Why surgery over EM?

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EclecticMind

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Just on the surface, I would be tempted to assume that those that choose surgery over a specialty like EM are relatively less concerned about a family life, social life, etc. I think there are probably many EM docs that would have enjoyed a career in surgery, but the opportunity to have a much more balanced life meant more to them than the satisfaction that they would have had becoming a surgeon. Like I said, I'm just saying that these are things that I would be tempted to believe, but I realize that there may be many gaps in my knowledge about the two fields... that's why I want you to help me by giving me your own personal opinions and reasons for choosing the career that you did. Thanks for your time.
 
Why surgery?

- Ability to follow through on the care of your patients
- Allows more depth of knowledge
- Truly great surgical skills
- You're not simply stabilizing the patient, again you are following through
 
I am willing to go out on a limb and make a gross generalization:

1. Most ER docs would love to be surgeons- if the lifestyle was better, etc, etc.
2. Most surgeons hate the ER.
 
ER has a LOT of primary care and medical issues. For every trauma, there are 100 r/o MIs, headaches, nausea/vomiting, etc. Not so appealing if you really like surgery.
 
I think most EM docs know that their specialty is fairly lucrative, and is shift-work...thusly, their lifestyle is very predictable. I do not agree that most EM docs wished to be surgeons...cetainly, there are a lot of surgeons that wish they did EM from time to time. Frankly, EM completely bores me, but I have a lot of respect for good EM docs. They deal with a lot of **** all day, but get to walk away from it.
 
Surgery is better if:
- You want to actaully figure out what is going on with a sick patient and fix it vs. the EM doc who just wants to decide if he needs to admit or not and then never gets to find out if his initial diagnosis was correct or what treatment worked for the patient. Very few things actually go through the whole course of diagnosis and treatment in the ER (despite what you see on tv)
- You really want to be able to do just about any invasive procedure well. Surgeons do more procedures than anyone else in the hosptial. So if this is what you really love to do, EM won't give you enough of that. I'm a surgery resident and can't tell you how many times we are called to do procedures the ER docs feel they can't handle or handling their complications on procedures they didn't do right. I'm not trying to be critical of them, they just don't get the opportunity to be exposed to as much invasive procedures and techniques as we do. Plus, ER docs never get to go to the OR and do real surgeries, so if you love this, surgery is what you must do.

The ER really is becomming a primary care walk in clinic. So many complaints are things that are no where near an emergency, but unfortunatley b/c so many people don't have a regular doctor or insurance, they go fill up the ERs. The ER may be busy, but not with exciting patients with life threatening problems - more often it's a bunch of coughs and colds and minor medical problems. If you've thought about family practice as a career you could do, you may be very happy with this, but if you dread caring for these minor medical complaints...the ER may not be what you are looking for.

The judgement that surgeons aren't as interested in family and social life is way off base, at least with most current residents these days. We surgery people love family and social life...but we love our jobs enough (most days) to be willing to sacrifice some of our personal life more than ER docs do. Don't be foolled though - the ER needs docs every night, holidays, and weekends, so you'll miss out on some social and family life there too, although of course the total hours at work tend to be much less than surgery.
 
Forgot to add everyone's favorite part of the ER - Truama.

In a trauma, both surgeons and ER people are there. Most of the time the surgeons run the trauma at most residency programs, with EM residents mostly handling airway if needed. If some really bad internal injury is suspected, the patient is rushed off to the OR where the surgeons have all the life-saving fun. If it's not urgent enough to go immediately to the OR, patient goes to CT scan (with surgery residents watching him to ensure the patient stays stable) and then the SICU, where surgery residents keep the critically ill patient alive all night. Or, if it's not so bad the patient goes to the floor on the surgery service. Either way, total time helping take care of the major truama patient is less than 30 minutes for the ER resident, very little actual care and involvement with these patients.

Oh, sure the ER residents handle many of the little ankle sprains and small lacerations that walk in the door, but in all the big traumas the EM physicians dont' get to do nearly as much as the surgeons do. Again, it's not like TV.
 
