Trying to decide between EM and psych

[Sasaro]

MS3 here with a very long post warning. I am torn between EM and psychiatry and would love some advice on how to decide. So far, I have rotated through surgery, IM, neuro, psych, and EM (2 weeks only). My only rotations left this year are OB/Gyn and peds, neither of which will help me decide, and I need to plan my 4th year electives.

Here are the pros and cons of EM and psychiatry that I've been considering:

EM pros:

• Great variety of patients. I like the process of coming up with a differential, narrowing down the diagnosis, and the detective work / critical thinking involved.
• Fast-paced work generally makes the time go faster for me and keeps me from getting bored.
• I like the idea of knowing a decent amount about various different fields of medicine.
• I want to be helpful if/when the zombie apocalypse happens. But in all seriousness, I want to be able to be helpful if there's an emergency in a plane or if a car overturns in front of me on a freeway. This has actually happened to me several times prior to medical school, and I was irritated at feeling useless in those situations.
• While not necessarily an 'adrenaline junkie', I do enjoy excitement. I jive well with the types of personalities that stereotypically to go into EM - the rock-climbing, craft-IPA drinking, triathlon-running types.
• I am good at working with my hands and would probably enjoy procedures, though I haven't been allowed to do anything more advanced than a lac repair yet.
• I love the outdoors and would love to be able to work in wilderness medicine in some capacity.
• Shift work - I like the idea of having some weekdays off and never having to be on call. I'm not having kids and am a natural night owl, so I don't think the nights would bother me much.
• Short training, great pay - I'm an older med student, and a 3 year residency that results in a nice paycheck is very appealing when I only have about 25 years to save for retirement.

EM cons:

• Patient population is often difficult. Intoxicated aggressive patients, drug seekers, patients cussing the EM docs out for the long waits, etc. I don't relish the idea of getting assaulted/physically injured on the job, which I hear is not a rarity in EM.
• The cool, exciting stuff is few and far between. Patients are using EDs more and more for their sniffles / chronic HTN / annual checkups, and I imagine this gets old quickly.
• This may sound pathetic, but I have an excessively sensitive nose. I am not at all bothered by gore, but I've come across some patients that sent me dry heaving (which I felt very bad about, because it's obviously not their fault). Fermenting feet and necrotic flesh really bother me, and I despise abscesses. Blood and guts are totally fine.
• I've already witnessed EM get **** on by pretty much every other specialty (as well as patients). Consults talk down to them to their face and call them idiots behind their backs. EM gets crap for both 'ordering CTs left and right', and also for NOT ordering them (because now the admitting service has to). It's off-putting to see this much disrespect directed at a specialty that, objectively, has a very difficult job to do.
• I am very concerned by the high burn-out rates, and the apparent necessity of having an 'exit strategy' in EM.
• Shift work - I don't know how OK with it I will actually be. I won't be able to 'try it out' before residency - my school does not place medical students on nights or swing shifts in EM rotations (which is kind but irritating, because how else do we get a good idea of what the schedule is actually like?). As mentioned previously, I'm already an older med student and will be in my late 30s by the time I finish residency - so I worry about the toll on my body as I get older.
• I don't like the idea of having to work for a hospital system my entire career, and being unable to work for myself. I worry about the changes to US healthcare that have been happening and will continue to happen in the next 10-20 years, and having to be a slave to hospital administration/Press-Ganey scores/algorithm-driven medicine worries me. I have already seen EM docs get screamed at by clipboard-brandishing nurse administrators for any number of things, from refusing to prescribe unnecessary antibiotics to refusing to take the liability for patients they didn't actually see/chart during their shift. I have no interest in urgent care work. If I were to go into EM, I would probably need to do a fellowship in sports medicine or maybe pain as an 'exit strategy'.

Psychiatry pros:
Pretty much everything that is opposite of EM cons.

• I love the flexibility and many options psychiatry offers - being able to work in inpatient or outpatient, open a private practice, work in C/L or in forensics, etc. The option of being able to work for myself rather than for a hospital is very appealing.
• I am good at speaking with patients, getting them to open up, and forming relationships with them, and I think I'd find this kind of work satisfying.
• I am fascinated by the stories you hear in psychiatry. While this happens in EM as well, the time crunch of the ED puts a firm limit on how much you can explore these stories with the patient. I think the human mind is absolutely incredible, and there is still so much unknown about it.
• Not having to deal with abscesses or fermenting feet.
• Although many people say psychiatry doesn't offer quick or effective cures, it's pretty amazing to see how rapidly psychotic or depressed patients can improve with intensive inpatient treatment or ECT.
• Longevity of a career in psychiatry would likely be much greater than in EM, and psych has some of the lowest burnout rates.
• I am attracted to the idea of being considered a specialist in something and being able to develop my own niche expertise, rather than being a generalist and an easily replaceable 'cog in the machine'.
• While well-paying EM jobs are getting harder to find in places I'd like to live (Denver/West coast), I'm guessing a cash-only psychiatry practice would be more easily achievable? Feel free to correct me if I'm wrong about this.
• No overnights and no circadian rhythm shifts.
• The future job prospects might be better for psych. From everything I've heard, the demand for psychiatrists in the next 10-20 years is only going to keep growing, while EM is currently red-hot and being flooded with new grads - and I have been warned about the dangers of 'buying high'.

Psychiatry cons:

• Not being able to use much of the knowledge I learned in medical school. I've heard psychiatrists say that they forgot a lot of medicine because they don't use it as frequently. I realize that some settings such as C/L are better about this, to a degree.
• The stigma of not being a 'real doctor'. Again, I've definitely heard these kinds of self-deprecating comments made by psychiatrists about their own field. I have also witnessed psychiatrists gets confused with psychologists, social workers, and various other non-medical staff.
• Not being able to work with my hands, or getting to examine a patient. I enjoy doing physical exams and occasionally picking up random but significant findings, and as a psychiatrist I am assuming that I would essentially never touch my patients again. If there are psychiatrists out there who actually do physical exams regularly, please feel free to correct me here. Psychiatry offers less tangible work and less tangible results, which I fear will be less satisfying.
• I worry that psychiatry will feel like a step backwards for me. I almost pursued a PhD in Clinical Psychology instead of medical school, but then decided that I want to learn anatomy, physiology, and diseases other than psychiatric ones. As a psychiatrist, I'd be going back to treating only the mind and not the rest of the body - see above point about not being able to use much of the 'hard medicine' I spent so long learning.
• I will be useless in a zombie apocalypse.

Please feel free to comment on any of the above points, especially if you feel that I'm wrong about something. I welcome any and all advice on how to make this decision. I think I may ultimately be equally happy (or equally miserable) in either field, but I only have 7 months before residency applications are due. I MAY have time to do both the required 2 EM sub-Is and a psychiatry sub-I before residency applications are due, but that would be cutting it very close (and I'd like to avoid the hassles of applying to both and having to decide on the interview trail).

