EmergentMagician
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- Jun 30, 2023
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TL;DR : EM sucks. I’m out. In Fellowship. Good luck to you all.
I have spent 10+ years lurking here and have benefited greatly from reading other Emergency Physicians’ trials and tribulations. I take a lot of solace in hearing others’ angst, in an addictive voyeur-like way. This forum provides an echo chamber (for better or for worse) and some validation for a lot of the feelings I've had in emergency medicine. I am very grateful for all the practical advice I've heard as well, in terms of taxes, SDGs, second career paths, etc. Perhaps my story can help others.
I finished residency seven years ago at a very academic (~powerhouse light?) four year program. I was a solid, above average resident. Not the all-star. Confident and capable. I worked the full spectrum of emergency rooms during and after residency, from very high acuity/high volume to low volume government facilities that barely resemble an ER. I have worked for corporate medical entities, government, and community hospitals. I was exposed to many SDG's in residency and flirted with several of them afterwards, though never signed on. I feel like I have a good grasp of what the world of emergency medicine offers, despite my relatively short career.
I have found that low acuity/low volume places do not necessarily mean less angst. Perhaps this is personality driven. These shops frequently come with their own headaches, or frustration with inappropriate utilization of the emergency room, or inappropriate patient expectations. I think I hit a good stride when I was splitting shifts between both low acuity facilities and high acuity facilities. IE, when I was tired of dealing with high maintenance/low acuity patients I would then work a couple shifts at a high acuity ER and do a lot of procedures/resus etcetera. It provided a good balance. I think that this is sort of the sweet spot for EM practice in terms of job satisfaction.
I flirted with academics for the past several years, ultimately working as academic faculty. I thought that this was maybe a path to satisfaction/sustainability. When I was working with pgy 3/4s, this was wonderful. IE, not calling consults, no scut work, basically just verifying and occasionally redirecting everything the resident does. I tried my hardest to hide my cynicism from them and taught them well. I would see my own patients in the waiting room to help move the meat along. I think that this is a sustainable model, though a lot of caution needs to be taken in making sure your skill set is preserved. I unexpectedly found that I disliked teaching the very junior learners- med students, pgy1s, and off service residents.
I feel a lot of shame in leaving EM. It makes me feel like a failure. I see a lot of my peers doing the job and succeeding. I don't know why I cannot derive any feelings of satisfaction anymore from the field. It feels like death from a thousand cuts. I have had no bad outcomes or lawsuits. I perform well on metrics. However, only a few times a year do I feel like I make any difference in the world. I feel like I am just moving the meat along in a stupid dysfunctional system.
Here we go…
Inappropriate use of the ER. ‘1 hr pediatric fever’, ‘wants pregnancy test’, every drizzle of vaginal bleeding wanting an OB Ultrasound, 1 year of knee pain, etc. Many patients have no understanding of what primary care is or see the ER as the most convenient path to care. We are simply the building with the red cross on it. ‘This is where you do medical stuff’. When certain patients are given free and unlimited access, this is the type of behavior it fosters.
Midlevels. The presence of the ER as a safety net makes the entire medical system’s use of midlevels possible. They can basically offload anything involving actual decision making to the ER. Or worse yet, fixing blatant midlevel f-ups day in and day out. I have started to see patients come to the ER with a pile of lab work and imaging, just wanting a physician to interpret “what is actually going on”. Very rarely have I ever felt an MD inappropriately sent a patient to the ER.
Old People. I hate myself for getting frustrated by old people in the ER. After my 10th patient on shift in their 80s/ 90s, I just can't do it anymore. I consider it the other type of “homeboy drop-off”, where a family member or SNF just dumps an old person in the ER and leaves. It is a losing game for the Emergency Physician. They have a very high pretest probability of pathology, but cannot relate ANY of their symptoms to you in any comprehensible fashion. Good luck on getting ANY coherent medical history. I have thought we should microchip the elderly like we do our dogs as a prerequisite to get Medicare. This chip could be scanned on arrival and would have all of their meds, PMH/PSH, etc. Sometimes SNF's and families just want to get an MD on the chart to offload all of the risk. They can do this any time of the day or night, as often as they want, and for FREE. Sometimes the families are seeking a clean bill of health, however this cannot possibly be done.
