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In a recent thread, a poster asked us to talk him into Emergency Medicine. I think we do a good job of telling people why to go into the field, but a poor job letting them know the realities that make our job tough. So, in an effort to keep it real, here are 12 reasons NOT to go into ER:

12. The ER has now become a sort of convenience-mart for the community, a problem solving center, especially in the department of psychiatry. While the psychiatrists sleep in their beds, you have to deal with psychiatric problems of patients who are on psychiatric holds, or who desire voluntary admission to the hospital. The patient really needs counseling, compassion, a quiet/safe place to re-group, etc., none of which are provided by the Emergency Department. However, psychiatry functions in an 8-5 manner, only wanting to deal with staffing issues when it is convenient for their unit, not the ER.
 
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11. The unfunded EMTALA mandate. I had a 3 month old patient with head injury after her mom fell down a few stairs. The child had a tiny head bleed, and was acting appropriately, feeding, alert, vitals normal. I wanted to transfer to a PICU by ground, which is about 2 hours away. The accepting facility wanted to meet our crew half-way. It was about 20 degrees out with a 40 mile an hour wind, and intermittent snow-flurries. We thought that it would be wise to meet in the ambulance bay of an ER about an hour from us. Our nursing supervisor thought that would be an EMTALA violation if the patient presented on the middle hospital's premises. My nursing supervisor talked to our hospital attorney, who thought it would be a bad idea. I spoke to the ER doc at the middle-ground, who spoke to their hospital attorney, who thought it was OK, as long as another physician had already stabilized the patient. The middle-ground hospital has an adult neuro-surgeon, whereas, we don't have any at all. So, in my mind, it would not violate EMTALA if in the worst-case scenario, the patient deteriorated and needed to by stabilized in the middle-ground ER. But because our hospital attorney thought it was a bad idea, the patient got transferred from ambulance to ambulance in the middle of a McDonald's parking lot with a below zero Fahrenheit wind-chill, carrying the infant across an icy parking lot, instead of in a heated, dry, ambulance bay. The very fact that we talked to our hospital attorney, and they talked to theirs to figure out what to do, speaks volumes about our current medicolegal climate.

I got a call a few months back from a local paramedic, who I trust, who said a woman fell from a significant distance, lost consciousness, then seized. She was given some ativan on scene and she came around, was talking, and only complaining of headache. She was protecting her airway and her vitals were stable, with no abdominal trauma or chest trauma that was obvious on physical or history. He said he was calling the helicopter to meet them at our hospital for emergent transfer to a trauma center with a neurosurgery availability as he thought she was at high risk of head bleed. I said, "Sounds great, get her out of here." A few weeks later, I was informed this was an EMTALA violation and I should have admitted her to our ER, generated paper-work, and then sent her out, to fulfill our EMTALA obligation. If I had told them to avoid our premises, say in a field somewhere, that wouldn't have been an EMTALA violation as they didn't come near our property. The fact that a helicopter pad is the best place to land for a helicopter doesn't factor into the equation.

The fear of breaking federal law gets in the way of doing what is right for the patient.
 
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deleted65604

10. The politics of an ER are complex and painful. We have many bosses. First, you have your ER director. You are also beholden to the CEO and medical staff of the hospital. If they don't like you, they can block you from having hospital privileges at the hospital, even though your director likes you. You also have medical records, and your billing office constantly hounding you to sign this and sign that, and don't order things using that abbreviation, etc. Hospital politics suck everywhere and you can really get thrown under the bus in a hurry.
 
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9. ER nurses can occasionally be difficult to work with. The young ones don't know a lot about setting up chest tubes, central lines for pressure monitoring, etc. and don't catch your mistakes like the more seasoned nurses. The older nurses are often jaded and as they age, they get increasingly @#!*% off that you get paid way more than them, even though they think they could do your job. This is especially bad because you generally have little input over who gets hired, fired, disciplined, talked to, etc. The drama and back-biting amongst nurses is the stuff soap-operas are made of, making a pretty consistently caustic, disfunctional work environment that tends to grind up and spit out a lot of nurses.

8. ER techs can come in two flavors: A. The pre-nurse, pre-med, uber-eager tech who will work their tail off for you in hopes that the experience will further them in life. B. The lackadaisical tech who doesn't quite know what to do with their life, who thinks they may want to be involved in medicine, but doesn't want to work too hard, or doesn't quite have the self-confidence to take the next step. The A's are fun after they have been working for several months, but they turn-over so fast that you get sick of trying to get things done your way. B's get increasingly lazy, and less helpful as time goes on, and unfortunately, stay on longer than A's.
 
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7. You are at the mercy of the randomness of chaos. Our ER announces the arrival of every patient with “Patient in triage” plus or minus “stat”. As I heard 8 people check in one hour yesterday, I would be talking with a patient, and would wince every time I heard the overhead page (I’m single coverage in a ten bed ER). By the eighth, I was cussing more and more vehemently. You don’t get this with an office. You know you have a maximum number of patients that you can be deluged with.

6. Patient satisfaction is currently god in hospitals. ERs consistently have the worst patient satisfaction of any part of the hospital. With emergent patients, I tend to focus on medical care and not on stroking their ego. With non-emergent patients, it is hard for me to keep up the act that I actually care. Anywhere you go, you are going to be constantly barraged by dark-suit business people, and clip-board carrying nurses giving you tips on how to get high scores. No one ever asks the question, are we sure this is the best thing for patient care?
 
