Too Smart for EM?

MSTigER said:

So I've decided that I'm tired of hearing I am "too smart" for Emergency Medicine on my M3 rotations. Does anyone else get that much? It seems as if every service I go on they are trying to drive a wedge between myself and my choice to be an EM doc. Guess Im just venting but If anyone has had a similar experience/advice I'd like to hear about it.

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Only the gifted go into Internal Medicine. If you're great at Zebra hunting on a ranch full of horses, then IM is for you!

Otherwise, if you like EM, and enjoy doing it, then go into it.

I'd pit our collective IQ as a specialty up against any other (well maybe not neurosurgery).

MSTigER said:

So I've decided that I'm tired of hearing I am "too smart" for Emergency Medicine on my M3 rotations. Does anyone else get that much? It seems as if every service I go on they are trying to drive a wedge between myself and my choice to be an EM doc. Guess Im just venting but If anyone has had a similar experience/advice I'd like to hear about it.

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If I had a nickel...

For me, it occurred most frequently on surgery.

GeneralVeers said:

...(well maybe not neurosurgery).

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I would.

Just tell them you like being a big fish in a little pond.

Less brains, more salary. Gotta love EM.

I think you'll find that each specialty likes to cut down every other specialty. Physicians in general are especially clueless about emergency medicine. When I was a fourth year med student, EM nationally was more competitive than IM and equally competitive with General Surgery. I doubt that situation has changed over the past few years. In my medical school class, the top student in the class went into EM and 2/3 of us were AOA members. (Incidentally, not a single AOA member went into General Surgery.) So, if you can really see yourself as an emergency physician, then go for it. Don't let the bastards drag you down!

wow. Thought that only happened to us Family docs. Sorry to hear that you are getting such negative feedback, and I hope you turn a deaf ear to it. I personally LOVE when our very smart ED residents do a great job stabilizing a sick patient or help get the ball rolling on a difficult work up. There's no such thing as an area of medicine that someone is "too smart" to be in. I want the smartest ED docs taking care of my kids when I bring them in at 1am, I want the smartest people as my PCP so that I will have any chronic diseases under control. If I have a weird skin thing, damn it, by derm doc better be smart! And if I have a mass removed I want my pathologist to be smart enough to know what the hell they are looking at under the microscope. We need the best and brightest in every field. Good luck in Emergency medicine.

Little off topic but I wouldn't tell your 3rd year rotations that you want to do EM. They tend to either just teach you what they think is related to EM, or think that you've already decided and don't care about their specialty. I just told them all I wasn't sure, got a lot of good teaching and didn't have to deal with people trying to talk me out of EM.

MSTigER said:

Thanks all for the words of wisdom, wish I could make it through a rotation without exposing my specialty of choice but it always seems to come out. Guess I need to keep my mouth shut.

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Don't worry about it - someone will eventually ask anyways, and you're going to be honest. I got used to the fact that my answer to the question "What specialty are you going into?" was not going to make all of my attendings happy.

I trained in EM at your institution and would venture that some of the smartest attendings in that hospital are in the ED.

Just say that "you're thinking _____________ (whatever rotation you're on) as a potential career.

In you're mind you can be dead set on EM, but you're "thinking" about how much you hate whatever you're on that month, but at least you're not lying by omitting that key fact, plus you're making whatever ________resident happy that you might be interested in their field.

I whipped out this strategy midway through the 3rd year and my grades went from consistent high pass to consistent honors.

Just play the game dude--it sucks, we all know, but you gotta do it

(hopefully this all makes sense--I just got done having a few too many cocktails . . . 4th year is great!!!)

Dare I play devil's advocate?