TL;DR: Torn between psychiatry and EM. I feel that psychiatry would be 'easier' for me to work in, and it is a more natural fit for my background. EM would probably offer bigger highs but worse cons.

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[gamerEMdoc]

Patient population is often difficult. Intoxicated aggressive patients, drug seekers, patients cussing the EM docs out for the long waits, etc. I don't relish the idea of getting assaulted/physically injured on the job, which I hear is not a rarity in EM.

Your biggest con for EM is dealing with aggressive patients, patients who swear at you, and the potential of being assaulted? Is that not an issue with psych? I ask this honestly, because I mean outside of just drunk/drugged up people, the most aggressive patients we get are psych patients.

 

[deleted859535]

Just a reminder: you're going to get some disgruntled members coming by telling you to save yourself and not do EM -- a specialty which is particularly variable based on practice environment, group, etc, and as a result, the attitudes of its physicians.

True for many specialties, but especially ours where some very vocally believe the sky is falling more than it is. EM has more than its fair share of issues, to be sure, but still has its reasons and perks.

Caveat lector.

As to your post: pros and cons to everything. Take time to be viscerally honest with yourself. You can make all the comparison lists and tables in the world, and you should, but in the end, the specialty to which you find yourself comparing everything else is the one you should choose.

 

[namethatsmell]

Think about what you want your life (and to a lesser degree, your personal identity) to look like over the course of 5-10-20 years and which field will help you get there. If one field truly fascinated you over the other you probably wouldn't be posting this question, so think about your future lifestyle as the work may likely become less exciting and interesting to you over time.

Both fields do have big pros and cons as you point out. Many on this forum think EM is entering darkening times. Psychiatry from what I've heard is in a golden age right now. Both of these things may last for several years or much longer. Nobody knows.

EM generally gets hit first by stupid things that make practicing medicine suck like corporate overlords taking advantage of you, patient satisfaction scores and dumb metrics, etc. However, should such things be applied to psychiatry on a broad scale--and they very well might with the way medicine is going--I could imagine practing pysch becoming as delightful as walking on shards of glass. And if socialized medicine were to actually come to fruition and all docs were required to participate...psych could become even more unpleasant.

 

[Sasaro]

Just a reminder: you're going to get some disgruntled members coming by telling you to save yourself and not do EM -- a specialty which is particularly variable based on practice environment, group, etc, and as a result, the attitudes of its physicians.

True for many specialties, but especially ours where some very vocally believe the sky is falling more than it is. EM has more than its fair share of issues, to be sure, but still has its reasons and perks.

Caveat lector.

As to your post: pros and cons to everything. Take time to be viscerally honest with yourself. You can make all the comparison lists and tables in the world, and you should, but in the end, the specialty to which you find yourself comparing everything else is the one you should choose.

Thanks for the feedback, I've been trying to do some introspection and will continue to do so.
I did debate whether posting this kind of question in the EM forum is inherently biased - though I'm not sure where I could get more impartial feedback (I guess I could cross-post to the psych forum??)

 

[Rekt]

Do psych. Easier lifestyle by far. Compensation will likely be higher due to endless demand and crashing EM market from oversaturation. Can walk into any fellowship at your interest.

 

[gamerEMdoc]

Do psych. Easier lifestyle by far. Compensation will likely be higher due to endless demand and crashing EM market from oversaturation. Can walk into any fellowship at your interest.

I'd counter that your choice of either shouldn't be based on market decisions. That stuff changes. Whether you like the job or not, and can see your self doing it for 30 years should be your deciding factor.

Not long ago, EM business was booming and psych was a field where people could scramble into. The market and salaries are supply and demand, and sure psych may be looking good now, but this can and will likely change for many fields several times in your career. I wouldn't choose my specialty based on what the solely around the market, because the market changes.

 

[Rekt]

I'd counter that your choice of either shouldn't be based on market decisions. That stuff changes. Whether you like the job or not, and can see your self doing it for 30 years should be your deciding factor.

Not long ago, EM business was booming and psych was a field where people could scramble into. The market and salaries are supply and demand, and sure psych may be looking good now, but this can and will likely change for many fields several times in your career. I wouldn't choose my specialty based on what the solely around the market, because the market changes.

Yeah but EM is much different than every single other specialty. There's not going to be EDs popping up all over the place. Can't just go build a hospital. Everyone else has many different outs. The only way our specialty can go is down unless they cut residency spots by a significant amount.

 

[Stephanopolous]

I'm a year ahead of you but also an older student and I'm applying EM this cycle.

My gut feeling after reading your post is that psych is the field for you. You had more enthusiasm with writing about the pros of psych than you did the pros of EM.

While I am not an ipa-drinking rock climber, I agree that EM is full of fun people, it's part of the reason why I love the specialty, albeit a smaller portion of my "why". Let me address a few of your notes to give you some perspective. I work in EMS as a medic and have for 8 years now to give you a little bit of my background/perspective.

• I want to be helpful if/when the zombie apocalypse happens. But in all seriousness, I want to be able to be helpful if there's an emergency in a plane or if a car overturns in front of me on a freeway. This has actually happened to me several times prior to medical school, and I was irritated at feeling useless in those situations.

You can be a psychiatrist and still do this. Of course, you wont be the "pro" if you're not using it all the time but there are plenty of ways that you could learn the few essential life-saving skills that are useful in most scenarios. The whole car on a freeway thing is honestly more sexy on paper than it is in real life. Could you carry a 14ga in your vehicle for the rare event where you identify a tension pneumo, dart someone, and save their life? Sure. Any of us docs technically can. That's going to be few and far between and most of the time good samaritans stopping at a scene pose a bigger safety threat than they do actually help. Many times these patients will require c-spine or some form of immobilization which is not going to be something easily done by a bystander, even if they are a doc, unless you're riding around with a QRV style set up. My point here is don't let this be a big persuader for you. Sure it's cool but I don't think that it should influence a career decision.

The smells are a real part of EM, and since we are the safety-net of medicine, you will never be able to pick and choose who you see. If they bother you now, consider how they may make you feel 10 years from now, when you're working your third night shift in a row, and maybe you're not feeling so hot. I don't say this to dissuade you, but I think picturing the worst-case-scenario helps to gain some perspective. You will see god-awful things in EM like people so unkempt and unable to care for themselves that they have maggots and flies in their wounds. On the flip side the person next door may be dressed head to toe and gucci and smell like a fountain of roses. I think that's fun but this is def not the shared view of many people lol.

• The stigma of not being a 'real doctor'. Again, I've definitely heard these kinds of self-deprecating comments made by psychiatrists about their own field. I have also witnessed psychiatrists gets confused with psychologists, social workers, and various other non-medical staff.

Just get rid of this. You did all the required training to become a doctor like the rest of us have/will. Anyone that would say something negative like this just has a lot of negativity in their own life or poor insight. Psychiatrists are a crucial part of medicine, especially with the amount of mental health issues we experience as humans.

