180--from IM to EM....thoughts?

[ThinkingIM]

I recently finished my required ED rotation (4 weeks, 16 shifts) at a level 1 trauma center in a medium sized urban area (this hospital is the main truama center for a population of 1+million) and absolutely loved the rotation. I left every shift feeling like I did something fun, got something done and even helped a person or two.

Now I'm roughly 1 week and 1 call into my 2nd medicine rotation (currently in the CCU) and can't stop thinking about how much I'd rather be in the ED. I'm a 3rd year, so I still have time to switch directions....and honestly, after doing sitdown rounds for literally 4.5 hours this am following a call night that was nothing short of horrendous, i'm about 99.9% sure I'll be happier with a career in EM. It's funny b/c I always used to be so sure I was gonna be the IM type. I'm a relatively cereberal person and like to think through problems, but I had such a better time in the ED, trying to get to the bottom of people's problems quickly and even doing quite a few procedures (well, just lac's and I&D's for me, but still fun). Also, I already really miss the "what is wrong and what do we need to do to help them?" mentality. And just thinking about belaboring whether somebody has a 19 pack year vs 21 pack year smoking hx (yes i'm serious, happened this am) makes me want to vomit.

This ever happen to anybody else? Anyways, just wanted to throw this out there and bounce it off the forum.

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[deleted109597]

And just thinking about belaboring whether somebody has a 19 pack year vs 21 pack year smoking hx (yes i'm serious, happened this am) makes me want to vomit.

How long was the discussion about the patients K of 3.4 before someone noticed that a newer lab value stated that it was 3.3?

 

[Dr. Will]

And just thinking about belaboring whether somebody has a 19 pack year vs 21 pack year smoking hx (yes i'm serious, happened this am) makes me want to vomit.

Ahhh yes...the joys of mental masturbation.

 

[sarahinromania]

I don't think that most people here will be steering you real hard towards IM. Most of us get twitchy on rounds, too. Do what makes you happy, my friend. Unless you're some kind of business mastermind, you're going to be working 25+ years no matter which specialty you pick. You want to get to drive home every day thinking, "I have the coolest job," rather than, "I'm so glad I finally got out of there." (although, inevitably, those days come every now and then regardless.)

You are most definitely not too late to change directions. You're at a very good place to step back, decide what you want, and make the appropriate schedule adjustments in order to get what you want.

 

[OptimisticRaes]

Give it some time, if you still feel this way after a month, change. Follow your heart and do what you think will make you happiest and do it when it's cheapest! It is your decision you will have to live with, so give it a little time

 

[darunc]

so you got to determine where your career to end up, whether academics or not... i'm EM sold and ready, but you need to realize that IM life outside of your (or mine or his or hers) academic life is a whole lot different. i have plenty of friends who love the idea of being a hospitalist. no rounds per se, aside from turning your patients over to the next attending (sound familiar?).

keep the options open, because as a med student, EM is fun- you get to do a whole lot and its fast paced. but it may not be what you are looking for in a career. if it is, welcome and good luck.

 

[seldomseen]

I think you'll find that EM can be cerebral as well (i.e. in terms of thinking of differentials, treatment plans, etc.), the difference is that you actually do something after the thinking.

Which is all to say, although EM sometimes has a "cowboy" stereotype, all kinds of personalities can thrive in that environment, including ones who have cerebral leanings. In the end, chose a career that you'll be happy doing, even if it's something that you haven't considered in the past.

 

[Dr.Evil1]

It sounds like you have already made up your mind and are just looking for confirmation. Go for it, there is a reason you do all sorts of rotations during your third year. Good luck and think about Detroit for your residency.

 

[Dr.Evil1]

BTW it is not a 180 from IM to EM. More like a 30-60 degree turn. Have fun

 

[AmoryBlaine]

Seen and agree with above. FWIW when I was on IM we only had long rounds because we had very complicated patients. The docs (who were admittedly hospitalists) didn't want to round for 3 hours any more than we did. But if we had a census of 15 with lots of complex issues you just couldn't cover that in 1 hour.

I do agree with the poster who said that an IM rotation is not IM. I guarantee you that your avg cardiologist/gastroenterologist isn't spending 3 hours talking about K, they are too busy playing in their money. So my point is not to rule out IM based on experience with one attending.

 

[NinerNiner999]

Oh - I'm sorry. I read the word "rounds" and fell asleep. There - all better now.

