Specialty Hate, Tragedy & Woecakes

[Snorfelkack]

My boyfriend is having a crisis. Bear with me, because this is going to be as detailed as I can manage.

Prior to this, my boyfriend was excited about EM. He has a lot of experience with it and seemed pretty confident about his choice. He started his intern year two weeks ago. Over the last few days he's come home and said he chose the wrong specialty, that he hates EM, he's ruined his life...blah de blah woecakes. You get the gist. He tends to have a flair for the dramatic and be a bit pessimistic, so it's been difficult to determine if this is just new resident woe or if he actually HAS chosen the wrong specialty.

Some background on why he chose EM: Wide variety of complaints, trauma, critical care component, procedures, not taking call, good money while still having time off to enjoy things outside of medicine. He's smarter than any of the residents I've ever met, but he's a bit arrogant and likes to feel like he's the one that can fix people.

Reasons he's given for not liking EM (so far):
- Having to call consultants and/or Consultants treating him like he's a ******* (Told him that they think every intern his a *******)
- Being considered pond scum by other specialties (Personally I believe this is in his head, and that once he develops/proves his skill as a doc he will be given respect)
- EM doesn't get a ton of respect from the rest of the medical community
- Thinks the residency isn't long enough.
- Didn't get into his 1st pick program - I think it's more about this than anything else. He matched into a VERY good program in a nice area, but it still wasn't his first choice.

In the last 48 hours he's said that he should have went into Urology, which he later followed by saying he would hate only being focused on the bladder, would miss working with heart/lungs, HATED tumor conferences, that it was monotonous BUT that at least he would feel more important. He thinks that Urology would be too competitive for him to switch into, but he definitely could have matched into a Urology residency during med school. Personally I don't think that he would become bored with this specialty.

I don't know if this is a normal Holy **** I'm A Resident What Have I Done reaction that will ease once he finds his stride or if he actually did choose the wrong specialty. Due to the program structure, he's had hardly any time in the ED and is spending more time in lectures, sim lab, etc.

I imagine a lot of new residents have this feeling at some point. It's still so early that I don't want to encourage him to switch into another specialty, but I do want to help. Has anyone else gone through this? What would you have/did you find helpful?

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[ThoracicGuy]

He's two weeks into training. He needs to lighten up, Francis.

Trying to switch now would be a bad decision. He's hardly given EM a chance.

 

[rokshana]

why does he think he would match Urology? after all a good percentage of those that apply don't match...very very few can confidently say that they WILL match in Urology...

and how is it he had a lot of experience in EM and NOT know that the things he doesn't like about EM are commonly known about EM?

sounds like he has more of an ego problem that he needs to deal with..i mean really? what intern is suppose to feel important? being regarded as important takes experience and actually accomplished something in your field...that does not happen 2 weeks into your intern year.

 

[Arch Guillotti]

He needs to lighten up, Francis.

 

[Gfliptastic]

I'd tell him to confide in residents and whomever about this. In the end only HE can fix what's wrong w/ him.

I am an intern too. But I'm pumped every day I go in. Yes I am in "Holy **** I am a Resident" mode too. But I go home mentally exhausted, yet content. Not one of my co-interns has yet to state anything as negative as your BF has.

He really does need to lighten up, Francis lol. We have AM report, noon conference, radiology rounds, attending rounds. Almost every day. So as you can see, in a 12-14 hr day, almost 1/3 of MY day is spent in discussions & didactics. He'll get more responsibility as he learns more. Cuz I think his arrogance is a problem. If he thinks he learned all he needs to know about EM already, that's pretty dumb. He needs all of the "away time" from the ED, I don't care who he is.

And his woecakes! lol (Never heard of that, but that's why I decided to read your post)

 

[AStark]

He's smarter than any of the residents I've ever met, but he's a bit arrogant and likes to feel like he's the one that can fix people.

This is likely the source of much of this. And while I don't doubt that some of the new interns in my program are - potentially - smarter than me, none of them know how to function as a intern yet let alone a senior resident like me.

- Having to call consultants and/or Consultants treating him like he's a ******* (Told him that they think every intern his a *******)

Are his presentation skills so impeccable when calling for a consult that some self-reflection isn't in order here?

- Being considered pond scum by other specialties (Personally I believe this is in his head, and that once he develops/proves his skill as a doc he will be given respect)

He's an intern less than a month in.

- EM doesn't get a ton of respect from the rest of the medical community

I don't think that's true. There are certainly plenty of bad emerg docs around, but there's lots of good ones too. Mostly I'm just glad I haven't committed myself to shift work for my whole career.

I don't know if this is a normal Holy **** I'm A Resident What Have I Done reaction that will ease once he finds his stride or if he actually did choose the wrong specialty. Due to the program structure, he's had hardly any time in the ED and is spending more time in lectures, sim lab, etc.

Again, only two weeks in... does he think he doesn't need those didactic or sim sessions?

I imagine a lot of new residents have this feeling at some point. It's still so early that I don't want to encourage him to switch into another specialty, but I do want to help. Has anyone else gone through this? What would you have/did you find helpful?

It really does sound more about ego at this point. Interns aren't allowed to have big egos in the hospital because they don't know very much yet. Eventually you become more competent (and sometimes even feel more competent), but far, far more aware of how much you need to know to pass your exams and practice independently.

 

[gutonc]

I feel like we're being massively trolled here.

 

[anonperson]

Guy sounds like a self important douche bag. Every intern is a dumb ass, especially this early in the year. Any intern who does not realize and accept these truths is usually very irritating and dangerous.

But I agree with gutonc on this being a troll.

 

[mercaptovizadeh]

This does not smell trollish.

And other specialties hate EM because they often have a sloppy approach of just triaging and not even ordering appropriate studies in the right sequence (no CXR on chest pain patient, no blood cultures before giving vanc and zosyn, etc.).

And IM (and GS) especially hate them because they dump patients on them, in collusion with other specialties like ortho or ENT or whoever, who like to be consultants while IM or someone else is doing the admission scutwork.

If he wants more respect from colleagues and a firmer foundation of medical knowledge/experience and to still work on the heart or lungs, he can do IM and then cards or pulm/CCM, or do GS then CT or trauma surg. But then his hours will be hell.

And who in the end cares? If he hates EM after 3 years, he can then do IM or GS and take it from there.

 

[littlejuan]

This does not smell trollish.

And other specialties hate EM because they often have a sloppy approach of just triaging and not even ordering appropriate studies in the right sequence (no CXR on chest pain patient, no blood cultures before giving vanc and zosyn, etc.).

And IM (and GS) especially hate them because they dump patients on them, in collusion with other specialties like ortho or ENT or whoever, who like to be consultants while IM or someone else is doing the admission scutwork.

If he wants more respect from colleagues and a firmer foundation of medical knowledge/experience and to still work on the heart or lungs, he can do IM and then cards or pulm/CCM, or do GS then CT or trauma surg. But then his hours will be hell.

And who in the end cares? If he hates EM after 3 years, he can then do IM or GS and take it from there.

I am going to call bull**** on this happening often. People bag on EM because they do not understand what the proper EM workup entails, and certainly do not understand what it is like to see the amount of patients we have to see, in the limited time we have, while properly ruling out the worst case scenarios with sometimes very difficult patient presentations.

 

[rokshana]

I am going to call bull**** on this happening often. People bag on EM because they do not understand what the proper EM workup entails, and certainly do not understand what it is like to see the amount of patients we have to see, in the limited time we have, while properly ruling out the worst case scenarios with sometimes very difficult patient presentations.

every.single.ED. i ave every had to deal with...then there is always "that guy" who can decide who needs to be admitted and who doesn't while never gettin' up from his computer (come on...you know its true...).