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5. EMTALA has castrated our ability to put limits on patient behavior. Because we are legally obligated to see all comers and rule out emergencies, we have to put up with their poor behavior until we can do that. Private offices/physicians can just tell jerks to take a hike. They can screen up front with firm secretaries/nurses that don’t put up with guff, and will tell people “Pay the co-pay or get the heck out of this office. Behave yourself, or we will call the police.”
It is hard to not become jaded by the drunks, personality disorder etc. Sometimes, patients suck your compassion in a manner very akin to dementors straight out of Harry Potter. I don’t know about you guys, but a bad patient interaction can really turn me ornery for hours, or even days (a couple of times, a few weeks for me). You go into medical school with intentions of becoming a compassionate human being and after a really rough shift, you’d rather drop-kick the next patient that checks in for a BS complaint or behaves inappropriately. We are in a similar boat to police officers. We see the absolute worst of society- the rapes, the assault, the addiction, the stupidity, the slothfulness, the manipulative behavior, etc. It’s an environment that could turn Obama Republican. Who are the policy makers and think-tank people in this country? The high-brow professors and executive types who spend all day in meetings, lectures and events associating with intelligent, high functioning individuals. The only interaction with humanity they have is from the windows of their cars as they drive through “that part of town”. They remark as they drive through, “Jeeves! Look at these poor people. They look absolutely miserable. We must do something for them!”
 
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4. Abuse by other doctors. We get dumped on a lot by other specialties, but they never like getting dumped on by us. Yesterday, I got a call from an internal med doc, who said,” I’m sending a patient in from radiology. She had a DVT for the past several weeks, but in the past day, her leg has become much more swollen. US today shows that the clot has propagated to the entire leg. My husband and I (her husband is one of our hospitalists) think she needs to have catheter-directed thrombolysis arranged. Will you do it, because I am home and don’t have the numbers?” Come to find out, the clot has been that big for the past 8 weeks, looking at the reports, and the vascular surgeon said the clot is too far out for thrombolysis to be effective. The same person who thought I should be dumped on consistently tries to block admissions on weak chest pain admits, and TIAs all the time, even though our groups and the CEO have met repeatedly over the matter and decided that when we decide to admit, there will be no push back.

It is really hard to work in the ER, and not make mistakes from time to time, either in being too aggressive in treatment, or not aggressive enough. As much as we complain about lawyers, NO ONE is more critical of one another than physicians. The frequency that you see people get thrown under the bus by colleagues is astounding.
 
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3. Lots of drug seekers. The lengths that people will go to in lying to get narcotics are astounding, and frustrating. The main way that you get information as a doctor is by performing a history and physical. With a history and physical in hand, you proceed with more advanced testing and treatments as clinically warranted. What do you do when people are making up symptoms, past medical problems, lying about social histories? What if they are too stupid/ demented to understand questions? Tell me I'm not the only one to have ever asked the question "Did the pain start suddenly or gradually?" and got the response..."I don't understand your question." You want to say, then you are too stupid to be wasting my time with. What do you do when people are faking severe abdominal pain? One of my personal pet peeves is facial droops and arm weakness that amazingly, have normal MRIs. The classic pseudoseizure patient is also gut-wrenchingly irritating.
 
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2. It is all about money. Many, if not most ERs in the country have become money generating boons to the hospital. The hospital administration, and the ER directors who generally work a lot less, if at all, want all the business through the ER that they can get. Where is the down-side from their perspective? The result is that most hospitals actually encourage BS complaints to come to their ERs. They WANT non-emergent patients. In fact, their bottom line depends on catering to people with non-emergent complaints, who use the ER out of convenience. Where I currently work, I have been told in no uncertain terms, that I will never, ever tell anyone that they are not welcome in the ER for any complaint day or night. That is a hard pill to swallow as I'm walking down the hall after the rare night-time nap, thinking, and "this darn well better be an emergency". It never is. But hey, I get paid good, so I just shut my mouth, put on a smile and welcome them back for any concerns whatsoever. "We're always open, you know that. We'd love to see you again if you have any concerns" I tell most of my patients.

This is manifested by the common marketing ploy of The Thirty Minute Promise. ERs advertise that you will be guaranteed to be seen within 30 minutes of checking in by a physician. ERs around my area have even started posting their wait times online in an effort to attract non-emergent patients from other, more busy, ERs.

The exception to this are the ERs that have no room to grow physically, and are consistently unable to meet the persistent onslaught of patients. Most of these hospitals also have limited in-patient beds with frequent ER boarding, resulting in massive ER wait times, poor morale, terrible patient satisfaction scores, and high risk of litigation. So, while they don't try to force their physicians to bend over backwards and kowtow to non-emergent patients, they are not generally pleasant places to work.
 
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1. Whiny, entitled patients-
Yesterday, I saw 27 patients in an 11 hour period. You would think that there was a local boot-camp for medicaid or something. There were a couple of interesting patients, but for the most part, it was an endless parade of nonsense. When your negative imaging rate is approaching 95%, you know your patients are a bunch of whiny hypochondriacs.
 

Packamylase

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1. Whiny, entitled patients-
Yesterday, I saw 27 patients in an 11 hour period. You would think that there was a local boot-camp for medicaid or something. There were a couple of interesting patients, but for the most part, it was an endless parade of nonsense. When your negative imaging rate is approaching 95%, you know your patients are a bunch of whiny hypochondriacs.

Thank you, Jarabacoa!! I really need to see this. Even though, I already knew all of this, I appreciate it written out.
 

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Great post, a MUST READ for all 3rd and 4th year medical students :)

This is so true I personally feel a little sad after reading it.