Increasing Volume and Litigation Risk. When I was a medical student, I didn’t understand that the actual day to day mechanics of being an Emergency Physician more closely resembled being a waiter: Imagine being the only waiter at a PACKED 30-table Denny’s at 2am. There is a line going out the door, and Denny’s corporate wants you to take their orders in the street. They are all HUNGRY and upset before they even get to Denny’s. Many of them are DRUNK. You receive nasty emails from corporate if you didn’t take their orders fast enough. There are homeless people in the bathroom smoking meth and smearing poop on the walls. You run from table to table, shoving food down fat people’s throats, trying to keep everyone happy. Then a child chokes on a sausage link. The child dies. Then you get sued. That is Emergency Medicine today.
Patient Expectations: It seems stupid, but my PTSD/ burnout is actually more from situations like the mom of the two year old literally yelling at me in the waiting room for not getting her discharge paperwork in a timely fashion. This is usually for a child that I wrote an antibiotic prescription for, when they absolutely did not need it, however I dreaded the inevitable argument and patient complaint that would ensue if I didn’t write the Rx, etc.etc.etc.. Meanwhile I am dealing with several ICU holds that the hospitalist (not intensivist) still hasn’t seen, central lines in the ICU, NSTEMIs marinating in the waiting room, stroke “codes” sepsis “codes”, no available beds, homeless people smoking meth in the ER, poop streaks in the hallway, etcetera etcetera. Society has absolutely no idea what we deal with on a day-to-day basis. Other physicians usually have no idea as well.
My dad had to go to the ER last year for chest pain. The only thing he could talk about was the time waiting in between physician contact/blood draw, imaging, etc. He had literally no understanding or clue about what actually constituted quality of care, despite hearing me bitch and moan about my experiences working in the ER for the past decade.
ER Blaming: One of my biggest flex points for failure in this field has been the complete disrespect of the emergency medicine profession by other specialties. I can't handle it when a hospitalist or intensivist treats me like an underling. I can't handle it when sub specialists such as ENT or urology are completely absent or do not take any ownership over their post operative complications. It seems that their algorithm basically says go to the ER for any concerns. I think this behavior has been worsening over the past 5 years. Didn't these people used to be available to their patients? A lot of my college buddies are urology, ortho, ENT, etc. They all have their stories about stupid consults from the ER or stupid **** the ER does. I like to tell them that we can always go back to the 1970s or European model where they are on call for basically everything related to their field. These specialists do not acknowledge the value we provide to the system, and need to understand that the whole system would completely fall apart if we were not there. If you want to know the dysfunction of any particular medical system, just go to the ER and you will find us there dealing with it directly.
Another flex point for failure has been treatment by the hospital system when things go wrong with patients. We are occasionally expected to do heroic things- ED thoracotomy, cric, Lateral canthotomy, pediatric resuscitations, etcetera. These are procedures that even the specialist will get nervous and anxious about. However, when we step up to the plate and perform these, the immediate response from the sub specialists is doubt and skepticism. When a child dies in the emergency room, it is met with suspicion. When i cric someone, I have to defend my actions.
COVID: Don’t even get me started.
What I am doing now: Palliative Care Fellowship. I am by far the oldest one in my fellowship class. Thank you Frazier for all of the posts. This isn’t a running away/snap decision, and is very likely a WRONG decision for many people leaving EM. You must want to do this type of work, and you need to have the disposition for it. I repeat: Do not run away to a Palliative Care Fellowship just to get away from EM. As a premed I was doing Hospice stuff, palliative rotations in med school, carried this interest through ICU rotations, etc
I used to think EM docs in their 50s/60s were outdated dinosaurs, but I increasingly find myself in awe of them. How the hell did they stick it out for so long? I have not decided if I'm going to give up on EM, as I could still see a role for me working in rural low volume places. I got my resuscitative reps and experience working in busy ERs. I stood the watch.
For me, right now, the juice is NOT WORTH the squeeze. I am lucky enough to have paid off all my loans, and have a small nest egg after being frugal during residency and in my 7 years as an attending. I have a spouse that earns 100k. We will be OK. I am incredibly grateful that she didn’t marry me for money or prestige, otherwise this could have gone a lot worse.
It is important to note that I did not burn out from working too many shifts. I typically worked 12-15 8s. There were periods where I flexed up to 15+ 12’s, but this was extremely rare and limited. I rarely worked more than 2 nights/month, and went several months at a time with no nights. (Though I do think nights are terrible for your health and undoubtedly lead to burnout). I tried many ways to change my schedule around to avoid burnout, however even cutting back to 7-9 shifts a month did not cure the negative feelings. If anything, it led to more career anxiety and longer periods of self-loathing between shifts. I spent a lot of Tuesday afternoons drinking beer by myself and wondering why I was a failure and couldn’t be happy in EM.