 

[daveshnave]

I agree with the above poster and want to again say that EM can be cerebral too... sure it will never be as cerebral as IM, but WTF is the point of being THAT cerebral (ie. the example of arguing over the K+)? A lot of people say that our job in the ED is to rule out the life-threatening emergencies, which of course is true, but a good EM doc reaches diagnoses if possible in the ER. Of course this goes without saying for the bread and butter cases (pneumonia, MI, sepsis, whatever...), but a good EM doc should be just as competent as IM in diagnosing... the only difference is that we just are not given the time IM has to make the diagnosis (sometimes days/weeks for certain patients).

My point is this.... you can make EM cerebral if you want to. It's up to you and your interest in doing so. True, I have seen those who skate by in EM and heavily rely on consultants, sometimes when they're inappropriately consulted because they don't know any better, but this is what differentiates a good vs. a bad EM doc. In fact, in many ways we have the potential to be cerebral about a much broader amount of medicine than IM, in that they often don't know much about current literature outside IM (ie. OBGYN, radiology, orthopedics, ENT, etc.). Try asking IM what's the best study to evaluate a 1st trimester pregnant woman for a PE, and they'll tell you to ask the radiologist. In fact, I've even had this discussion with radiologists who don't know they're OWN literature and have tried to tell me the wrong info. A bad EM doc would go along blindly with whatever the consultant says, whereas a good EM doc knows what the literature in various specialties says as it pertains to ER patients... my two cents.

 

[ThinkingIM]

Thanks for all the input, believe it or not it does help to read some anonymous opinions (even though some might be slightly biased as this is an EM forum)....Even though I do think I was feeling a bit reactionary while writing that post (post call and had a particularly intolerable 4.5 hour rounds), I'm still thinking I found my likely career in EM. This is the thing: That was the first rotation where I actually felt disapointed at the end of my last shift (granted I didnt' have a shelf looming, but still). At every other rotation I just left feeling like, "well, that was okay, I learned some things, did a few cool things, blah blah". Suffice it to say I plan to play out this current rotation for 2 more weeks and if I'm still feeling the same way I'm going to contact the EM attending I think got to know me the best and ask him to be my advisor and write me a LOR.....If/when I get to that point I wonder if I should change my SDN name?

 

[Apollyon]

Half of third year is as much "OK, I do NOT want to do that specialty" as "try out" rotation.

When you're an EM resident and have to some sucky/boring/stupid/offensive off-service rotation, then they're referred to as "career-affirming months".

 

[deleted87716]

BTW it is not a 180 from IM to EM. More like a 30-60 degree turn.

Agreed. We're all generalists.

 

[Hard24Get]

Ahhh yes...the joys of mental masturbation.

I was actually pontificating with my team the other day on Cardiology rounds and, after about half an hour said, "wow, this is a great mental masturbation case for us, isn't it?!" The attending looked at me like he ate a frog.

Whoops.....

 

[BKN]

I was actually pontificating with my team the other day on Cardiology rounds and, after about half an hour said, "wow, this is a great mental masturbation case for us, isn't it?!" The attending looked at me like he ate a frog.

Whoops.....

Well, ask him for a LOR!

 

[bulgethetwine]

Half of third year is as much "OK, I do NOT want to do that specialty" as "try out" rotation.

When you're an EM resident and have to some sucky/boring/stupid/offensive off-service rotation, then they're referred to as "career-affirming months".

You know, it's a relatively new phenomenon that people get tracked into one specialty as early as we do now. It's a shame... even for well intentioned, open-minded students, the pressure to build up a resume with research, superstar rotations, network building in a particular specialty is huge.

I would echo Apollyon's comments -- it's as much a rule out year as a rule in year. For those things that you do to try and build a strong app for residency, try and keep them as general as possible so they are easily portable regardless of where you apply. That way, you can choose at the last possible moment -- not as a symptom of indecisiveness, but as an informed consumer.

I remember doing med school interviews. Yes, dedication was always a plus when we were evaluating people for admission ("I've wanted to be a doctor since I was 7, I volunteered at the local hospital as a teenager, and I actively participated in health care activities during college blah blah blah) but I remember being particularly impressed by one candidates perspective:

"Well, I didn't really know I wanted to do medicine at first. I looked around at many different careers -- physiotherapy, nursing, even engineering because of my interest in problem solving. After the pre-requisites for med school were done, I took a lot of courses exposing me to other career pathways. But in the end, after considering all those other options -- medicine was for me".

I always thought the second girl was much more impressive. I think the same kind of approach is warranted for specialty selection.

Good Luck

(By the way -- search the threads for IM/EM combinations... and follow the discussions of the emergency medicine-trained intensivists seeking board certification. You'll certainly agree that IM vs. EM isn't a 180' difference...)