• I worry that psychiatry will feel like a step backwards for me. I almost pursued a PhD in Clinical Psychology instead of medical school, but then decided that I want to learn anatomy, physiology, and diseases other than psychiatric ones. As a psychiatrist, I'd be going back to treating only the mind and not the rest of the body - see above point about not being able to use much of the 'hard medicine' I spent so long learning.

I could see other ways to remain in an academic environment, teaching at a med school, for example. It sounds like you have a curious mind and passion for learning many things so there's avenues to nurture that for sure.

• Not being able to work with my hands, or getting to examine a patient. I enjoy doing physical exams and occasionally picking up random but significant findings, and as a psychiatrist I am assuming that I would essentially never touch my patients again. If there are psychiatrists out there who actually do physical exams regularly, please feel free to correct me here. Psychiatry offers less tangible work and less tangible results, which I fear will be less satisfying.

I'm an osteopath and the psychiatrist I rotated with was an MD who practiced cranial OMT on all of his patients. He also examined almost every patient. What's to stop you from performing a physical exam if the patient is ok with it? Of course there's organic causes for mental health issues (I.e. you palpate a mass or thyromegaly).

edit: and I definitely agree with gamer on this one, my psych patients have been my scariest ones (one told me he was going to hunt for me and kill me, the other told me he had killed me in his dream last night, and another lunged at me and tried to choke me) to quote a few of these experiences

So my gut feeling is that psych is the right fit for you. Good luck in figuring this out OP! I wish you all the best.

 

[Sasaro]

Your biggest con for EM is dealing with aggressive patients, patients who swear at you, and the potential of being assaulted? Is that not an issue with psych? I ask this honestly, because I mean outside of just drunk/drugged up people, the most aggressive patients we get are psych patients.

I wouldn't call it my biggest con, I listed them in no particular order. I'd argue that unless I'm working as an ED psychiatrist, I would be in less physical danger overall compared to EM. The undifferentiated, 'unknown' agitated patient is the most dangerous IMO. Besides, as a psychiatrist I could avoid working in the ED or high acuity inpatient units (where those dangerous heavily manic/psychotic patients are encountered), while I could not avoid those patients in EM.

As an aside, mentally ill aggressive patients tend to bother me much less than people who are just dinguses (intoxicated or otherwise).

 

[holabuster]

A few thoughts:
1) The danger of being assaulted in the ED, the aggressive patients, and the scrutiny/derision from consultants/medicine service--these all vary so greatly from hospital to hospital. My girlfriend works in an ED with next to no psych/intox patients, whereas these amount to 40-50% of patients in my ED. Point is, if these bother you, you can find an ED that has less risk and a hospital with better relationships with consultants/nicer hospital culture.
2) I also liked both and almost decided to do psych. In the end, the variety and the critical thinking aspects of EM won out. Think about the core aspects of the job. In EM, it'd be quick, short, interactions with pts to come up with a differential, enact a plan, accept some uncertainty with the outcome, and send the patient to the right place. In psych, it'd be lengthier relationship building with pts and delving deeply into someone's inner thoughts and feelings. Try to figure out for yourself which would appeal most to you in the long run.
3) My brother's friend is doing telepsych, and is making $200/hr, sitting a home, talking to people on his webcam, half of the time shooting the ****, the rest of time about their actual psychiatric issue. He's able to travel around the world and work when he wants, as much as he wants. Seems like an easy, comfortable job, and kinda makes me envious. The other posters' comments that good/bad markets come and go have some truth, though--it's hard to predict. But's hard not to be envious when I work exhausting, very high stress shifts to make about the same amount. For many, a job just becomes a job, and psych overall is a much easier, lower burnout job.
4) In the end, like someone else said, what do you think you'd look back on in 20 years and be proud of? Another exercise is, what kind of crap do you best put up with? Every specialty has its negatives, and sometimes by consider which negatives you tolerate best, you can figure out what's right for you.

All the best to you, and let us know what you decide!

 

[miacomet]

Agreed that EM is dead and will not be resuscitated in the near future.

Psych is not immune. PhDs may get prescribing rights, and NPs are a huge threat. But there are always wealthy parents willing to shell out cash for ADHD meds....

 

[VA Hopeful Dr]

Yeah but EM is much different than every single other specialty. There's not going to be EDs popping up all over the place. Can't just go build a hospital. Everyone else has many different outs. The only way our specialty can go is down unless they cut residency spots by a significant amount.

But there are UC's popping up everywhere. Its a pay cut to be sure (unless you start your own and are good at it) but to many the lack of nights can be worth it. You also have fellowship options as many on this board can attest to.

 

[miacomet]

But there are UC's popping up everywhere. Its a pay cut to be sure (unless you start your own and are good at it) but to many the lack of nights can be worth it. You also have fellowship options as many on this board can attest to.

UCs will be 100% midlevels pretty soon IMHO.
Palli and Occ Med are ripe for midlevel takeover
CCM is tightening up just like EM
Pain is a good deal, if you can get it
What are all these lucrative fellowships?

 

[Birdstrike]

MS3 here with a very long post warning. I am torn between EM and psychiatry and would love some advice on how to decide. So far, I have rotated through surgery, IM, neuro, psych, and EM (2 weeks only). My only rotations left this year are OB/Gyn and peds, neither of which will help me decide, and I need to plan my 4th year electives.

Here are the pros and cons of EM and psychiatry that I've been considering:

EM pros:

• Great variety of patients. I like the process of coming up with a differential, narrowing down the diagnosis, and the detective work / critical thinking involved.
• Fast-paced work generally makes the time go faster for me and keeps me from getting bored.
• I like the idea of knowing a decent amount about various different fields of medicine.
• I want to be helpful if/when the zombie apocalypse happens. But in all seriousness, I want to be able to be helpful if there's an emergency in a plane or if a car overturns in front of me on a freeway. This has actually happened to me several times prior to medical school, and I was irritated at feeling useless in those situations.
• While not necessarily an 'adrenaline junkie', I do enjoy excitement. I jive well with the types of personalities that stereotypically to go into EM - the rock-climbing, craft-IPA drinking, triathlon-running types.
• I am good at working with my hands and would probably enjoy procedures, though I haven't been allowed to do anything more advanced than a lac repair yet.
• I love the outdoors and would love to be able to work in wilderness medicine in some capacity.
• Shift work - I like the idea of having some weekdays off and never having to be on call. I'm not having kids and am a natural night owl, so I don't think the nights would bother me much.
• Short training, great pay - I'm an older med student, and a 3 year residency that results in a nice paycheck is very appealing when I only have about 25 years to save for retirement.

