRA in 1986 and all of a sudden, EPs are required by law to see any emergency, urgent, and non-urgent patient 24hr 7 days per week. It is an unfunded mandate. EPs became de facto employees of the federal government at that point, responsible not only for emergency care, but to shore up the massive shortage in primary care. Now, each EP is in effect (if not literally) owned by the federal government under the threat of a $50,000 fine, and has no way to exit hospital-EMTALA-based medicine due to the fact that they decided in lock step to give up their primary specialties. EPs at this point become wholly owned by what will become the all omni-powerful Government-Hospital-CMG complex. Along comes the unattainable concept of 15-minute wait times and perfect "customer satisfaction" applied to a stressed and bursting system with doctors who have no power to opt out and you have exactly what ERdoc00 describes for a large portion of EPs (except for those in saturated pockets, and Texas). Most leverage that would have been available to opt out of their onerous system, had been surrendered by making EM an enter-only specialty. Now, the remaining founder fathers (and mothers) of EM, ever protected in their academic other-worlds, are powerless to change it, explain it, or offer a solution. There is a solution.

If an EP feels abused by hospital administrators, threatened with their job for low Press-Ganey scores due to not compromising ethics and good medicine, or burned out due to a CMG insisting they work 30% more hours or seeing 30% more patients than they can tolerate due to being required to pick up the slack in an understaffed specialty, you have very little recourse. You can't go back to IM clinic. You can't apply to Cardiology fellowship like you could if you were an internist. You can't opt out of hospital based work and take your patients to an ASC like an orthopedic surgeon can (unless you're in one of the niche states that allows physician owned Emergency Care Centers) and in most jobs, you can't easily just cut your hours due to physician shortages. If you're in an area where EPs are in short supply, everyone's working more hours than they want to, they all want to cut their hours, and therefore no one actually can.

A minority (I'd guess around 30%?) of EPs may be in saturated and competitive markets (the rainbows and unicorn guys on here that are independently wealthy, in academics, in big cities, or Texas). They likely can cut their hours and call their shots a little more. But the majority of EPs are in the vast flyover country where there are shortages. They have to work more hours than they want, and see more patients than is reasonable. They can't cut to less. Is it any coincidence the 70% number keeps coming up as to the proportion of EPs that feel burned out? So in perpetuity, a minority of EPs won't understand "what the big deal is" where as a large number will feel as ERdoc00 does. The minority continue to sell EM as a cushy lifestyle job, relying upon the selling point that the doctors that feel overwhelmed are themselves the problem, when in fact the problems themselves, are systemic widespread and require real solutions.

Where does it all go right? Solution: de-link yourself from EMTALA-Hospital based care. In that setting you are powerless. Whether it's by doing a fellowship (Pain, Sports, Hospice/Palliative), opening an urgent care or free standing ED, getting an MBA, law degree, or going into hospital or academic administration,

DE-LINK YOURSELF FROM EMTALA-HOSPITAL-BASED WORK.

You need to have some ability or skill to earn your salary outside of an ED, if needed. If you do so, autonomy and therefore peace of mind will be the reward. You will be diversified with the ability to opt in, or out, of the system. Otherwise you have little control as the rope in a tug of war between ethics, patient care and peace of mind on one side, and the insatiable demands of the profit assembly line that is the Government-Hospital-CMG complex on the other side. It's no mystery as to why many other specialties are pulling back, opting out of call, after hours responsibilities and whatever other demands they can. They're feeling the squeeze, too. Cut the umbilical cord. Spread those wings and fly. After all, EM leadership has been quietly doing it for years, by reducing clinical shifts, and generating income outside the ED in various other roles such as administration, chairmanships, directorships, consulting, legal reviews/expert witness work, paid courses, book publishing, and corporate positions with CMGs, just to name a few.
 
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A minority (I'd guess around 30%?) of EPs may be in saturated and competitive markets (the rainbows and unicorn guys on here that are independently wealthy, in academics, in big cities, or Texas). They likely can cut their hours and call their shots a little more. But the majority of EPs are in the vast flyover country where there are shortages. They have to work more hours than they want, and see more patients than is reasonable. They can't cut to less. Is it any coincidence the 70% number keeps coming up as to the proportion of EPs that feel burned out? So in perpetuity, a minority of EPs won't understand "what the big deal is" where as a large number will feel as ERdoc00 does. The minority continue to sell EM as a cushy lifestyle job, relying upon the selling point that the doctors that feel overwhelmed are themselves the problem, when in fact the problems themselves, are systemic widespread and require real solutions.​

This would appear to violate the "law" of supply and demand.

My experience working in fly-over country has been that if I ask for fewer shifts my requests are honored. Do I still get asked to work more? Yes, and if I can help I will. But if it's going to screw up my life I don't pick up the shift(s).

