apply to EM, but not big on procedures..?

[borderlineinCle]

hey everyone!

i'm very interested in psychiatry, but i also really enjoy EM and the EM environment. what i love most about psychiatry is acute psychosis, mania, etc, and i know I can also get that with EM.

Currently, I'm taking a research year focusing on disease prevention in urgent care / ED settin. I already did MS3, did an AI in internal medicine (required at my school) and a CL psych elective, then started research year).

the thing is... my stoke level isn't high regarding doing procedures (suturing, intubate, etc). It's not that I *mind* doing these and wouldn't jump to the front of the line doing these if i was a resident (since I want to be competent and efficient in the skills required of me), but it's not something that excites me remotely. For example, I see all the residents begging to do more and more procedures, whereas I get more excited by the patients with complex medical issues in the ED that need stabilization. (And no, can't do IM... the rounding kills me, and the excitement for each admission is usually the first 24-36 hours ordering the workup, followed by days of dispo.)

So, I say all that to say, I was talking to one of my buddies who is a pgy-2 in IM about this and he said "procedures in the acute setting is what separates FM from EM, if you don't love procedures then don't do EM".

Would you all agree with this? Any advice or suggestions would be super appreciated.
Apologies in advance if this is a silly / dumb question. Thought this might be a different way to ask the "psych vs EM" question.

Happy Holidays!

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[Angry Birds]

I hate procedures, and always have. I ended up fine, but this was something I struggled with. If you don't get excited by procedures, then you are less likely to jump to do them during residency... This was a handicap for me. It meant that I mastered my procedures later than I would have wanted to. But, I had to force myself and spend extra time to make up for this, and even had to "get up to speed" during my first year out as an attending.

There are only a few core procedures in EM, like intubation, central line, and chest tube. I would say in all three I only attained an acceptable level of mastery after residency... which is of course not good. But, now I'm fine. Just on my last shift, I put in a rescue central line for my colleague after they were unsuccessful. That felt good, especially knowing how far I've come.

So, the bottom line is: this will or could be a problem for you in the beginning, but eventually you will overcome. Of course, I am assuming that you don't like procedures because, like me, you don't have a natural talent for them. This may be a mistaken assumption on my part however.

Also, don't do psych. That's crazy talk.

By the way, I also love the medically crashing patient, i.e. flash pulmonary edema.

 

[borderlineinCle]

I hate procedures, and always have. I ended up fine, but this was something I struggled with. If you don't get excited by procedures, then you are less likely to jump to do them during residency... This was a handicap for me. It meant that I mastered my procedures later than I would have wanted to. But, I had to force myself and spend extra time to make up for this, and even had to "get up to speed" during my first year out as an attending.

There are only a few core procedures in EM, like intubation, central line, and chest tube. I would say in all three I only attained an acceptable level of mastery after residency... which is of course not good. But, now I'm fine. Just on my last shift, I put in a rescue central line for my colleague after they were unsuccessful. That felt good, especially knowing how far I've come.

So, the bottom line is: this will or could be a problem for you in the beginning, but eventually you will overcome. Of course, I am assuming that you don't like procedures because, like me, you don't have a natural talent for them. This may be a mistaken assumption on my part however.

Also, don't do psych. That's crazy talk.

By the way, I also love the medically crashing patient, i.e. flash pulmonary edema.

thanks so much for the reply! i really appreciate it. it's good to hear your experience. and yeah, you hit the nail on the head -- i just don't have a natural talent for them, but it seems like something that becomes easier with much more exposure in residency

 

[DrDrummer]

You can specialize in "emergency psychiatry" if that is your specific interest. Most people in this are boarded in psychiatry. There are people who work in this field both in research and in clinical settings, and I see no reason that the job prospects and maybe specific fellowship training won't continue to expand.

 

[The White Coat Investor]

hey everyone!

i'm very interested in psychiatry, but i also really enjoy EM and the EM environment. what i love most about psychiatry is acute psychosis, mania, etc, and i know I can also get that with EM.

Currently, I'm taking a research year focusing on disease prevention in urgent care / ED settin. I already did MS3, did an AI in internal medicine (required at my school) and a CL psych elective, then started research year).

the thing is... my stoke level isn't high regarding doing procedures (suturing, intubate, etc). It's not that I *mind* doing these and wouldn't jump to the front of the line doing these if i was a resident (since I want to be competent and efficient in the skills required of me), but it's not something that excites me remotely. For example, I see all the residents begging to do more and more procedures, whereas I get more excited by the patients with complex medical issues in the ED that need stabilization. (And no, can't do IM... the rounding kills me, and the excitement for each admission is usually the first 24-36 hours ordering the workup, followed by days of dispo.)