Well, not exactly. I'm an EM resident, so obviously I do not think that we're dumb people (or else I've just got some self-esteem issues). I do think that there's a difference between smart and intellectual. EM tends to attract less intellectual people, more the practical, let me do it types, rather than the thoughtful, let me mull it over, do some research on it, then do it types. Research in EM is relatively new and still underdeveloped, also EM as a field is still breaking away from the old stereotypes (still prevalent in other countries) of who would go in to EM other than IM/FP/GP docs who want to do urgent care. It is up to those of us who are emerging leaders to point out to everyone else that we are a specialty just like everyone else, that we have some PHENOMENAL role models who are super bright, and that we have skills that are intellectual in nature, but many more too. I'm at two institutions that have very strong off-services with very bright people, and I personally really like to point out to these other smart folks how smart we in EM are too.

I'm honest about my interest in EM when my attendings ask me what I'm thinking of going into. I also make it clear that I feel having a knowledge of all the specialties will make me a better EM doc. I think that EM people just tend to be interested in a lot of things - intellectual and procedural - and enjoy that, what the ED may lack in continuity and depth of care, it makes up for in breadth of knowledge and procedural skill. I've actually had the same thing said to me, about being "too smart" for ED and as flattering as it is to be called smart, not to mention a little weird that someone would make that call based on what.... breaking into my student records? the color skirt I was wearing that day? finding the groundbreaking research I published at the age of 10 about transgenic mice with a knockout on locus Q145... just kidding... ... it's obviously not a compliment, but a elbow under the chin since they're saying I'm "too smart" for what it is I enjoy doing, thus suggesting I'm choosing to do something pointless and become dumb by association. *eye roll*. I prefer to point out that I can't wait to become a jack of all trades and a master of one (that's what that eventual board certification proves right? Just like the certification from the internet proves that i'm an ordained minister?) ... okay, time for bed, obviously.

If you believe money is the measure. I believe I saw it somewhere that per hour we are 4th.. I think Em people have interests outside of medicine.

Some of the smartest people I know are in EM.. Are there smart people in other fields too.. but... plenty of smart people in EM...

Thats all im saying

I just had a cardiologist tell me that the reason why EMPs are so bad is that our field is "in its infancy and does not have any data to practice evidence based medicine." And this is someone right out of fellowship...and I though you had to be reasonably smart to be a cardiologist!

ERNerd said:

Physicians in general are especially clueless about emergency medicine.

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Probably because we are a a relatively "new" specialty.

Perhaps they are jealous of your mad skillz and long forgotten pager.

Seriously, while I still have a long long long way to go, the EM docs and staff have largely been the most fun to be around. I guess the biggest difference was that while they were all incredibly intelligent, they didn't go out of their way to prove it.

MSTigER said:

Maybe we could find a way to start rounding in EM, and we could then spend hours pontificating the minute details of a single patient's care.

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EM does all the fun stuff and then punts the scut to some other specialty being paid less to do it. EM is the Tom Sawyer of medicine; letting them think they're smarter is just part of the scam.

Jarabacoa said:

Ya, we get paid more than anybody...

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We get paid more than anybody who does a 3 year residency. That is irrefutable. The longer one spends in residency, the more one makes (which does NOT extrapolate to fellowship across the board).

Jarabacoa said:

Ya, we get paid more than anybody... except for ENT, cardiology, orthopedic surgery, neurosurgery, ophthalmology, cardiothoracic surgery, vascular surgery, pulmonology, allergy and immunology, plastic surgery, general surgery, urology, gastroenterology, and dermatology. A well-run family practice clinic can pull in 400,000 if they are doing OB and office procedures a lot. Even a lot of dentists kick our butts financially. Sure, some family practitioners are going out of business with the recession, medicare cuts, and a patient population too heavy in medicaid, but most are doing fine.

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Yes, but how many of the above specialties actually make $200+ per hour? All the surgeons (except plastics) charge huge fees and get paid a small percentage and are required to follow the patient through their entire hospital stay for the same inclusive fee. A CT surgeon I know is always in the lockerroom before 6am and rarely leaves the hospital before 7pm and says he makes about $250 an hour if he averages it out, but he works a ton more then the average ED physician.