 

[littlejuan]

every.single.ED. i ave every had to deal with...then there is always "that guy" who can decide who needs to be admitted and who doesn't while never gettin' up from his computer (come on...you know its true...).

Don't act like poor physicians only exist in the EM world. Also, mercap is saying that for a patient with chest pain who presented sick enough to either be admitted or have a consult called did not get a basic chest X-ray. He is either exaggerating, making things up, there was a simple screw up with orders, or something of that nature rather than the cognitive misstep he alluded to.

 

[Winged Scapula]

Don't act like poor physicians only exist in the EM world.

I'm not sure where I see @rokshana is stating that this occurs *only* in the EM world. She is simply stating that her experience (which many of us have had).

Also, mercap is saying that for a patient with chest pain who presented sick enough to either be admitted or have a consult called did not get a basic chest X-ray. He is either exaggerating, making things up, there was a simple screw up with orders, or something of that nature rather than the cognitive misstep he alluded to.

So bad physicians aren't found in the ED?

Of course they are. There are bad physicians in every field. Because the point of this thread is not to bash other specialties, I won't go into my personal and professional experiences with various EDs around the country, but I will say you should consider yourself either lucky, naive or ignorant if you don't think that what @mercaptovizadeh describes happens.

Let's get back to the OP's issues. Its much more fun talking about a 2-week newly minted intern who seems to be a tad bit arrogant.

 

[Jimmy B]

2 weeks as an intern??

 

[littlejuan]

I'm not sure where I see @rokshana is stating that this occurs *only* in the EM world. She is simply stating that her experience (which many of us have had).

"every.single.ED." The periods add emphasis as if it is a pervasive issue within EM.

So bad physicians aren't found in the ED?

Of course they are. There are bad physicians in every field. Because the point of this thread is not to bash other specialties, I won't go into my personal and professional experiences with various EDs around the country, but I will say you should consider yourself either lucky, naive or ignorant if you don't think that what @mercaptovizadeh describes happens.

Did I say that? But even a poor physician who barely gets off his chair to see the patient will order a chest xray for a patient who they are attempting to admit for chest pain. Unless there is something major we are missing from this scenario, I really cannot see why that would ever happen. Regardless, while you are stating that this is not a specialty bash thread, that is exactly what mercaptovizadeh did. "And other specialties hate EM because they often have a sloppy approach of just triaging and not even ordering appropriate studies in the right sequence"

Let's be real, there is a lot of **** talking that occurs against EM, usually though, it is done by people who really don't understand the field and have no sense of context.

I'll just say, this is the last I will touch on the subject in this thread.

 

[mercaptovizadeh]

Don't act like poor physicians only exist in the EM world. Also, mercap is saying that for a patient with chest pain who presented sick enough to either be admitted or have a consult called did not get a basic chest X-ray. He is either exaggerating, making things up, there was a simple screw up with orders, or something of that nature rather than the cognitive misstep he alluded to.

...patient with dirty UA and CVA tenderness admitted for pyelo, given ceftriaxone in the ED after blood cultures drawn...but no urine sent for culture, and lab tells me the UA sample is too old to use...

I'm done, don't care to go on in this vein. Let's talk about intern year instead.

 

[littlejuan]

****, you reeled me back in!

...patient with dirty UA and CVA tenderness admitted for pyelo, given ceftriaxone in the ED after blood cultures drawn...but no urine sent for culture, and lab tells me the UA sample is too old to use...

Notice I did not refer to that, because that is a misstep that can happen, especially in residency because well, residency. No chest xray for a chest pain admit.... yeah.. a little less inclined to believe, and lets not ignore the fact that you disparaged the entire field stating "often have a sloppy approach of just triaging." There is also tons of Monday morning quarterbacking, hindsight is 20/20 that goes on with EM.

I'm done, don't care to go on in this vein. Let's talk about intern year instead.

It's your first response to me, why so angry? Actually, I have to say, most of the people that tend to talk crap about EM seem to be really angry, I often wonder if they just tend to hate what they do so much and EM is just an easy scapegoat for them? Hmm..

 

[Dral]

"every.single.ED." The periods add emphasis as if it is a pervasive issue within EM.



Did I say that? But even a poor physician who barely gets off his chair to see the patient will order a chest xray for a patient who they are attempting to admit for chest pain. Unless there is something major we are missing from this scenario, I really cannot see why that would ever happen. Regardless, while you are stating that this is not a specialty bash thread, that is exactly what mercaptovizadeh did. "And other specialties hate EM because they often have a sloppy approach of just triaging and not even ordering appropriate studies in the right sequence"

Let's be real, there is a lot of **** talking that occurs against EM, usually though, it is done by people who really don't understand the field and have no sense of context.

I'll just say, this is the last I will touch on the subject in this thread.

Lol, try being a Dermatologist. We get ragged on by everyone all the time. Just go to the allopathic forum and start a thread...about anything. But at the end of the post, just type 'Dermatology'. Within 5 posts someone will somehow find a way to talk crap on Derm.

Doesn't bother me. I love what I do.

You don't have to defend EM. It is what it is and you're unlikely to change anyone's opinion here. Just don't be that doc that the others described and it's all good. If you are defending it this much, you probably already aren't a bad ED doc.

 

[littlejuan]

Lol, try being a Dermatologist. We get ragged on by everyone all the time. Just go to the allopathic forum and start a thread...about anything. But at the end of the post, just type 'Dermatology'. Within 5 posts someone will somehow find a way to talk crap on Derm.

Doesn't bother me. I love what I do.

You don't have yo defend EM. It is what it is and you're unlikely to change anyone's opinion here. Just don't be that doc that the others described and it's all good.

People are likely insanely jealous of Derm. I've actually never seen anyone rag on Derm. That is new to me.

 

[mercaptovizadeh]

People are likely insanely jealous of Derm. I've actually never seen anyone rag on Derm. That is new to me.

I rag on cosmetic derm. I don't rag on derm that actually manages disease. And I am not jealous of what derm does, if I had to do just that every day I would probably leave medicine altogether.

 

[mercaptovizadeh]

****, you reeled me back in!



Notice I did not refer to that, because that is a misstep that can happen, especially in residency because well, residency. No chest xray for a chest pain admit.... yeah.. a little less inclined to believe, and lets not ignore the fact that you disparaged the entire field stating "often have a sloppy approach of just triaging." There is also tons of Monday morning quarterbacking, hindsight is 20/20 that goes on with EM.




It's your first response to me, why so angry? Actually, I have to say, most of the people that tend to talk crap about EM seem to be really angry, I often wonder if they just tend to hate what they do so much and EM is just an easy scapegoat for them? Hmm..

I only said that because I didn't want to continue offending you needlessly. You obviously take it all to heart, which makes me think that you are not someone who doesn't give a **** and are a careful ED physician.

And every single example I gave was real, stuff that I have seen in intern year.

I'm really not angry. I have seen some very angry people in my residency program, but it's usually when they are holding the admissions pager at night and are getting 100+ pages from the floor nurses and ED "consults" (i.e. mandatory admits, and nothing you can do about it) through the night.

 

[startswithb]

Has your bf ever had a real job with a boss before? Or only been in academia where being consistently told "you're so smart, good job" is the norm?

I am an intern, too. We are all doing a poor job in comparison to what those just one year ahead of us are doing. I have a feeling he is upset he is not getting praise everyday like he probably did as an MSIV. Luckily, this will change once we actually become more competent. So "being the one that can fix things" or "getting respect" isn't going to happen until we actually can fix things. I think he'll feel much better once he hits his stride and can successfully manage patients. Then, on to the next thing.

 

[Arcan57]

I'm not sure where I see @rokshana is stating that this occurs *only* in the EM world. She is simply stating that her experience (which many of us have had).



