Why is it that people don't want to go in to Emergency Medicine?

[Fakhter]

It seems like it will always be a stable job. People will always be in need of the emergency room no matter what break through we have. Where as Cardiac Surgeons will likely fade away because of preventive and non-invasive procedures.

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[Omppu27]

Burnout and the hours (holidays, weekends, etc.) can be tough when you have a family/kids.

EDIT: There's obviously tons more reasons, but these are the two that turn me off a little from the field.

http://www.medscape.com/features/slideshow/lifestyle/2013/public#2 if you look at the first chart in the slide, it shows EM is at the top with over 50% burnout. This is smiliar to another chart i saw in another thread a couple weeks ago.

 

[Mountaineer12]

Burnout and the hours (holidays, weekends, etc.) can be tough when you have a family/kids.

EDIT: There's obviously tons more reasons, but these are the two that turn me off a little from the field.

http://www.medscape.com/features/slideshow/lifestyle/2013/public#2 if you look at the first chart in the slide, it shows EM is at the top with over 50% burnout. This is smiliar to another chart i saw in another thread a couple weeks ago.

Agreed. While the amount of hours are nice, 12+ hour shifts that can be on weekends, holidays, and even nights really turns me off. I hate that the schedule changes so drastically in EM.

I also feel like the pressure and pace in the ER is not sustainable for very long before becoming burnt out. It may be exciting while you're in your early 30s, but I personally couldn't see myself keeping up that pace into my 60s. Not to mentioned some of the crazy patients that you would have to deal with.

 

[Daodejing]

Some people want to be in a "jack of all trades" field, and others don't. You also deal with a disproportionate amount of low-lives (i.e. narc seekers).

 

[TheWeeIceMan]

I've heard it's not as stable as people may think. EM groups sometimes lose contracts with hospitals and the physicians are forced to move. I could be wrong though since I only have anecdotal evidence.

 

[Barcu]

Shift work is a big plus for some, horrible for others.

The lack of a continued relationship with a patient is the same. And the patients you do see over and over again usually aren't your favorites.

Sometimes the patient population isn't great. You see a lot of low-acuity, angry people.

 

[KinesiologyNerd]

EM is at the top of my big 3 (EM, crit care, trauma). I like the variability, pace, high acuity patients, and no on-call. My opinion now is 180 degrees from before I became a scribe. It's really sold me on the field. Also, our docs (mostly) work 8 hour shifts, 7 on / 7 off. That's a pretty appealing schedule to me. Obviously its not the most common schedule, though.

 

[rompebielas]

Burnout like others mentioned. Quite a few EM docs I rotated under were also toxicologists and had side gigs.

 

[def1]

Every time I've ever gone to the ER, the doctors never seem in a good mood. Yesterday I had to go to the ER and the doctor seemed mad at the fact I was there. I'm sure some people love it, but I think some people get tired of the pace and schedule.

 

[Cambino]

Every time I've ever gone to the ER, the doctors never seem in a good mood. Yesterday I had to go to the ER and the doctor seemed mad at the fact I was there. I'm sure some people love it, but I think some people get tired of the pace and schedule.

Probably because you thought you had to go to the ER...




my cervical radiculopathy is 3/10 pain can has flexeril and IM dilaudid plssssss

 

[music2doc]

A lot of old-timer EM docs are quite jaded and it's hard not to become like that.

That said, you make your question seem as though EM were not competitive. This is FAR from the truth and EM is rapidly catching up with other extremely competitive fields. It's probably also the #1 "I think I want to go into that" field for students entering med school -- at least here. Great pay for relatively few (albeit extremely intense) hours of work. Shift work/little to no continuity of care to deal with. Challenging patients are the norm. Plenty of variety ('though of 3/4 of your case load is just glorified primary care).

 

[music2doc]

Every time I've ever gone to the ER, the doctors never seem in a good mood. Yesterday I had to go to the ER and the doctor seemed mad at the fact I was there. I'm sure some people love it, but I think some people get tired of the pace and schedule.

Why did you "have" to go to the ER? Patients and ED staff have a VERY different definition of "have to," I think. Had your heart stopped? Was a major limb (head, dominant hand/arm, both legs above the knee) amputated? Was a life-sustaining organ at least 50% OUTSIDE your body?

If not, that's what your PCP is for!