Is this $200/hr figure pretty firm or is it more regionally dependent?

strongboy2005 said:

Is this $200/hr figure pretty firm or is it more regionally dependent?

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It's regional in that the average for each region is different. But you can find $200/hr jobs in every region. That was a bad way to say that. I mean that while there are those jobs in every region some regions have more than others.

I have a healthy respect for EM physicians -- there is absolutely no way I could juggle that much knowledge. At the same time, you guys are kind of "good-in-everything-expert-at-none", which is why I think you see comments like that.

I was a professional musician in my past life.
Arguments about which specialty is the most difficult, etc, reminds me of talks about which instrument was the most challenging.

People would tend to point out the difficulties in their own instrument because that was really the only thing they could evaluate.

In any case, the argument really is pointless. Pick the field that you find the most enjoyable and know that many people won't think you are making a good decision. You are the one who has to do the work.
I have great respect for various fields, even ones I could never imagine doing myself. Not because I'm too smart or too dumb, just because I don't think I'd like it.

Anyone who makes remarks criticizing the value or difficulty of another field is small-minded and their advice is probably of minimal use anyway.

gman33 said:

People would tend to point out the difficulties in their own instrument because that was really the only thing they could evaluate.

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I don't have to be a neurosurgeon to know that they have a 5+ year residency and are routinely working 90 hours a week, and that derm residents are...well....not.

Nothing to do with who is better or worse but it's a fact that certain fields are giving up more of their personal life to their practice. That being said, 40 hours a week doing something I hate would make me leave medicine. I'd rather work a lot more doing something fun than dealing with acne.

Apollyon said:

We get paid more than anybody who does a 3 year residency. That is irrefutable. The longer one spends in residency, the more one makes (which does NOT extrapolate to fellowship across the board).

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Again I saw previously that per hour we are 4th. We make a bunch of money and if you look you can easily find a job making 400k+.. it might not be in the location of choice but if you want money you can find money. I want to see pure IM or FP or Peds do that.

EctopicFetus said:

Again I saw previously that per hour we are 4th.

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Can you provide a reference for that? I looked around and I can't find it. I have thought the same thing myself but can't find any legit source to verify it.

I have heard the average pay/hr was $125-150/hr.....

thoughts?

J DUB said:

I have heard the average pay/hr was $125-150/hr.....

thoughts?

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That's what I thought too...

$125 per hour is about $250,000 per year (40 hrs per wk, 50 wks per yr)
$200 per hour is about $400,000 per year

Seems like a big difference...

So, hypothetically, if one found an EM job paying $225 per hour, and then voluntarily worked 60 hours per week they could make $675,000 per year?

For a little perspective, I used to make $20,000 a year teaching freshman composition classes at the English department of a college on the East Coast

strongboy2005 said:

That's what I thought too...

$125 per hour is about $250,000 per year (40 hrs per wk, 50 wks per yr)
$200 per hour is about $400,000 per year

Seems like a big difference...

So, hypothetically, if one found an EM job paying $225 per hour, and then voluntarily worked 60 hours per week they could make $675,000 per year?

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exactly....seems like fuzzy math to me...

strongboy2005 said:

That's what I thought too...

$125 per hour is about $250,000 per year (40 hrs per wk, 50 wks per yr)
$200 per hour is about $400,000 per year

Seems like a big difference...

So, hypothetically, if one found an EM job paying $225 per hour, and then voluntarily worked 60 hours per week they could make $675,000 per year?

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That's correct. BUT... the jobs that pay better tend to be pretty busy, ie. seeing lots of patients per hour. Most jobs that hit the $200/hr mark will have a good payer mix and will have you really moving seeing >3/hr. In those environments 60hrs/week would be really grueling and even doing more than 40/wk is hard. Also keep in mind that those numbers are pretax.

docB said:

That's correct. BUT... the jobs that pay better tend to be pretty busy, ie. seeing lots of patients per hour. Most jobs that hit the $200/hr mark will have a good payer mix and will have you really moving seeing >3/hr. In those environments 60hrs/week would be really grueling and even doing more than 40/wk is hard. Also keep in mind that those numbers are pretax.

