Here is my pro/con list I shared recently with
@MeatTornado, plz ridicule me as much as possible for these, hopefully while pointing out delusions.
The reasons Ive been having second thoughts on EM is
- #1 I actually do like the idea of having an outpatient practice and not being stuck in the hospital all of the time.
- #2 I think I might hate 50% of my patients if I did E.M.
- If that's the case, I think you stand a good chance of hating 50% of your patient's regardless, it's just that you'll be stuck with them for more than 8-12hrs (think days to weeks)
- #3 I think I would actually like being the person that gets the 3am phone calls because I am the expert on something as opposed to the one constantly making the 3am calls to other people who then talk down to me/lecture me/yell at me when i have 20 people waiting to be seen.
- Since this will never happen to you on a general medicine service 😵
- I think that this is a syndrome of being in an academic center. Talk with some private practice folks, it's a whole different world out there. I would also argue that no matter what service you are, you will require other experts at some point (GI, Cards, neuro, etc in the ICU for instance).
- #4 Kind of like #1, I feel that if I have my own outpatient practice, I have some ownership of my patients and am not 100% beholden to the nuances of hospital politics and various contract issues, at the very least have a little more political power.
- No, instead you'll get to bend over for CMS or some insurance executive. I guess you can at least have some variety though. The exception is maybe in a concierge practice, but I can only imagine the pain if you accidentally pick up a couple of borderline personality/severe anxiety disorder people in such a practice.
- #5 Though I am really not excited about doing research, the stuff I find most interesting (mechanical ventilation, fluid resuscitation, vasopressors/inotropes, fluids/electrolytes, and sepsis) have more prospective mentors studying these topics in IM/Pulm/CCM. Doing EM would limit my opportunities to work with people like this.
- Probably true, but that will still be important to EM practice.
- #6 EM/CCM would probably have fewer employment opportunities in community practice than IM/Pulm/CCM.
- Maybe. However, given the shortage of CC people I doubt you'd end up unemployed
- #7 More fellowship options in IM in-case I change my mind down the road.
- Accurate, but not a selling point to me, different strokes I guess. Personally, if I end up burned out it's probably going to be on medicine in general, not just my particular specialty. I'll likely leave the field entirely for either admin or a computer science/workflow type of deal (e.g. EMR company)
- #8 I want to teach medical students, and would think IM is a better place to get more consistent teaching opportunities.
- This probably depends more on you than the specialty
- #9 I think if I do end up getting burned out in EM, I would be absolutely miserable.
- I think this will be true regardless of specialty.
The problems I have envisioned with IM is
- #1 Possibly being suck doing primary care or hospital medicine if I don't get into a fellowship or for some reason am too burned out to continue.
- See my response to #1 above
- #2 Missing out on the so-called "excitement" of those very small % of critical patients in EM (not sure how much medical ICU work makes up for this because my own experience has been in large community hospitals, not academia).
- this depends on where you practice. Some places, the ED is a glorified urgent care/fm practice without continuity. Others, you will run every code and trauma that comes in multiple times per day. It totally depends on where you are. Personally, I actually find the "small %" to be one of the exciting things about EM: a lot of super-sick people don't look like it immediately.
- #3 Less exposure to ICU procedures in IM residency as opposed to EM.
- Yeah, this will depend on where you are. To my understanding, some IM residencies will give you a ****-ton of procedural experience. By and large though, probably true.
- #4 I don't like research and have no interest in doing it, but I'm sure I would have to in order to complete a fellowship.
- Mwam wam noises
- #5 General internal medicine wards are proclaimed to be a nightmare of just coordinating 5-6 different specialists and feeling like you don't make a difference.
- Depends where you are.
- #6 IM residency is proclaimed to be a horrible experience with little autonomy and a lot of mental masturbation sessions on rounds (i.e. a huge amount of frustration with how much your time is wasted).
- I think it depends on attitude, but I sympathize with this. I thought that it was usually incredibly interesting sometimes. Though I did frequently consider throwing myself off the roof when we debated between different diuretics or statins at equivalent strengths.
- #7 More mid-level creep into IM and ICU as opposed to ER, or at least it seems that way.
- I honestly think this is mostly SDN hysteria. There is so much work to be done, and I'm glad that mid-levels take what usually sucks the most out of our jobs.
- #8 Better salaries in EM than general IM (at least for right now), though most sub-specialists make more than EM.
- Not necessarily per hour. But this will likely change multiple times during our career.
- #9 IM/Pulm/CC would be 6 years whereas EM/CC would be 5.
- This assumes you still want to do CC in three years, but yeah, true. Personally I wanted to do CC for quite a while (the unit is just a very cool place), but I always hear from pulm docs about how they like pulm better than the unit further in their careers.
You sound an awful lot like an internist. That's the worst I got
😛
I included comments above from my perspective, which you might not be interested in seeing as I'm in the same year as you.
Overall it sounds like you really want to do IM, with the only fear being the uncertainty of getting a specialty placement. That sounds like a uniquely terrible reason to do EM. It's hard to want to woo someone into a specialty that they clearly don't enjoy as much as another one. It's a bit of a turn-off, like trying to talk with a guy/gal who won't give you the time of day and is making googly eyes at someone else.
Having said that, I hope you end up doing what you like, and not doing stuff based on BS SDN hysteria. I really like EM, but I totally get why someone would love IM. It's intellectually stimulating, you get to take "proper" care of people, take into account the whole history, and you can be there from the moment they are admitted until the day that they return to the nursing or funeral home (I kid, I kid).
My list of Cons for IM
1. Placement and social work BS
Watching someone spend multiple days in the hospital (or weeks sometimes) for no reason just kills me. It puts those patients at so many risks, and seeing this happen on a daily basis was probably the main reason that I simply can't do IM. There are elements of this in the ED as well, but they make up a far smaller portion of your day. I am feeling residual anger and frustration just thinking about this right now.
2. Placement and social work BS (it should be mentioned twice)
3. Rounding
4. Slow spots (kill me )
5. No kiddos. Sad face (however, comes with the corresponding positive...no parents)
6. Family has time and ability to dump stuff on you that is in no way your job
7. Increased paperwork and charting burden
8. Less trauma/fun stuff
9. Less procedures
However, I know for some folks my list of cons is actually a list of pros. I've met people who wanna do palliative who get super-excited about family meetings. I've also met people who worship the potassium channel and the differencese between bumex and lasix (holy be its name). If it's the right choice for you, go for it man. I hope it makes you happy
🙂
), homeless people using the ED as a shelter, police dropping off drunks, the expectation of patients that you "fix" their problem, the expectation of the hospital administration that you kick them out the door in the blink of an eye. No thanks. I definitely made the right decision staying away from EM.