I hope everyone can keep fighting the good fight. I truly believe that there is no more difficult or important job in medicine than what we do.
I have spent 10+ years lurking here and have benefited greatly from reading other Emergency Physicians’ trials and tribulations. I take a lot of solace in hearing others’ angst, in an addictive voyeur-like way. This forum provides an echo chamber (for better or for worse) and some validation for a lot of the feelings I've had in emergency medicine. I am very grateful for all the practical advice I've heard as well, in terms of taxes, SDGs, second career paths, etc. Perhaps my story can help others.
I finished residency seven years ago at a very academic (~powerhouse light?) four year program. I was a solid, above average resident. Not the all-star. Confident and capable. I worked the full spectrum of emergency rooms during and after residency, from very high acuity/high volume to low volume government facilities that barely resemble an ER. I have worked for corporate medical entities, government, and community hospitals. I was exposed to many SDG's in residency and flirted with several of them afterwards, though never signed on. I feel like I have a good grasp of what the world of emergency medicine offers, despite my relatively short career.
I have found that low acuity/low volume places do not necessarily mean less angst. Perhaps this is personality driven. These shops frequently come with their own headaches, or frustration with inappropriate utilization of the emergency room, or inappropriate patient expectations. I think I hit a good stride when I was splitting shifts between both low acuity facilities and high acuity facilities. IE, when I was tired of dealing with high maintenance/low acuity patients I would then work a couple shifts at a high acuity ER and do a lot of procedures/resus etcetera. It provided a good balance. I think that this is sort of the sweet spot for EM practice in terms of job satisfaction.
I flirted with academics for the past several years, ultimately working as academic faculty. I thought that this was maybe a path to satisfaction/sustainability. When I was working with pgy 3/4s, this was wonderful. IE, not calling consults, no scut work, basically just verifying and occasionally redirecting everything the resident does. I tried my hardest to hide my cynicism from them and taught them well. I would see my own patients in the waiting room to help move the meat along. I think that this is a sustainable model, though a lot of caution needs to be taken in making sure your skill set is preserved. I unexpectedly found that I disliked teaching the very junior learners- med students, pgy1s, and off service residents.
I feel a lot of shame in leaving EM. It makes me feel like a failure. I see a lot of my peers doing the job and succeeding. I don't know why I cannot derive any feelings of satisfaction anymore from the field. It feels like death from a thousand cuts. I have had no bad outcomes or lawsuits. I perform well on metrics. However, only a few times a year do I feel like I make any difference in the world. I feel like I am just moving the meat along in a stupid dysfunctional system.
Here we go…
Inappropriate use of the ER. ‘1 hr pediatric fever’, ‘wants pregnancy test’, every drizzle of vaginal bleeding wanting an OB Ultrasound, 1 year of knee pain, etc. Many patients have no understanding of what primary care is or see the ER as the most convenient path to care. We are simply the building with the red cross on it. ‘This is where you do medical stuff’. When certain patients are given free and unlimited access, this is the type of behavior it fosters.
Midlevels. The presence of the ER as a safety net makes the entire medical system’s use of midlevels possible. They can basically offload anything involving actual decision making to the ER. Or worse yet, fixing blatant midlevel f-ups day in and day out. I have started to see patients come to the ER with a pile of lab work and imaging, just wanting a physician to interpret “what is actually going on”. Very rarely have I ever felt an MD inappropriately sent a patient to the ER.
Old People. I hate myself for getting frustrated by old people in the ER. After my 10th patient on shift in their 80s/ 90s, I just can't do it anymore. I consider it the other type of “homeboy drop-off”, where a family member or SNF just dumps an old person in the ER and leaves. It is a losing game for the Emergency Physician. They have a very high pretest probability of pathology, but cannot relate ANY of their symptoms to you in any comprehensible fashion. Good luck on getting ANY coherent medical history. I have thought we should microchip the elderly like we do our dogs as a prerequisite to get Medicare. This chip could be scanned on arrival and would have all of their meds, PMH/PSH, etc. Sometimes SNF's and families just want to get an MD on the chart to offload all of the risk. They can do this any time of the day or night, as often as they want, and for FREE. Sometimes the families are seeking a clean bill of health, however this cannot possibly be done.
Increasing Volume and Litigation Risk. When I was a medical student, I didn’t understand that the actual day to day mechanics of being an Emergency Physician more closely resembled being a waiter: Imagine being the only waiter at a PACKED 30-table Denny’s at 2am. There is a line going out the door, and Denny’s corporate wants you to take their orders in the street. They are all HUNGRY and upset before they even get to Denny’s. Many of them are DRUNK. You receive nasty emails from corporate if you didn’t take their orders fast enough. There are homeless people in the bathroom smoking meth and smearing poop on the walls. You run from table to table, shoving food down fat people’s throats, trying to keep everyone happy. Then a child chokes on a sausage link. The child dies. Then you get sued. That is Emergency Medicine today.