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how about in the rural areas where most folks dont wanna go?

That's where I would like to go....and work like 24hr shifts...

I wouldn't get too worked up about people like that. My prior roommate was an ortho intern when he was told by an IM guy "You're too smart to go into surgery". You'll get that with anything, it's a way for someone to indirectly tell themselves that they're smart. It's like telling the chick at the party that she's WAAYYY too cute to be with that dude, am I right?

Is there any source that gives accurate info in terms of total comp, salary, etc...? for EM....

gman33 said:

I was a professional musician in my past life.
Arguments about which specialty is the most difficult, etc, reminds me of talks about which instrument was the most challenging.

People would tend to point out the difficulties in their own instrument because that was really the only thing they could evaluate.

.

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Well, unless you are a bassist. Then you are lying to yourself about being most difficult for 99% of songs.

(Coming from a drummer and guitarist)

I've heard the "dumb er doc" line a few times. It's funny when IM residents come down to do their rotations in the ED they often look like a deer caught in car headlights. We had an IM resident that saw 5 patients over a 12 hour shift and three of those pt's she admitted, which were later declared "bullsh@t" admits by her colleagues.

Of course, it seems every time I tee up a "bullsh@t" admit they keep the patient on the floor for a week ordering 30+ plus tests and sitting around stroking their cerebral cortex trying to figure out what the hell is going on. When I did my medicine month and the medicine team complained that particular ED admission was weak. I offered to go write the dc orders right then and there. That went over like a fart in church and the senior and attending were appalled. My thinking was if there is no need for this patient to be in the hospital let's dc them..right?

When they have to make that decision to dc a patient with non-specific symptoms they shutter and always decide "let's keep him/her another day."

Surgery was the best...they would keep the patient and wait for the patient to "declare themselves." Bascially, we have no idea what's going on but let's hope the patient will manifest signs and symptoms that we recognize, or their condition worsens to a point we can make a diagnosis.

During any given shift we have to be a surgeon, internist, neurologist, cardiologist etc etc. Other doctors simply don't understand what we do.

And I'm still convinced we have the best job in medicine

enfuegoEP said:

Surgery was the best...they would keep the patient and wait for the patient to "declare themselves." Bascially, we have no idea what's going on but let's hope the patient will manifest signs and symptoms that we recognize, or their condition worsens to a point we can make a diagnosis.

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Reminds me of the Scrubs episode when JD boasts about his 'Wait and See' approach to Elliot. So why are doctors so afraid to do anything before ordering 30 different tests, and making the patient wait so long? (Sorry for the naive Q, I am only a humble 2nd year Med Student)

J DUB said:

Is there any source that gives accurate info in terms of total comp, salary, etc...? for EM....

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Try out the site salarywizard.com, here is just a breakdown for physicians working in MI, don't know if this is what you were referring too...

Physician - Emergency Room - MI
Benefit Median Amount % of Total
Base Salary $262,166 77.8%
Bonuses $1,559 0.5%
Social Security $10,446 3.1%
401k / 403b $9,310 2.8%
Disability $2,637 0.8%
Healthcare $6,103 1.8%
Pension $12,250 3.6%
Time Off $32,458 9.6%
Total $336,930 100%

enfuegoEP said:

I've heard the "dumb er doc" line a few times...

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I was in noon conference during my neurosurgery rotation when an attending tossed up a head CT showing a clear intracranial abscess. The attending promptly went into a 10-minute diatribe about the "dumb er doc" from an OSH who cut into it, much to the grunting approval of the residents.

What the attending didn't say is that the patient came in for a zit on back of the head. Patient had localized erythema, pain on palp, and swelling, but no temp, neuro deficits, seizures, neck stiffness, or changes in MS. Doc gave local and after some drainage, felt it went deep, and then got the CT. You look closely at the CT and you can see the thin line where the abscess ate through the lambdoid suture to the skin.