EM cons:

• Patient population is often difficult. Intoxicated aggressive patients, drug seekers, patients cussing the EM docs out for the long waits, etc. I don't relish the idea of getting assaulted/physically injured on the job, which I hear is not a rarity in EM.
• The cool, exciting stuff is few and far between. Patients are using EDs more and more for their sniffles / chronic HTN / annual checkups, and I imagine this gets old quickly.
• This may sound pathetic, but I have an excessively sensitive nose. I am not at all bothered by gore, but I've come across some patients that sent me dry heaving (which I felt very bad about, because it's obviously not their fault). Fermenting feet and necrotic flesh really bother me, and I despise abscesses. Blood and guts are totally fine.
• I've already witnessed EM get **** on by pretty much every other specialty (as well as patients). Consults talk down to them to their face and call them idiots behind their backs. EM gets crap for both 'ordering CTs left and right', and also for NOT ordering them (because now the admitting service has to). It's off-putting to see this much disrespect directed at a specialty that, objectively, has a very difficult job to do.
• I am very concerned by the high burn-out rates, and the apparent necessity of having an 'exit strategy' in EM.
• Shift work - I don't know how OK with it I will actually be. I won't be able to 'try it out' before residency - my school does not place medical students on nights or swing shifts in EM rotations (which is kind but irritating, because how else do we get a good idea of what the schedule is actually like?). As mentioned previously, I'm already an older med student and will be in my late 30s by the time I finish residency - so I worry about the toll on my body as I get older.
• I don't like the idea of having to work for a hospital system my entire career, and being unable to work for myself. I worry about the changes to US healthcare that have been happening and will continue to happen in the next 10-20 years, and having to be a slave to hospital administration/Press-Ganey scores/algorithm-driven medicine worries me. I have already seen EM docs get screamed at by clipboard-brandishing nurse administrators for any number of things, from refusing to prescribe unnecessary antibiotics to refusing to take the liability for patients they didn't actually see/chart during their shift. I have no interest in urgent care work. If I were to go into EM, I would probably need to do a fellowship in sports medicine or maybe pain as an 'exit strategy'.

Psychiatry pros:
Pretty much everything that is opposite of EM cons.

• I love the flexibility and many options psychiatry offers - being able to work in inpatient or outpatient, open a private practice, work in C/L or in forensics, etc. The option of being able to work for myself rather than for a hospital is very appealing.
• I am good at speaking with patients, getting them to open up, and forming relationships with them, and I think I'd find this kind of work satisfying.
• I am fascinated by the stories you hear in psychiatry. While this happens in EM as well, the time crunch of the ED puts a firm limit on how much you can explore these stories with the patient. I think the human mind is absolutely incredible, and there is still so much unknown about it.
• Not having to deal with abscesses or fermenting feet.
• Although many people say psychiatry doesn't offer quick or effective cures, it's pretty amazing to see how rapidly psychotic or depressed patients can improve with intensive inpatient treatment or ECT.
• Longevity of a career in psychiatry would likely be much greater than in EM, and psych has some of the lowest burnout rates.
• I am attracted to the idea of being considered a specialist in something and being able to develop my own niche expertise, rather than being a generalist and an easily replaceable 'cog in the machine'.
• While well-paying EM jobs are getting harder to find in places I'd like to live (Denver/West coast), I'm guessing a cash-only psychiatry practice would be more easily achievable? Feel free to correct me if I'm wrong about this.
• No overnights and no circadian rhythm shifts.
• The future job prospects might be better for psych. From everything I've heard, the demand for psychiatrists in the next 10-20 years is only going to keep growing, while EM is currently red-hot and being flooded with new grads - and I have been warned about the dangers of 'buying high'.

Psychiatry cons:

• Not being able to use much of the knowledge I learned in medical school. I've heard psychiatrists say that they forgot a lot of medicine because they don't use it as frequently. I realize that some settings such as C/L are better about this, to a degree.
• The stigma of not being a 'real doctor'. Again, I've definitely heard these kinds of self-deprecating comments made by psychiatrists about their own field. I have also witnessed psychiatrists gets confused with psychologists, social workers, and various other non-medical staff.
• Not being able to work with my hands, or getting to examine a patient. I enjoy doing physical exams and occasionally picking up random but significant findings, and as a psychiatrist I am assuming that I would essentially never touch my patients again. If there are psychiatrists out there who actually do physical exams regularly, please feel free to correct me here. Psychiatry offers less tangible work and less tangible results, which I fear will be less satisfying.
• I worry that psychiatry will feel like a step backwards for me. I almost pursued a PhD in Clinical Psychology instead of medical school, but then decided that I want to learn anatomy, physiology, and diseases other than psychiatric ones. As a psychiatrist, I'd be going back to treating only the mind and not the rest of the body - see above point about not being able to use much of the 'hard medicine' I spent so long learning.
• I will be useless in a zombie apocalypse.

Please feel free to comment on any of the above points, especially if you feel that I'm wrong about something. I welcome any and all advice on how to make this decision. I think I may ultimately be equally happy (or equally miserable) in either field, but I only have 7 months before residency applications are due. I MAY have time to do both the required 2 EM sub-Is and a psychiatry sub-I before residency applications are due, but that would be cutting it very close (and I'd like to avoid the hassles of applying to both and having to decide on the interview trail).

TL;DR: Torn between psychiatry and EM. I feel that psychiatry would be 'easier' for me to work in, and it is a more natural fit for my background. EM would probably offer bigger highs but worse cons.

Psychiatry equals managing insanity, in the setting of a great schedule, no nights, weekends, holidays or call, feeling as rested as you want to feel, with control of your schedule.

EM equals managing insanity, in the setting of a horrible schedule, constantly working nights, weekends and holiday, feeling jet-lagged all the time, with little to no control of your schedule.

Choose.

Only do EM if you must do EM to live. If you do go into EM, have an iron clad mid-career plan to reduce your clinical shifts by >50% without a reduction in income. The odds are >50% you'll feel enough burnout within 5-10 years to put you on an unstoppable collision course into an immovable wall of emotional exhaustion, without one. That's just a fact. People that tell you otherwise are either lying to you, lying to themselves or have no idea what they're talking about.

EM with an iron clad mid-career exit option is a reasonable choice (most common).
EM without an iron clad mid-career burnout plan, is an irresponsible choice (least common).

 

[Hippocrates II]

Just my perspective, but a lot of your list for either specialty seems very superficial, and will likely have no bearing on your happiness once you're a doctor. Things like wanting to be a hero on an airplane, or not being perceived as a real doctor by others, are not great reasons to pursue or avoid a specialty IMO. At some point, this will just be a job that you go to every day, and you should think about the day to day that you will experience and whether that's something you want to live, not about the exceedingly small chance that a plane full of people might cheer you on as a hero because you helped a person out in a way that a psychiatrist could not.

 

[VA Hopeful Dr]

UCs will be 100% midlevels pretty soon IMHO.
Palli and Occ Med are ripe for midlevel takeover
CCM is tightening up just like EM
Pain is a good deal, if you can get it
What are all these lucrative fellowships?

In order:

Nope, every UC within 60 miles of me is always hiring physicians. None are hiring midlevels at the moment. I can't say with 100% certainty that it won't change in 10 years, but we can't say that about anything.
I don't know anything about occupational, but palliative is also always on the look-out for physicians - not so much midlevels.
I don't know about the CCM job market to comment.

