ED's role in the hospital?

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quagmire223

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Hi, I'm doing a rotation in internal medicine now, and before, have been really interested in going into Emergency. However, I've heard that Emergency docs are looked down upon by pretty much all fields, since they treat without thinking of long term consequences, and because they are just into rote memorization of treatment algorithms instead of thinking about the physiology or underlying nature of patient complaints.

I'm not posting this to start a flame war or anything, I'm just really curious to see how your perception of Emergency is. I'm still really interested as I need a really active field of medicine (or surgery?) and I really dislike ward rounds! Thanks for any advice....
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quagmire223 said:
Hi, I'm doing a rotation in internal medicine now, and before, have been really interested in going into Emergency. However, I've heard that Emergency docs are looked down upon by pretty much all fields, since they treat without thinking of long term consequences, and because they are just into rote memorization of treatment algorithms instead of thinking about the physiology or underlying nature of patient complaints.

I'm not posting this to start a flame war or anything, I'm just really curious to see how your perception of Emergency is. I'm still really interested as I need a really active field of medicine (or surgery?) and I really dislike ward rounds! Thanks for any advice....
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Your post makes me want to eat lead paint.
 
Also do a search on "Fatty McFattypants" and you will find your answer.
 
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that is typical internist blather....they talk about em as glorified triage but you could also say the same thing about any outpt primary care field. it is the job of the em clinican to identify and treat problems that will kill the pt or cause serious disbility or loss of function in the near future...anything else isn't an emergency...it's an urgent care or ambulatory care complaint.....
you could just as easily say that internal medicine is the practice of spending an hr with a pt to learn what the em clinician knows in 5 min.....whther the pt is "sick" or not and whether they need to be hospitalized or not....
 
quagmire223 said:
Hi I've heard that Emergency docs are looked down upon by pretty much all fields
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You can find something to say about every field:

IM = give steroids when you don't have a clue
Surg = butchers
Gas = lazy
etc...

The point is find out for yourself what you like and what you want to do for a living.
just my 2c
 
LOL no southerndoc, don't need to worry I'm a troll. I'm someone else in disguise. It's disturbing that there are similar posts though. Oh well, guess I should try to do a rotation myself and see what kind of picture I get.
 
quagmire223 said:
LOL no southerndoc, don't need to worry I'm a troll. I'm someone else in disguise. It's disturbing that there are similar posts though. Oh well, guess I should try to do a rotation myself and see what kind of picture I get.
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Right. Also, if you are concerned about your image among your peers, then you shouldn't do emergency medicine. EM is only for people with a thick skin. All your mistakes will always be pointed out and criticized. You could do 20 good things after that mistake, but the admitting physician will still remember you by your mistakes.
 
FWIW, the EPs I have worked with seem to have very good diagnostic ability and the ability to consider the long-term risk/benefit of particular treatments. This is especially important in the neighborhood this hospital provides treatment for, as many of our patients do not have their own provider.
 
Just my two cents.
EP's are the best doc's in the hospital, my attendings rock (and I feel completely ******ed compared to their knowledge) and they are as well trained as any doc in the hospital. In addition, I can see 4 pts in the time the IM intern can see 1 and I can see three in the time a surgical/sugical sub intern can see one. Surprise, surprise we come to the same differential/diagnosis basically - I don't put much thought into the zebras like IM or ruminate (i.e. get a chubby) about the technique I am about to do like the surgeons.
My patients like me and my history is focused (OB to me - when was her LMP ME Don't know, I don't care when she thinks her LMP is I have a positive HCG and a CRL of 10 weeks - done - I don't need to waste five minutes while she tries to figure out what month that was she stopped bleeding) and well thought out (surgeon to me - well we are considering infective versus ischemic colitis - probably infective, did you send off c. Diff me - yes, but no abx in last 3 months, and did she tell you about her postprandial pain - surgeon umm no I didn't ask, but maybe it is ischemic - was ischemic).
Two examples from last night - IM intern to me -I want every test known to man - happy to oblige my consultant I spend 5 minutes logging in orders on our awkward system - not set up for the IM order sets. IM intern then wants 5 IV of ativan, and 50 of librium, and I had already hit the guy with 5 Iv of valium for his Dt's I refused, did want the pt who was already snowed to stop breathing entirely
hand surgeon (resident) called for pt who cut his proper palmer digital artey of the thumb, got an x-ray as it was cut on glass. surgeon sews it up without looking at x-ray (I suspect). When I look at it of course it has glass in it, surgeon then says in snide tone oh yeah that was not in the tissues, it was on top of the skin, I irrigated it out. I got a repeat hand film, glass still there, ortho says its artifact, just put him on abx to be safe. I cut orthos sutures find the glass in about 30 seconds of exploration and sew it back up.
Draw your own conclusions, EM is not the red-headed stepchild, rather the opposite. Respect the might of EM
My $0.02

The mish
 
quagmire223 said:
Hi, I'm doing a rotation in internal medicine now, and before, have been really interested in going into Emergency. However, I've heard that Emergency docs are looked down upon by pretty much all fields, since they treat without thinking of long term consequences, and because they are just into rote memorization of treatment algorithms instead of thinking about the physiology or underlying nature of patient complaints.