So bad physicians aren't found in the ED?

Of course they are. There are bad physicians in every field. Because the point of this thread is not to bash other specialties, I won't go into my personal and professional experiences with various EDs around the country, but I will say you should consider yourself either lucky, naive or ignorant if you don't think that what @mercaptovizadeh describes happens.

Out of line Winged. Your feelings about EM are well publicized in the surgery forum and I have no significant problem with specialty bashing in specialty forums as a form of blowing off steam. This is not a specialty forum and to have a mod spend most of a post defending some quite inflammatory statements about another specialty is disappointing.

 

[dozitgetchahi]

Oh please. Don't act like what she said is untrue or over the top.

 

[mercaptovizadeh]

OMG, I am so tempted right now to relate the conversation my IM senior resident had with the ED attending at 4 AM regarding a patient's rash...

 

[Winged Scapula]

Out of line Winged. Your feelings about EM are well publicized in the surgery forum and I have no significant problem with specialty bashing in specialty forums as a form of blowing off steam. This is not a specialty forum and to have a mod spend most of a post defending some quite inflammatory statements about another specialty is disappointing.

I believe you either misinterpreted or misread what I wrote because my intention was to say that these things happen in every field and to defend her right to say what she's experienced in response to a user who seems to believe that others are lying or is unwilling to accept that there are bad practitioners out there in every field.

I never said that EM was the only specialty with these problems. Far from it.

My intent was to validate that we've all had trouble with other specialties but that we should move on and back to the topic at hand. I was not attempting to encourage her to bash your specialty but rather highlight that these things occur and we shouldn't assume others are lying when they say they do (on response to the user who stated that these things don't happen/others are lying or exaggerating).

Clearly my intention was poorly communicated and I apologize for that.

Finally, my experience with emergency medicine is far from the negative picture that you painted. As a matter of fact, during residency at a meeting between our mutual departments I was raised as the sole surgical resident who was reasonable and easier to work with. Now out in practice, I can tell you I have much more difficulty with substandard hospitalists than I do with anyone in the emergency department here.

 

[Siggy]

Notice I did not refer to that, because that is a misstep that can happen, especially in residency because well, residency. No chest xray for a chest pain admit.... yeah.. a little less inclined to believe, and lets not ignore the fact that you disparaged the entire field stating "often have a sloppy approach of just triaging." There is also tons of Monday morning quarterbacking, hindsight is 20/20 that goes on with EM.

Here's the thing that gets me about EM... and why I'm starting to become happier that I didn't match, did an intern year again, and ended up in IM.

On one hand, there's the "Our job is to rule out emergent diseases and see if the patient needs admission" and on the other hand there's complaining about people calling EM triage (which, as every EM and EMS book immediately mentions after first using that word, it's French for "to separate"). So, which is it? Is your job to sort out who is having an emergency and who isn't and who needs admission and who doesn't, or is it something else?

...and of course there's MMQ and 20/20 regarding EM... and EM does the same thing when an outpatient clinic either misses an emergency or over triages a non-emergency.

 

[littlejuan]

I believe you either misinterpreted or misread what I wrote because my intention was to say that these things happen in every field and to defend her right to say what she's experienced in response to a user who seems to believe that others are lying or is unwilling to accept that there are bad practitioners out there in every field.

This was my initial response in this thread to mercap's insinuation that EM often has a 'sloppy approach of just triaging':

"I am going to call bull**** on this happening often. People bag on EM because they do not understand what the proper EM workup entails, and certainly do not understand what it is like to see the amount of patients we have to see, in the limited time we have, while properly ruling out the worst case scenarios with sometimes very difficult patient presentations."

rokshana's response also made it seem like it was a pervasive issue within EM.

Nowhere did I say that there were no bad practitioners in EM. In fact, the very first sentence in my response to rokshana said, "Don't act like poor physicians only exist in the EM world." I think you completely misunderstood my posts here. The thing that I often see happen with people criticizing the ED is that: a) they act as if they are infallible and b) they take a few bad instances and use it to admonish the entire field. I think this tends to happen more at places where there is a certain culture that encourages this though, and I find it to be highly unprofessional.

 

[Law2Doc]

I think EM gets ragged on because at its heart it's really about disposition not diagnosis. All patients need to get sent home or sent upstairs as quickly as possible. So they are quick to order extensive studies and call multiple consults because each of these may provide a justification for disposition. And in an effort to expedite these things a lot of this happens in triage, before an ED physician has had the opportunity to examine the patient. And that creates a lot of the situations we see lampooned all over the web.

 

[mercaptovizadeh]

This was my initial response in this thread to mercap's insinuation that EM often has a 'sloppy approach of just triaging':

"I am going to call bull**** on this happening often. People bag on EM because they do not understand what the proper EM workup entails, and certainly do not understand what it is like to see the amount of patients we have to see, in the limited time we have, while properly ruling out the worst case scenarios with sometimes very difficult patient presentations."

rokshana's response also made it seem like it was a pervasive issue within EM.

Nowhere did I say that there were no bad practitioners in EM. In fact, the very first sentence in my response to rokshana said, "Don't act like poor physicians only exist in the EM world." I think you completely misunderstood my posts here. The thing that I often see happen with people criticizing the ED is that: a) they act as if they are infallible and b) they take a few bad instances and use it to admonish the entire field. I think this tends to happen more at places where there is a certain culture that encourages this though, and I find it to be highly unprofessional.

I don't think anybody here is denying that all specialties have substandard physicians.

I don't blame the ED for not doing workups for the admitting service. That's not their job. It would also ruin our experience because it would take out the thrill of diagnosis. I don't even blame the ED for not ordering all the basic studies, such as a CXR on a CP patient. So what? The admitting team can always order a CXR, nothing has been ruined.

My issues with the ED can be broken down into 3 categories:

1.) Ruining stuff. Please culture all sources as indicated before giving antibiotics. Blood cultures are not enough and when you fail to get a sputum culture or a wound culture or a urine culture before starting antibiotics, you are making life harder for the admitting team. Likewise, a woman with a mass in her brain on MRI - if she is stable and is not in danger of neurologic decompensation, and there are no primaries found on C/A/P CT scan, and she will have that mass biopsied by neurosurgery in 1-2 days - please don't give her decadron just because of her 3 week long headache. If you do, you just ruined the structure of the lymphoma in her brain and made it harder for the pathologist and oncologist to diagnose and treat her appropriately.

2.) Have patience. The other day I admitted a patient who in the midst of an outpatient surgical procedure developed bradycardia and asystole, with anesthesia restarting the heart with administration of atropine. The PACU nursing notes mentioned this but neither anesthesia nor surgery mentioned anything in their notes (yes, non-ED physicians who did a horrible job at documenting). When he awoke from GA, patient was transferred for crushing CP to the ED. They got one set of CBM that were "intermediate" abnormal. Instead of waiting 4 hrs to get a second set, they rapidly shunted the patient over to me on the IM floor to do the admission. The next set of CBM had a floridly elevated troponin I and had to be sent to the CCU for NSTEMI.

3.) Triage appropriately. Medicine is not your ****ting ground for anything that surgery refuses. If other services refuse and the patient belongs with them, insist that they go there. I admitted a patient with a skull fracture and intraparenchymal hemorrhage. NSU refused to admit him, so the ED sent him to IM. After 2 days of observation, sent him home. He came back several days later with the blood spread to the subarachnoid space and fevering. Again IM was forced to admit him (NSU refused), overnight team started antibiotics for presumed meningitis, then we stopped them because it was neurogenic fever. His wife told me personally (I'm flushing with embarrassment even now) that our discharging him last time without giving them anticipatory guidance about the possibility of SAH developing (we didn't know!) was worse treatment than the care their dog got when discharged from the veterinary hospital. This patient would have been way better served by being on an NSU service from the beginning. It was the ED's duty to insist that happen rather than dump the man on physicians with relatively little experience with managing intracranial bleeds.

