Incorrect statements about EM

sydney_ne · Feb 11, 2005

I'm considering EM and a couple other specialties. There are many things I like about EM, and I think there are many good reasons to go into it. But I noticed a couple recurring themes in SDN posts that I think are incorrect, or possibly that I don't understand.

My post is not meant to troll. And my comments are limited by the fact that I'm a medical student, and still learning. I just wanted to play devil's advocate and vet some of these statements. Please don't flame me or anyone else who replies.

1. The EM lifestyle is better because there's no call.

What's worse, overnight call or shift work? I think it's a push, or definitely something that depends on personal preference. Both will keep you up at night. It's true that with shift work in the ER, you have protected time off. But if you're in a group practice, call is also scheduled, so you still have protected time off.

2. EM is not satisfying because there's no continuity of care in EM.

I don't think this is such a big deal, and I think many non-EM docs blow this way out of proportion. Many specialties have no continuity of care, including anesthesia, radiology, and pathology. And others have limited continuity, such as derm and surgery.

3. There's more flexibility in EM because of shift work.

This is definitely true. But it seems to come at a price that isn't always considered. The same system that provides you with flexibility also limits your autonomy. The EM doc working in an ER is an employee where corporate profit, seniority, shift equity, and political issues can all be abused. Also, the EM doc has to work with staff that he/she did not hire, can not evaluate, and can not fire. To some extent, this is true of other specialties (surgeons work with OR staff they did not hire), and any doc can work as an employee (such as for Kaiser). But it seems to be more of an issue in EM, because you don't have a choice of practice options.

4. EM is not triage.

Of course, an ER doc is not a glorified triage nurse. But in a way, an EM doc does a type of "triage", which requires the skill of a physician, and that in many cases involves assessment with no treatment. Each patient in the ER is put in one of 3 categories: those that are not sick, those that need acute treatment, and those that need to be admitted. The ER doc will assess patients in all 3 groups, but only treats patients in the second group, typically with a brief intervention before discharge or admission.

5. You get to assess undifferentiated patients in the ER.

Sort of. The implication is that you get to "differentiate" these undifferentiated patients. The problem is that you only get to differentiate the basic cases. If a complicated case comes in, you must defer the full differentiation to the doctor who is admitting the patient. For many patients who are admitted, the ER doc is left wondering what the true state of the patient was.

6. Non-EM-trained docs burn out in the ER, not the EM-residency-trained ones.

Is there really any proof that IM/Peds/OB/Derm/Surg docs working in the ER burn out, and that EM docs don't? I don't think so. Burn-out is common to everyone, and to every specialty. For example, the older IM doc who takes less call, or the older OB/GYN who only does office gynecology. There's every reason to believe that EM is no exception, such as the older EM doc who does urgent care, works less overnight shifts, or goes into research. (Back to shift equity - every overnight shift that an older EM doc does not take is an extra overnight shif that we will work.)

7. You must have ABEM certification to work in EM.

This parochial stance does not reflect the reality of other specialties. There are several ways to become competent in primary care (FM, IM, Peds), in adolescent medicine (Peds, IM, FM), in OB (OB/GYN, FM), in critical care (IM, GS, GAS, EM), in thyroid surgery (ENT, GS), and also emergency medicine (ABEM residency, Peds EM Fellowship, BCEM fellowship). An article often used to defend the ABEM-training-only stance is often misquoted (J. Emerg. Med. 2000;19:99-105). For example, the article does not compare ABEM trained residents to those who completed a BCEM fellowship, but is often used to criticize BCEM. (For what it's worth, I think continuing the BCEM practice track is wrong, but that a BCEM fellowship for primary care docs is a valid way to go. I also think the ABEM should come up with a one-year primary care fellowship for EM docs who want to transfer into primary care.)

ERMudPhud · Feb 11, 2005

sydney_ne said:
1. The EM lifestyle is better because there's no call.

What's worse, overnight call or shift work? I think it's a push, or definitely something that depends on personal preference. Both will keep you up at night. It's true that with shift work in the ER, you have protected time off. But if you're in a group practice, call is also scheduled, so you still have protected time off.

You are right it is personal preference but I and my colleagues prefer to work our 4-15 8 hour shifts per month and then be free. Working all day friday and then being on call for an entire weekend would be torture.

sydney_ne said:
2. EM is not satisfying because there's no continuity of care in EM.

For some of us this is a plus not a minus.

sydney_ne said:
3. There's more flexibility in EM because of shift work.

This is definitely true. But it seems to come at a price that isn't always considered. The same system that provides you with flexibility also limits your autonomy. The EM doc working in an ER is an employee where corporate profit, seniority, shift equity, and political issues can all be abused. Also, the EM doc has to work with staff that he/she did not hire, can not evaluate, and can not fire. To some extent, this is true of other specialties (surgeons work with OR staff they did not hire), and any doc can work as an employee (such as for Kaiser). But it seems to be more of an issue in EM, because you don't have a choice of practice options.