True that surgery and EM may attract the same, more aggressive personality types but that's where the similarities end. They are ENTIRELY different. EM is ONE HUGE CLINIC (especially these days). Surgeons hate clinic. The "procedures" that EM docs do are a far cry from being in the OR. EM resident involvement in traumas is institution dependent, but as stated earlier, it ain't like it is on TV. The trauma surgery service/chief is responsible for the patient. Period.
 
ER hmmm
A good ER doctor has to know a lot..
They have to know enough to keep patient alive until the definitive care is possible by Surgery or Medicine.

Plus, during ER shifts you have to focuse on multiple patients going out of whack simultaneously..what a mess that is...

Now, Surgeons can concentrate on real issues pertaining to surgical patients.

Decision making is rather different really
ER guys decide admit or kick them out..if admit decision then keep them stable enough for denitive transfer or admission.

Surgeons decide okay surgery now or later or is it really surgical case or not..
if not surgical then dump it fast or dump it but watch it stand by...
if surgical still ask for medicine to admit since consult rate is rather different than primary admitting attending case pay wise....then is it pt cooked for surgery or not cooked yet? if cooked then open now or open later
if already open then fix and close or close later then as soon as pt get stable kick them home or back to medicine.

I think in the entire sense Surgery is easier but you have to follow pt for long
ER guys do 12 hrs then they clock out..no beeper no more notes to write.

I think it is very poor comparison overall since very different specialties really.
 
I appreciate all of your responses... really I do.

Sadly, I really think that I'm beginning to decide against a career in surgery... although it's something that I know I would enjoy doing... or at least I thought that I would. It's really tough nowadays deciding to go into a general surgery residency. Too many people saying that "general surgeons are too overworked, too underpaid, and face the possibility of their field becoming obselete (although I don't think that will happen). Then you hear that the only way to make it in surgery these days is to do a subspecialty... AFTER a 5 year GS residency. Then, one day 7 years or more AFTER finishing medical school, you are FINALLY able to become an independent surgeon. So there's nearly an entire decade you can chalk up to practically living in a hospital while your family sits at home and patiently waits for the day that you can be at home more.

You know to be honest, I actually like trauma surgery enough that I would almost be willing to make those sacrifices. But what do you hear when you even mention the possibility that you may go into trauma surgery? Everything from "no, trauma surgery sucks"; "they have the worst lifestyle"; "they seldom get to do surgeries anymore"; "they mostly babysit for ortho and neuro"; etc, etc. So needless to say that shot that idea straight to hell.

As for a career in EM, yeah... I do agree that these guys do have to put up with a lot of BS... but when you consider that these guys only spend 3 years in residency, then they're out making 200+/year... not to mention that they only work an average of 40 hours/wk... AND they are given an opportunity to spend nearly as much time with their family than they do at work... it starts to really pan out in my opinion. I think those are the things that overshadow the BS that they deal with at work. But... to each his own. Again, thanks for the feedback.
 
i realize residencies vary from place to place, or hospitial to hospital, but...

two Q's...

1) are MOST gs's trained for emergency situations?

2) are MOST ep's trained to do various surgical procedures??

😕

i would like to have a wide amount of knowledge, but i would also like to have emergency training. the fp aspect does appeal to me, but i also like the "following through" aspect as well, something that apparently fp and gs has but not em, i like the family aspect of fp and em but not so much of gs... i like parts of all three but not all parts of all three. hmmmm
 
Yes, cooldreams, most gs's are trained to handle many emergency situations. In most residency programs they get tons of trauma and ICU experience, meaning they handle tons of emergent situations. Throughout the hospital, they are the ones called to put in emergent central lines, chest tubes, cric someone who needs an airway emergently, stop any kind of bleeding, etc.

If there's one classic characteristic of a general surgeon it's that they have a hard time standing by and watching something happen without getting their hands in there to help. As an intern I arrived at medical codes in the hosptial and jumped right in to help, while some of the medicine interns sat on the sidelines watching their senior residents or staff. If anesthesia or EM are not around, they'll grab a tube and intubate if a patient needs it. Surgeons just aren't affraid to step up and help out in any situation.