PGY-1 EM
 
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4. Abuse by other doctors. We get dumped on a lot by other specialties, but they never like getting dumped on by us. Yesterday, I got a call from an internal med doc, who said," I'm sending a patient in from radiology. She had a DVT for the past several weeks, but in the past day, her leg has become much more swollen. US today shows that the clot has propagated to the entire leg. My husband and I (her husband is one of our hospitalists) think she needs to have catheter-directed thrombolysis arranged. Will you do it, because I am home and don't have the numbers?" Come to find out, the clot has been that big for the past 8 weeks, looking at the reports, and the vascular surgeon said the clot is too far out for thrombolysis to be effective. The same person who thought I should be dumped on consistently tries to block admissions on weak chest pain admits, and TIAs all the time, even though our groups and the CEO have met repeatedly over the matter and decided that when we decide to admit, there will be no push back.

It is really hard to work in the ER, and not make mistakes from time to time, either in being too aggressive in treatment, or not aggressive enough. As much as we complain about lawyers, NO ONE is more critical of one another than physicians. The frequency that you see people get thrown under the bus by colleagues is astounding.

Awesome post. It's very difficult to appreciate many of these points as a medical student- even if you are well informed. Med students usually have some inkling that a thick skin is needed to survive in EM, but that level of understanding only scratches the surface. Reason #4 is one of the biggest reasons I am happy to minimize my EM time.

In the various EDs I worked at, similar to EDs across the country, the ED clearly served a dumping ground function for our fellow physicians. Granted, the slow collapse of American primary care has left little incentive for PCPs to avoid using the ED in this fashion. However, it was really frustrating to get so much push back on weak admits when the ED was getting overrun. In addition, while there was never any shortage of retrospective commentary or complaints about mistakes, there were precious few expressions of gratitude for taking care of their sick patients.
 

EMCritCare

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2. It is all about money. Many, if not most ERs in the country have become money generating boons to the hospital. The hospital administration, and the ER directors who generally work a lot less, if at all, want all the business through the ER that they can get. Where is the down-side from their perspective? The result is that most hospitals actually encourage BS complaints to come to their ERs. They WANT non-emergent patients. In fact, their bottom line depends on catering to people with non-emergent complaints, who use the ER out of convenience. Where I currently work, I have been told in no uncertain terms, that I will never, ever tell anyone that they are not welcome in the ER for any complaint day or night. That is a hard pill to swallow as I’m walking down the hall after the rare night-time nap, thinking, and “this darn well better be an emergency". It never is. But hey, I get paid good, so I just shut my mouth, put on a smile and welcome them back for any concerns whatsoever. “We’re always open, you know that. We’d love to see you again if you have any concerns” I tell most of my patients.

This is manifested by the common marketing ploy of The Thirty Minute Promise. ERs advertise that you will be guaranteed to be seen within 30 minutes of checking in by a physician. ERs around my area have even started posting their wait times online in an effort to attract non-emergent patients from other, more busy, ERs.

You're lucky if your ED is still a money maker for your hospital. Imagine how your hospital administrators would treat you if your ED was a financial blackhole compared to other areas of operation. Many urban EDs ceased to be money makers (if they ever were) long ago. While it is true that the business types have long known that non-emergent patients with private insurance are a relative boon for the bottom line and encouraged these folks to come to the ED with their URIs and sore throats, this is financially less relevant in urban settings. Because most of the patients have Medicaid, Medicare, or are self-pay, the ED only has value as the front door for bringing in patients who will require higher reimbursement services (ortho, cardiology, GI, etc.).

The devastating end result is that there is little financial incentive for urban hospitals and even university medical centers to invest in their EDs.
Just as annoyingly, it leaves these EPs as expendable/interchangeable hourly wage workers whose salaries and ED operating costs are liabilities only partially offset by serving as the front door for patients who will provide revenues to more profitable areas of operation.
 

EMCritCare

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6. Patient satisfaction is currently god in hospitals. ERs consistently have the worst patient satisfaction of any part of the hospital. With emergent patients, I tend to focus on medical care and not on stroking their ego. With non-emergent patients, it is hard for me to keep up the act that I actually care. Anywhere you go, you are going to be constantly barraged by dark-suit business people, and clip-board carrying nurses giving you tips on how to get high scores. No one ever asks the question, are we sure this is the best thing for patient care?

Could not agree more. Over my career, I have watched as the business types and ED directors steadily disincentivized the provision of thoughtful diagnostic and therapeutic care in emergency medicine. Other than making sure you are keeping the hospital up to snuff on JCAHO/CMS core measures (MI, pneumonia, etc.), the primary focus is on making sure the customers are ranking the hospital highly and that the rainmaker departments are happy with the ED.

Once I reached the point where my job in the ED was to "move the meat" as quickly as possible while billing as many RVUs as possible, all the while making sure that the non-emergent patients (discharged patients fill out satisfaction surveys for the ED) were happy with their pain med prescriptions, unnecessary XRs and abx- it was time to cut way back on my EM time.
 

TysonCook

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A must read... Hopefully those that do realize that we are paid by the hospital to do the above job so eloquently described.

We are paid to do THEIR version of EM, not necessarily OUR version of EM. If you can go into our field and practice with that mentality you may not get TOO irate (but yet you will still become pretty dang irate).
 

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So knowing all this stuff, would you still pick EM as a field if you were going to pick a career in medicine? I'm a third year trying to make that decision.
 

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I read this and thought... whoa, this guy must work in my ED. The problem with many of us in NYC anyway, is that we're NOT earning more than 200k.

You know what gman? I totally don't want to sound disheartening. I still value medicine and EM for being a "noble" profession. I don't hate my job, I have some satisfaction out of it. But honestly if I had to choose again, I might have avoided medicine in it's entirety. There's just too many non-medical influences that have control over your life and your ultimate happiness.
 