I'm not posting this to start a flame war or anything, I'm just really curious to see how your perception of Emergency is. I'm still really interested as I need a really active field of medicine (or surgery?) and I really dislike ward rounds! Thanks for any advice....
Click to expand...

I've got to be honest - I think you are a troll, but I'll indulge you anyway.

Let me ask you a question. What color shirt am I wearing right now? WRONG! I'm not wearing a shirt. How could you be so dumb. See, anyone can look very smart by asking only questions that they know the answers to. This is how IM manages to convince medical students that they are "smarter" than EM. They will say things like "I bet those idiots didn't even consider {insert long term chronic disorder here}". They are probably right. We didn't consider that esoteric malarkey that might require some Elidel cream after the patient is discharged. Our job is to evaluate and treat for emergent conditions, not chronic ones.

If you want to see real "failure to consider" bad things, work for a month at an academic center where IM residents moonlight in the surrounding EDs. I've seen c-spine fractures sent in without collars, I've seen flexor tendons sewn into hand lacerations, and I've learned that every woman's biggest fear ought to be an internist with a speculum (2x lacerations to the neck of the cervix requiring suture repair).

As far as the science and pathophysiology - the famous line in EM is "we need to know what we need to know and one step more". True, we don't know the four or five steps more in IM, but we do know steps in surgery, OB, peds, etc., that an internist doesn't. Different strokes for different folks.

I now return you to your regularly scheduled trolling...

- H
 
regardless of whether this is a troll or not i'm very interested to hear more people's responses.

I too have sensed a certain biased against EP in the SND and blog world. It seems to me like many other speciatlies don't think EP are capable of doing anything outside their own little world.
 
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They might also believe that the moon is made of green cheese, but that doesn't make it so.

Anybody who has anything but constructive criticism about the job somebody else is doing is prick, plain and simple. Medicine is a team sport, and we're all in it together. Worry less about what other people think and more about taking good care of your patients and enjoying your job.
 
er's job is simply to make everyone elses tougher! Thats pretty much why we all go into it, we love harassing folks, heck i've been harassing folks since I was 8 years old (this is how I started my personal statement too :)

haha yeah I agree with all the above posters. Every part of medicine has a different role in the health care, and good internal medicine may not be good emergency medicine (even though it may seem that medicine is medicine) Even surgeons and general medicine disagree on some general management issues, and emergency has its own studies done and specific mortality/morbidity benefits of certain therapeutic actions that may not be "good internal medicine". Can't name anything in specific, but so many times people go why did they get that CT or that lab (which is always easier to say 48 hours after person had a seizure haha).
 
bartleby said:
They might also believe that the moon is made of green cheese, but that doesn't make it so.

Anybody who has anything but constructive criticism about the job somebody else is doing is prick, plain and simple. Medicine is a team sport, and we're all in it together. Worry less about what other people think and more about taking good care of your patients and enjoying your job.
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and I was under the impression the moon was made of green cheese? was I told wrong?
 
While I, too, smell troll, I have but one thing I'll bite on:

quagmire223 said:
However, I've heard that Emergency docs are looked down upon by pretty much all fields,
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Yes, this is true. We are looked down on by other specialties. Guess what, though... every specialty is looked down on by every other specialties. It seems to be in our physician DNA.

The one exception to my 'everyone else is an idiot' rule might be radiology and pathology. Since they rarely have much interaction, it might not occur to them that the other guy is an idiot. If they bump into each other in the hallway, however, I'm sure they'll reach that conclusion quickly enough.

Here's the sad truth. The vast majority of us are intellectual snobes. There must be something in the water or maybe its the preservatives in the anatomy tanks. I suspect that it is unintentionally selected for in the admission process.

This idea, BTW, is one of the main ideas I came to grips with during my intern year. That and most people get better; we just need to learn how to convince them we had something to do with it.

Take care,
Jeff
 
Gmw1386 said:
I too have sensed a certain biased against EP in the SND and blog world. It seems to me like many other speciatlies don't think EP are capable of doing anything outside their own little world.
Click to expand...