To answer your cooldream's other question, EP's do some procedures, yes. But in most residency programs, surgeons will generally be more comfortable with most any of these basic procedures by the end of their 1st 3 years than any EM resident in 3 years b/c they've done more - by the fact that they see mostly surgery patients who get procedures vs. EM who sees all patients AND by the fact that surgery residents work 80 hours a week vs. 60 or so at many EM programs. So yes, EP's do procedures, but if you ask me who I'd prefer to put a line, chest tube, or any needle or knife into my family members - a surgeon would be MUCH preffered over an EP.
 
If you want to go into emergency medicine, you have to remember that you will deal with a lot of medical emergencies as well, ie. DKA, MI, CHF etc. You'll get comfortable with all the procedures you need to do. If you're an EM resident, you need to do chest tubes, crics etc -- don't let surgery push you out of the way. What many people seem to forget is that most hospitals don't have a trauma surgery team in house of even at all. If you're an er doc in a community hospital, chances are that you're going to be doing any and all procedures that need to be done in the ER.
 
endo said:
If you want to go into emergency medicine, you have to remember that you will deal with a lot of medical emergencies as well, ie. DKA, MI, CHF etc. QUOTE]

Don't forget the ER's major "emergencies" -- headaches, sorethroats, earaches, coughs, constipation,...
 
Harrie said:
Don't forget the ER's major "emergencies" -- headaches, sorethroats, earaches, coughs, constipation,...

Harrie is right that you will see your share of "emergent" tooth pain, back aches and sore throats. But unlike in the office of an internist / family doc, you _will_ see MIs, DKA, CHF, appys, mesenteric ischemia, etc. Where else do these things present? Usually in a shift you will have about 10-20% of interesting patients / findings / dxs. That's enough to keep me interested. Sure, you see a lot of nothing complaints, such as headache, but last week these were a couple of headaches I saw: a guy with bacterial meningitis and a lady who I admitted for TIA that ended up getting an angio showing moyamoya.

Every specialty has its drawbacks. EM is certainly not an exception. If what you like is predominately trauma, do trauma surgery.
 
How much emergency in emergency medicine?

It depends on where you would be working. If you work in a high-volume center with a wing or two dedicated to sniffles and primary care (with associated mid-levels and primary care docs managing) you would being seeing more emergency work-ups than an EM doc working solo in the boonies.

For me surgery offers in-depth management of a sizable percentage of seriously ill patients. EM offers (from my perspective) minimal management of relatively few acutely ill patients. By "minimal" I don't mean that EM docs aren't skilled etc, just more diversified.
 
Emergency Medicine is a cross between surgery and medicine...we know more medicine than surgeons and more surgery than medicine docs. The general EM doc multitasks and thinks much faster than GS's or IM's primarily due to the environment. This environment is not for everyone, as there is very little followup and often times definitive treatment may be seen in the surgical table or hospital floor but the intial stablization (perhaps the most critical time) can be found in the ED. Furthermore, as difficult as it is to get hospital beds and ICU beds, many of the critically ill stay in the ED for upwards of 3-12 hours. The face of the ED has certainly changed as overcrowding has become commonplace. I have seen trauma teams SHRINK and the EM resident or attending becomes the "guy" as there are just are not enough surgical upperlevels to go around (thanks to ACGME regulations).
As a 3rd year EM guy, I have 2 classmates who left GS to become EM residents and there are 4 lowerclassmen that did the same. Clearly there is a difference somewhere.
Some people simply dislike the OR...I am one of them. If you LOVE the OR, go into surgery. Sometimes it is as simple as that.
 
I think shows like "ER" foster the idea that EM and surgery are very similar things (which is one of many reasons I hate that show.) Anyways...

Surgeons operate; EM physicians do procedures. You obtain an incredible knowledge base in surgery, learn how to operate and manage a huge varitey of things, follow complicated problems and their outcomes, etc. Do you love the operating room and the ability to fix a range of problems? What is your energy level- do you do well when awake for more than 24 hours? Most of all, do you love the OR more than anything else? If this is true, surgery may be for you.

You can still do procedures in EM. You also learn to evaluate and care for many acute medical issues. There is a huge variety of patient age and pathology that you will deal with. The shifts are shorter and you don't have to deal with call and clinic. On the other hand, there is a lot of triaging and little continuity of care (I do realize that there are frequent flyers in ED's that probably seem like continuity of care.)