(I kid I kid....sorta)

 

[milkphlegm]

Probably because you thought you had to go to the ER...




my cervical radiculopathy is 3/10 pain can has flexeril and IM dilaudid plssssss

 

[NontradCA]

I worked in an ER for a year and the Nurses would complain about the low acuity and non emergent siuations. I found it funny because without these ERs would not be busy at all and the amount of revenue being generated would be lower and thus compensation. I always thought to myself "whatever, if every one of these cases were trauma or complicated cards you'd be crying "

 

[mcloaf]

It seems like it will always be a stable job. People will always be in need of the emergency room no matter what break through we have. Where as Cardiac Surgeons will likely fade away because of preventive and non-invasive procedures.

Let me know when they figure out the non-invasive heart transplant.

 

[sinombre]

I worked in an ER for a year and the Nurses would complain about the low acuity and non emergent siuations. I found it funny because without these ERs would not be busy at all and the amount of revenue being generated would be lower and thus compensation. I always thought to myself "whatever, if every one of these cases were trauma or complicated cards you'd be crying "

Well, sort of.... except that a good number of those patients don't pay what they owe.

 

[NontradCA]

Well, sort of.... except that a good number of those patients don't pay what they owe.

Depends on payer mix. Nice name, that movie is awesome.

 

[PennDippody]

It seems like it will always be a stable job. People will always be in need of the emergency room no matter what break through we have. Where as Cardiac Surgeons will likely fade away because of preventive and non-invasive procedures.

A bit off topic but I can't let this go: CT-surg will always have a place in modern medicine (albeit varied in supply/demand)

 

[sinombre]

Depends on payer mix. Nice name, that movie is awesome.

You're actually the first person to recognize the movie

But yeah, it's obviously highly variable. This isn't a question to you, but a general question for everyone: where do you think uninsured patients go to receive medical care? And who do you think pays for it?

 

[music2doc]

I worked in an ER for a year and the Nurses would complain about the low acuity and non emergent siuations. I found it funny because without these ERs would not be busy at all and the amount of revenue being generated would be lower and thus compensation. I always thought to myself "whatever, if every one of these cases were trauma or complicated cards you'd be crying "

What we really get tired of, at least in my experience as a tech and in EMS, are the dental pn, etc. cases where it is truly abuse. Bad N/V/D (to the point of severe dehydration, metabolic alkalosis/acidosis), falls, etc. make sense. Dental pn and such...not really.

If I do EM, I'd really like the following to be my protocol for dental pains:

"Tylenol Extra Strength 2 tab Q4h PO; Toothbrush + Floss TiD a.c. Dental referral."

I mean... they always come in wanting narcs but what kind of idiot gives someone noncompliant enough end up w "emergent dental pn" narcs?! Oh, waaaaaaaai...crap.

 

[NontradCA]

You're actually the first person to recognize the movie

But yeah, it's obviously highly variable. This isn't a question to you, but a general question for everyone: where do you think uninsured patients go to receive medical care? And who do you think pays for it?

I've had to write papers on it for 2 different classes.

A lot of the time the uninsured will use the ER, but a lot of insured patients use it as well. Also, true emergency patients are just as likely to be uninsured as well. Also you have to realize it can take months to get a PCP or weeks to get an appointment.

 

[NontradCA]

What we really get tired of, at least in my experience as a tech and in EMS, are the dental pn, etc. cases where it is truly abuse. Bad N/V/D (to the point of severe dehydration, metabolic alkalosis/acidosis), falls, etc. make sense. Dental pn and such...not really.

If I do EM, I'd really like the following to be my protocol for dental pains:

"Tylenol Extra Strength 2 tab Q4h PO; Toothbrush + Floss TiD a.c. Dental referral."

I mean... they always come in wanting narcs but what kind of idiot gives someone noncompliant enough end up w "emergent dental pn" narcs?! Oh, waaaaaaaai...crap.

I worked in a military hospital so the vast majority of dental patients were in excrutiating pain, but as a whole were rare due to the fact that the military provides good dental care. Dependents really seemed to like Narcs in general, although I saw more drug seekers in IM.

 

[Akail]

Uh...a lot of people want to do EM. It's become considerably popular and increasingly competitive.

 

[Daodejing]

It's probably also the #1 "I think I want to go into that" field for students entering med school -- at least here.

Lol it's definitely neurosurg everywhere else.

 

[sinombre]

A lot of the time the uninsured will use the ER, but a lot of insured patients use it as well.

Absolutely--there are obviously lots of insured patients who present with emergent chief complaints. But think of it this way--in 2010 there were just under 50 million uninsured Americans (>16% of the population according to the 2010 census). Where do you think they went for conditions that are typically treated by PCPs?

Also, true emergency patients are just as likely to be uninsured as well.