Was the ER doc really dumb? How often should intracranial abscess be in DDX for a big zit? How hard is it to know the answer when the patient carries a referral with the diagnosis?

J DUB said:

how about in the rural areas where most folks dont wanna go?

That's where I would like to go....and work like 24hr shifts...

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That's an option. In my experience though those places tend to suffer from low volume and poor payer mix so the hourly is low although working 24s can make up for that in absolute income. It really depends on what you like. A low hourly at a low volume place can be ok. I know a guy who routinely has his wife bring the kids into the hospital caf so he can eat dinner with them on his 24. He's in the hospital all night but it's a lower tempo.

RxnMan said:

I was in noon conference during my neurosurgery rotation when an attending tossed up a head CT showing a clear intracranial abscess. The attending promptly went into a 10-minute diatribe about the "dumb er doc" from an OSH who cut into it, much to the grunting approval of the residents.

What the attending didn't say is that the patient came in for a zit on back of the head. Patient had localized erythema, pain on palp, and swelling, but no temp, neuro deficits, seizures, neck stiffness, or changes in MS. Doc gave local and after some drainage, felt it went deep, and then got the CT. You look closely at the CT and you can see the thin line where the abscess ate through the lambdoid suture to the skin.

Was the ER doc really dumb? How often should intracranial abscess be in DDX for a big zit? How hard is it to know the answer when the patient carries a referral with the diagnosis?

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I usually pipe in with a question like "So you want to be consulted on any scalp abscesses we see from now on?"

When I was in residency one of the gen surg faculty published this really snide paper about how EM docs are *****s and any patient with a suspected appy should have "an exam by a surgeon's learned hands" before wasting time with a CT scan. You better believe every EM resident had a copy of that POS in our back pockets.

RxnMan said:

I was in noon conference during my neurosurgery rotation when an attending tossed up a head CT showing a clear intracranial abscess. The attending promptly went into a 10-minute diatribe about the "dumb er doc" from an OSH who cut into it, much to the grunting approval of the residents.

What the attending didn't say is that the patient came in for a zit on back of the head. Patient had localized erythema, pain on palp, and swelling, but no temp, neuro deficits, seizures, neck stiffness, or changes in MS. Doc gave local and after some drainage, felt it went deep, and then got the CT. You look closely at the CT and you can see the thin line where the abscess ate through the lambdoid suture to the skin.

Was the ER doc really dumb? How often should intracranial abscess be in DDX for a big zit? How hard is it to know the answer when the patient carries a referral with the diagnosis?

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EM does the real diagnosing....nothing to build on many times!!

docB said:

When I was in residency one of the gen surg faculty published this really snide paper about how EM docs are *****s and any patient with a suspected appy should have "an exam by a surgeon's learned hands" before wasting time with a CT scan. You better believe every EM resident had a copy of that POS in our back pockets.

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Where I live the surgeon's can't make a diagnosis without a CT. We have to beg them to examine a 17 y/o kid with periumbilical pain that now is localized to the RLQ and exacerbated by movement. +rebound tenderness. +Fever. +Rovsing's sign. +anorexia. High white count. Nausea. Vomiting. His grandmother, grandfather, great aunt bessie, mom, dad, next door neighbor and big brother have all had appendectomies....and appendicitis is tattooed on her forehead. When I call the first thing out of the surgeon's mouth "what did the CT show?"

enfuegoEP said:

Where I live the surgeon's can't make a diagnosis without a CT.

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Don't get me wrong, I enjoy a good surgeon bashing as much as the next guy, but I felt the need to at least point out the surgeons in my community practice have come in and done ex-laps on several pregnant patients that we didn't want to CT and had equivical US on. They've come in to see young kids with clear stories that we didn't want to nuke.

Our hospitalists may groan about some of our admits but they also readily acknowledge that, on initial presentation, nobody can figure out what is going on with some patients.