I work for a democratic group. Once you make partner everyone has equal share of the profits, equal voting rights, and equal shifts. We don't hire the ER staff but if we don't like them they won't be around for long. We do have some choice of practice options democratic group, corporate EM, hospital employee, university employee but the availabillity of specific options does vary some geographically.

sydney_ne said:
4. EM is not triage.

Of course, an ER doc is not a glorified triage nurse. But in a way, an EM doc does a type of "triage", which requires the skill of a physician, and that in many cases involves assessment with no treatment. Each patient in the ER is put in one of 3 categories: those that are not sick, those that need acute treatment, and those that need to be admitted. The ER doc will assess patients in all 3 groups, but only treats patients in the second group, typically with a brief intervention before discharge or admission.

Actually you do plenty of treatment on the third group too. Sometimes your treatment is definitive and sometimes it is only a stopgap. Look at the recent Rivers article in NEJM to see how important ER treatment is in Sepsis outcomes

sydney_ne said:
5. You get to assess undifferentiated patients in the ER.

Sort of. The implication is that you get to "differentiate" these undifferentiated patients. The problem is that you only get to differentiate the basic cases. If a complicated case comes in, you must defer the full differentiation to the doctor who is admitting the patient. For many patients who are admitted, the ER doc is left wondering what the true state of the patient was.

I'm not always right but then again sometimes the patient gets discharged from the hospital 2 weeks later and they still don't have a diagnosis. The majority of the time before the patient goes upstairs I know what is wrong with them or have a pretty good idea what is wrong

sydney_ne said:
6. Non-EM-trained docs burn out in the ER, not the EM-residency-trained ones.

Is there really any proof that IM/Peds/OB/Derm/Surg docs working in the ER burn out, and that EM docs don't? I don't think so. Burn-out is common to everyone, and to every specialty. For example, the older IM doc who takes less call, or the older OB/GYN who only does office gynecology. There's every reason to believe that EM is no exception, such as the older EM doc who does urgent care, works less overnight shifts, or goes into research. (Back to shift equity - every overnight shift that an older EM doc does not take is an extra overnight shif that we will work.)

This has been studied and the results are suggestive but hardly conclusive. I'll dig up a reference when I can. Some people will burn out regardless of their background but if you go into it because it is what you love and with your eyes open to what you are getting into at least you shouldn't be surprised by what you end up with.

sydney_ne said:
7. You must have ABEM certification to work in EM.

This parochial stance does not reflect the reality of other specialties. There are several ways to become competent in primary care (FM, IM, Peds), in adolescent medicine (Peds, IM, FM), in OB (OB/GYN, FM), in critical care (IM, GS, GAS, EM), in thyroid surgery (ENT, GS), and also emergency medicine (ABEM residency, Peds EM Fellowship, BCEM fellowship). An article often used to defend the ABEM-training-only stance is often misquoted (J. Emerg. Med. 2000;19:99-105). For example, the article does not compare ABEM trained residents to those who completed a BCEM fellowship, but is often used to criticize BCEM. (For what it's worth, I think continuing the BCEM practice track is wrong, but that a BCEM fellowship for primary care docs is a valid way to go. I also think the ABEM should come up with a one-year primary care fellowship for EM docs who want to transfer into primary care.)

The research for that paper predates BCEM for the most part and was done mostly in Colorado which had few if any BCEM physicians. If you know up front that you want to do EM and you want to do it in even a halfway competitive market better to do it the right way.

As for the rest of your argument there might be multiple paths to some practices but that is hardly universal. There is no BCEM equivalent of interventional cardiology. There might be multiple "sport med" fellowships but only the orthopod track leads to fixing your ACL. I don't believe BCEM is at all close to the training I had and I know that a PEDS EM fellowship is not even close to my training in adult EM.

roja · Feb 11, 2005

sydney_ne said:
1. The EM lifestyle is better because there's no call.

What's worse, overnight call or shift work? I think it's a push, or definitely something that depends on personal preference. Both will keep you up at night. It's true that with shift work in the ER, you have protected time off. But if you're in a group practice, call is also scheduled, so you still have protected time off.

2. EM is not satisfying because there's no continuity of care in EM.

I don't think this is such a big deal, and I think many non-EM docs blow this way out of proportion. Many specialties have no continuity of care, including anesthesia, radiology, and pathology. And others have limited continuity, such as derm and surgery.

3. There's more flexibility in EM because of shift work.

This is definitely true. But it seems to come at a price that isn't always considered. The same system that provides you with flexibility also limits your autonomy. The EM doc working in an ER is an employee where corporate profit, seniority, shift equity, and political issues can all be abused. Also, the EM doc has to work with staff that he/she did not hire, can not evaluate, and can not fire. To some extent, this is true of other specialties (surgeons work with OR staff they did not hire), and any doc can work as an employee (such as for Kaiser). But it seems to be more of an issue in EM, because you don't have a choice of practice options.