I don't know any EP working in fly-over country who has ever been fired for not picking up extra shifts.
 
This would appear to violate the "law" of supply and demand.

My experience working in fly-over country has been that if I ask for fewer shifts my requests are honored. Do I still get asked to work more? Yes, and if I can help I will. But if it's going to screw up my life I don't pick up the shift(s).

I don't know any EP working in fly-over country who has ever been fired for not picking up extra shifts.
If there's a national shortage of dermatologists, patients wait. If there's a national shortage of EPs, which everyone agrees there is, and you have a federal mandate that you must see every patient, combined with hospital/employer demands to not let patients wait and see all patients in an arbitrary door to doctor time (ie 15 or 30min) then by definition, the existing doctors must work either more hours than they want, or greater patients per hour than they can/want to.

I would bet that somebody in those sites you're referring to is either pressured to work hours more than they want to, or more patients per hour than they feel comfortable with, to make that formula work. Physician /patient hours are the only thing in the formula the powers that be are allowing to flex. Physicians are expected to shore up the shortage created by EMTALA and worsened by inflexible corporate time goals.

My guess is, that the simple fact you're being asked to go to those sites, is that they are short, and the permanent site physicians are either maxed or beyond max, in hours, patients per hour, or both.

Most doctors will do what they are told, and few if any will push an issue such as work hours to the point they're fired. They'll try to "suck it up" as they've been trained to do for years in the deeply ingrained workaholic culture we have in Medicine. Unless you find some way to leverage yourself out of that equation, you'll be plugged in and be expected/pressured/manipulated to do the impossible. There's an illusion of control, but it's not there unless you make it happen. I say that 30-40% have made it happen. 60-70% haven't and that's why those numbers consistently come up in burnout surveys.
 
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My response is that the everyone is different. EM works for some people. For the people that it doesn't work for, some of the solutions are "change jobs" or "cut back hours" or "pay someone to do your nights". But these are only temporizing measures if you really don't enjoy the work.

I personally have cut back to part-time, around 72 hours a month in order to make it work. The only reason this works is because it's a few enough shifts that I can justify getting beaten up at work by enjoying the fact that I have most of the month off to do whatever else in life I like. So in my situation, EM is actually a better lifestyle fit for me than ortho. But people need to realize it's a huge pay cut and that it's not "Doctor money." With that said, there are few other positions in life that you can work so few days and make a very good living. So for that, I'm quite thankful. The caveat, though, is that I don't have kids I need to pay for and I don't get to live a "doctor's lifestyle" from a wealth perspective.

The bottom line for me is that full-time EM is not for me. I think too much and worry too much. I also like to spend time with patient's and look at each encounter as an intellectual challenge. This mentality doesn't fit in emergency medicine. I've worked enough places to know that while certain aspects can change, overall emergency medicine is very similar regardless of where you practice. The common threads in nearly every ER/ED are:

1.) They are understaffed: For as much as everyone wants to get wait times down and patient satisfaction up, the bottom line is that nobody wants to actually pay for it. Not enough techs, not enough nurses, and not enough doctors. Also, in my personal opinion 1.5 pts/hr is the maximum any doctor should see at a busy ER with moderate-to-high acuity. But again, nobody wants to pay for it and doctors don't want to take a pay cut.

2.) You are the grunt of the hospital: From an administrative standpoint, nobody really cares about what you have to think. All the hospital cares about is that you don't piss people off and keep people out of the waiting room. You can be the biggest ***** to ever graduate from medical school, but as long as you get along with staff and pay lip service to all of your patients, they could not care less how poor the quality of medicine you practice. i.e... as long as you don't affect their bottom line and don't rock the boat, you're a golden child.

3.) The patient are the same everywhere: I used to think that maybe different parts of the country would be different, but the patient's are the same everywhere. East coast, west coast, mid west... liberal, conservative... rich, poor... the ER patients don't ever change. Your average patient is entitled, frustrated, and doesn't really care what you think so long as you just do what they want. Many patient's have personality disorders... many patient's have agendas... and just about everyone has a sense of entitlement of what they "deserve" while in the ER. This used to not be such a big issue when physician's were treated as professionals. But in the current consumer/business-driven EM model, it's a nearly intolerable environment to work in. As hospitals continue to kowtow to every single patient and their complaints, it's gotten to the point where you might as well just hand them a menu and let them order whatever they want.

4.) Just about every physician hates the ER and doctors in it: I remember being told in residency "Once you're out in the community, things will be better. Specialists will want the consults because it means more money for them." Well I can tell you that this is false. In the community, in academics, in the county... one universal truth still exists: People don't want to work more than they already are. Every time you call another doctor, it means more work for them. They all hate the ER. The hospitalists hate the ER, the general surgeons hate the ER, the ophthalmologists hate the ER, the ENTs hate the ER, the orthopedists hate the ER... It starts to really get old when every admission or consult becomes an argumentative debate about "appropriateness" or "need" of the admission or consultation. And because this is an essential part of EM practice, it will never go away.