EMCritCare

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So knowing all this stuff, would you still pick EM as a field if you were going to pick a career in medicine? I'm a third year trying to make that decision.

No, probably would not choose EM if I had to do residency over again. While I definitely appreciate the scheduling predictability of shift work and the work life and personal life balance it allows, for me it is not worth having to put up with all the other stuff. In addition, some ICUs have moved towards shift work staffing models anyway.
 

rockydoc

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No, probably would not choose EM if I had to do residency over again. While I definitely appreciate the scheduling predictability of shift work and the work life and personal life balance it allows, for me it is not worth having to put up with all the other stuff. In addition, some ICUs have moved towards shift work staffing models anyway.

Do you mind my asking if you would have chosen another specialty or gotten out of medicine all together as a previous attending noted?

EM has always been one of the specialties I think about going into, mostly because of that life/work balance of shift work, variety, and a mix of both procedural and cerebral work. But these downsides you bring to light are hard to swallow, and Im scared they are even harder to appreciate until it's too late in the game (ie in residency).


I guess my biggest question is that if every medical specialty made a list like this, what would be the lesser of evils? I am coming to understand there is no perfect specialty. The hard part is figuring out which one I can put up with the best. Im just not sure I know how to do that.
 

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No, probably would not choose EM if I had to do residency over again. While I definitely appreciate the scheduling predictability of shift work and the work life and personal life balance it allows, for me it is not worth having to put up with all the other stuff. In addition, some ICUs have moved towards shift work staffing models anyway.

I was talking to an ED faculty recently this past month, and he told me, that now that he is approaching 50, that he can't imagine how much longer he can work in the ED. He says that he might be able to go 5 years more, but he couldn't imagine being able to work more than that. The shifts, poor sleep schedule, night time away from family and BS from patients has melted him down.

Have you seen this from other older ED physicians? What are other practice options?
 
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Do you mind my asking if you would have chosen another specialty or gotten out of medicine all together as a previous attending noted?

EM has always been one of the specialties I think about going into, mostly because of that life/work balance of shift work, variety, and a mix of both procedural and cerebral work. But these downsides you bring to light are hard to swallow, and Im scared they are even harder to appreciate until it's too late in the game (ie in residency).


I guess my biggest question is that if every medical specialty made a list like this, what would be the lesser of evils? I am coming to understand there is no perfect specialty. The hard part is figuring out which one I can put up with the best. Im just not sure I know how to do that.

You are very right in asserting that there is no such thing as a perfect specialty. Ideally, an individual would be able to weigh the various pros and cons of a specialty against their personal values/preferences in order to make an informed individualized decision. However, getting to know the ins and outs of a specialty is challenging as a medical student given the limited amount of time you have available to spend doing rotations in your areas of interest. Adding a further wrinkle is the fact that what you value most as a student may even change over time. In my humble opinion, I think a lot of students choose EM because they are attracted to the advantages of shift work, feel they will spend most of their time taking care of patients with actual emergencies, and/or like the broad exposure provided by a generalist specialty.

While most EM residents quickly realize that most of their time will not be spent taking care of people with life-threatening emergencies/critical illness, it takes somewhat longer to realize how typical hospital politics and the overall financial landscape of healthcare adversely affect the day to day practice of emergency medicine versus other specialties. I have been an attending for years, yet from time to time I am still exposed to new levels of inanity unique to EM- usually owing to fallout from EMTALA, rational consumption of an "unlimited" and "free" good by Medicaid recipients, or the ongoing collapse of American primary care.

It's interesting that you describe EM as "a mix of both procedural and cerebral work." That's one of the EM ideals that attracted many of us. As a medical student and junior resident, I enjoyed having the first chance to work up an undifferentiated patient and try to make the diagnosis. However, as an attending, I found the reality of EM as a business to be starkly different. With regard to "moving the meat" and generating RVUs, trying to come up with a diagnosis or even thoughtfully working up a patient in the ED is a money loser. The emphasis is on identifying the "syndrome" (chest pain syndrome, neurological syndrome, sepsis syndrome, respiratory syndrome, etc), initiating a protocolized treatment (whenever possible), and deciding the disposition/handing off the patient as quickly as possible. This is the way the business folks want you to maximize ED throughput. There were times in the ED when I felt like thinking was being backhandedly discouraged by the nature of the game.

As an example, one of the EDs I worked in had a lot of nursing home patients who often suffered from sepsis due to drug resistant organisms. I would try to review their history whenever there was time in order to provide coverage for their ESBL, etc. What did I get for thinking? I got a notice that I was deviating from the protocolized antibiotic cocktail at the hospital. I then started to write on the charts why I was doing so. What did I get? I got a memo from the ED director informing me that the protocolized antibiotics had been chosen in conjunction with ID and pharmacy staff and were to be adhered to unless otherwise directed by an ID consultant.

You ask if I would haven chosen another specialty or not gone into medicine all together. There are non-EM aspects of my current set-up that I like and feel are somewhat more suited to my tastes. It's hard for me to say whether I would still go into medicine if I had to do it over. Given all the hypotheticals involved in imagining an entirely different career, it's difficult for me to say one way or the other with confidence. I would like to believe that I like enough aspects of medicine to choose it over again.
 
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fuzzywuz

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I read this and thought... whoa, this guy must work in my ED. The problem with many of us in NYC anyway, is that we're NOT earning more than 200k.

You know what gman? I totally don't want to sound disheartening. I still value medicine and EM for being a "noble" profession. I don't hate my job, I have some satisfaction out of it. But honestly if I had to choose again, I might have avoided medicine in it's entirety. There's just too many non-medical influences that have control over your life and your ultimate happiness.