Well, that's interesting, because I don't think that I've ever heard of an internist doing surgery or an surgeon doing psych. No one in medicine doesn't 'anything outside their own little world'. The big difference is that in EM our 'own little world' is freakin' huge.

my $0.02
 
Dr.MISHKA said:
hand surgeon (resident) called for pt who cut his proper palmer digital artey of the thumb, got an x-ray as it was cut on glass. surgeon sews it up without looking at x-ray (I suspect). When I look at it of course it has glass in it, surgeon then says in snide tone oh yeah that was not in the tissues, it was on top of the skin, I irrigated it out. I got a repeat hand film, glass still there, ortho says its artifact, just put him on abx to be safe. I cut orthos sutures find the glass in about 30 seconds of exploration and sew it back up.
Draw your own conclusions, EM is not the red-headed stepchild, rather the opposite. Respect the might of EM
My $0.02

The mish
Click to expand...
You are lucky he actually came in to see it even if he did F it up. I would have said take care of it and went back to sleep.
 
Apollyon said:
At Duke, Plastics and Ortho alternate hand coverage, and no one ever had such a poor attitude - ever.
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That's great. Who fricking cares how they are at Duke? Not me - ever. Mishka did a great job and didn't need anyone's help. That's my point. What did the hand resident do that couldn't have been done by the ER there or stitched up and done electively. Nothing. I don't send my residents in for anything like that and I would defend any resident who didn't go in for something like that.
 
dawg44 said:
That's great. Who fricking cares how they are at Duke? Not me - ever. Mishka did a great job and didn't need anyone's help. That's my point. What did the hand resident do that couldn't have been done by the ER there or stitched up and done electively. Nothing. I don't send my residents in for anything like that and I would defend any resident who didn't go in for something like that.
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Well, patients at Duke "fricking care". And they're pretty big in hand care.

What you sound like is refusing a consult. Are you a resident or attending (or fellow)?
 
Apollyon said:
Well, patients at Duke "fricking care". And they're pretty big in hand care.

What you sound like is refusing a consult. Are you a resident or attending (or fellow)?
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I know if it's my hand, I'd want a hand surgeon to fix it. Sewing tendon lacs is not typically an ER procedure. It's a big deal when you're talking about restoring someone's hand function. Needs to be done properly.
 
Attending. Again I ask you what exactly did he do that could have been done by the ER staff or sewn up and done electively? And yes I know Duke is "big in hand". I've worked with some of their past residents. I would say sew up the skin after you get the glass out and if you can't send it to the office. Sewing tendon lacs in the ER is something most hand surgeons in practice will never do. Do it in the controlled environment of the OR and get paid to boot.
 
KentW said:
No, FM is really only looked down on by EM. Everyone else needs the referrals. ;)
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FM has my respect. Yesterday they admitted my paraplegic drug-seeker with "polymyositis" who was out of his oyxcontin and diluadid, and going through withdrawal, with no possibility of placemnt in an ECF for 24-48 hours.
 
If I am right, quite a lot of ERs are covered by moonlighting residents (and not just EM residents) and physicians from other specialties who got EM board certification but not an EM residency. So the perception of an 'ER doc' would include these other physicians who have not received specialized EM education. Now, I am not sure if there is evidence that EM residency trained docs are superior to these others, but it would seem so (otherwise what's the point of EM residency programs?)..

Before someone makes judgement about my sanity, let me clarify I am an IMG and I do not have much hands on experience in US healthcare. I am applying to EM this year, and this reasoning is what I like give to my friends who come up with the same criticism of EM as the first poster. I would like to know if this could be a contributing factor to EM's reputation. Any thoughts?
 
62% of all ED's have at least 1 board certified/eligible EM doc on staff. I can't say that "quite a lot" are covered by moonlighting residents.

As the practice track closed 14 years ago, people "grandfathered" in don't make much of a difference - the time closes the gap that not training in the specialty provided. Boarded by ABEM/AOBEM is boarded.
 
dawg44 said:
Attending. Again I ask you what exactly did he do that could have been done by the ER staff or sewn up and done electively? And yes I know Duke is "big in hand". I've worked with some of their past residents. I would say sew up the skin after you get the glass out and if you can't send it to the office. Sewing tendon lacs in the ER is something most hand surgeons in practice will never do. Do it in the controlled environment of the OR and get paid to boot.
Click to expand...

One of the big differences between private practice and academic practice. My hand surgeon pretty much won't come in for anything other than catastrophic vascular injury, compartment syndrome, high pressure injection injuries (grease guns), or exsanguination. Re-plants get transferred. Maybe there is some other true hand emergency I've forgotten. Everything else gets cleaned up, closed up, splinted and followed up as an outpatient or admitted for repair the next day. When I really need them they are responsive so I really don't mind sending the rest out for follow up.
 
you could just as easily say that internal medicine is the practice of spending an hr with a pt to learn what the em clinician knows in 5 min
Click to expand...
Come now, you must see all the articles/news about the death of primary care. In primary care we get 15 minutes per patient. Maybe 30 years ago they got an hour. Don't exaggerate.
 
i guess I've noticed that every profession bashes other professions. It doesn't matter what field you're in, you're going to develop the self-preservation mindset that somwhat elevates your own profession while putting down the other ones. It's just how stuff works in medicine. Don;t take it personally. Sure, EM is "glorified triage" but then IM is rounding to death, and surg is full of bizatches and butchers.
 