So, I say all that to say, I was talking to one of my buddies who is a pgy-2 in IM about this and he said "procedures in the acute setting is what separates FM from EM, if you don't love procedures then don't do EM".

Would you all agree with this? Any advice or suggestions would be super appreciated.
Apologies in advance if this is a silly / dumb question. Thought this might be a different way to ask the "psych vs EM" question.

Happy Holidays!

You would be a very rare EP. Most EPs dislike the practice of psychiatry and love procedures. I would give very serious thought as to whether you really want to do EM. They're very different specialties. For instance, I loved everything about MS3 year...except psych.

Acute psychosis in the ED isn't particularly exciting. IM Haldol and a crisis consult for placement....If you want to really treat acute psychosis and mania, I'd recommend going into psych and doing inpatient work.

 

[borderlineinCle]

You would be a very rare EP. Most EPs dislike the practice of psychiatry and love procedures. I would give very serious thought as to whether you really want to do EM. They're very different specialties. For instance, I loved everything about MS3 year...except psych.

Acute psychosis in the ED isn't particularly exciting. IM Haldol and a crisis consult for placement....If you want to really treat acute psychosis and mania, I'd recommend going into psych and doing inpatient work.

Yeah I should’ve said that acute psychosis and mania aren’t the only things I like, they’re just the main things I like about psych. From what I’ve seen being an ED physician who is sympathetic towards some of the most disparaged patients might be a benefit. Also interested in social emergency medicine


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[enalli]

What would be the negatives for you of being an inpatient psychiatrist, an emergency psychiatrist, or a consultation-liaison psychiatrist? It sounds like one of these three would also really suit you.

 

[borderlineinCle]

What would be the negatives for you of being an inpatient psychiatrist, an emergency psychiatrist, or a consultation-liaison psychiatrist? It sounds like one of these three would also really suit you.

That’s a great question actually, and something I’m definitely thinking about. Inpatient psych is ok, but after the ED presentation when they get back to the unit it’s mainly adjusting meds, or daily talks to asses SI/HI/AVH and working in disposition — which I don’t mind compared to IM since it’s a lot of more interesting social issues. But... felt like I wasn’t *doing* that much for each patient and could see an NP doing my job effectively too. Psych EM wouldn’t be bad at all, but like I said about it isn’t the only reason why I’m glad I’m becoming a doctor, but the thing I like most about psych. From what I’ve read, you don’t do that much different from an EM doc except take a better psych / social history and maybe prescribe a second generation antipsychotic like zyprexa or geodon instead of a B52 bomb. If I’m going to be in the ED I would like to do more. As for CL, did a month elective in it and liked it. I was only inpatient consults though, and 90% of it was stuff the primary teams *shouldve been able to do* — like a basic delirium work up, or a sad patient just diagnosed with cancer. A lot of consults were for that and I felt like a great patient advocate, but for delirium we always did the same drugs (zyprexa and abilify). Granted, CL is much more than just that, but I’m having a very difficult time *hanging up* the stethoscope, as it were. Working in the ED for research year I’ve greatly enjoyed working up patients and could see myself being in that environment and I like the medicine. (Did very well on my medicine sub-I, but just not a fan of IM or the outpatient life at all). I think I would probably happy doing both, it’s just the darnest thing choosing. Bleh


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[RustedFox]

That’s a great question actually, and something I’m definitely thinking about. Inpatient psych is ok, but after the ED presentation when they get back to the unit it’s mainly adjusting meds, or daily talks to asses SI/HI/AVH and working in disposition — which I don’t mind compared to IM since it’s a lot of more interesting social issues. But... felt like I wasn’t *doing* that much for each patient and could see an NP doing my job effectively too. Psych EM wouldn’t be bad at all, but like I said about it isn’t the only reason why I’m glad I’m becoming a doctor, but the thing I like most about psych. From what I’ve read, you don’t do that much different from an EM doc except take a better psych / social history and maybe prescribe a second generation antipsychotic like zyprexa or geodon instead of a B52 bomb. If I’m going to be in the ED I would like to do more. As for CL, did a month elective in it and liked it. I was only inpatient consults though, and 90% of it was stuff the primary teams *shouldve been able to do* — like a basic delirium work up, or a sad patient just diagnosed with cancer. A lot of consults were for that and I felt like a great patient advocate, but for delirium we always did the same drugs (zyprexa and abilify). Granted, CL is much more than just that, but I’m having a very difficult time *hanging up* the stethoscope, as it were. Working in the ED for research year I’ve greatly enjoyed working up patients and could see myself being in that environment and I like the medicine. (Did very well on my medicine sub-I, but just not a fan of IM or the outpatient life at all). I think I would probably happy doing both, it’s just the darnest thing choosing. Bleh


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It sounds to me like you have reasonable qualms and really want to "think this through" all the way.
Good on yah.
That being said, everything that I've read from your messages says "I want to go into psych".
The way you speak about the nuances in psych is telling.