I'm interested in staying in NYC to practice EM. I'm currently M2 and REALLY considering this field. Have been for a long time.

I do realize that one of the disadvantages of practicing in a large city is that you will need to take a pay cut. But is would you say avg pay is <200k for a MD whose 5 years out of postgrad training?
 

EMCritCare

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I was talking to an ED faculty recently this past month, and he told me, that now that he is approaching 50, that he can't imagine how much longer he can work in the ED. He says that he might be able to go 5 years more, but he couldn't imagine being able to work more than that. The shifts, poor sleep schedule, night time away from family and BS from patients has melted him down.

Have you seen this from other older ED physicians? What are other practice options?

There are definitely EPs who want to eliminate night shifts and work more regular hours as they get older. There are EM groups that protect EPs above a certain age from having to work overnights. In my experience, these groups are increasingly rare. In the past, some EPs would "retire" to occupational medicine/employee health practices. Although occupational medicine has been a distinct discipline for quite some time, the ability of EPs to work in this setting owes to the ongoing supply/demand imbalance in occ med.

Most of the older EPs who wanted out of the ED that I have encountered chose to restrict their practice to urgent care/fast track. Some work exclusively for urgent care/doc-in-a-box clinics.
 

docB

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These are all really important points. I think it's good for prospective EPs to hear about these problems. I also echo critcare's sentiment that we are seeing the final erosions in healthcare that will doom medicine as it is.

So knowing all this stuff, would you still pick EM as a field if you were going to pick a career in medicine? I'm a third year trying to make that decision.

I would choose EM again. I continue to think EM is one of the best places to be. I would not go into medicine again. But if you're in medicine I think EM is a good choice.
 

It'sElectric

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I hear and respect what everyone is saying (especially from the seasoned attendings), and maybe I'm just looking through the rose-colored lenses of a junior resident, but I think you really have to keep things in perspective. There are very few gigs out there that you can work 40 hours or less a week and still bank 200K. Compound this with many of the other positives that many on this board associate with EM, and it really is a pretty good job, especially in comparison to many of the other specialties.

Politics, drama, BS, ****ty co-workers, and bureaucracy can be found in nearly every job, across all walks of life.

I repeatedly hear attendings and residents say how they can't imagine doing this job in 25 years...well, I hate to be the bearer of bad news, but there are very, very few jobs out there that anyone would love to do for 25 years. I've heard accountants, teachers, bankers, lawyers, business people, etc. say those exact words (frequently within a much shorter time frame, however). Most all jobs eventually grow old, providing less and less incentive to continue on - that's simply the nature of doing anything for so long.

I know that Jarabacoa was just providing this thread as a counterpoint to the many other "EM is amazing" threads that are on here, but I just wanted everyone to keep things in perspective. Happiness is certainly a relative thing.
 

Meibomian SxN

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Yesterday, I saw 27 patients in an 11 hour period. You would think that there was a local boot-camp for medicaid or something. There were a couple of interesting patients, but for the most part, it was an endless parade of nonsense. When your negative imaging rate is approaching 95%, you know your patients are a bunch of whiny hypochondriacs.

This post was excellent & I'm not even an ER doc!
 

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EM has always been one of the specialties I think about going into, mostly because of that life/work balance of shift work, variety, and a mix of both procedural and cerebral work. .

You may want to consider derm (even though EM and derm are pretty opposite when you first think about it). In derm you never deal with hospital admin cause it's all outpatient and you are your only boss. You rarely deal with pain meds and rarely deal with other specialties second-guessing you.

Of course you don't deal with any acute issues, so if that is what you enjoy you won't like derm. But despite what people think, derm is about 5% cosmetic (many, many, derms do NO cosmetics), 60% skin cancer and 35% inflammatory/autoimmune conditions... so if you like procedures and thinking it may be for you (think about regular office hours with a mix-in of excisions, biopsies, injections and for those who like it, reading path slides).
 

chinocochino

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Yeah, but dermatology is much, much more competitive than EM.

You may want to consider derm (even though EM and derm are pretty opposite when you first think about it). In derm you never deal with hospital admin cause it's all outpatient and you are your only boss. You rarely deal with pain meds and rarely deal with other specialties second-guessing you.

Of course you don't deal with any acute issues, so if that is what you enjoy you won't like derm. But despite what people think, derm is about 5% cosmetic (many, many, derms do NO cosmetics), 60% skin cancer and 35% inflammatory/autoimmune conditions... so if you like procedures and thinking it may be for you (think about regular office hours with a mix-in of excisions, biopsies, injections and for those who like it, reading path slides).
 

ABBY109

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Ive been out of residency for close to 20 some years. I spend more time in the hospital than most of my EM residents ( but I get paid for it). I like/look forward to work each day.

One of our off service residents was really personally offended and upset about how rude and mean a surgical consult resident was to him regarding an admission. He was whining for most of the shift. I scribbled something on a note pad and handed it to him.

"Whats this?"

Its a prescription for 2 testicles - have it filled pronto

Although most of the points above are valid - you have to have a thick skin.


props to Dr Perry Cox
 
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This is manifested by the common marketing ploy of The Thirty Minute Promise. ERs advertise that you will be guaranteed to be seen within 30 minutes of checking in by a physician. ERs around my area have even started posting their wait times online in an effort to attract non-emergent patients from other, more busy, ERs.

I see at least 2 billboards doing this same thing ever time I head across town. And just the other day saw in the newspaper an advertisement for a local ER where you could TEXT them for an appointment time instead of "waiting for hours".

EM was one of the fields I was first seriously considering coming into med school. Talking with attendings and residents over the past few years pretty much all of the above points have been repeated to me in various forms, definitely gave me a lot to think about.
 