Both have their ups and downs, spend some time in each and see what you think.
 
I started med school thinking that I'd wind up in EM. But then as I participated in my schools EM interest group activities, I came to realize that EM is really mainly primary care under less than ideal circumstances. I don't have the patience to deal with the attitude of many pts in the ED. For example, pts who will call 911 to get a ride to the hospital so they can get Rx for anti-lice cream so that they don't have to pay for it themselves. Or take the pt I got consulted on the other day who gets recurrent abscesses. He has been told multiple times to follow up in a surgery clinic and go there for these abscesses. He came to the ED on a Sat night for an abscess that had been going on for 4-5 days. My med student asked him why he never goes to the clinic that he has been referred to. He said "why should I? I can come here whenever I want and get it taken care of in just a few hours". He was hanging out, with his cell phone plugged into the wall, chatting with friends and watching the Olympics on TV. The proportion of these kinds of patients in the ED is rather high, and the proportion of people with true emergencies is actually rather low. And I have ZERO patience for people with this kind of attitude.

Plus, I LOVE the OR. And I like trauma, even the non operative kind. I like taking care of ICU pts. And my very favorite kind of case is a trauma laparotomy, especially if you wind up doing a damage control procedure.

So I wound up in surgery. For me, part of having a good lifestyle is having a job you love. I wound up going back to med school as an older student. I had always wanted to go, but didn't purse it earlier because of various life events. I always regretted it. I decided that I would not settle for less than I really wanted to do ever again. If I had done anything other than surgery, I would have felt like I settled.

However, I don't currently have a spouse/SO to take into consideration. So now I'm in the position where anyone I get involved with will know early on what my schedule is like and will have to be OK with it. I'm currently relatively happy with my lifestyle in my time off. I get to the gym, have gone to Europe twice since graduating med school, gone on short weekend camping trips, have time to see occasional movies, etc.
 
EM is very different from General Surgery... oh my. I have never ever wanted to be a General Surgeon... the only part I like about scrubbing into surgery is when you walk in with your hands all wet and you get handed the sterile towel and put the gown on. I get off on that but that's about it. I despise the OR.

When I did a month of trauma last year (as an EM PGY1), I sat down and shared a pizza with my senior. I asked him about his love for surgery. I said "what is it about the OR you like so much (besides putting on the cool gown 🙂 )?" He said it is the most peaceful environment in the world, that he could spend ~12 hours in the OR and be completely content. In there, he is the only person that matters (besides the patient I guess) and the only other place he'd rather be is at home with his kids. I asked him about being in the ED and he said "can't stand it."

I can't stand being in the OR but absolutely love being in the ED. I like the bustle, I like the multitasking, I like the controlled chaos. If I could wash my hands and show up with the charge nurse handing me my sterile gloves I'd be in heaven. 🙂

There's a decent amount of crap that I see in the ED... but off the top of my head in the last few shifts I've treated:
about 10 DKAers
two AMIs
three perfed ulcers
a catamenial PTX
uber traumas (including a galeazzi's fx)
septic arthritis
~5 miscarriages
several acute psychotic episodes
tons of lacerations/fracture/dislocation reductions
sternal osteomyelitis
a handful of medical codes
postpartum psychosis

lots of variations, lots of procedures (lines, ultrasounds, intubations, joint aspirations, reductions). I'm completely content when I look back on my patient logs and ~50% of my patients were either admitted to the floor/OR/ICU. Not all my days are quite as exciting but that's okay too.

I think there's a pretty big difference in specialties but basically one common theme... both surgeons and EMers "like to be in the action."
Q
 
I am an MS II and I just started a surgery clerkship. So far I enjoy it. It's fast paced and hands on. Yesterday I saw a kidney transplant. Very Cool! I know EM is hands on and fast paced as well. So, I am thinking about going into one of these fields (note:I have not rotated throught the ER yet). But I was wondering .... Surgery definetly has an acdemic focus. There's alot of research. But I "hear" that EM does not really have an academic focus. Do you find this to be true? And was it a factor indeciding to go into EM?
 
That is probably more true than not although some programs still have a very big academic focus.
 
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