5.) There isn't time to do anything other than see patients: This may sound like whining, but it starts to really get old when you are at work for 12 hours and the "norm" is that you aren't going to be able to take a break to eat, pee, have a BM, drink water, or any other essential life task. In your average ER, you are busy from shift begin to shift end. I am so envious of any job where people aren't nose-to-the-grindstone for every single second of their work day. Yes we get paid good money, but that's because we have literally zero time to do anything else while at work.


These are my personal feeling and observations of EM. I think the people that are most happy in emergency medicine are people that are able to take the work at face value (cog in the machine of modern medicine), don't mind being involved as a businessperson/waiter of medicine, don't mind kowtowing to patients/consultants/administration, and don't mind being wrong or missing diagnoses. Or they work in a unicorn job that is not representative of actual emergency medicine.

At the risk of being inflammatory, I really feel that if you have intellectual tendencies, try to act in a moral and ethical manner, and a generally desire to provide the most exceptional care possible, emergency medicine burns you out very quickly. You can only work in a broken system and deal with *****s for so long before the infrastructure of your sanity starts to self-destruct.

Sorry for the rant, but hopefully this helps somebody trying to make decisions about specialty...
erdoc00,

Here's another question I have for you. Have you found Emergency Medicine to be different now that you practice it, compared to what you thought it was going to be like, going in?
 
Birdstrike - Yes, the docs at my sites have been pressured to do all of the things you mention, and many other things. My point is that none of us have been fired for saying "no".

Just because administrators ask me to do things, or even call me into the office to review my metrics, does not require me to do unethical or unsustainable things.

Yes, it's uncomfortable to not do what the boss is asking, but who ever said that being an ethical person who stands up for what's right is easy?

My point is not that physicians are not being pressured to do bad things - we most certainly are.

My point is that, as BCEP's, we still hold the cards. If you don't think it's right, don't do it.
 
Birdstrike - Yes, the docs at my sites have been pressured to do all of the things you mention, and many other things...Yes, it's uncomfortable to not do what the boss is asking, but who ever said that being an ethical person who stands up for what's right is easy?

My point is not that physicians are not being pressured to do bad things - we most certainly are.
QFT
 
Quoted from above post:

"3.) The patient are the same everywhere: I used to think that maybe different parts of the country would be different, but the patient's are the same everywhere. East coast, west coast, mid west... liberal, conservative... rich, poor... the ER patients don't ever change. Your average patient is entitled, frustrated, and doesn't really care what you think so long as you just do what they want. Many patient's have personality disorders... many patient's have agendas... and just about everyone has a sense of entitlement of what they "deserve" while in the ER. This used to not be such a big issue when physician's were treated as professionals. But in the current consumer/business-driven EM model, it's a nearly intolerable environment to work in. As hospitals continue to kowtow to every single patient and their complaints, it's gotten to the point where you might as well just hand them a menu and let them order whatever they want."

- add on top of this that the good majority of patients are... really sick. I don't mean sick in terms of crashing right-now and in-front of you... I mean the average patient has at least 3 to 4 serious comorbidies... most commonly

DM
HTN
Hyperlipidemia
COPD
Morbid Obesity
Atrial fibrillation
Pre-existing and extensive CAD
Depression/anxiety/bipolar disorder
Outstanding smoking history
Alcoholism/drug abuse
TIA/CVA

... and the list goes on. The average American ER patient is a far cry from healthy, even at baseline. There's only so much that can be done without serious effort/reform on the patient's part. They're often times the least helpful and reliable source of history, as they can't be bothered to remember the names of the meds that they take. A good 30-40 percent of the patients at my job... can't tell me the name of their PCP, or cardiologist, or (insert doc here).
 
Just got back from a week vacation from Playa. 1st off. beautiful, resort beautiful. All three kids (2,4,6) loved it. Can't wait til they are alittle older and I can enjoy some Adult aspects of vacations. But now, its still great. What I have learned

1. Great to take a week off and not have to worry about pts. I went to Nebraska to visit my mother for a week in May. Went to Playa with kids for a week in June. Going to Canada for a vacation in July (5 dys), and then to Boston with the family for a family Vaca in August before school starts. And all it took was requesting a 7-10 dys off. I didn't have to talk to my Partners. Didn't have to reschedule surgeries/patients.
2. My daughter got an Otitis externa from swimming. In a foreign country, would an ortho doc know what to do about this? I doubt it and this is a simple issue. I just went to the resort store, got what I need, and she is all good now. Guess what would happen if she had something more serious? Daddy would be best to handle it if he was an EM doc vs ortho. This follows me around all my life. I feel competent to take care of all my kids issues eventhough I let the Pediatrician do it.
 