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deleted109597

To go with some of the above, thick skin helps. For a long time I avoided confrontation as I always thought it was mean, and I was worried about what people thought of me (people who know me are not allowed to laugh at that).
Then one day someone told me not to apologize for calling someone. I thought about it, and they were right. I shouldn't apologize for calling them. They're getting paid for it. If they don't want to be called, they shouldn't be on the schedule. I do thank them for calling me, but I don't apologize anymore. It makes the days go by so much better.
 

Raryn

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Came across this article this morning, and it just emphasizes the points in this thread:

http://www.ajc.com/opinion/er-care-now-is-583584.html

The most jaw-dropping line (for me at least, not being a physician yet): "That's because under EMTALA, the average emergency physician carries about $140,000 in unpaid charges each year..."

I'm still considering EM for all of the positives that the field has, but articles like that and posts like this are a sobering thing for students me to think about as we mull over what specialty we want to chose.
 

docB

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The most jaw-dropping line (for me at least, not being a physician yet): "That’s because under EMTALA, the average emergency physician carries about $140,000 in unpaid charges each year..."

Here's a thread from way back where I estimated my personal costs from EMTALA. These figures are old so raise the estimates as you see fit. Take into account that my volume is higher and my payer mix worse than it was back then.
 
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Here's another one I didn't see here.

How about a divorced woman whose ex-husband has to pay the kids' medical bills who takes her kids to doctors and ERs just to soak him? I have a relative who used to do this until the kids said they didn't want to spend their time in doctor's offices and ER waiting rooms.

This was a really tragic situation, a middle class family where neither parent should have had custody. The kids are probably permanently estranged from their father (nobody will tell me why except that I should not be sorry about this) and the mom was kicked out of half the therapists' offices in her town for telling the kids things like, "Now, tell the nice counselor how much you hate Daddy" and it would not surprise me if she tried to file false sexual abuse charges against him.
 

leorl

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I'm interested in staying in NYC to practice EM. I'm currently M2 and REALLY considering this field. Have been for a long time.

I do realize that one of the disadvantages of practicing in a large city is that you will need to take a pay cut. But is would you say avg pay is <200k for a MD whose 5 years out of postgrad training?

Just say you get a job at a city hospital (non-group, lowest paying of the bunch, no pension plan) then you're looking at about 190k per annum. This is before taxes so after taxes you're actually talking a bit lower. At least you're not hitting the additional tax cut you'd be taking under obama's new plan for people earning more than 210-220k.

I don't know exactly how allowances are made for being pgy 10 vs a pgy 5.

There are some good things about this specialty. But when you look at what happened at Monte North where 5 senior attendings got fired out of the blue suddenly in favor of hiring 5 brand new out-of-residency junior attendings, job security suddenly doesn't look so secure. Disclaimer: I don't know the full story.
 

leorl

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No one can doubt that anyone in ER has thick skin. It's part of our natures. that's why we're so good at arguing with other services and on behalf of patients. But what other specialties don't have to do is deal with it every single day for the rest of their lives. Every day is going to bring its good things but also a very large dose of frustration.

I'm joining the group for "I hate EMTALA." It creates more problems than it helps people. On the other hand, if we didn't have it I could see individual patient situations (ie insured vs non-insured) getting out of control very quickly.
 
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deleted65604

Ways to survive in the ER.

Gratitude-
I can't think of a better field to go into. I get paid really well, even by George Soros standards. I can't think of a more fun occupation. Five years ago, I would have cut off a testicle to earn what I do in a year. What more fun is there than ordering tests to prove your hypothesis? In the past year, I have reduced innumerable fractures. I've got good at hematoma blocks and can now reduce most wrist fractures with no conscious sedation. I've intubated several people, including a young child in status. I've put in several central lines. I've put in a couple of chest-tubes. I've looked at hundreds of CT's. I usually know the diagnosis even before the radiologist calls me. I've sewed up innumerable lacerations. I've reduced knee-caps, nurse-maid elbows, elbows, shoulders, hips, fingers, toes, ankles. I've drained perirectal abscesses, bartholin gland cysts. I've tapped knees, ankles, and an abscess anterior to the shoulder in one patient. I've helped ease the suffering of thousands of people, helped hundreds of people stop vomiting from gastroenteritis. I've ruled out emergencies on thousands of patients and found life-threatening illness in hundreds of people. I've treated hundreds of UTIs, pneumonias, cellulitis, dental infections, and several peritonsillar abscesses. I've diagnosed meningitis in and adult and in an infant. I've diagnosed fulminant liver failure, subdural bleeds, kidney failure. I've brought dozens of asthma/COPD/CHF patients from the brink of death. I've helped arrange for patients to get put on hospice, and I've comforted sobbing family members after the death of their family. 4 months ago, I delivered a baby in the waiting room of our ER. I've seen birth, death, healing, and been a part of it all. How cool is that?

I'm a board certified Emergency Physician. There is not a more mobile, employable, valuable asset than me. I could get a job within a month in pretty much any city in America. (OK, my current contract requires I give 6 months notice). If I get sick of my current location, I quit. No practice to leave behind, no equipment to move. An office practice is not solvent financially for months, if not years when it starts up in a new place. As an ER doctor, I walk in the first day with a full schedule, no advertising, no staff to hire, no equipment to buy, it is all there.

I don't have to give my patients access to my pager number. I don't get woke up at night when I'm home and asked questions by my patients about their health-care.
 