There is a pretty strong (and intuitive) correlation between poverty and health--and without pulling up any actual statistics (although I suppose I can if this statement is actually hard to believe) I think it's safe to assume that unhealthy people have more medical emergencies than healthy people. Regardless, the bigger point here is that the majority of patients seen in the ER present with non-emergent complaints. The emergencies cost a lot more, but the non-emergent stuff absolutely adds up.

 

[music2doc]

Lol it's definitely neurosurg everywhere else.

Maybe... We have a number of those, but I always take them with a pretty big grain of salt. NSurg is just sorta....yeah. I don't think hardly any M1 really knows what it involves. At least they have some vague idea of what an EM doc does.

 

[music2doc]

Absolutely--there are obviously lots of insured patients who present with emergent chief complaints. But think of it this way--in 2010 there were just under 50 million uninsured Americans (>16% of the population according to the 2010 census). Where do you think they went for conditions that are typically treated by PCPs?

There is a pretty strong (and intuitive) correlation between poverty and health--and without pulling up any actual statistics (although I suppose I can if this statement is actually hard to believe) I think it's safe to assume that unhealthy people have more medical emergencies than healthy people. Regardless, the bigger point here is that the majority of patients seen in the ER present with non-emergent complaints. The emergencies cost a lot more, but the non-emergent stuff absolutely adds up.

Non-emergent stuff is about 80-90% of the case-load at most EDs is that stat I've heard a lot in med school. Back home, I wouldn't have been surprised if it exceeded 95% some days....

 

[NontradCA]

Absolutely--there are obviously lots of insured patients who present with emergent chief complaints. But think of it this way--in 2010 there were just under 50 million uninsured Americans (>16% of the population according to the 2010 census). Where do you think they went for conditions that are typically treated by PCPs?

There is a pretty strong (and intuitive) correlation between poverty and health--and without pulling up any actual statistics (although I suppose I can if this statement is actually hard to believe) I think it's safe to assume that unhealthy people have more medical emergencies than healthy people. Regardless, the bigger point here is that the majority of patients seen in the ER present with non-emergent complaints. The emergencies cost a lot more, but the non-emergent stuff absolutely adds up.

 

[KnuxNole]

Because they don't want to be burned out and/or hate working in the ED.

Also, some people tend to hate people who come to the ED for "minor" complaints or for routine things(med refills). This won't stop in the future haha

 

[Daodejing]

Absolutely--there are obviously lots of insured patients who present with emergent chief complaints. But think of it this way--in 2010 there were just under 50 million uninsured Americans (>16% of the population according to the 2010 census). Where do you think they went for conditions that are typically treated by PCPs?

They may have utilized urgent-care centers. These only serve to alleviate the exorbitant cost at ED's, not to mention the god-awful wait times.

 

[galaxyx]

The EM doctors I work with seem relatively happy, but its at a low volume, no trauma place, with a fast track staffed by midlevels. So, mostly its abdominal pain/chest pain/abnormal vitals that they see. There has to be something potentially wrong. If its not the middle of the night the cold/flu/minor fractures/peds etc. get seen by the midlevels.

As far as the needing to schedule PCP visits months out, I've seen people come to the ED with complaints...'this has been bothering me for 4 months'. That's when I see the doctors get frustrated and ask the questions like "So what is your emergency? What's NEW tonight that brought you to the EMERGENCY room?" and the patients do notice this.

That being said, EM residencies are becoming very competitive with no spots unfilled in the match last year and 3 this year, so the whole premise of this thread is a little off-base.

 

[sinombre]

They may have utilized urgent-care centers. These only serve to alleviate the exorbitant cost at ED's, not to mention the god-awful wait times.

Definitely, and good point. I guess it's more of a prominent phenomenon after hours/on weekends/holidays.

 

[music2doc]

Because they don't want to be burned out and/or hate working in the ED.

Also, some people tend to hate people who come to the ED for "minor" complaints or for routine things(med refills). This won't stop in the future haha

What I still don't get is why we continue to pander to this. EMTALA is specific to emergent conditions:

If the patient does not have an "emergency medical condition", the statute imposes no further obligation on the hospital.

If the patient presents for a prescription refill, there is nothing legally or ethically demanding the pt not be turned away with an immediate referral to go see a PCP (i.e., a "phonebook referral" of sorts). By refilling the pt's meds we are encouraging the pt not to seek long-term care by encouraging further return visits -- which is unethical and ultimately harmful to the pt due to a loss of continuity of care as well as harmful to society, which must now pay the exorbitantly and unnecessarily high cost of the care for this person.