And you know what the ED attending wanted us to admit at 4 AM? Man with rash that she found concerning for tinea corporis vs. SJS. I don't think that's an ED-specific issue, I just think she sucks horrendously at physical exam and diagnosis and wanted to clean out the ED bed (and her own responsibility in the affair) and someone else to do all her work for her.

 

[exsanguination]

I honestly love when other specialties start railing on EM (I'm an EM PGY2). To me it's either two things

1. They're sad or depressed with their own lot in life
2. They're jealous over what we have in EM

Shift work, no call days, leave work at work, predictable work hours, ability to expand/contract your practice to fit your yearly paycheck desires.. etc etc, I could go on for days. Three to four years of residency to be making 350k/year in a specialty that society thinks is EXTREMELY important and glorified fully on TV? Sign me up. Seriously, go ask any person "what's the most important part of the hospital?" and tell me how many times people answer "The ED!!" It's far more than "the wards" or "the operating rooms." Hell, I'd say the only thing giving the ED a run for it's money with my question is "the cafeteria." Ha!

And I'll say it here: I LOVE calling a consultant at 3am for a borderline legit matter if I know that consultant is usually an a**hole during even regular business hours. This has become easier and easier too as administration cares less and less about what their contracted call physicians say about the ER calling them for "inappropriate" reasons. Sorry buddy, there's a long list of docs that would love to take call at our hospital, you're paid handsomely to do so, and it's an EMTALA violation to refuse to come and see the patient if I think it's necessary. Too easy. As specialists continue to get marginalized by hospital admin, the getting will just continue to get better and better in the ED!

 

[ThoracicGuy]

Lol, try being a Dermatologist. We get ragged on by everyone all the time. Just go to the allopathic forum and start a thread...about anything. But at the end of the post, just type 'Dermatology'. Within 5 posts someone will somehow find a way to talk crap on Derm.

Doesn't bother me. I love what I do.

You don't have to defend EM. It is what it is and you're unlikely to change anyone's opinion here. Just don't be that doc that the others described and it's all good. If you are defending it this much, you probably already aren't a bad ED doc.

You Dermies just can't be bothered to work at all!!!! Do you guys even take call?

 

[mercaptovizadeh]

I honestly love when other specialties start railing on EM (I'm an EM PGY2). To me it's either two things

1. They're sad or depressed with their own lot in life
2. They're jealous over what we have in EM

Shift work, no call days, leave work at work, predictable work hours, ability to expand/contract your practice to fit your yearly paycheck desires.. etc etc, I could go on for days. Three to four years of residency to be making 350k/year in a specialty that society thinks is EXTREMELY important and glorified fully on TV? Sign me up. Seriously, go ask any person "what's the most important part of the hospital?" and tell me how many times people answer "The ED!!" It's far more than "the wards" or "the operating rooms." Hell, I'd say the only thing giving the ED a run for it's money with my question is "the cafeteria." Ha!

And I'll say it here: I LOVE calling a consultant at 3am for a borderline legit matter if I know that consultant is usually an a**hole during even regular business hours. This has become easier and easier too as administration cares less and less about what their contracted call physicians say about the ER calling them for "inappropriate" reasons. Sorry buddy, there's a long list of docs that would love to take call at our hospital, you're paid handsomely to do so, and it's an EMTALA violation to refuse to come and see the patient if I think it's necessary. Too easy. As specialists continue to get marginalized by hospital admin, the getting will just continue to get better and better in the ED!

Wow, how superficial...and unsurprising.

 

[Druggernaut]

Some background on why he chose EM: Wide variety of complaints, trauma, critical care component, procedures, not taking call, good money while still having time off to enjoy things outside of medicine. He's smarter than any of the residents I've ever met, but he's a bit arrogant and likes to feel like he's the one that can fix people.

Reasons he's given for not liking EM (so far):
- Having to call consultants and/or Consultants treating him like he's a ******* (Told him that they think every intern his a *******)
- Being considered pond scum by other specialties (Personally I believe this is in his head, and that once he develops/proves his skill as a doc he will be given respect)
- EM doesn't get a ton of respect from the rest of the medical community
- Thinks the residency isn't long enough.
- Didn't get into his 1st pick program - I think it's more about this than anything else. He matched into a VERY good program in a nice area, but it still wasn't his first choice.

In the last 48 hours he's said that he should have went into Urology, which he later followed by saying he would hate only being focused on the bladder, would miss working with heart/lungs, HATED tumor conferences, that it was monotonous BUT that at least he would feel more important.

It used to bother me more how little respect EM gets. Then I noticed that medicine is full of narcissistic children who think that they're the most brilliant people ever, and everyone else is a *****. EM just is in a position that they have to dump on everyone, so everyone hates them. And yes, everyone dumps on someone, that's the way the game is played. Sounds like your boyfriend's ego is getting in the way. Instead of doing what he apparently liked, he'd rather do something he hates just so other people make him feel smart.

Of course, if he was a urologist, he'd be upset people were saying he's just a c**k doc...

On one hand, there's the "Our job is to rule out emergent diseases and see if the patient needs admission" and on the other hand there's complaining about people calling EM triage (which, as every EM and EMS book immediately mentions after first using that word, it's French for "to separate"). So, which is it? Is your job to sort out who is having an emergency and who isn't and who needs admission and who doesn't, or is it something else?

The job is primarily to rule out emergent/urgent things, diagnose them if they're present, and initiate appropriate treatment. Diagnosing and treating the rest is secondary, but no one is going to completely refuse this.

People associate triage with simply determining disposition based on initial presentation rather than evaluation and treatment, which is where they take offense. Being dismissed as a "triage nurse" doesn't help, either.

I don't blame the ED for not doing workups for the admitting service. That's not their job. It would also ruin our experience because it would take out the thrill of diagnosis. I don't even blame the ED for not ordering all the basic studies, such as a CXR on a CP patient. So what? The admitting team can always order a CXR, nothing has been ruined.

[...]

2.) Have patience. The other day I admitted a patient who in the midst of an outpatient surgical procedure developed bradycardia and asystole, with anesthesia restarting the heart with administration of atropine. The PACU nursing notes mentioned this but neither anesthesia nor surgery mentioned anything in their notes (yes, non-ED physicians who did a horrible job at documenting). When he awoke from GA, patient was transferred for crushing CP to the ED. They got one set of CBM that were "intermediate" abnormal. Instead of waiting 4 hrs to get a second set, they rapidly shunted the patient over to me on the IM floor to do the admission. The next set of CBM had a floridly elevated troponin I and had to be sent to the CCU for NSTEMI.

3.) Triage appropriately. Medicine is not your ****ting ground for anything that surgery refuses. If other services refuse and the patient belongs with them, insist that they go there. I admitted a patient with a skull fracture and intraparenchymal hemorrhage. NSU refused to admit him, so the ED sent him to IM. After 2 days of observation, sent him home. He came back several days later with the blood spread to the subarachnoid space and fevering. Again IM was forced to admit him (NSU refused), overnight team started antibiotics for presumed meningitis, then we stopped them because it was neurogenic fever. His wife told me personally (I'm flushing with embarrassment even now) that our discharging him last time without giving them anticipatory guidance about the possibility of SAH developing (we didn't know!) was worse treatment than the care their dog got when discharged from the veterinary hospital. This patient would have been way better served by being on an NSU service from the beginning. It was the ED's duty to insist that happen rather than dump the man on physicians with relatively little experience with managing intracranial bleeds.