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deleted65604

Humor-
Who could read the "things I learned from my patients" thread and not be a fan of the ER? I have a series of penile foreign body x-rays that I love to show every new person who works in the ED. One of our more pathologic patients has a dog that "senses seizures". Since our patient doesn't actually have seizures, we call the dog Stanton, the Pseudo-Seizure-Sensing-Dog. She won't come to the ER without him.
The other day, I got an x-ray of an ankle on a massively obese girl. As I looked at the images, I couldn't help laughing for 2 minutes straight when I noticed the huge soft-tissue shadow cast by her 30 inch circumference calves. I can just imagine the radiologist looking at the indication "find etiology of ankle pain", and shaking their head as they say, "duh".
 
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deleted65604

Service-
If someone asks me to walk with them a mile, it is more enjoyable to walk with them a mile, than to tell them that me walking by their side is stupid and a waste of time. For example, a patient comes in with minor symptoms and wants a test to rule out something. I’ve come to realize that it is no sweat of my back to check a box. You want a chest x-ray? Sure, (check box), chest x-ray coming your way. True cost? The electricity to run the machines. The tech is there, they don’t get paid more if they do more studies than if they are sitting on their can. They’ve asked a favor of you as a doctor, that only you can provide them. About 5% of the time, I get results that I would have never expected.
 
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deleted65604

Tolerance-
I still struggle with the selfishness of wanting patients to act the way I think they should act. One of my attending in residency noticed my frequent frustration with patient behavior and said, "Jarabacoa, you've got to treat these people like three year-olds. You don't expect a three-year old to behave rationally, you just treat them with love, let them scream in a corner for a minute and come back to them when they've calmed down a little." I struggle with my own arrogance of wanting to be treated by respect by patients, administrators, and co-workers. I struggle to remember that there is so much good in the worst of us and so much bad in the best of us, that labeling people as good or bad is not a judgment I should want to make.

You could also say that there is so much stupidity in the most intelligent of us and so much wiseness in a man with a low IQ, that labeling as smart or dumb is also a useless exercise.
It is hard to remember that we have gone to school for 11 years to get where we are. It is hard to remember that we too once were completely ignorant of even the most basic of physiologic processes. Ideas that our patients express to us that make us involuntarily laugh out-loud or squint at, don't seem all that strange to them.

I remember sitting in a fast-food restaurant with my Dad and looking at a series of trashily dressed/shabby/crazy appearing people. I remarked on the weirdness of some people. My Dad, (who unlike me, is never long-winded, and never philosophizes) said, "Son, it takes all kinds."
 
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deleted65604

Humility-
I’m a naturally defensive person. I now strive (and fail usually) to comply with silly requests, even if I might disagree with them. If my boss wants me to mark a certain box on every chart, I do it. If administration wants me to order a certain medication using a pre-approved abbreviation, I do it. If the head nurse wants me to thank every patient for allowing us to take care of them, I do it. Why should I demand that I get respect from every single patient? It is irritating when demanding people act inappropriately, but I strive (and fail usually) to not take it personally. If administration wants to meet with me and discuss the care of a big-wig, what is it to me? When you focus on personal growth, rather than winning arguments and battles, life is more peaceful.
 
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deleted65604

So, would I do it again? In a heart-beat. There is opposition in all things. That is how we grow. Anyone who has had kids knows that you pay for the good times with the bad. That is how I view my job, I muddle through the rough times and enjoy the pleasant times, and hopefully, learn along the way.
 

ccfccp

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Man Dr. J... you're on a roll recently. I wish I could fit that last statement on a t-shirt :)

Very sound advice though... You sound like the type of person I'd enjoy having a beer (or whatever) with.
 

Venko

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I love my profession and would do this again in a moment's notice! I would become an EP even if residency was 7 years long like neurosurgery. I have been blessed to meet so many of the greatest patients, and greatest teachers in my road thus far and cannot wait to keep going.

I believe, that many of the points that are wonderfully articulated by Dr. Jarabcoa occur on a national scale and there are likely some hospitals in which all of these points occur concurrently, however, there are hospitals where I have not encountered all or any of the "Top 12 Reasons not to go into EM."

The traits to bring to your career to maximize the rewards from EM are wonderful and broadly applicable beyond the walls of the Emergency Department, or the ideology of medicine in general...they are excellent traits to bring to life.

TL
 

txterp98

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Far and away, one of the best...if not the best...thread on this forum. I've lurked for years, sporadically posted for a few more, and can't remember such great insight.

Maybe this is one for the sticky? (and consider removing all non-Jarabacoa posts...including mine....his pros/cons of the field are awesome!)
 

ABBY109

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Ed Leap summed it up best about 7 years ago..

The White Knights of Medicine

One morning last summer I went to a local ophthalmology office to have an assessment for refractive surgery. I was the only patient in what would be considered a palatial facility by emergency department standards. The nurses and receptionists were all smiles. The floor was clean as a whistle. The marble counter tops sparkled. I filled out my tome of waivers and waited to be seen. I was escorted to the exam room by a very pleasant nurse who did tonometry, mapped my cornea and performed numerous exams that I probably wouldn’t have understood if I’d read a book on them. I was then seen by a very friendly ophthalmologist with whom I had a great chat. I was pronounced a superior candidate, escorted back to the waiting room to speak to a scheduler, then given a can of soda and allowed to watch “Dances with Wolves” on the big screen TV in the waiting room (being too dilated to read). When my wife came to pick me up, I didn’t want to leave. Wow. What a wonderful experience. But it was wonderful for more reasons than the courtesy that I received. It was a learning experience because it was a study in contrast to my own career.

My learning experience didn’t have to do with improving my own customer service, or the cleanliness of my facility, or the smiles on our nurses’ faces. It wasn’t (although it crossed my mind) a learning experience about how my life might have been if I’d chosen a different specialty. It was, however, a profound insight into what a unique job emergency medicine is, and about how proud we should all be.