As an aside, I didn't say lucrative. In fact the physician who posted here recently about switching to palliative care even made a big point about taking a pay cut but that it was worth it as his/her stress level decreased significantly.

 

[Groove]

Do psychiatry. There's a huge need and if you find the right city, you can rake in an enormous amount of $$$ by providing services at multiple hospitals/facilities. Our local psych guys are killing it. That being said, you should legitimately enjoy psychiatry and it sounds like you do. Personally, I haven't met too many people torn between EM and Psychiatry that didn't belong in psychiatry. They really are very different fields. That being said, if you choose EM just remember that we're probably about to go into a market "recession" whereas psych is doing very well and on the up d/t market forces and supply/demand.

 

[Birdstrike]

Do psychiatry. There's a huge need and if you find the right city, you can rake in an enormous amount of $$$ by providing services at multiple hospitals/facilities. Our local psych guys are killing it. That being said, you should legitimately enjoy psychiatry and it sounds like you do. Personally, I haven't met too many people torn between EM and Psychiatry that didn't belong in psychiatry. They really are very different fields. That being said, if you choose EM just remember that we're probably about to go into a market "recession" whereas psych is doing very well and on the up d/t market forces and supply/demand.

The psych people around me are all cash-only, do entirely office based psych and work 4-4.5 days per week. Psych isn't the kind of thing you drool over in medical school, but after all the adrenaline stuff becomes routine, and you see the burnout in people working stupid hours, taking call and chronic circadian depression, it looks like a pretty good use of a medical degree.

 

[Groove]

The psych people around me are all cash-only, do entirely office based psych and work 4-4.5 days per week. Psych isn't the kind of thing you drool over in medical school, but after all the adrenaline stuff becomes routine, and you see the burnout in people working stupid hours, taking call and chronic circadian depression, it looks like a pretty good use of a medical degree.

Agreed. If there was a 1-2 year psych fellowship and a crossover track, I'd seriously consider it in today's market.

 

[Sushirolls]

Psychiatry cons:

• I will be useless in a zombie apocalypse.

Its about that time to side track...

As a Psychiatrist I need to correct this statement, completely wrong. Most every physician will be useless during a Zombie Apocalypse. No antibiotics, less readily available clean water, surgical tools (and clean), and really no medicine around. So as an EM you diagnosed the ruptured appendix quickly, so what, its still ruptured, now what are you going to do about it?

A Psychiatrist on the other hand will have spent ample time identifying personality disorders, PTSD, depression, bipolar, psychosis, etc. This is valuable for who you (or your group) decide to interact with, or who in your group is struggling. Psych will have a leg up on reading and understanding other people and their current struggles, which is more valuable than being able to identify a spontaneous pneumothorax and not having a clean tube anywhere.

 

[Mad Jack]

Your biggest con for EM is dealing with aggressive patients, patients who swear at you, and the potential of being assaulted? Is that not an issue with psych? I ask this honestly, because I mean outside of just drunk/drugged up people, the most aggressive patients we get are psych patients.

EM docs are slightly more likely to be assaulted, while psych docs are far more likely to be murdered

 

[Mad Jack]

Its about that time to side track...

As a Psychiatrist I need to correct this statement, completely wrong. Most every physician will be useless during a Zombie Apocalypse. No antibiotics, less readily available clean water, surgical tools (and clean), and really no medicine around. So as an EM you diagnosed the ruptured appendix quickly, so what, its still ruptured, now what are you going to do about it?

A Psychiatrist on the other hand will have spent ample time identifying personality disorders, PTSD, depression, bipolar, psychosis, etc. This is valuable for who you (or your group) decide to interact with, or who in your group is struggling. Psych will have a leg up on reading and understanding other people and their current struggles, which is more valuable than being able to identify a spontaneous pneumothorax and not having a clean tube anywhere.

Realistically the most useful doctor in the apocalypse is a veterinarian

 

[Sushirolls]

Realistically the most useful doctor in the apocalypse is a veterinarian

Dentist as runner up perhaps?

 

[VA Hopeful Dr]

Realistically the most useful doctor in the apocalypse is a veterinarian

Nonsense, in a zombie apocalypse you'll be begging me for a good poultice. Plus I'll have a leg up on the barter economy:

 

[Candidate2017]

Psychiatry cons:

• Not being able to use much of the knowledge I learned in medical school. I've heard psychiatrists say that they forgot a lot of medicine because they don't use it as frequently. I realize that some settings such as C/L are better about this, to a degree.
• The stigma of not being a 'real doctor'. Again, I've definitely heard these kinds of self-deprecating comments made by psychiatrists about their own field. I have also witnessed psychiatrists gets confused with psychologists, social workers, and various other non-medical staff.
• Not being able to work with my hands, or getting to examine a patient. I enjoy doing physical exams and occasionally picking up random but significant findings, and as a psychiatrist I am assuming that I would essentially never touch my patients again. If there are psychiatrists out there who actually do physical exams regularly, please feel free to correct me here. Psychiatry offers less tangible work and less tangible results, which I fear will be less satisfying.
• I worry that psychiatry will feel like a step backwards for me. I almost pursued a PhD in Clinical Psychology instead of medical school, but then decided that I want to learn anatomy, physiology, and diseases other than psychiatric ones. As a psychiatrist, I'd be going back to treating only the mind and not the rest of the body - see above point about not being able to use much of the 'hard medicine' I spent so long learning.
• I will be useless in a zombie apocalypse.

Regarding some of your cons,

Medical knowledge:
Lots needed in psychiatry. Lots of primary care issues in inpatient as well as ruling out emergent issues. Ordering/reading labs, EKG etc. Often we are the physician of last resort because everyone else writes off "psychiatric patients" as non-medical patients. For example, I've caught new onset A-fib in an elderly ED patient labeled suicidal because I was the only one to bother to look at his EKGs. We also prescribe meds that can kill or induce serious side effects, which you need to know how to manage... AEDs, TCAs, SGAs, BZDs, MATs/opioid substitutes etc, even SSRIs. At the same time, part of being a specialist is being able to punt because your knowledge and time are limited resources better spent by focusing on your specialty area. Yes some older docs are pretty bad with medical knowledge but it’s a function of older docs dgaf.

Real doctor:
See above. Choosing a specialty means not caring what others think and letting go of bright-eyed desires of "I wanna be a navy seal, rocket scientist, pro athlete, ninja, paleontologist, pediatric brain surgeon AND rockstar who counsels patients on smoking cessation."

Physical exams: Neuro exam is important, PCP stuff above.

Working with hands: Lots of free time for manual hobbies.

Tangible results: Plenty. Amazing to resolve mania or psychosis, take someone from suicidal and hopeless to thriving, including fellow physicians.

Zombie apocalypse: +1 veterinarian. They do everything. Or hone your shotgun skills.

 

[Candidate2017]

Your biggest con for EM is dealing with aggressive patients, patients who swear at you, and the potential of being assaulted? Is that not an issue with psych? I ask this honestly, because I mean outside of just drunk/drugged up people, the most aggressive patients we get are psych patients.