There is no good and firm answer, from my standpoint.

There are days where I go into work, and I say to myself: "Just please let me have a decent day; only one crashing patient, maybe two. A tube and/or a central line, pick one."

There are days where I go into work, sand I say to myself "Just let them all be acutely dying so I can tube and central line them all and don't have to spend 2 minutes talking to each patient to figure out that it will take me 30 minutes of chart-diving to sort out the issue why they're here... which is neither urgent nor emergent, and is largely due to the fact that there's a secondary gain issue, a self-negligence issue, an Axis-II disorder, or just plain ol' being dumb.

In the end, I'd rather deal with the acutely crashing patient than the complicated "well, it all started forty years ago when my mommy left me alone with my big sister and then I had asthma and my back pain started and when I vomit my headaches get bad and my headaches are causing my vomiting and I stopped taking my ZyprexaBan because I didn't like the way it made lemons look."

I worked in a Level-1 Bull$hit center today. Its a shame that it pays way more than the Level-1 Trauma Center across town.

 

[dadaddadaBATMAN]

hey everyone!

So, I say all that to say, I was talking to one of my buddies who is a pgy-2 in IM about this and he said "procedures in the acute setting is what separates FM from EM, if you don't love procedures then don't do EM".

Would you all agree with this? Any advice or suggestions would be super appreciated.
Apologies in advance if this is a silly / dumb question. Thought this might be a different way to ask the "psych vs EM" question.

Happy Holidays!

Ignoring the premise of your question because I wanted to address the thing said by your IM buddy, who has no idea what he/she is talking about.

The only real similarity between fm and em is that they serve the entire population without restrictions regarding ob or peds.

the conditions we treat and have expertise in are completely different. Primary care patients show up to the ed, and ed patients show up to primary care, but usually both sides are good at directing the patient to the other when that happens. I'm not going to manage your chronic hypertension, and if you have an mi in the office they'll give you asa and call an ambulance.

I guess others might feel differently but this idea that the specialties are similar irritates me. They have almost nothing to do with one another.

Procedures are a small but important aspect of em.

 

[Janders]

I wouldn't worry that much about your lack of love of procedures. As long as you are competent you don't have to go searching them out.

I would make sure you love the rest of the day-to-day in the ED though. Do you like urgent care medical visits? Do you like acute ortho injuries? Do you like codes and resus? Do you like old people with vague complaints and likely SOMETHING wrong? AND acute psych / addiction medication? If so EM might be for you.

But as the other say, there are neat niches within psych for people who like the ED/acute side of psychiatry!

IMHO there could be a very nice (possibly) academic niche for someone in EM/psych who wants to push the envelope with ED treatment, access to care for patients, system-based strategies to avoid long ED "bed holds" etc etc.... We've had a state grant to work on this stuff in my ED the past couple years, and it is both interesting and truly an untapped frontier--- ain't much glory in acute psych for the underserved / ED / dual-diagnosis population, but there is a lot of NEED and I think potentially resource savings...

 

[borderlineinCle]

I wouldn't worry that much about your lack of love of procedures. As long as you are competent you don't have to go searching them out.

I would make sure you love the rest of the day-to-day in the ED though. Do you like urgent care medical visits? Do you like acute ortho injuries? Do you like codes and resus? Do you like old people with vague complaints and likely SOMETHING wrong? AND acute psych / addiction medication? If so EM might be for you.

But as the other say, there are neat niches within psych for people who like the ED/acute side of psychiatry!

IMHO there could be a very nice (possibly) academic niche for someone in EM/psych who wants to push the envelope with ED treatment, access to care for patients, system-based strategies to avoid long ED "bed holds" etc etc.... We've had a state grant to work on this stuff in my ED the past couple years, and it is both interesting and truly an untapped frontier--- ain't much glory in acute psych for the underserved / ED / dual-diagnosis population, but there is a lot of NEED and I think potentially resource savings...

Pretty much would love to be that guy in EM that wants to use the ED for access to cafe and systems based stuff


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[GeneralVeers]

I hate psych and procedures.....