And you know what the ED attending wanted us to admit at 4 AM? Man with rash that she found concerning for tinea corporis vs. SJS. I don't think that's an ED-specific issue, I just think she sucks horrendously at physical exam and diagnosis and wanted to clean out the ED bed (and her own responsibility in the affair) and someone else to do all her work for her.

IM loves to talk a big game about making the diagnosis, but how many undiagnosed patients are you really getting from the ED? I've seen plenty of hospitals and plenty of different EM programs, and patients who were being admitted without a diagnosis or at least a pretty clear path to confirming or ruling it out were a pretty small minority at every one of them.

2.) You want them to sit on a guy who arrested and now has crushing chest pain for 4 hours for a second set of enzymes? What would that have accomplished, besides tying up a bed for another 4 hours and keeping a few other patients from being seen, treated, and dispositioned? You're also completely ignoring the realities of working in a hospital. Administration would probably feel it was entirely inappropriate for a patient to be sitting in the ED 5-6+ hours, and has likely made that known. Direct your frustration at the real source.

3.) Sounds like your medicine department needs to step up and make other services take patients. The patient had to come into the hospital, neurosurgery has the power to refuse the admission at your institution, but apparently medicine doesn't. How was EM supposed to force them to take the patient if you can't? And you couldn't even get a NS consult with IM as the primary team? Not even on the bounceback? I don't understand, and it brings me to one of the things that drove me absolutely nuts about the IM residents at my medical school: the absolute inability to step up and take ownership of mistakes. They'd have the patient for a week after they were in the ED for 2 hours, but cry that the ED should've ordered an MRI after the CT was negative (for example). It's clearly EM's fault, even though IM had the patient 84 times longer and could have ordered it themselves. So why couldn't you get NS involved, but the ED absolutely should have? I mean, we're just triage nurses down here, can't you real doctors handle it?

Your rash example does sound legitimately bad, and I'm totally willing to accept that there's some pretty awful emergency physicians. I've also seen plenty of IM guys flounder in the ED, bungle management in the ICU resulting in patient deaths, and fail to recognize a patient was sick until they were on death's door. Or surgery insisting that a guy didn't have a surgical problem even though radiology and IM say there's free air in the abdomen on multiple imaging modalities.

Every specialty will mismanage patients. They all also have their own areas of expertise, and sometimes their decisions will seem wrong to you but actually be appropriate. Before you go spewing hate at EM next time, stop and consider that maybe your perspective isn't totally accurate given that they're the ones who are giving you the most work, and that maybe your specialty isn't comprised exclusively of rockstars that we should all strive to emulate.

 

[mercaptovizadeh]

IM loves to talk a big game about making the diagnosis, but how many undiagnosed patients are you really getting from the ED? I've seen plenty of hospitals and plenty of different EM programs, and patients who were being admitted without a diagnosis or at least a pretty clear path to confirming or ruling it out were a pretty small minority at every one of them.

2.) You want them to sit on a guy who arrested and now has crushing chest pain for 4 hours for a second set of enzymes? What would that have accomplished, besides tying up a bed for another 4 hours and keeping a few other patients from being seen, treated, and dispositioned? You're also completely ignoring the realities of working in a hospital. Administration would probably feel it was entirely inappropriate for a patient to be sitting in the ED 5-6+ hours, and has likely made that known. Direct your frustration at the real source.

3.) Sounds like your medicine department needs to step up and make other services take patients. The patient had to come into the hospital, neurosurgery has the power to refuse the admission at your institution, but apparently medicine doesn't. How was EM supposed to force them to take the patient if you can't? And you couldn't even get a NS consult with IM as the primary team? Not even on the bounceback? I don't understand, and it brings me to one of the things that drove me absolutely nuts about the IM residents at my medical school: the absolute inability to step up and take ownership of mistakes. They'd have the patient for a week after they were in the ED for 2 hours, but cry that the ED should've ordered an MRI after the CT was negative (for example). It's clearly EM's fault, even though IM had the patient 84 times longer and could have ordered it themselves. So why couldn't you get NS involved, but the ED absolutely should have? I mean, we're just triage nurses down here, can't you real doctors handle it?

Your rash example does sound legitimately bad, and I'm totally willing to accept that there's some pretty awful emergency physicians. I've also seen plenty of IM guys flounder in the ED, bungle management in the ICU resulting in patient deaths, and fail to recognize a patient was sick until they were on death's door. Or surgery insisting that a guy didn't have a surgical problem even though radiology and IM say there's free air in the abdomen on multiple imaging modalities.

Every specialty will mismanage patients. They all also have their own areas of expertise, and sometimes their decisions will seem wrong to you but actually be appropriate. Before you go spewing hate at EM next time, stop and consider that maybe your perspective isn't totally accurate given that they're the ones who are giving you the most work, and that maybe your specialty isn't comprised exclusively of rockstars that we should all strive to emulate.

1.) 1/3 are undiagnosed in my hospital. Easily, if not more. The ED is that bad. But again, I don't consider that their job.

2.) The ED should have sent that person straight to the CCU, not their usual medicine floor dumping ground.

3.) The ED never should have "consulted" IM for a guy with skull fracture and intraparenchymal bleed. Call NSU. Call the neuro ICU. Call even neurology if you like. But what do they do when NSU says "nothing for us to do"? Rather than be responsible physicians who say, "No, this IS your problem, and you WILL take this patient," they just send them over to the usual dumping ground, the IM floor who has no power to refuse admissions. Ortho, GSU, ENT, uro, NSU, psych can all refuse admissions. IM cannot. Top 10 kind of place. Too bad our ED is so awful.

 

[Gastrapathy]

My only question for the ER docs is why call me if you aren't going to bother doing what I ask. I know oral contrast makes a CT take longer and I know you heard me ask for it. You ordered the urolithiasis CT on purpose. If you aren't going to listen, don't wake me up. Now I'm awake perusing SDN. Thanks.

For the OP, your boyfriend is weak. If he can't take a little heat, he's in for a long miserable ride. He almost certainly won't be a urologist now.

 

[KnuxNole]

Medicine is the dumping ground everywhere. It sucks, but it is what it is...

 

[Perrotfish]

I honestly love when other specialties start railing on EM (I'm an EM PGY2). To me it's either two things

1. They're sad or depressed with their own lot in life
2. They're jealous over what we have in EM

Shift work, no call days, leave work at work, predictable work hours, ability to expand/contract your practice to fit your yearly paycheck desires.. etc etc, I could go on for days. Three to four years of residency to be making 350k/year in a specialty that society thinks is EXTREMELY important and glorified fully on TV? Sign me up. Seriously, go ask any person "what's the most important part of the hospital?" and tell me how many times people answer "The ED!!" It's far more than "the wards" or "the operating rooms." Hell, I'd say the only thing giving the ED a run for it's money with my question is "the cafeteria." Ha!

And I'll say it here: I LOVE calling a consultant at 3am for a borderline legit matter if I know that consultant is usually an a**hole during even regular business hours. This has become easier and easier too as administration cares less and less about what their contracted call physicians say about the ER calling them for "inappropriate" reasons. Sorry buddy, there's a long list of docs that would love to take call at our hospital, you're paid handsomely to do so, and it's an EMTALA violation to refuse to come and see the patient if I think it's necessary. Too easy. As specialists continue to get marginalized by hospital admin, the getting will just continue to get better and better in the ED!

I think a lot of people are just annoyed by what they see as a parade of preventable errors coming out of the ED. The problems I see with modern EM:

1) A culture of undertraining: I think ED may be the single most difficult job in the hospital. They are responsible for the management of not just all subcategories of patients (Peds, OB, surgical, and IM) but also all acuities (the mild cold to the coding ICU patient) and at a very fast pace. Also, unlike IM/Peds/Surgery they are almost always the first point of contact in the hospital, dealing with an undifferentiated patient. And the EM training programs have responded to this almost insurmountable challenge with... the weakest, shortest training program in medicine. 3 years, almost all in the ED, with an incredibly wide range of clinical hours which is sometimes less than full time work and almost always less than the hours worked by IM/FM/Peds (not even close to OB/Surgery). If you train less than a family doctor why would you expect to be better at dealing with patients than a family doctor? The result is that a safe ED is a challenge that is not being met in most hospitals.