I could have come away angry, given the cost of refractive surgery. But I wasn’t. I could have been envious of the quiet environment and the nice furniture and sculpture. But my patients would just use sculpture to hold empty potato chip bags and cigarette packs. I did, however, come away disappointed in the way we treat our specialty and ourselves, for we are our own worst detractors and critics.

There are countless reasons that we emergency physicians should be impressed with ourselves. But mostly, they have to do with the things that conspire to make our practice of medicine difficult, and which we somehow manage to overcome each day.

First, we practice in a specialty unlike any other, for we are self-proclaimed experts in an indefinable field of knowledge. Day in and day out, night after night we make snap decisions in two hours that would give most physicians hypertension and heartburn. We collate the half-truths presented as history with physical data that makes medical school look like fiction, then try to establish diagnoses in patients who often have problems that are far more social, psychiatric or purely imagined than physical. We deal with complaints that aren’t found in any textbook, or we face medical nightmares so complex that all we can do is establish the ABC’s and punt. We are a creative group of cowgirls and cowboys.

We also practice in an environment that is as close to a legal minefield as the metaphor will allow. In spite of our requirement to see patients for free, we always run the risk of multi-million dollar lawsuits as thanks for providing that free care. And even as lawsuits loom all around, we are counseled to cut costs by ordering less, admitting less and taking more risk. Furthermore, as if the contingency suits weren’t bad enough, we have to face the growing specter of federal accusations of fraud for honest errors in a hopelessly complex system of billing codes.

Likewise, we are the victims of social engineering. Since the government can’t actually provide free care to everyone (nothing actually being free anyway), they creatively found a way to make us do it via EMTALA. This must surely be one of the biggest unfunded mandates in history, in which we fundamentally work as slaves to the federal government. (To be compelled to work without compensation being the very essence of slavery). And it isn’t just the government. Our comrades in the specialty are continually coming up with more ways that we should be the instruments of social intervention, whether it is via mandatory reporting of domestic violence, counseling our patients about substance abuse, or immunizing in the E.D. There simply aren’t enough hours in a shift to do all this for the people who might conceivably benefit from it. Thus, we come to expect too much of our limited time and then are led to feel guilty about it.

And in the midst of the madness, we are constantly reminded to be aware of the “customer service” aspect of our specialty. However well the customer service model might work in the general marketplace, it fails when the service must be provided for free. Imagine how long any industry or small business would remain solvent if it were compelled to give its services or products with only the possibility of payment. What if a department store were forced to give everyone clothes (everyone needs clothes, right?), and were not allowed to ask for payment on the spot? What if a barber could bill for haircuts, but not ask for compensation at the time the service was provided? No other industry that I can think of is forced to work under such conditions.

Finally, we don’t practice a specialty that promotes long life and well being. We work odd, varying hours which disturb our sleep cycles. Not only are we awake in the wee hours of the night, we areawake and stressed. We eat poorly, drink too much caffeine and do too few things to promote our personal happiness. Furthermore, we are constantly exposed to the risk of communicable diseases or violence in our workplace. And every minute of every shift, anything imaginable can come through the door, whether on an ambulance stretcher or in the arms of a distraught parent. It may be an apneic child, it may be an exsanguinating gang member, it’s all ours to sort through and try to save. When we fail, we have the equally horrific task of telling family members, then watching as they scream and slump to the floor.

As an unforgettable illustration, one terrible night this past summer, my partner and I cared for another of our partners who sustained a lethal head injury in an MVA on the way home from a shift. Could we close the doors, hang a wreath and mourn? Of course not, for the patients kept on coming. What can I say? Surreal doesn’t begin to describe our job.

So I’m weary of criticism. I think we are amazing. I think we do incredible things in conditions that most practitioners would find simply unbearable. We work hard, we work fast, we try to be nice when we are being cursed, we endure the disdain of other specialties who consider us incompetent (except after 5pm), and through it all, we manage to actually care for the people who come to us. They aren’t always nice and they don’t always pay us, but most of the time they need us and sometimes they actually appreciate us. You see, we are the white knights of medicine.

That may sound a bit melodramatic, but we are the members of the medical community who always do the right thing no matter what. We do it because we were trained to, because we consider it honorable and because the law requires it. We are in battle day and night. We always get to do the things no one else wants to do, to the people no one else wants to care for, like lumbar punctures on AIDS patients, sexual assault exams, “pre-jail screenings” of drunk felons and psychiatric commitments after hours. This is our world, these are our people. And someone has to do it.

In the end, I love what I do. My schedule is reasonable. I have time off with my wife and children. I make a good living. I meet lots of people, some nice, some not so much. Some normal, some bizarre. I usually know what’s going to be in the newspaper before it comes out. Sometimes I bond with sociopaths; sometimes I act like one myself. I perform interesting procedures and make fascinating diagnoses. I am constantly entertained by waves of mind-numbing human stupidity. I talk to the dying and I talk to their families. And even though it may not always be fair, no one gets turned away for lack of money, so I get to view the world of medicine from the moral high ground.

I ultimately had my refractive surgery in the beautiful office with the nice marble and smiling nurses. And I didn’t complain. Everyone chooses his or her own path. I’m proud I chose mine. And I encourage all my sisters and brothers in the specialty to be proud, because we provide an invaluable service to society. We mustn’t let anyone tell us otherwise. As a specialty, we should try a little harder to praise our fellow troops and take pride in our role. And we should learn more often to ignore the volumes of negative studies and articles that seem to tell us, month after month, how poorly we serve the public. But most of all, we should never let ourselves believe that what we do, and the way we do it, is anything less than heroic.
 
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