4. EM is not triage.

Of course, an ER doc is not a glorified triage nurse. But in a way, an EM doc does a type of "triage", which requires the skill of a physician, and that in many cases involves assessment with no treatment. Each patient in the ER is put in one of 3 categories: those that are not sick, those that need acute treatment, and those that need to be admitted. The ER doc will assess patients in all 3 groups, but only treats patients in the second group, typically with a brief intervention before discharge or admission.

5. You get to assess undifferentiated patients in the ER.

Sort of. The implication is that you get to "differentiate" these undifferentiated patients. The problem is that you only get to differentiate the basic cases. If a complicated case comes in, you must defer the full differentiation to the doctor who is admitting the patient. For many patients who are admitted, the ER doc is left wondering what the true state of the patient was.

6. Non-EM-trained docs burn out in the ER, not the EM-residency-trained ones.

Is there really any proof that IM/Peds/OB/Derm/Surg docs working in the ER burn out, and that EM docs don't? I don't think so. Burn-out is common to everyone, and to every specialty. For example, the older IM doc who takes less call, or the older OB/GYN who only does office gynecology. There's every reason to believe that EM is no exception, such as the older EM doc who does urgent care, works less overnight shifts, or goes into research. (Back to shift equity - every overnight shift that an older EM doc does not take is an extra overnight shif that we will work.)

7. You must have ABEM certification to work in EM.

This parochial stance does not reflect the reality of other specialties. There are several ways to become competent in primary care (FM, IM, Peds), in adolescent medicine (Peds, IM, FM), in OB (OB/GYN, FM), in critical care (IM, GS, GAS, EM), in thyroid surgery (ENT, GS), and also emergency medicine (ABEM residency, Peds EM Fellowship, BCEM fellowship). An article often used to defend the ABEM-training-only stance is often misquoted (J. Emerg. Med. 2000;19:99-105). For example, the article does not compare ABEM trained residents to those who completed a BCEM fellowship, but is often used to criticize BCEM. (For what it's worth, I think continuing the BCEM practice track is wrong, but that a BCEM fellowship for primary care docs is a valid way to go. I also think the ABEM should come up with a one-year primary care fellowship for EM docs who want to transfer into primary care.)

I agree with what most of what ERMudPhud says. I'll add in my .02.

1. The lifestyle is not better. Its different. Despite the fact that my natural awake cycle is 9-5, I love the ED and I love not being tied to office hours and then call. I know exactly when I go to work and when I leave. I don't mind nights. I love my time off. I like that I could pick up and work anywhere in the country for a while and then again somewhere else. I would rather work 12 intense hours in the ED 3 times a week than 5 days of wards from 7-5, even with the downtime.

2. I don't mind the lack of follow up. You definately have frequent fliers (and not just alcohol abusers) just sick patients that only come to your ED.

3. You will always be at someones mercy. My father has a solo practice, not part of an hmo. He definately has major autonomy in terms of staffing, but he also suffers all the complications of *staffing*. There is flexibility, group, perdiem, traveller, corporate, group, etc etc.

4. In EM, you treat all groups. Sometimes your treatment is motrin and follow up with a PMD. But you always have an A/P with treatment as the rule. You treat patients that are being admitted, those that are really sick and those that aren't.

5. You will be surprised how much you differentiate. I have diagnosed malaria. The differential for chest pain is vast. And is usually diagnosed. Same for lots of other complaints. Yes, there are still those undifferentiated patients but I find that to be less than I thought.

6. I'm not sure what this issue is. The issue is not that forefront anymore as it is getting more and more difficult to work as a 'non-em' trained md to work in ED's. (unless its really small ed's)

7. This is a complicated issue. I personally feel that as EM residency is vital to work in an ED. If one of my family is injured, I want them to be comletely comfortable with *all* EM procedures and pathways. When to use iib/iiia inhibitors, how to put in a chest tube, needle decompress, when/how to intubate, etc etc. There is a reason it requires a residency adn why there is CME requirements as well as recert requirements. Its a difficult issue because most EM trained md's feel residency is necessary and yet, most don't want to work in a 10,000/year ED (although I think this is changing). EVen the two EMP's we have here who are grandfathered in don't think that EM should grandfather people in.

I think for most people, EM is either really obvious or really not. Its very different from all other aspects of medicine and the lifestyle is not similar to much else. It was hard for me to tell what it is you are concerned about.

Theres my 2 cents!

jazz · Feb 11, 2005

agree with most of above

1. The EM lifestyle is better because there's no call.

EM is not for everyone. if you can't shift your sleep, don't do EM.
however, once you work in an ED and see how many times a primary may be called a night (and some every night b/c they cover their own service -- ie solo), i wouldn't wish call on anyone.

2. EM is not satisfying because there's no continuity of care in EM.

there are some patients you'll glad you don't have to follow up with.
others you wonder what happened and you can call them or talk with colleagues (if they got admitted)

3. There's more flexibility in EM because of shift work.

true. agree with ermudphud. there are many practices out there.