Patient Expectations: It seems stupid, but my PTSD/ burnout is actually more from situations like the mom of the two year old literally yelling at me in the waiting room for not getting her discharge paperwork in a timely fashion. This is usually for a child that I wrote an antibiotic prescription for, when they absolutely did not need it, however I dreaded the inevitable argument and patient complaint that would ensue if I didn’t write the Rx, etc.etc.etc.. Meanwhile I am dealing with several ICU holds that the hospitalist (not intensivist) still hasn’t seen, central lines in the ICU, NSTEMIs marinating in the waiting room, stroke “codes” sepsis “codes”, no available beds, homeless people smoking meth in the ER, poop streaks in the hallway, etcetera etcetera. Society has absolutely no idea what we deal with on a day-to-day basis. Other physicians usually have no idea as well.
My dad had to go to the ER last year for chest pain. The only thing he could talk about was the time waiting in between physician contact/blood draw, imaging, etc. He had literally no understanding or clue about what actually constituted quality of care, despite hearing me bitch and moan about my experiences working in the ER for the past decade.
ER Blaming: One of my biggest flex points for failure in this field has been the complete disrespect of the emergency medicine profession by other specialties. I can't handle it when a hospitalist or intensivist treats me like an underling. I can't handle it when sub specialists such as ENT or urology are completely absent or do not take any ownership over their post operative complications. It seems that their algorithm basically says go to the ER for any concerns. I think this behavior has been worsening over the past 5 years. Didn't these people used to be available to their patients? A lot of my college buddies are urology, ortho, ENT, etc. They all have their stories about stupid consults from the ER or stupid **** the ER does. I like to tell them that we can always go back to the 1970s or European model where they are on call for basically everything related to their field. These specialists do not acknowledge the value we provide to the system, and need to understand that the whole system would completely fall apart if we were not there. If you want to know the dysfunction of any particular medical system, just go to the ER and you will find us there dealing with it directly.
Another flex point for failure has been treatment by the hospital system when things go wrong with patients. We are occasionally expected to do heroic things- ED thoracotomy, cric, Lateral canthotomy, pediatric resuscitations, etcetera. These are procedures that even the specialist will get nervous and anxious about. However, when we step up to the plate and perform these, the immediate response from the sub specialists is doubt and skepticism. When a child dies in the emergency room, it is met with suspicion. When i cric someone, I have to defend my actions.
COVID: Don’t even get me started.
What I am doing now: Palliative Care Fellowship. I am by far the oldest one in my fellowship class. Thank you Frazier for all of the posts. This isn’t a running away/snap decision, and is very likely a WRONG decision for many people leaving EM. You must want to do this type of work, and you need to have the disposition for it. I repeat: Do not run away to a Palliative Care Fellowship just to get away from EM. As a premed I was doing Hospice stuff, palliative rotations in med school, carried this interest through ICU rotations, etc
I used to think EM docs in their 50s/60s were outdated dinosaurs, but I increasingly find myself in awe of them. How the hell did they stick it out for so long? I have not decided if I'm going to give up on EM, as I could still see a role for me working in rural low volume places. I got my resuscitative reps and experience working in busy ERs. I stood the watch.
For me, right now, the juice is NOT WORTH the squeeze. I am lucky enough to have paid off all my loans, and have a small nest egg after being frugal during residency and in my 7 years as an attending. I have a spouse that earns 100k. We will be OK. I am incredibly grateful that she didn’t marry me for money or prestige, otherwise this could have gone a lot worse.
It is important to note that I did not burn out from working too many shifts. I typically worked 12-15 8s. There were periods where I flexed up to 15+ 12’s, but this was extremely rare and limited. I rarely worked more than 2 nights/month, and went several months at a time with no nights. (Though I do think nights are terrible for your health and undoubtedly lead to burnout). I tried many ways to change my schedule around to avoid burnout, however even cutting back to 7-9 shifts a month did not cure the negative feelings. If anything, it led to more career anxiety and longer periods of self-loathing between shifts. I spent a lot of Tuesday afternoons drinking beer by myself and wondering why I was a failure and couldn’t be happy in EM.
I hope everyone can keep fighting the good fight. I truly believe that there is no more difficult or important job in medicine than what we do.