By the time they get to the psych ward they’ve spent at least 3 days cooped up in the ED getting haldol’ed, ketamined, restrained etc. Can't stay agitated forever. That rhabdo. Then they come to the psych ward and get promised a lawyer, crayons, clothes, a dining room, a nearly private room and shower, peers to socialize with and staff who ask about their feels.

I’m more wary of the criminals with no psychiatric issues. We've had some murder or seriously hurt others post-psych hospitalization. But most criminals tend to behave on the psych ward because they want out after a few days after realizing there's nothing to gain and they get tired of hoards of people constantly asking them about their feels.

Outpatient psych patients tend to be pleasant because personality disordered people, criminals and substance abusers tend not to be able to keep jobs with good insurance.

 

[thegenius]

MS3 here with a very long post warning. I am torn between EM and psychiatry and would love some advice on how to decide. So far, I have rotated through surgery, IM, neuro, psych, and EM (2 weeks only). My only rotations left this year are OB/Gyn and peds, neither of which will help me decide, and I need to plan my 4th year electives.

Here are the pros and cons of EM and psychiatry that I've been considering:

EM pros:

• Great variety of patients. I like the process of coming up with a differential, narrowing down the diagnosis, and the detective work / critical thinking involved.
• Fast-paced work generally makes the time go faster for me and keeps me from getting bored.
• I like the idea of knowing a decent amount about various different fields of medicine.
• I want to be helpful if/when the zombie apocalypse happens. But in all seriousness, I want to be able to be helpful if there's an emergency in a plane or if a car overturns in front of me on a freeway. This has actually happened to me several times prior to medical school, and I was irritated at feeling useless in those situations.
• While not necessarily an 'adrenaline junkie', I do enjoy excitement. I jive well with the types of personalities that stereotypically to go into EM - the rock-climbing, craft-IPA drinking, triathlon-running types.
• I am good at working with my hands and would probably enjoy procedures, though I haven't been allowed to do anything more advanced than a lac repair yet.
• I love the outdoors and would love to be able to work in wilderness medicine in some capacity.
• Shift work - I like the idea of having some weekdays off and never having to be on call. I'm not having kids and am a natural night owl, so I don't think the nights would bother me much.
• Short training, great pay - I'm an older med student, and a 3 year residency that results in a nice paycheck is very appealing when I only have about 25 years to save for retirement.

EM cons:

• Patient population is often difficult. Intoxicated aggressive patients, drug seekers, patients cussing the EM docs out for the long waits, etc. I don't relish the idea of getting assaulted/physically injured on the job, which I hear is not a rarity in EM.
• The cool, exciting stuff is few and far between. Patients are using EDs more and more for their sniffles / chronic HTN / annual checkups, and I imagine this gets old quickly.
• This may sound pathetic, but I have an excessively sensitive nose. I am not at all bothered by gore, but I've come across some patients that sent me dry heaving (which I felt very bad about, because it's obviously not their fault). Fermenting feet and necrotic flesh really bother me, and I despise abscesses. Blood and guts are totally fine.
• I've already witnessed EM get **** on by pretty much every other specialty (as well as patients). Consults talk down to them to their face and call them idiots behind their backs. EM gets crap for both 'ordering CTs left and right', and also for NOT ordering them (because now the admitting service has to). It's off-putting to see this much disrespect directed at a specialty that, objectively, has a very difficult job to do.
• I am very concerned by the high burn-out rates, and the apparent necessity of having an 'exit strategy' in EM.
• Shift work - I don't know how OK with it I will actually be. I won't be able to 'try it out' before residency - my school does not place medical students on nights or swing shifts in EM rotations (which is kind but irritating, because how else do we get a good idea of what the schedule is actually like?). As mentioned previously, I'm already an older med student and will be in my late 30s by the time I finish residency - so I worry about the toll on my body as I get older.
• I don't like the idea of having to work for a hospital system my entire career, and being unable to work for myself. I worry about the changes to US healthcare that have been happening and will continue to happen in the next 10-20 years, and having to be a slave to hospital administration/Press-Ganey scores/algorithm-driven medicine worries me. I have already seen EM docs get screamed at by clipboard-brandishing nurse administrators for any number of things, from refusing to prescribe unnecessary antibiotics to refusing to take the liability for patients they didn't actually see/chart during their shift. I have no interest in urgent care work. If I were to go into EM, I would probably need to do a fellowship in sports medicine or maybe pain as an 'exit strategy'.

Psychiatry pros:
Pretty much everything that is opposite of EM cons.

• I love the flexibility and many options psychiatry offers - being able to work in inpatient or outpatient, open a private practice, work in C/L or in forensics, etc. The option of being able to work for myself rather than for a hospital is very appealing.
• I am good at speaking with patients, getting them to open up, and forming relationships with them, and I think I'd find this kind of work satisfying.
• I am fascinated by the stories you hear in psychiatry. While this happens in EM as well, the time crunch of the ED puts a firm limit on how much you can explore these stories with the patient. I think the human mind is absolutely incredible, and there is still so much unknown about it.
• Not having to deal with abscesses or fermenting feet.
• Although many people say psychiatry doesn't offer quick or effective cures, it's pretty amazing to see how rapidly psychotic or depressed patients can improve with intensive inpatient treatment or ECT.
• Longevity of a career in psychiatry would likely be much greater than in EM, and psych has some of the lowest burnout rates.
• I am attracted to the idea of being considered a specialist in something and being able to develop my own niche expertise, rather than being a generalist and an easily replaceable 'cog in the machine'.
• While well-paying EM jobs are getting harder to find in places I'd like to live (Denver/West coast), I'm guessing a cash-only psychiatry practice would be more easily achievable? Feel free to correct me if I'm wrong about this.
• No overnights and no circadian rhythm shifts.
• The future job prospects might be better for psych. From everything I've heard, the demand for psychiatrists in the next 10-20 years is only going to keep growing, while EM is currently red-hot and being flooded with new grads - and I have been warned about the dangers of 'buying high'.

Psychiatry cons:

• Not being able to use much of the knowledge I learned in medical school. I've heard psychiatrists say that they forgot a lot of medicine because they don't use it as frequently. I realize that some settings such as C/L are better about this, to a degree.
• The stigma of not being a 'real doctor'. Again, I've definitely heard these kinds of self-deprecating comments made by psychiatrists about their own field. I have also witnessed psychiatrists gets confused with psychologists, social workers, and various other non-medical staff.
• Not being able to work with my hands, or getting to examine a patient. I enjoy doing physical exams and occasionally picking up random but significant findings, and as a psychiatrist I am assuming that I would essentially never touch my patients again. If there are psychiatrists out there who actually do physical exams regularly, please feel free to correct me here. Psychiatry offers less tangible work and less tangible results, which I fear will be less satisfying.
• I worry that psychiatry will feel like a step backwards for me. I almost pursued a PhD in Clinical Psychology instead of medical school, but then decided that I want to learn anatomy, physiology, and diseases other than psychiatric ones. As a psychiatrist, I'd be going back to treating only the mind and not the rest of the body - see above point about not being able to use much of the 'hard medicine' I spent so long learning.
• I will be useless in a zombie apocalypse.