4. EM is not triage.

EM involves "triaging" because you have to decide who gets admitted and who goes home. as a inpatient physician, it seems so easy because you are only seeing those who get admitted. but we see so much that we send home (including chest pain) that the answer is not so cut and dry in the ed.

i diagnosed b/l PE in a 17 year old with chest pain (normal vitals, no risk factors (ocp's smoking, fam hx) and no episode of chest pain in the er, (nl xray, ekg).

5. You get to assess undifferentiated patients in the ER.

where i work, i often wonder what medicine does on the floor. most of the time the diagnosis is made. often, they want all studies done in the ed prior to taking the patient up.

6. Non-EM-trained docs burn out in the ER, not the EM-residency-trained ones.

i think this is true. all physicians burn out at about the same rate (IM, EM, PEDS) etc but in their respective fields. non-em trained docs burn out earlier. i mean, if i had to do hospitalist work (i know i wouldn't last more than a year or two)

7. You must have ABEM certification to work in EM.

no comment. bad about keeping up with the politics....

good luck. i'm sure this reiterates what the previous posters have said

docB · Feb 12, 2005

sydney_ne said:
7. You must have ABEM certification to work in EM.

This parochial stance does not reflect the reality of other specialties. There are several ways to become competent in primary care (FM, IM, Peds), in adolescent medicine (Peds, IM, FM), in OB (OB/GYN, FM), in critical care (IM, GS, GAS, EM), in thyroid surgery (ENT, GS), and also emergency medicine (ABEM residency, Peds EM Fellowship, BCEM fellowship). An article often used to defend the ABEM-training-only stance is often misquoted (J. Emerg. Med. 2000;19:99-105). For example, the article does not compare ABEM trained residents to those who completed a BCEM fellowship, but is often used to criticize BCEM. (For what it's worth, I think continuing the BCEM practice track is wrong, but that a BCEM fellowship for primary care docs is a valid way to go. I also think the ABEM should come up with a one-year primary care fellowship for EM docs who want to transfer into primary care.)

While this is not completely true it is becomming more so with each passing year. Yes, you can still find some ER jobs out there that don't require ABEM cert but these are dwindeling. My advice for anyone still in school or training is that if you want to work in an ER go the ABEM route.

docB · Feb 12, 2005

docB said:
While this is not completely true it is becomming more so with each passing year. Yes, you can still find some ER jobs out there that don't require ABEM cert but these are dwindeling. My advice for anyone still in school or training is that if you want to work in an ER go the ABEM route.

Or ABOEM obviously.

sydney_ne · Feb 12, 2005

Thanks for the great feedback. I have one other question. How do you feel about remarks that EM may not be as intellectually challenging as other specialties?

On the one hand, I think maybe this is a non-issue, in that there is nothing wrong with the idea that each specialty has its own unique challenges. But for those who are interested, do you feel there are adequate opportunities for intellectual stimulation and/or research opportunites within the scope of EM?

Thanks.

NinerNiner999 · Feb 12, 2005

I think it depends how you define "intellectually challenging." For example, if you want a field where you order specific tests in the diagnostic pathway to find some obscure disease, or find yourself nose deep into medical texts and pathology books to diagnose Captain Fleming Von Nuremburgers Syndrome this isn't the field for you. While we don't debate the mag and phos levels of every adult floor patient we see, we still have the intellectual challenge of incorporating every detail we can possibly obtain, every clinical finding we see, and every piece of history we can hear into a diagnosis that rules in or out life-threatening emergencies - and doing it at times within minutes or less - while managing 10-12 other patients who all have varying levels of acuity. Again - I guess it depends how you define intellectually challenging.

EM actually poses tons of practical intellectual challenges and research if open to any area, including public health, informatics, efficiency, and the application of medical science to enhance all of the above.

DocWagner · Feb 12, 2005

Intellectually challenging is relative.
Ask a general surgeon to reduce a shoulder...painlessly.
Ask a internest to run a trauma.
Ask a pediatrician to treat a 20 year old.
Ask a trauma doc to treat heart failure.

I do all of that.

What I want in my profession is to make money, enjoy life, enjoy my family, and WANT to come back to work.
If I wanted that was "intellectually challenging" EVERY SINGLE DAY and never got easier I would be a professional crossword puzzler. Now that can be some hard ****e.

roja · Feb 13, 2005

gonna have to concur with the general statements here.

EM is definately intellectually challenging. Some days way more than others. It's very diverse, you have to have a broad base of knowledge, you have to be able to prioritize and think quickly.

there are TONS opportunities for research (bench and clinical).

Basically, you have to figure out if you like the pace and style of the ED. Do a rotation, for most people it rapidly becomes clear.

kungfufishing · Feb 13, 2005

I went to college on a crossword puzzle scholarship and EM still presents enough intellectual challenge to keep things interesting.

People characterize EM as not being very cerebral, but I would argue that the limited time/histories, multitasking, and constantly ruling out the worst case scenario requires plenty of thinking, just not as much sitting and thinking.