"Let the diagnosis present itself" is a time-tested and very sound strategy for folks you're concerned about but have a high level of diagnostic uncertainty. We clearly know this in EM, it's nice that my admitting colleagues do as well. At least in my shop. Most of the time.

There. I feel better now. Let the bashing continue.

Take care,
Jeff

docB said:

When I was in residency one of the gen surg faculty published this really snide paper about how EM docs are *****s and any patient with a suspected appy should have "an exam by a surgeon's learned hands" before wasting time with a CT scan. You better believe every EM resident had a copy of that POS in our back pockets.

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Since I was thinking of that paper I looked it up:
Computed Tomography and Ultrasonography Do Not Improve and May Delay the Diagnosis and Treatment of Acute Appendicitis
Steven L. Lee, MD; Alicia J. Walsh, BS; Hung S. Ho, MD

Here are some of the juiciest nuggets:

During the last decade, studies of white blood cell scan, ultrasonography (US), and computed tomographic (CT) scan have suggested that these diagnostic imaging modalities may improve the diagnostic accuracy for acute appendicitis.8-11 On the other hand, there were also concerns about the appropriateness and accuracy of these modalities without a surgical evaluation.10-11
In this report, we reviewed the current epidemiology of acute appendicitis in a tertiary care center and assessed the impacts of US, CT scan, and laparoscopy on its management, with the hypothesis that CT scan and US do not improve the overall diagnostic accuracy for acute appendicitis.

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In patients clinically suspected of having acute appendicitis, neither CT scan nor US improved the diagnostic accuracy compared with clinical assessment alone.

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Evaluation by surgeons correctly diagnosed 536 of 646 patients with acute appendicitis and correctly ruled out the condition in 38 of 120 patients who did not have acute appendicitis. Overall, clinical assessment yielded an accuracy of 74.9%.

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Clinical acumen remains the most reliable diagnostic asset for evaluating a patient with suspected acute appendicitis in the ED. In such patients, a history of migratory pain or leukocytosis greater than 12 x 109/L provides high positive predictive values above 90%. These patients should have immediate appendectomy; imaging modalities such as CT scan or US do not improve the overall accuracy, but may delay surgical consultation and the eventually needed appendectomy. The lack of prospective data in our study prevents us from concluding that the early use of diagnostic laparoscopy is a more cost-effective, accurate, and rapid method of diagnosing atypical cases of acute appendicitis. However, its low morbidity and high yield of alternative diagnoses merit prospective, randomized clinical trials of the selective use of laparoscopic appendectomy in the management of atypical acute appendicitis. Such an approach may reduce further the perforation rate and subsequently the mortality and morbidity, especially in women of childbearing age or in the older age group.

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You can imagine what a living Hell this paper made life for our surg residents. "Why would I get imaging on this patient? Dr. Ho proved that all we need are the hands of a surgeon to evaluate the patient. So bring 'em on down."

I advise everyone to keep an eye on the papers published by the professors in the other departments in your institution. And if Dr. Ho is still at UCD everyone there should definitely keep a laminated copy of this on them at all times.

Brilliant!

I LOVE it!

I am a fan of the patient "declaring," even if the declaration is nothing more than "this guy needs to be admitted because his VS are still abnormal, etc." It can be challenging in a busy dept, but is sometimes best to buy you time to think and reevaluate.

enfuegoEP said:

That went over like a fart in church

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This line had me laughing out loud in the computer lab. Thanks for that.

I've heard the "too smart" line many times as well. My interpretation is that if your attendings and residents like you, they want you to reaffirm their own life decisions. I.E., the surgery resident wants you to follow in his footsteps because he liked you on your rotation and this whole "You're too smart for EM" business is a compliment to you (in that he liked you) and therefore a compliment to himself (in that he feels that people he likes should also be smart and do what he did).

It's not really an insult. But it's hamhanded in delivery and feels like one.