Please feel free to comment on any of the above points, especially if you feel that I'm wrong about something. I welcome any and all advice on how to make this decision. I think I may ultimately be equally happy (or equally miserable) in either field, but I only have 7 months before residency applications are due. I MAY have time to do both the required 2 EM sub-Is and a psychiatry sub-I before residency applications are due, but that would be cutting it very close (and I'd like to avoid the hassles of applying to both and having to decide on the interview trail).

TL;DR: Torn between psychiatry and EM. I feel that psychiatry would be 'easier' for me to work in, and it is a more natural fit for my background. EM would probably offer bigger highs but worse cons.

Well thought out (and detailed) response.

First I wrote something about this last year here. Please read it.

I agree with others, basically you have to use your gut instinct. EM and psych are vastly different fields. Both can be rewarding.

I think you might have contradicted yourself though. You write with EM Pros

I like the idea of knowing a decent amount about various different fields of medicine.

Then you write in Psych Pros:

I am attracted to the idea of being considered a specialist in something and being able to develop my own niche expertise, rather than being a generalist and an easily replaceable 'cog in the machine'.

Which one is it?

I personally would go with EM. Nothing beats the feeling of saving someone's life. You want to make a difference in people's lives? Lots of doctors do that. They manage chronic disease and do it well and it's very meaningful. But what about saving someone's life? Nothing beats that feeling and sense of accomplishment.

 

[thegenius]

Only do EM if you must do EM to live. If you do go into EM, have an iron clad mid-career plan to reduce your clinical shifts by >50% without a reduction in income. The odds are >50% you'll feel enough burnout within 5-10 years to put you on an unstoppable collision course into an immovable wall of emotional exhaustion, without one. That's just a fact. People that tell you otherwise are either lying to you, lying to themselves or have no idea what they're talking about.

EM with an iron clad mid-career exit option is a reasonable choice (most common).
EM without an iron clad mid-career burnout plan, is an irresponsible choice (least common).

A little bleak, no? I understand it's your opinion. I'm not sure that the odds are > 50%. Where I work, with 22 docs, more than half have been there more than 10 years. They all seem to be in cruise control.

Psych you are literally dealing with insanity / schizophrenia / anxiety / depression all the time.
There are lots of normal people who use the ER appropriately, more or less, and they are fine to deal with.

 

[Mad Jack]

Regarding some of your cons,

Medical knowledge:
Lots needed in psychiatry. Lots of primary care issues in inpatient as well as ruling out emergent issues. Ordering/reading labs, EKG etc. Often we are the physician of last resort because everyone else writes off "psychiatric patients" as non-medical patients. For example, I've caught new onset A-fib in an elderly ED patient labeled suicidal because I was the only one to bother to look at his EKGs. We also prescribe meds that can kill or induce serious side effects, which you need to know how to manage... AEDs, TCAs, SGAs, BZDs, MATs/opioid substitutes etc, even SSRIs. At the same time, part of being a specialist is being able to punt because your knowledge and time are limited resources better spent by focusing on your specialty area. Yes some older docs are pretty bad with medical knowledge but it’s a function of older docs dgaf.

Real doctor:
See above. Choosing a specialty means not caring what others think and letting go of bright-eyed desires of "I wanna be a navy seal, rocket scientist, pro athlete, ninja, paleontologist, pediatric brain surgeon AND rockstar who counsels patients on smoking cessation."

Physical exams: Neuro exam is important, PCP stuff above.

Working with hands: Lots of free time for manual hobbies.

Tangible results: Plenty. Amazing to resolve mania or psychosis, take someone from suicidal and hopeless to thriving, including fellow physicians.

Zombie apocalypse: +1 veterinarian. They do everything. Or hone your shotgun skills.

With regard to the "real doctor" thing, I feel like I'm respected more than most specialists in the hospital, because every specialty panics when their patient starts having psychosis or expressing SI and no one outside my service is comfortable dealing with it.

And the meds... There's a lot more to them and knowing how they react with all of the rest of a patient's meds than you'd think, you're always a doctor first and a psychistrist second

 

[Mad Jack]

Well thought out (and detailed) response.

First I wrote something about this last year here. Please read it.

I agree with others, basically you have to use your gut instinct. EM and psych are vastly different fields. Both can be rewarding.

I think you might have contradicted yourself though. You write with EM Pros

Then you write in Psych Pros:


Which one is it?

I personally would go with EM. Nothing beats the feeling of saving someone's life. You want to make a difference in people's lives? Lots of doctors do that. They manage chronic disease and do it well and it's very meaningful. But what about saving someone's life? Nothing beats that feeling and sense of accomplishment.

I derive more satisfaction from bringing a 20 year old back to reality and living as a functional member of society that can pursue their hopes, dreams, and aspirations than I ever got out of saving people that had largely already lived their lives and were clinging to a few more moments with minimal QoL remaining. There's a difference between keeping someone alive and saving their life. Most interventional measures I dealt with in my many years of critical care in my past life were merely prolonging suffering, not saving lives.

 

[thegenius]

I derive more satisfaction from bringing a 20 year old back to reality and living as a functional member of society that can pursue their hopes, dreams, and aspirations than I ever got out of saving people that had largely already lived their lives and were clinging to a few more moments with minimal QoL remaining. There's a difference between keeping someone alive and saving their life. Most interventional measures I dealt with in my many years of critical care in my past life were merely prolonging suffering, not saving lives.

That’s too bad. I guess everyone has their own experiences. I don’t consider keeping bedbound grandma alive for another two months saving a life, BTW. But I knew you knew that.

 

[Birdstrike]

A little bleak, no? I understand it's your opinion. I'm not sure that the odds are > 50%.

76% of EM residents say they feel burned out.
-Annals of Emergency Medicine

65% of EM attendings report feeling burned out.
-Western Journal of Emergency Medicine

 

[Sasaro]

76% of EM residents say they feel burned out.
-Annals of Emergency Medicine

65% of EM attendings report feeling burned out.
-Western Journal of Emergency Medicine

What are your thoughts regarding burnout in terms of physician age vs how long they've been practicing? As I mentioned above, I will be in my late 30s by the time I finish residency. Should I be more concerned about career longevity in EM than, say, the average EM doc who starts practicing a decade earlier? I realize that mileage varies widely from person to person, but this is something I've wondered about.

 

[Sasaro]

Just my perspective, but a lot of your list for either specialty seems very superficial, and will likely have no bearing on your happiness once you're a doctor. Things like wanting to be a hero on an airplane, or not being perceived as a real doctor by others, are not great reasons to pursue or avoid a specialty IMO. At some point, this will just be a job that you go to every day, and you should think about the day to day that you will experience and whether that's something you want to live, not about the exceedingly small chance that a plane full of people might cheer you on as a hero because you helped a person out in a way that a psychiatrist could not.