WilcoWorld · Feb 13, 2005

DocWagner said:
Intellectually challenging is relative.
Ask a general surgeon to reduce a shoulder...painlessly.
Ask a internest to run a trauma.
Ask a pediatrician to treat a 20 year old.
Ask a trauma doc to treat heart failure.

I do all of that.

What I want in my profession is to make money, enjoy life, enjoy my family, and WANT to come back to work.
If I wanted that was "intellectually challenging" EVERY SINGLE DAY and never got easier I would be a professional crossword puzzler. Now that can be some hard ****e.

AMEN

Jeff698 · Feb 13, 2005

kungfufishing said:
People characterize EM as not being very cerebral

I suspect that's because 'cerebral' has been defined by people who hang out on the floors endlessly pontificating about lab values and doing nothing. Of course, the few times I've been a babysitter, I tried to come up with things to think about, too.

Take care,
Jeff <- admittedly biased

jazz · Feb 13, 2005

kungfufishing said:
People characterize EM as not being very cerebral, but I would argue that the limited time/histories, multitasking, and constantly ruling out the worst case scenario requires plenty of thinking, just not as much sitting and thinking.

agree. people who criticize EM as not cerebral do so because they already have the diagnosis. of course, the diagnosis is made in the ed.

i still am confused why people don't think EM is cerebral since most of the diagnosis is made in the ED, and if not, we've ruled out the catastrophes. i suppose it's a view point thing -- severe anemia presenting as sob.... i suppose sending iron studies to work up anemia can be considered cerebral but not for me.

Homunculus · Feb 13, 2005

DocWagner said:
Ask a pediatrician to treat a 20 year old.

change 20 to 40 and i'll believe you--20 year olds are essentially 18 year olds with bigger attitudes.

the pathology is the same.

i agree that the ED is a different type of intellect-- there's not a lot of time for stewing, and often decisions have to be made on only partial information. unlike a gomer's IM or FP doc, ED docs don't have the luxury of knowing that Mr Oldfart's 180/105 BP is *good*, that his baseline sodium for some reason is 129, that he will probably need a different diabetic med on his next visit and that he has had chronic renal problems and will get worked up for them soon. All you get in the ED is "i'm on meds for my pressure, i have the sugar, and i feel weak". A portion of ED is informed intuition, and when seen by a primary provider it seems like "shotgunning". A different intellect for sure, but not at all inferior.

--your friendly neighborhood finishing up his adult ed block caveman

Apollyon · Feb 13, 2005

Homunculus said:
--your friendly neighborhood finishing up his adult ed block caveman

No kidding - your Peds residency gives you a month in the adult ED? That's progressive. Our peds people don't do any time, and our PICU people do a month of anesthesia - otherwise nothing else. I don't know if it's required, but some Peds EM fellowships give a month or two in the adult ED.

Andy Kahn · Feb 13, 2005

Apollyon said:
No kidding - your Peds residency gives you a month in the adult ED? That's progressive. Our peds people don't do any time, and our PICU people do a month of anesthesia - otherwise nothing else. I don't know if it's required, but some Peds EM fellowships give a month or two in the adult ED.

I spoke with the Peds EM fellowship director recently and she had mentioned they do a good number of adult months. I know that many PEM fellowships require 3 yrs for peds trained residents but only 2 yrs for EM trained residents. I didn't know if that was because of the requirements for adult months.

-Andy

bartleby · Feb 13, 2005

sydney_ne said:
1. The EM lifestyle is better because there's no call.

Tell me that "call isn't so bad" when you've actually been on home call for a weekend... and never had a chance to go home if you're a consultant or spend some time with your family if you're on for your practice and keep getting bugged for percocet refills every 45 minutes.

Plus, in EM, your shift is when you work, and that's it. In IM/Surg/etc, if you're on call and you're up all night, guess what you get to do the next day? Work your regularly scheduled clinic or cover your previously scheduled OR cases on no sleep.

2. EM is not satisfying because there's no continuity of care in EM.

Continuity works both ways. When you see how much fun it is for an office-based doc to have to "uninvite" a patient from his/her practice for calling up and screaming at the office staff for 20 minutes every day, you'll learn to appreciate a lack of continuity.

3. There's more flexibility in EM because of shift work.

This is definitely true. But it seems to come at a price that isn't always considered. The same system that provides you with flexibility also limits your autonomy. The EM doc working in an ER is an employee where corporate profit, seniority, shift equity, and political issues can all be abused. Also, the EM doc has to work with staff that he/she did not hire, can not evaluate, and can not fire. To some extent, this is true of other specialties (surgeons work with OR staff they did not hire), and any doc can work as an employee (such as for Kaiser). But it seems to be more of an issue in EM, because you don't have a choice of practice options.

4. EM is not triage.

Hate to break it to you, but everyone in medicine has to triage patients. General IM people triage to everybody (including the ED), general surgeons triage to colo-rectal specialists, interventional cardiologists triage to electrophysiololgists, and all of the sub-sub specialists triage back to IM. One big happy medical family.