 

[KnuxNole]

I agree with you. It's possible to change the dynamics of it...but society is slow to adapt :/

 

[alpinism]

What I still don't get is why we continue to pander to this. EMTALA is specific to emergent conditions:



If the patient presents for a prescription refill, there is nothing legally or ethically demanding the pt not be turned away with an immediate referral to go see a PCP (i.e., a "phonebook referral" of sorts). By refilling the pt's meds we are encouraging the pt not to seek long-term care by encouraging further return visits -- which is unethical and ultimately harmful to the pt due to a loss of continuity of care as well as harmful to society, which must now pay the exorbitantly and unnecessarily high cost of the care for this person.

Because hospital administrators and CEOs love to use the ED as a cash cow regardless of what's best for patients. $40 for APAP, $400 for a CT, $100 for a CBC, etc...

 

[The Buff OP]

Could be they feel like they don't do much. I was re-watching Hopkins Med the other day and this 2nd year EM resident says, "Sometime I just feel like I'm putting a bandage over it and send them out". It went something like that.

 

[pathologyDO]

 

[medic86]

Probably because you thought you had to go to the ER...




my cervical radiculopathy is 3/10 pain can has flexeril and IM dilaudid plssssss

Get it right! It's 10 of valium and 1 of IV dilaudid.

What we really get tired of, at least in my experience as a tech and in EMS, are the dental pn, etc. cases where it is truly abuse. Bad N/V/D (to the point of severe dehydration, metabolic alkalosis/acidosis), falls, etc. make sense. Dental pn and such...not really.

If I do EM, I'd really like the following to be my protocol for dental pains:

"Tylenol Extra Strength 2 tab Q4h PO; Toothbrush + Floss TiD a.c. Dental referral."

I mean... they always come in wanting narcs but what kind of idiot gives someone noncompliant enough end up w "emergent dental pn" narcs?! Oh, waaaaaaaai...crap.

A lot of the docs I worked with would just take some bupivicaine and band-aid that crap with a referral to dental.

Then again, I worked in a military hospital, where the ED is closely-tied with the primary care system and dental.

Because hospital administrators and CEOs love to use the ED as a cash cow regardless of what's best for patients. $40 for APAP, $400 for a CT, $100 for a CBC, etc...

Your numbers are pretty low for a CT... lol.

 

[as1212559]

Burnout and the hours (holidays, weekends, etc.) can be tough when you have a family/kids.

EDIT: There's obviously tons more reasons, but these are the two that turn me off a little from the field.

http://www.medscape.com/features/slideshow/lifestyle/2013/public#2 if you look at the first chart in the slide, it shows EM is at the top with over 50% burnout. This is smiliar to another chart i saw in another thread a couple weeks ago.

Every ER doc I've ever spoken to loved their hours. Working holidays is hard to avoid in many medical fields (nursing, EMT, etc.). It's all personal preference. To me the idea of shift work, high pace, lots of pathology, frequent procedures, etc. sounds appealing. The lack of continuity of care, narc hunters, non-emergent cases, etc. sound unappealing. You might disagree with me entirely. It's all preference.

And I agree that like 75% of med students or entering I talk to suggest they might want EM. It's pretty popular.

 

[JGimpel]

If you take into account either a PCP or ED physician doing side gigs like office-based procedures, addiction medicine or the perpetual cash cow: Botox, they can both substantially increase their income. I actually had a PCP show me this side of medicine and it was definitely an interesting way to improve lifestyle and take-home pay.

If you want to start on this earlier, look into what your program will let you do in your 2nd year and beyond doing moonlighting jobs. Those can be harder to keep for an ED physician if the schedule is more variable than a PCP's.

 

[DrBodacious]

I've had to write papers on it for 2 different classes.

A lot of the time the uninsured will use the ER, but a lot of insured patients use it as well. Also, true emergency patients are just as likely to be uninsured as well. Also you have to realize it can take months to get a PCP or weeks to get an appointment.

Actually, insured patients are more likely to get outpatient care & get directly admitted, if they have something serious.

ER is about 25% to 40% psych (people who are crazy and have nothing wrong, no reason to go to the ER, or too unintelligent to navigate the health care system). The "psych" patients are usually uninsured.

The remaining patients are largely triaged to other services. This is the most important part of their job, IMHO. So, an ER physician is really a well-qualified triage person. ER docs seem to resent this, at times (not always).

There are very few problems an ER doc definatively treats (minor laceration, minor infection requiring po abx,.. hard pressed to think of many more).