2) A culture of understaffing: How many times have you heard some variant of the following from an ED Physician: "of course we need to work half as many clinical hours as the other specialties, the ED is so much more stressful that any other specialty! We see twice as many patients as IM does every hour that we're there!" If an average day involves you sprinting from patient to patient without so much as a bathroom break maybe the problem is that you're expectation for PPH is way too high and your expectations for adequate staffing (and the number of shift you should work) is way too low. If a standard high acuity ED shifted their PPH from 2.5 to 2, and increased their shifts worked proportionally, I think we'd have way fewer errors and, as a bonus, much less ED burnout.

One of the interesting things for me, as a Pediatrician, is that I actually get to se an alternative system in play: Peds EM. I get admits from both Peds EM trained physicians at childrens hospitals (and some who just work in normal EDs) and EM pathway trained physicians in other EDs. Peds EM may be a 2 year fellowship on EM or a 3 year fellowship on Peds, but it seems to achieve similar results: a dramatically better results when triaging and treating my patient population. The medical errors and serious misses we see all the time from EDs just don't seem to happen with Peds EM. In my experience that's even true for Peds EM trained physician who are in regular EDs, so its not just the culture that comes out of a children's hospital. The grumbling that you always hear and that so many ED doctors dismiss as 'jealousy' or whatever also seems to go away with more training. Maybe it really is about outcomes? And that's an outcome that happens with nothing more than a more thorough training pathway: they even have the same culture of seeing 2.5 PPH as the adult ED down the road.

If EM was a 5 year residency, and ED doctors saw 2 PPH, I suspect 90% of the concerns people have about ED doctors would disappear.

 

[Perrotfish]

My boyfriend is having a crisis. Bear with me, because this is going to be as detailed as I can manage.

Prior to this, my boyfriend was excited about EM. He has a lot of experience with it and seemed pretty confident about his choice. He started his intern year two weeks ago. Over the last few days he's come home and said he chose the wrong specialty, that he hates EM, he's ruined his life...blah de blah woecakes. You get the gist. He tends to have a flair for the dramatic and be a bit pessimistic, so it's been difficult to determine if this is just new resident woe or if he actually HAS chosen the wrong specialty.

Some background on why he chose EM: Wide variety of complaints, trauma, critical care component, procedures, not taking call, good money while still having time off to enjoy things outside of medicine. He's smarter than any of the residents I've ever met, but he's a bit arrogant and likes to feel like he's the one that can fix people.

Reasons he's given for not liking EM (so far):
- Having to call consultants and/or Consultants treating him like he's a ******* (Told him that they think every intern his a *******)
- Being considered pond scum by other specialties (Personally I believe this is in his head, and that once he develops/proves his skill as a doc he will be given respect)
- EM doesn't get a ton of respect from the rest of the medical community
- Thinks the residency isn't long enough.
- Didn't get into his 1st pick program - I think it's more about this than anything else. He matched into a VERY good program in a nice area, but it still wasn't his first choice.

In the last 48 hours he's said that he should have went into Urology, which he later followed by saying he would hate only being focused on the bladder, would miss working with heart/lungs, HATED tumor conferences, that it was monotonous BUT that at least he would feel more important. He thinks that Urology would be too competitive for him to switch into, but he definitely could have matched into a Urology residency during med school. Personally I don't think that he would become bored with this specialty.

I don't know if this is a normal Holy **** I'm A Resident What Have I Done reaction that will ease once he finds his stride or if he actually did choose the wrong specialty. Due to the program structure, he's had hardly any time in the ED and is spending more time in lectures, sim lab, etc.

I imagine a lot of new residents have this feeling at some point. It's still so early that I don't want to encourage him to switch into another specialty, but I do want to help. Has anyone else gone through this? What would you have/did you find helpful?

To avoid completely derailing this thread, to the OP: No matter what specialty he's in I promise he is going to come to you miserable, over and over for the rest of this year. He's definitely not in a position right now to know if he made the right choice or not in terms of his profession, and he's correct that even if it was the wrong choice its either too late or too early to do anything about it now. If he follows the most common pattern he's going to come to you angry or depressed a lot for the first month or two, then it will get better (but still happen), then it will get worse again and sometime around/after Christmas it will probably get worse than its ever been, especially if that's his ICU month. He'll start feeling better later in the year and will start acting mostly normal by the end of Intern year (though he will still have spasms of frustration and depression through the end of residency). He may also follow a less common pattern.

Over the Internet its almost always impossible to tell when standard Intern year depression is deviating into true clinical depression. During the first month of Intern year its probably not all that possible even up close. Be supportive, help/make him prioritize sleep and exercise, help/make him trade money for time/stress when possible, and remind him frequently that its just a year and years end.

Finally if he ever starts making comments about how he wishes he could die, rather than how he wishes he could quit, take that very seriously.

 

[Doctor Bob]

If EM was a 5 year residency, and ED doctors saw 2 PPH, I suspect 90% of the concerns people have about ED doctors would disappear.

Nah. We'd be a source of annoyance for other services regardless because when we call it's only to give people more work to do. Even when the call is justified, it's still an annoyance. And when people are annoyed, they find things to complain about.

But keep in mind that no matter how dumb the consults, admissions, etc... eventually your service caps. Eventually all of your beds are full and the inflow of work slows/stops. My service never caps. I can't stop people from coming in the front door, and my liability begins the moment they set foot inside the door.

Plus at 120 minutes in the ED the patient's name turns red on my tracking board and I start getting phone calls from various administrators asking why the wait times / ED visit times are so long. Since we're not hospital employees, if admin feels our throughput times are too long, they'll dump our group and get a different one. Doesn't matter if we're giving exemplary care or not, or making things easier for the inpatient teams... all that matters is good scores on a bunch of irrelevant metrics.

And damned if every shift I don't get at least one patient sent to the ED from clinic who clearly should have been a direct admit to the hospital; who was sent to the ED "because it's quicker to get a CT in the ED than on the floor" or some other ridiculous reason.

 

[Siggy]

The job is primarily to rule out emergent/urgent things, diagnose them if they're present, and initiate appropriate treatment. Diagnosing and treating the rest is secondary, but no one is going to completely refuse this.

People associate triage with simply determining disposition based on initial presentation rather than evaluation and treatment, which is where they take offense. Being dismissed as a "triage nurse" doesn't help, either.

...and yet during my EM rotations both during med school and residency, I've heard more than once to essentially decide on a disposition as soon as possible and start guiding the patient that way. Also, let's be honest, a lot of patients can be determined whether they're going to be admitted or not based on their initial presentation.

IM loves to talk a big game about making the diagnosis, but how many undiagnosed patients are you really getting from the ED? I've seen plenty of hospitals and plenty of different EM programs, and patients who were being admitted without a diagnosis or at least a pretty clear path to confirming or ruling it out were a pretty small minority at every one of them.

EM loves to talk a big game about making diagnosis too, but how hard is it to make the majority of diagnoses in the first place? RLQ ABD pain? CT, appy, consult surgery. RUQ? Ultrasound, gall bladder, consult surgery. Chest pain in a 60 year old? CXR, EKG, trops, consult medicine for R/O ACS.
The vast majority of day to day medicine isn't exactly hard. When it does, though, EM generally doesn't have the time to come down to an actual diagnosis. That's also not their job, which should be accepted by both sides.