Thanks for the response. I realize that much of my list probably sounds flippant, but I'm trying to make a (largely irreversible) decision about the next 20-30 years of my career with very limited insight into the day-to-day work of that career. We get just a few weeks of exposure to different specialties, and as students our roles are SO different from what physicians ultimately do every day.

I've tried to consider both the emotional and the logical pros and cons of each specialty, with mixed success. It's frustrating to me that medical students essentially have to make these life-determining decisions by 'going with your gut', as someone put it above. I really envy people who can do this decisively and without doubting themselves, but unfortunately I'm not one of them.

 

[thegenius]

What are your thoughts regarding burnout in terms of physician age vs how long they've been practicing? As I mentioned above, I will be in my late 30s by the time I finish residency. Should I be more concerned about career longevity in EM than, say, the average EM doc who starts practicing a decade earlier? I realize that mileage varies widely from person to person, but this is something I've wondered about.

I finished residency in 2014 at age 39. I already had a first career as a software engineer. I graduated with 300K debt and two kids who were, at the time, 8 and 9 years old. So we were already behind the 8 ball in terms of saving money for retirement, being able to put our kids through college, etc.

So I decided to work more. Since being an attending for the past 5 years, I've average about 17-18 shifts / month. Work at two hospitals. I was able to pay off 300K student loan debt in 4.5 years. We have been renting the entire time. We have been debt free (except for 11K on my car loan at 0%) for over a year. We just got word that our landlords want to move back into this house by June. So we are now finally looking to buy. It's a bit premature for us, I was hoping to save more money, but alas such is life.

Regarding getting burned out: If I get burned out of ER it's because I'm doing it to myself. Although I do admit that each year I am very slowly becoming less empathetic towards patients. I used to try hard, for each patient that came in, to deliver the best possible care I could. I was calling primary care doctors, calling pharmacies, doing all sorts of crap to help my patients. What I learned (and took me 2-3 years) is that there are bunch of ding-dongs that come into the ER all the time and don't really care about anything, and I stopped helping those. They actually don't want help, they don't want to get better, and what they want is for you to enable them to further their terrible, unhealthy lifestyle. However, for people who use the ER appropriately, I still try very hard to put in the extra effort to help them because they appreciate it. I try hard not to let the ER bother me, although it does get to me. I understand the whole issue of burnout. But I'm not leaving ER because I already had one career change and I don't think I can afford, literally, another career change. I'm quite happy with ER and it's nice to be able to work quickly, stabilize patients, and you get to do cool stuff that nobody else can or wants to do.

 

[SamtheWise]

Thanks for the response. I realize that much of my list probably sounds flippant, but I'm trying to make a (largely irreversible) decision about the next 20-30 years of my career with very limited insight into the day-to-day work of that career. We get just a few weeks of exposure to different specialties, and as students are roles are SO different from what physicians ultimately do every day.

I've tried to consider both the emotional and the logical pros and cons of each specialty, with mixed success. It's frustrating to me that medical students essentially have to make these life-determining decisions by 'going with your gut', as someone put it above. I really envy people who can do this decisively and without doubting themselves, but unfortunately I'm not one of them.

your list doesn't sound flippant, honestly reading through it I feel like a lot of the cons you put for EM are sort of the realities of the specialty (patient satisfaction, pandering to the worried well, intoxicated homeless patients with abscesses on their feet, etc) and a lot of the pros are more imagined than reality (just because you like IPAs and triathlons doesn't mean you actually like the medicine we practice in the ED). I love EM, and I would choose it again in a heartbeat, but that being said just looking at your list I think your interests may better align with pscyh. But honestly either are good choices, better than general surgery or IM.

 

[Birdstrike]

What are your thoughts regarding burnout in terms of physician age vs how long they've been practicing? As I mentioned above, I will be in my late 30s by the time I finish residency. Should I be more concerned about career longevity in EM than, say, the average EM doc who starts practicing a decade earlier? I realize that mileage varies widely from person to person, but this is something I've wondered about.

It can work both ways. In my opinion, the older you get, the harder the nights and circadian rhythm changes get, which might work against you starting out a few years older. But also, the longer you've been doing EM, the longer the cumulative stress builds. This might work to your advantage since you won't have been doing EM as long as some of those around you that are of the same age.

A lot of how burnout affects you is very individual, though. If you're 35, with 3 young kids and your sleep is disrupted because of work, and then disrupted when you need to rest because of family demands, that can be hard. That 35-year-old person, even though younger than someone 55, might feel more "burned out" than the 55-year-old who's more financially independent, therefore doesn't need to work as much, and whose kids are out of the house and can dedicate more off time to sleep and rest.

For me, the biggest thing was the schedule. If I was told that I could work the 7 am to 3 pm shift, Mon through Friday, for the rest of my career, I don't think I would have nearly as motivated to do what I did, which was to do an Interventional Pain fellowship, mid-career. If that option existed, I probably would've dealt with the other stresses, knowing that I could be assured two thing that became critically important to me, after having been deprived of them for so long, 1) The ability to reliably feel well rested, and 2) The ability to have a normal life and schedule, aligned with that of my family. But I couldn't see any scenario where that would be consistently possible with continuing general EM for a whole working career.

That's when I looked to diversify my skills, so the medical knowledge and skills I had attained would no longer be dependent upon, and pigeon-hole me, into working only in one medical setting (Emergency Departments) and into only one possible temporal setting (where I was equally need on all 24 hours of the clock, all seven days of the week, all 365 days of the year). I felt I had to make a change, because the effects the schedule had on me became much to high of a long term risk to my health and well being.

 

[Birdstrike]

It's frustrating to me that medical students essentially have to make these life-determining decisions by 'going with your gut', as someone put it above. I really envy people who can do this decisively and without doubting themselves, but unfortunately I'm not one of them.

A lot of life is that way. And trust me, others are doubting themselves just as much as you, if not more. They just aren't being as honest about it. But there's nothing to fear. You make the best decision you can at the time and change course as new information comes in. We can't have all the data we'll ever have, all the time. That's part of what makes life worth living.

 

[miacomet]

A lot of life is that way. And trust me, others are doubting themselves just as much as you, if not more. They just aren't being as honest about it. But there's nothing to fear. You make the best decision you can at the time and change course as new information comes in. We can't have all the data we'll ever have, all the time. That's part of what makes life worth living.

It can be really, really hard to change course....

 

[Birdstrike]

It can be really, really hard to change course....

Yes, it can. It was for me. But often, it's well worth it.

 

[miacomet]

Yes, it can. It was for me. But often, it's well worth it.

Yes. EM probably has fewer exit strategies than psych, and certainly than IM. Psych there's private practice, C-L, emergency psych coverage (big $$$), child (neurotic parents will pay) etc. OTOH psych is midlevel and PhD-friendly, so who knows? Maybe the bottom will fall out soon....