While we're at it, the alternative name for the ED should be the Diagnosis Center, because nobody gets admitted without one. ED Docs have become the pre-eminent diagnosticians in medicine, as no patient can get a bed in a hospital without a billable diagnosis.

7. You must have ABEM certification to work in EM.

You can't really make the case that you are as qualified to work in an ED and an EM-trained doc after two months or so of ED experience in an IM residency. People are shocked that EM people have been defending their recognition as a board certified specialty with over 130 residencies that lead to board eligibility... but how do you think cardiologists would respond if surgeons decided tomorrow that they were going to have a 1 year fellowship which would allow them to do cardiac caths and stents?

Homunculus · Feb 13, 2005

Apollyon said:
No kidding - your Peds residency gives you a month in the adult ED? That's progressive. Our peds people don't do any time, and our PICU people do a month of anesthesia - otherwise nothing else. I don't know if it's required, but some Peds EM fellowships give a month or two in the adult ED.

yup. it may have something to do with being military-- as a pediatrician i'm deployable in a general medicine role. apparently they like us to have at least a little taste of general-ish adult medicine during residency. though i can't imagine seeing many "i feel bad" gomers and gomeres in Iraq, lol.

--your friendly neighborhood keep them away from neuro height caveman

Homunculus · Feb 13, 2005

bartleby said:
ED Docs have become the pre-eminent diagnosticians in medicine, as no patient can get a bed in a hospital without a billable diagnosis.

for your sake i pray the internists don't see this gem :scared:

--your friendly neighborhood wants to bill his mental status changes caveman

DocWagner · Feb 13, 2005

Homunculus...every pediatrician I have met runs for the hills when their "pediatric" patient gets pubic hair. I stand by my "Pediatrician treating a 20 year old" statement

Yeah the 19 year old female with abdominal pain stays in the rack a REALLY long time at the pediatric hospital here.

bcsmith · Feb 14, 2005

Captain Fleming Von Nuremburgers Syndrome

Heheh, good stuff man. I think I have this condition.

I had a no-nonsense chief medicine resident when I was a MS4 who liked to call this type of thinking "mental masturbation." Of course, I was disappointed to find out that an orgasm could not be acheived through this rumination. So... I went into EM

B

kinetic · Feb 14, 2005

DocWagner said:
Intellectually challenging is relative.
Ask a general surgeon to reduce a shoulder...painlessly.
Ask a internest to run a trauma.
Ask a pediatrician to treat a 20 year old.
Ask a trauma doc to treat heart failure.

I do all of that.

What I want in my profession is to make money, enjoy life, enjoy my family, and WANT to come back to work.
If I wanted that was "intellectually challenging" EVERY SINGLE DAY and never got easier I would be a professional crossword puzzler. Now that can be some hard ****e.

If you knew how to "treat" all that stuff, you wouldn't be calling so many frickin' consults, now, would you?

Jeff698 · Feb 14, 2005

kinetic said:
If you knew how to "treat" all that stuff, you wouldn't be calling so many frickin' consults, now, would you?

Oh, you obviously misunderstood. Those consults are just to annoy you.

Take care,
Jeff

kinetic · Feb 14, 2005

I know; and the cleverly done incomplete workups are also for the same purpose. :laugh:

FoughtFyr · Feb 14, 2005

kinetic said:
I know; and the cleverly done incomplete workups are also for the same purpose.

Hmm, having just stepped off the helicoptor after delivering a patient with an "onset of pain-to-cath" time of under 1 hour where I dianosed the AMI, established 2 large bore IVs, heparinized, controlled rate and pressure, activated the cath lab and safely delivered the patient in the 17 minutes I had him, I'll take any slam you think you can send my way Kinetic. There is a 38 year old with a brand new stent who will see his two kids tomorrow morning - you can't touch that with a ten-foot pole. And any time you want to come play on the helo with us, just pass your boards and sign up - oh yeah, those are the EM boards - sorry :laugh:

- H

kinetic · Feb 14, 2005

OMG! Wow, let's get rid of the cardiologists! Make way for you! :laugh:

FoughtFyr · Feb 14, 2005

kinetic said:
OMG! Wow, let's get rid of the cardiologists! Make way for you!

Nope, let's keep them. I need them and they need me. I don't claim to be able to do a cath. I am, however, able to keep a patient alive long enough to diagnose them, begin treatment, stabilize, and transport the patient to the cath lab (activated by me). I can't do the cath, but the cardiologists can't do my job either.

Gosh, aren't teams fun!

- H

kinetic · Feb 14, 2005

Wow, so you mean ED docs CAN'T take care of all patients, unlike the other specialties?! OMG!! Thanks for reaching the same conclusion as me, but like ten posts too late!!