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2. My daughter got an Otitis externa from swimming. In a foreign country, would an ortho doc know what to do about this? .
I doubt it, but a second week medical student sure as hell would.
 
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2. My daughter got an Otitis externa from swimming. In a foreign country, would an ortho doc know what to do about this? I doubt it and this is a simple issue. I just went to the resort store, got what I need, and she is all good now. Guess what would happen if she had something more serious? Daddy would be best to handle it if he was an EM doc vs ortho. This follows me around all my life. I feel competent to take care of all my kids issues eventhough I let the Pediatrician do it.
This is a non sequitur. It takes 5 seconds to look up otitis externa on uptodate or an extra 10 seconds to find a recent review article on the matter (like an AAFP article) if you need a refresher on the dosing and abx selection. Most midlevels can diagnose that. Hardly bragging material. Great, you can diagnose things a nurse with 1/4th your education can do.

When your kids have a volar Barton distal radius fx after falling from a bicycle, I'm sure you will feel very competent to take care of it too. Putting in a consult doesn't count.
 
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This is a non sequitur. It takes 5 seconds to look up otitis externa on uptodate or an extra 10 seconds to find a recent review article on the matter (like an AAFP article) if you need a refresher on the dosing. Most midlevels can diagnose that. Hardly bragging material. Great, you can diagnose things a nurse with 1/4th your education can do.

It was not a non sequitur. A non sequitur is when the conclusion doesn't follow from the premises. You rejected one of emergentmd's premises, rather than the structure of the argument.

#beatApollyontoit
 
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This is a non sequitur. It takes 5 seconds to look up otitis externa on uptodate or an extra 10 seconds to find a recent review article on the matter (like an AAFP article) if you need a refresher on the dosing and abx selection. Most midlevels can diagnose that. Hardly bragging material. Great, you can diagnose things a nurse with 1/4th your education can do.

When your kids have a volar Barton distal radius fx after falling from a bicycle, I'm sure you will feel very competent to take care of it too. Putting in a consult doesn't count.

Its not irrelevant. I did not intend to hurt anyone's feelings/degrade any profession. I have great respect for all fields.

My point was that a benefit of being an ED doc is I can care for most of their medical problems even an otitis media without having to look it up. But I would also feel comfortable with much more complicated issues.

I have had calls to the ED from other specialties asking me how to treat simple issues.
 
Dont do it. Ortho residency/fellowship is painful for the next 4-5 years. EM will be painful for the rest of your working life.

Thats not even taking into consideration that orthos probably make 3x what an er doc makes.


I don't think that's true at all. ED attendings actually make pretty solid money. Many fresh grads from my program making 350+ in pretty desirable areas for 32-36 hours a week. I don't think starting orthos make 1MM these days working less than 40 hours a week...
 
The bottom line for me is that full-time EM is not for me. I think too much and worry too much. I also like to spend time with patient's and look at each encounter as an intellectual challenge. This mentality doesn't fit in emergency medicine.

Its hard to take any of your complaints seriously when you obviously should never have chosen EM medicine.

Thats like me going to OB and saying, "The bottom line for me is that full-time OB/GYN is not for me. I don't like women, hate pelvic exams, and hate delivery babies. I hate being on call and being in clinic most of the day. "
 
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This is a non sequitur. It takes 5 seconds to look up otitis externa on uptodate or an extra 10 seconds to find a recent review article on the matter (like an AAFP article) if you need a refresher on the dosing and abx selection. Most midlevels can diagnose that. Hardly bragging material. Great, you can diagnose things a nurse with 1/4th your education can do.

When your kids have a volar Barton distal radius fx after falling from a bicycle, I'm sure you will feel very competent to take care of it too. Putting in a consult doesn't count.

I think his point was more along the lines that he feels comfortable outside of the hospital handling a wide variety of complaints as this is what he is trained to do (whether or not they are urgent care complaints or emergent complaints). If his child fractures their tooth or gets something stuck in their nose or something stuck in their ear or has a weird rash or gets a fishhook stuck in their arm or has a really bad nosebleed or stops breathing or goes into cardiac arrest, as an EM doc, he should feel prepared to handle the situation.

If my child has a "volar Barton distal radius fx" (redundant phrasing), they are getting brought to the local ER for an xray and pain control. They are then getting transferred to a dedicated pediatric hospital, because 95% of orthopedic doctors will not be competent in performing pediatric ORIFs and/or will likely not be credentialed to do so.

Consulting other physicians when something is outside of your scope of practice is essential for all healthcare providers. Why mock the ER provider for consulting a specialist? We would never mock you for sending a patient from your clinic to the ER who was having an asthma attack or chest pain or a seizure would we?
 
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