The job of the ED is to literally triage patients at a high rate of speed with a physician's level of knowledge. Complaining about that is like nurses who complain about being called butt wipers and not realizing just how important it is to recovery to keep patients clean and dry both for comfort and to prevent further infections and complications.

2.) You want them to sit on a guy who arrested and now has crushing chest pain for 4 hours for a second set of enzymes? What would that have accomplished, besides tying up a bed for another 4 hours and keeping a few other patients from being seen, treated, and dispositioned? You're also completely ignoring the realities of working in a hospital. Administration would probably feel it was entirely inappropriate for a patient to be sitting in the ED 5-6+ hours, and has likely made that known. Direct your frustration at the real source.

...and where did I claim that? If I expected the ED to do my job and come up with a final diagnosis on every patient, then yes. I would expect them to sit on a chest pain for 4 hours waiting to see if it pops positive. However I don't expect the ED to do my job, so I don't. Now if the clinical case leads to the possibility that the patient won't need admission (recent clean cath, frequent flyer, etc) and there's a possibility of straight discharge, then sure. The 99.99% of the rest of the patients, then sure... triage them to admission and let/force us to do our job.

3.) Sounds like your medicine department needs to step up and make other services take patients. The patient had to come into the hospital, neurosurgery has the power to refuse the admission at your institution, but apparently medicine doesn't. How was EM supposed to force them to take the patient if you can't? And you couldn't even get a NS consult with IM as the primary team? Not even on the bounceback? I don't understand, and it brings me to one of the things that drove me absolutely nuts about the IM residents at my medical school: the absolute inability to step up and take ownership of mistakes. They'd have the patient for a week after they were in the ED for 2 hours, but cry that the ED should've ordered an MRI after the CT was negative (for example). It's clearly EM's fault, even though IM had the patient 84 times longer and could have ordered it themselves. So why couldn't you get NS involved, but the ED absolutely should have? I mean, we're just triage nurses down here, can't you real doctors handle it?

Your rash example does sound legitimately bad, and I'm totally willing to accept that there's some pretty awful emergency physicians. I've also seen plenty of IM guys flounder in the ED, bungle management in the ICU resulting in patient deaths, and fail to recognize a patient was sick until they were on death's door. Or surgery insisting that a guy didn't have a surgical problem even though radiology and IM say there's free air in the abdomen on multiple imaging modalities.

Every specialty will mismanage patients. They all also have their own areas of expertise, and sometimes their decisions will seem wrong to you but actually be appropriate. Before you go spewing hate at EM next time, stop and consider that maybe your perspective isn't totally accurate given that they're the ones who are giving you the most work, and that maybe your specialty isn't comprised exclusively of rockstars that we should all strive to emulate.

Who, exactly, are you responding to with these?

 

[calvnandhobbs68]

Nah. We'd be a source of annoyance for other services regardless because when we call it's only to give people more work to do. Even when the call is justified, it's still an annoyance. And when people are annoyed, they find things to complain about.

But keep in mind that no matter how dumb the consults, admissions, etc... eventually your service caps. Eventually all of your beds are full and the inflow of work slows/stops. My service never caps. I can't stop people from coming in the front door, and my liability begins the moment they set foot inside the door.

Plus at 120 minutes in the ED the patient's name turns red on my tracking board and I start getting phone calls from various administrators asking why the wait times / ED visit times are so long. Since we're not hospital employees, if admin feels our throughput times are too long, they'll dump our group and get a different one. Doesn't matter if we're giving exemplary care or not, or making things easier for the inpatient teams... all that matters is good scores on a bunch of irrelevant metrics.

And damned if every shift I don't get at least one patient sent to the ED from clinic who clearly should have been a direct admit to the hospital; who was sent to the ED "because it's quicker to get a CT in the ED than on the floor" or some other ridiculous reason.

So would you rather be a hospital employee and have them able to straight up fire you for it? I don't get your complaint about being a contracted group...there's really only two ways to do things. Yeah, like all contractors if the person paying you doesn't like the job you're doing then they can get rid of you. Works the same way for the contractor who comes and works on my house.

 

[Doctor Bob]

So would you rather be a hospital employee and have them able to straight up fire you for it? I don't get your complaint about being a contracted group...there's really only two ways to do things. Yeah, like all contractors if the person paying you doesn't like the job you're doing then they can get rid of you. Works the same way for the contractor who comes and works on my house.

I wasn't complaining about what the hospital administrators measure my performance by (well... I do, but that's for another discussion).

My point was, when the hospitalists/consultants get upset at me for dispositioning people out of the ED quickly and I have to weigh that against the hospital administrators who might get upset at me for not dispositioning people out of the ED fast enough, I'm going to have to be content with upsetting the hospitalists. They don't control my contract.

When I have a waiting room that's 30 people deep and xray is backed up 2-3 hours, then the 80yr old with pneumonia is probably going to get admitted without a chest xray. If they stay in the ED for the amount of time necessary to get that study (a factor out of my control... I can't force xray to go any faster), my metrics will suffer and the administrators (who control my contract) will get upset with me (again, for something beyond my control). I can clinically diagnose pneumonia and determine with a quick bedside walking pulse-ox that grandma isn't going home so that's good enough to warrant an admission.

 

[IlDestriero]

but he's a bit arrogant and likes to feel like he's the one that can fix people.

->here's the problem

Reasons he's given for not liking EM (so far):
- Having to call consultants and/or Consultants treating him like he's a ******* (Told him that they think every intern his a *******)

->this won't change

- Being considered pond scum by other specialties (Personally I believe this is in his head, and that once he develops/proves his skill as a doc he will be given respect)
-most other physicians won't respect him, or even give him a second thought
-he won't get respect because EM doesn't get a ton of respect from the rest of the medical community

->see above, all I care about is if there is a working IV from the ED so I can put the patient to sleep in the OR, whatever else he does, outside of activating the massive transfusion protocol for a big trauma could have been done by the surgeon for all I know

- Thinks the residency isn't long enough.
- Didn't get into his 1st pick program - I think it's more about this than anything else. He matched into a VERY good program in a nice area, but it still wasn't his first choice.

See embedded answers above. ->
He sounds like he has an ego problem, anesthesia doesn't get a lot of respect either, but we are the grease that keeps the OR $$ engine going. I am happy to leave at 3 and cash my bloated check. Most of the good we do goes unnoticed, often even by the surgeon, because if we are doing a good job, the crisis is averted before anyone else knows it's on the horizon.
If he can't come to terms with that, and go home knowing he did a good job, and that the ungrateful patients are better off for it, than he should consider a different career choice.
I did one month in the ED and after a few shifts knew it wasn't for me. Most of the things he seems to want to do are the <10%, the >90% is fairly benign and protocol driven.
This is also true of anesthesia, but I subspecialized and work at a major specialty hospital to keep it interesting. Perhaps he can do something similar.

 

[VisionaryTics]

For the OP, your boyfriend is weak. If he can't take a little heat, he's in for a long miserable ride. He almost certainly won't be a urologist now.

Yeah, I would love to see this guy as a gen surg intern. Being treated like a *******? Pond scum? Lack of respect? All day, every day.

 

[Perrotfish]

Nah. We'd be a source of annoyance for other services regardless because when we call it's only to give people more work to do. Even when the call is justified, it's still an annoyance. And when people are annoyed, they find things to complain about.