P.S. I don't know why you're so proud about "activating" a cath lab that you wanted to explicitly mention it twice. :laugh:

Doczilla · Feb 14, 2005

Jeff698 said:
I suspect that's because 'cerebral' has been defined by people who hang out on the floors endlessly pontificating about lab values and doing nothing. Of course, the few times I've been a babysitter, I tried to come up with things to think about, too.

Agreed. Those who argue that there is little challenge in EM have not had to decide to send someone with chest pain home.

The nice thing about flagellating about rare disorders on hospitalized patients is that the patient is STILL IN THE HOSPITAL. There is a limited amount of time that will elapse before the patient is seen by the doctor or nurse again. The admitting doc is more than happy to sit on the patient and do lab tests ad nauseum because the patient isn't going anywhere. They get to observe the patient over days and watch how the patient progresses and see the blood culture results and the MRI. The so-called "triage" of EM carries a real risk to it because often the patient is going to be on their own or accompanied by people who don't know how to interpret the change in mental status or the dizziness on standing or the funky Cheyne-Stokes breathing pattern after discharge from the ED.

Those who charge EM with being "not very cerebral" are looking at it from their own tiny perspective on medicine. I will freely admit that I will never know as much as a surgeon does about surgery and postoperative care. Then again, I wouldn't want to have him reading my EKG either. These same people argue that ER docs have relatively little depth of understanding (true, I don't really know how to do a TIPS procedure, nor do I know much about maple syrup urine disease), but they fail to see the breadth of knowledge required to authoritatively (or even tentatively) diagnose conditions with relatively little data and without the chance to observe the natural course of the patient's disease.

Kinetic said:
If you knew how to "treat" all that stuff, you wouldn't be calling so many frickin' consults, now, would you?

And you're right, ER docs call a lot of other folks to treat the patient. You say this as though it's because the ER doc doesn't know how to treat them. Very seldom does the ER doc call the admitting team to say, "I have no idea what's wrong with this patient." On the contrary, ER docs frequently know how to treat them over the course of the next several days, but that's not our job, now, is it?

'zilla

kinetic · Feb 14, 2005

Yes, that's right: the ED knows the diagnosis and how to treat said diagnosis; the other teams are basically just there to enact their plans for the patient, which, did I mention, they already knew. You guys crack me up.

Doczilla · Feb 14, 2005

kinetic said:
Yes, that's right: the ED knows the diagnosis and how to treat said diagnosis; the other teams are basically just there to enact their plans for the patient, which, did I mention, they already knew. You guys crack me up.

How many times have I written the admission orders for another team because they were too busy to come down to the ED and do it themselves? Yeah, in fact, the other teams do execute the plans for the patient, considering we start their treatment in the ED. Funny how given the same data, the same lab tests, the same x-rays, the admitting team comes to the same conclusions about the patient that I do. Hot appy? Who starts the antibiotics? Chest pain? Who starts the beta blockers and the heparin and the Plavix and the first set of enzymes? Virtually anything? Who resuscitates the patient so they are still alive by the time you drag yourself in to the hospital to admit?

Don't break your arm patting yourself on the back. I am sure that your extensive residency training gives you sole providence over the treatment of chest pain. We must be lucky to have you around. I keep forgetting to specify "cardiac diet" on the order sheet. Glad you're there to catch it.

'zilla

FoughtFyr · Feb 14, 2005

kinetic said:
Yes, that's right: the ED knows the diagnosis and how to treat said diagnosis; the other teams are basically just there to enact their plans for the patient, which, did I mention, they already knew. You guys crack me up.

Yep, you have it right. We hand it off to other doctors. The key question is which doctor? Is the syncope cardiogenic or neurologic? Is this a surgical belly or an OB problem? Is this "just" a trauma, or did they have the MI before they cracked up their car? Yes, I need the cardiologist to take care of the cardiac patients I see. Unfortunately, that cardiologist can not treat the 20 other patients I'll see today. Nor can the internist, surgeon, or OB/GYN.

But hey, if you want to specialize in treating one or two specific things, one or two ways, feel free. I love taking all comers, treating them for a few minutes, getting rid of them and going home with no more committments!

The best analogy I have heard is that EPs are "long drive" specialists, we get the ball on the green and someone else putts it in.

BTW - the reason that the activation of the cath lab is a big deal is that the diagnosis was mine - not a referral as you seem to believe we do with all of our patients.

- H

kinetic · Feb 14, 2005

Doczilla said:
How many times have I written the admission orders for another team because they were too busy to come down to the ED and do it themselves? Yeah, in fact, the other teams do execute the plans for the patient, considering we start their treatment in the ED. Funny how given the same data, the same lab tests, the same x-rays, the admitting team comes to the same conclusions about the patient that I do. Hot appy? Who starts the antibiotics? Chest pain? Who starts the beta blockers and the heparin and the Plavix and the first set of enzymes? Virtually anything? Who resuscitates the patient so they are still alive by the time you drag yourself in to the hospital to admit?