Warning: For normal people (med students), ER is a bad job. There is a certain type of person that may enjoy it long term. I do not mean this in such a negative way, God bless you ER people! If you like ER please feel free to ignore this.

Sent from my HTC One X+ using SDN Mobile

 

[45408]

What I still don't get is why we continue to pander to this. EMTALA is specific to emergent conditions:

If the patient presents for a prescription refill, there is nothing legally or ethically demanding the pt not be turned away with an immediate referral to go see a PCP (i.e., a "phonebook referral" of sorts). By refilling the pt's meds we are encouraging the pt not to seek long-term care by encouraging further return visits -- which is unethical and ultimately harmful to the pt due to a loss of continuity of care as well as harmful to society, which must now pay the exorbitantly and unnecessarily high cost of the care for this person.

Because if you don't, your Press Ganey patient satisfaction scores will suffer, and the ACA (ObamaCare) has linked reimbursements to patient satisfaction scores, so your hospital will literally get paid less, even for the "real" patient care encounters.

 

[music2doc]

Because if you don't, your Press Ganey patient satisfaction scores will suffer, and the ACA (ObamaCare) has linked reimbursements to patient satisfaction scores, so your hospital will literally get paid less, even for the "real" patient care encounters.

Yeah....I know, but this in and of itself is pandering to them. Press Ganey is pandering to poor pt care and so are Obama's little munchkins. I wish somebody would pull their head out of their a** from time to time and look to see what the effects of their decisions actually are.... Pt satisfaction (taken as an aggregate) and pt outcomes (as an aggregate) were not particularly well correlated last I heard....

 

[gravitywave]

Because hospital administrators and CEOs love to use the ED as a cash cow regardless of what's best for patients. $40 for APAP, $400 for a CT, $100 for a CBC, etc...

... and in spite of that, most EDs are cost centers for hospitals. The $$$ you see on an ED bill are the results of how many staff they have to keep around 24-7 no matter how busy things are, which inevitably means that a substantial part of those resources aren't being used a lot of the time that they're being paid. Also, most ED patients are un(der)insured, so there's the cost shift.

So, if you're the hospital CEO, why have an ED? Because it's how you get many of the admissions to the units that are profit centers. They wouldn't be as profitable if they didn't have the ED as a magnet for the patients they'd be missing out on otherwise. But EDs themselves don't typically make money.

 

[nysegop]

My cousin is an ER physician. She works crazy hours. She had to get up at 5 AM, then she got home at 12, she slept for 5-6 hours, then went back in at 7. It changes pretty much everyday for her. She and her husband manage well though. They have been together for a long time. They are both hardworking and independent but they still love each other. I guess you just need the right personality.

 

[NontradCA]

... and in spite of that, most EDs are cost centers for hospitals. The $$$ you see on an ED bill are the results of how many staff they have to keep around 24-7 no matter how busy things are, which inevitably means that a substantial part of those resources aren't being used a lot of the time that they're being paid. Also, most ED patients are un(der)insured, so there's the cost shift.

So, if you're the hospital CEO, why have an ED? Because it's how you get many of the admissions to the units that are profit centers. They wouldn't be as profitable if they didn't have the ED as a magnet for the patients they'd be missing out on otherwise. But EDs themselves don't typically make money.

Isn't the amount on the bill result of insurance companies trying to lowball the hospital? It doesn't cost that ridiculous amount to staff an ER. I would think that if that money was for "staffing" then the Physicians would be making 7 figs.

 

[music2doc]

Isn't the amount on the bill result of insurance companies trying to lowball the hospital? It doesn't cost that ridiculous amount to staff an ER. I would think that if that money was for "staffing" then the Physicians would be making 7 figs.

About 10-30% of pts typically pay (as in, AT ALL). When you are being paid by <<50% of your customers, you have to raise the prices for those who do pay in order to (nearly) break even. In other words: cost-sharing.

 

[NontradCA]

About 10-30% of pts typically pay (as in, AT ALL). When you are being paid by <<50% of your customers, you have to raise the prices for those who do pay in order to (nearly) break even. In other words: cost-sharing.

So you're saying only 10-30% of EM patients are insured? Source? (I'm not sure what the % is). Sounds like bs to me.

 

[Beargryllz]

Probably because you thought you had to go to the ER...




my cervical radiculopathy is 3/10 pain can has flexeril and IM dilaudid plssssss

No, it's 10/10

 

[Bacchus]

Let me know when they figure out the non-invasive heart transplant.

Let us know when you can provide enough hearts to have an ample amount of cases a day.