Again, all I can say is that I get to see an alternative system in play with Peds EM, and most of the complaints go away. Peds EM also can't stop patients from walking through the door, they also work at a fast pace, they also see patients sent to the ED for stupid reasons, and they also only call to give people more work to do. The only difference is in the length and quality of their training and the associated outcomes, and that's enough (in my experience) to get rid of most of the complaints from the hospitalists and floor residents. Not all of them, of course, every service complains about every other service, but in my experience the volume and vitriol of the complaining is more in line with what you hear when people talk about consulting a Pediatric subspecialty, or surgery, or dermatology. Normal interdepartmental eye rolling. With normal EM the complaints are much more in line with what you hear about DNPs. Its righteous indignation directed towards a profession that is perceived not to be adequately policing itself.

 

[Perrotfish]

Yeah, I would love to see this guy as a gen surg intern. Being treated like a *******? Pond scum? Lack of respect? All day, every day.

And they all whine about it when they get home. Give the guy a break: he's not here justifying why he snapped and started screaming at his boss, or even why he lost his temper and kicked the dog. This is his girlfriend asking why he's been so down on his life decisions when he's at home. Regretting your match is a perfectly reasonable reaction to being treated like pond scum. Interns regret going into medicine, their specialty, or both.. Its pretty much universal. Some come out of it, some don't and focus on early retirement, but they almost all feel that way for at least a while. Even Surgery Interns.

FWIW I think that that it is an excellent sign that the OP's boyfriend is concerned that his residency is too SHORT. That definitely doesn't smell like ego or overconfidence to me.

 

[Arcan57]

Again, all I can say is that I get to see an alternative system in play with Peds EM, and most of the complaints go away. Peds EM also can't stop patients from walking through the door, they also work at a fast pace, they also see patients sent to the ED for stupid reasons, and they also only call to give people more work to do. The only difference is in the length and quality of their training and the associated outcomes, and that's enough (in my experience) to get rid of most of the complaints from the hospitalists and floor residents. Not all of them, of course, every service complains about every other service, but in my experience the volume and vitriol of the complaining is more in line with what you hear when people talk about consulting a Pediatric subspecialty, or surgery, or dermatology. Normal interdepartmental eye rolling. With normal EM the complaints are much more in line with what you hear about DNPs. Its righteous indignation directed towards a profession that is perceived not to be adequately policing itself.

Troll much? If I'm getting the gist of your argument, extra training in a specialized area results in perceived improvement in patient care within that specialized area. That is indeed an earthshaking supposition. I'm not even going to get into how big a difference having specialized nurses, RTs, child-life techs makes in the ability to even obtain the information that most higher level pediatric emergency care is based upon. Peds EM is largely based off of a series of propositions that don't hold true for the adult population:
1) Most symptoms in kids are caused by benign, self-limited diseases.
2) Most kids that are sick also look sick.
3) Most complicated kids present within the system that provides their routine care.
4) Imaging (especially U/S or cross-sectional) is being obtained and read by people that are proficient in pediatric radiology.
5) Resuscitative procedures are uncommon and there will typically be a specialist (usually in house) available to perform it (peds surgery for chest tubes/central lines, anesthesiology for airways on congenital abnormalities, ortho with fluoro for complicated reductions)

This isn't to bash on peds EM but to point out that their practice environment looks little to nothing like what wild-type EPs have available. While you can argue that lengthening training would improve overall competency, there doesn't seem to be a national crisis of newly minted EM attendings slaughtering patients left and right so I think you'd be looking at a really large sample size to show even a small statistically significant difference. Surely you are also going to recommend that this lengthened training should be spent doing off-service rotations so that we learn how to properly evaluate a patient through other specialty's prisms. This ignores the fact that off-service rotations dramatically lower your patient encounters/day and the acuity for anything other than specialty surgery and ICU rotations is dramatically lower for junior residents then what we see in the ED. Especially for institutions for which decision-making never falls below the fellow level and is often at the subspecialty attending level. Finally how a particular specialty works up a particular complaint as an inpatient is a great way to learn how to work up that complaint in the inpatient setting. It doesn't teach nearly as much about how to even suspect that condition in the first place in the morass of complaints from the undifferentiated ED patient or how to figure out how to get the work-up performed urgently as an outpatient in a safe manner in a patient without resources.

 

[AStark]

I am going to call bull**** on this happening often. People bag on EM because they do not understand what the proper EM workup entails, and certainly do not understand what it is like to see the amount of patients we have to see, in the limited time we have, while properly ruling out the worst case scenarios with sometimes very difficult patient presentations.

Well recently I got a consult for "AECOPD". Asked for a gas to be done while I reviewed the EMR. Still not done much less entered an hour later. So I did it myself. Setting aside that the patient's symptoms did not remotely suggest the putative diagnosis, the gas was entirely normal. Normal pH, PO2, PCO2. Of course, the patient did have a severe structural heart disease that is intrinsically progressive in nature. This wasn't an issue with "workup" either. Simply a matter of taking 30 seconds to look at the most recent cardiology notes and echo report. It's hardly the first time something like this has happened.

I rag on cosmetic derm. I don't rag on derm that actually manages disease. And I am not jealous of what derm does, if I had to do just that every day I would probably leave medicine altogether.

Pimple popper MD!

Shift work, no call days, leave work at work, predictable work hours, ability to expand/contract your practice to fit your yearly paycheck desires.. etc etc, I could go on for days. Three to four years of residency to be making 350k/year in a specialty that society thinks is EXTREMELY important and glorified fully on TV? Sign me up. Seriously, go ask any person "what's the most important part of the hospital?" and tell me how many times people answer "The ED!!" It's far more than "the wards" or "the operating rooms." Hell, I'd say the only thing giving the ED a run for it's money with my question is "the cafeteria." Ha!

I can't stand shift work. Call is one thing, but routinely working entire nights my whole career? And dealing with the skeets who come in at 3am Saturday nights? No thanks. But, yes, as others have said, real mature.

Fortunately at my centre we absolutely can refuse admissions ("no indication for acute medical admission"), especially anything social or functional, which then becomes a "community emergency" admission that's managed by the emergency physician. Generally speaking we're happy to take anyone with a legitimate reason to be in hospital, and - mostly - different services are good about taking patients appropriately. But we did have a lady diagnosed as a UTI in emerg who wound up having a perf'd gallbladder. That was the admitting IM team's fault too in not investigating the patient's "epigastric pain" properly in the first place too.

If EM was a 5 year residency, and ED doctors saw 2 PPH, I suspect 90% of the concerns people have about ED doctors would disappear.

EM is a 5 year residency in Canada. Perhaps that improves things somewhat, but then we also have lots of 3 year family/emerg physicians staffing our EDs. With variable results. One of the worst at my centre is a 5 year...

 

[justaregularmed]

1.) 1/3 are undiagnosed in my hospital. Easily, if not more. The ED is that bad. But again, I don't consider that their job.

2.) The ED should have sent that person straight to the CCU, not their usual medicine floor dumping ground.

3.) The ED never should have "consulted" IM for a guy with skull fracture and intraparenchymal bleed. Call NSU. Call the neuro ICU. Call even neurology if you like. But what do they do when NSU says "nothing for us to do"? Rather than be responsible physicians who say, "No, this IS your problem, and you WILL take this patient," they just send them over to the usual dumping ground, the IM floor who has no power to refuse admissions. Ortho, GSU, ENT, uro, NSU, psych can all refuse admissions. IM cannot. Top 10 kind of place. Too bad our ED is so awful.

You appear to be a pretty typical overworked medicine intern at an academic place, I would hazard to guess you have yet to rotate in the ED, I don't feel the community vibe in you. You see admissions as work, they don't yet pay the bills yet so they frustrate you. Your concerns are legitimate but somewhat silly. If you are unhappy with the workups, speak up and dont spaz out over the phone, ask them to be fixed. You don't yet seem to know how to leverage the ED to start your diagnostic testing or are not allowed to. Your hospital also seems fairly dysfunctional if they allow brain bleeds to be on the medicine floor, seems like a systems issue to me.