Don't break your arm patting yourself on the back. I am sure that your extensive residency training gives you sole providence over the treatment of chest pain. We must be lucky to have you around. I keep forgetting to specify "cardiac diet" on the order sheet. Glad you're there to catch it.

'zilla

WAH HA HA HA! "Oh, man, why won't everyone recognize that I know and do it all as an ED doc? They must be too busy writing "cardiac diet" on the order sheet!" Please post more!

FoughtFyr · Feb 14, 2005

kinetic said:
WAH HA HA HA! "Oh, man, why won't everyone recognize that I know and do it all as an ED doc? They must be too busy writing "cardiac diet" on the order sheet!" Please post more!

Wow, what a cogent and thoughtful response!

- H

kinetic · Feb 14, 2005

And yet it accomplished the task at hand. :laugh:

questionguy · Feb 14, 2005

kinetic said:
And yet it accomplished the task at hand.

Nice job taking out of context quotes from this thread and posting them as new threads all over the forums

----->

http://forums.studentdoctor.net/showthread.php?t=179406

http://forums.studentdoctor.net/showthread.php?t=179413

http://forums.studentdoctor.net/showthread.php?t=179414

kinetic · Feb 14, 2005

How were they out of context? :laugh:

Because you didn't like the way they sounded? Also, note that I provided a link to the thread. :laugh:

SUCKAHS!

questionguy · Feb 14, 2005

kinetic said:
How were they out of context? Because you didn't like the way they sounded? Also, note that I provided a link to the thread. SUCKAHS!

I find it very hard to understand how an individual who was kicked out of a surgical internship who spends 8-10 hours/day posting on SDN finds the audacity to criticize a group of individuals who are actually able to enter and competently complete an accredited residency. Ah, but I guess the aggression comes from a repressed sense of absolute inferiority as one sits at home contemplating whether to watch an afternoon soap opera or start a new thread about how better than ED Docs he is.

Feel free to throw in another banal response with a generous helping of these--->( :laugh:

) I hope it makes you feel better about yourself and your pathetic situation.

I am done with this thread.

kinetic · Feb 14, 2005

questionguy said:
I find it very hard to understand how an individual who was kicked out of a surgical internship who spends 8-10 hours/day posting on SDN finds the audacity to criticize a group of individuals who are actually able to enter and competently complete an accredited residency.

I've been quite open about getting the boot; also, I've been quite open about what LED to it -- speaking of taking things out of context. :laugh:

Moreover, since you're Mr. Brilliant, I'm surprised that you fail to see that my getting the boot has nothing to do with the statements that ED docs are making on this forum. WHOOPS! It's about as relevant as the people in the Allopathic forum telling the Pre-Allos that they suck because they aren't in medical school. :laugh:

What you really mean is that the statements being made in here are pretty piss poor and you don't like the way that makes you guys look, so the best thing to do is to try to talk about my personal life.

PWNAGE!

bcsmith · Feb 14, 2005

Hey guys, ignore kinetic's replies. He's just someone who likes to stir the pot / start a flame war. Perhaps some underlying inability to stand up to others to their face in real life... ?

Maybe when he gets out of his second internship he will develop a more mature understanding... but even that might be asking too much.

B

kinetic · Feb 14, 2005

OMG! You're right! I'm immature ...so that caused YOU guys to say all those things! Now I've seen the light!

kinetic · Feb 14, 2005

By the way, nice save on changing "getting out of medical school" to "getting out of his second internship." WAH HA HA HA!

bcsmith · Feb 14, 2005

love, catch the wave dude.

bcsmith · Feb 14, 2005

30.61 posts per day... Thats a lot of hot air =)

cooldreams · Feb 14, 2005

kinetic... dood what motivates you to aggrevate everyone?

can you really honestly say that the medical system would be better without ED Doctors?

every specialty will have people who will agree with it and those who will curse it... that is life... who cares... if ED did nothing, they would not be getting paid.

l8rs...

kinetic · Feb 14, 2005

WAH HA HA HA! Now come the rips on post count! Aw, don't like how bad you guys sound, so the answer is to start talking about post count. Aww.

PWNAGE!

kinetic · Feb 14, 2005

cooldreams said:
can you really honestly say that the medical system would be better without ED Doctors?

I could, but I haven't until now. If you read the thread carefully, you will note that all I have done is questioned the fantastic assertions being made by the ED docs in here. :laugh:

cooldreams · Feb 14, 2005

kinetic said:
I could, but I haven't until now. If you read the thread carefully, you will note that all I have done is questioned the fantastic assertions being made by the ED docs in here.

i think you should also take into account that in various settings, the ED will possiblly perform different functions. - same goes for pretty much all specialties... could be a rural setting, maybe hospital politics, law suits, understaffed hospital, etc etc...

kinetic · Feb 14, 2005

cooldreams said:
i think you should also take into account that in various settings, the ED will possiblly perform different functions.

Of course. But that has nothing to do with the manner in which people were posting in here. But what do I know? The ED docs are CLEARLY mature. :laugh:

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