 

[trkd]

I agree with the above poster and want to again say that EM can be cerebral too... sure it will never be as cerebral as IM, but WTF is the point of being THAT cerebral (ie. the example of arguing over the K+)? A lot of people say that our job in the ED is to rule out the life-threatening emergencies, which of course is true, but a good EM doc reaches diagnoses if possible in the ER. Of course this goes without saying for the bread and butter cases (pneumonia, MI, sepsis, whatever...), but a good EM doc should be just as competent as IM in diagnosing... the only difference is that we just are not given the time IM has to make the diagnosis (sometimes days/weeks for certain patients).

My point is this.... you can make EM cerebral if you want to. It's up to you and your interest in doing so. True, I have seen those who skate by in EM and heavily rely on consultants, sometimes when they're inappropriately consulted because they don't know any better, but this is what differentiates a good vs. a bad EM doc. In fact, in many ways we have the potential to be cerebral about a much broader amount of medicine than IM, in that they often don't know much about current literature outside IM (ie. OBGYN, radiology, orthopedics, ENT, etc.). Try asking IM what's the best study to evaluate a 1st trimester pregnant woman for a PE, and they'll tell you to ask the radiologist. In fact, I've even had this discussion with radiologists who don't know they're OWN literature and have tried to tell me the wrong info. A bad EM doc would go along blindly with whatever the consultant says, whereas a good EM doc knows what the literature in various specialties says as it pertains to ER patients... my two cents.

To the OP, I agree with above. I find myself to enjoy "cerebral" medicine but I don't find that it is lacking in my experiences with EM. In fact, I originally didn't consider EM for this reason until my required 3rd year EM rotation. You can have the best of both worlds. Yeah I might want to think about the patients a bit more but I guess I will learn to treat the patient with what they need quickly and maybe mentally masturbate about the case later. Also, you can maybe veer towards some ED settings that are more "that was an interesting case, lets talk about it in teaching rounds after the shift" if you want. Some places do more teaching than others and you might enjoy that. Consider all options. Good luck!

(BTW, if in residency or beyond I ever see a LOR in which the attending says that student used the term "mental masturbation".... I will vote for them to be ranked to match!)

 

[deleted109597]

and follow the discussions of the emergency medicine-trained intensivists seeking board certification.

If they're trained by a residency, they can get board certification. If they get that BCEM thing, then they don't deserve it. I can't get an equivalency board by working in a clinic for 2 years, what makes them think they can get one because they work in an ED? Working is not training. Training is work.

 

[bulgethetwine]

If they're trained by a residency, they can get board certification. If they get that BCEM thing, then they don't deserve it. I can't get an equivalency board by working in a clinic for 2 years, what makes them think they can get one because they work in an ED? Working is not training. Training is work.

I think we're having a misunderstanding

I was referring to those board certified, emergency medicine trained individuals who subsequently complete a fellowship in critical care medicine. Currently, such candidates are not eligible for board certification in critical care. However, a push is on (albeit for awhile with no breakthrough yet) for such EM-trained, post-fellowship candidates to be board certified in critcal care. Including a recommendation to that effect in the last IOM report. I emphasize again, however, that this has been a movement pushed for some years without, as of yet, success. Note that in Europe and Canada, it is already the standard.

I will stop here. There are other threads on this board as well as the critical care board that exhaustively cover this issue.

 

[deleted109597]

Oh, ok then. Yeah, the CC board is something different. I know some people who are getting the European board. Sorry, I was making sure that you weren't talking about the FPs and IMs trying to get licensed in NC (read most recent AAEM mailbox stuffer).

 

[roja]

1. The trend will most likely be that EM trained MD's who do a fellowship will eventually get to take the CC boards. Currently they take the european boards and have no trouble working as an intensivist. Like all things, there are tons of politics, however, there is also a massive shortage in intensivist across the country.

2. Keep an open mind about your third year rotations. I enjoyed some aspect of all of my rotations. When I hit the ER, I knew I had found my home. I didn't want to be anywhere else. Part of why I knew EM was for me, is I did like every rotation.... just not enough to do it as an entire specialty. I also loved the pace in the ED, and the same thing you did: feeling like I was directly helping someone each shift. The ED, you will have to enjoy all aspects of medicine because you will do it all: IM, cards, neuro, ortho, gyn, ob, etc etc etc.......

EM definately has cerebral moments.. even if you are just a standard EMP. Or you can do a fellowship: tox, research, critical care, international, peds,. etc....

 

[Hard24Get]

1. The trend will most likely be that EM trained MD's who do a fellowship will eventually get to take the CC boards. Currently they take the european boards and have no trouble working as an intensivist. Like all things, there are tons of politics, however, there is also a massive shortage in intensivist across the country.

That's great to hear. I was shocked to find that I feel just as at home in the SICU as I do in the ED - such different worlds but somehow the underlying philosophy is the same.