TPS report said:
i guess I've noticed that every profession bashes other professions. It doesn't matter what field you're in, you're going to develop the self-preservation mindset that somwhat elevates your own profession while putting down the other ones. It's just how stuff works in medicine. Don;t take it personally. Sure, EM is "glorified triage" but then IM is rounding to death, and surg is full of bizatches and butchers.
Click to expand...

I just don't get this. When I think negative thoughts about other specialties, it is in terms of what is right or wrong for ME. I see the look on my classmates/residents/attendings faces and I know that what they do excites them, and that they are in fields that make critical contributions to medicine. That's part of the beauty of medicine, that there is an important branch of it to fit every personality.

Why the bashing, unless people are unhappy with their chosen profession or just plain bullies that like to put others down, anyway??? :confused:
 
Hard24Get said:
.

Why the bashing, unless people are unhappy with their chosen profession or just plain bullies that like to put others down, anyway??? :confused:
Click to expand...

You're a sweet person, don't ever change. It isn't just Medicine, although we should be better. Half the human race is inhuman. (See WW2, WW1, USA conquers native americans, Stalin and purges, and on backwards through time).
 
dhb said:
You can find something to say about every field:

IM = give steroids when you don't have a clue

The point is find out for yourself what you like and what you want to do for a living.
just my 2c
Click to expand...

;) Actually that's less IM and more Rheumatology also known as "Doing the Rheum thing!"

[And unfortunately this is another thread I need to print out for the ED providers at my institution who hand out medrol dose packs for every thing from back pain to scabies--"well it looked like a rash so I did some steroids, can't hurt right?" (of course not never mind that the patient has DM, HTN, and GERD and is now in my office crying because the rash is worse) :idea: Someday we'll have EM trained providers in our ED--hopefully soon]
 
BKN said:
You're a sweet person, don't ever change. It isn't just Medicine, although we should be better. Half the human race is inhuman. (See WW2, WW1, USA conquers native americans, Stalin and purges, and on backwards through time).
Click to expand...
KentW said:
In a word, insecurity.
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Ha - BKN, I'm going to save your quote for those who think I've turned callous in grad school! :p

Seriously, though, your post saddens me. Don't you think the truly horrible people are the exception to the rule and that most of us doing wrong are committing isolated acts out of hurt and insecurity, ie KentW? Working in the ED, we get a peek into the lives of people who are involved in some crazy stuff, but when you see the reality they deal with, you know there is a reason why they do the things they do.

What surprises me is that you would think that physicians would not have so much insecurity in terms of their career, and certainly would not be as vicious. We are supposed to be the "good guys" and should be doing much, much better. :( .... Great, now I'm stuck researching physician unhappiness. PMID: 1786225.
 
Hard24Get said:
Ha - BKN, I'm going to save your quote for those who think I've turned callous in grad school! :p

Seriously, though, your post saddens me. Don't you think the truly horrible people are the exception to the rule and that most of us doing wrong are committing isolated acts out of hurt and insecurity, ie KentW? Working in the ED, we get a peek into the lives of people who are involved in some crazy stuff, but when you see the reality they deal with, you know there is a reason why they do the things they do.

What surprises me is that you would think that physicians would not have so much insecurity in terms of their career, and certainly would not be as vicious. We are supposed to be the "good guys" and should be doing much, much better. :( .... Great, now I'm stuck researching physician unhappiness. PMID: 1786225.
Click to expand...

I'm sorry my post saddened you. Boy, what an opportunity for a profound endless discussion. Unfortunately, I've got a couple of lectures to write.

Briefly, being an optimist and a 60's child, I'd like to believe that people are basically good. I like most of the people I know and I trust them. But history is mostly about power plays and inhumanity.

Doctors absolutely should be better and mostly are. But it's a long road and there are casualties who turn angry and hard.

Anyway, back to the grind.
 
Hard24Get said:
if people are generally satisfied, what's the problem?
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I'm not sure that's the conclusion I'd draw from that article...
More than 70% of US physicians reported being satisfied or very satisfied with their careers in medicine. These high satisfaction levels among most physicians, despite the many challenges of our changing health care system, are testaments to the enduring rewards of the science and practice of medicine. However, only about 2 out of 5 physicians are very satisfied with their careers, and nearly 1 in 5 are dissatisfied. These somewhat mixed results are disappointing given the enormous individual and societal investments required to prepare a fully-trained physician.
Click to expand...

I've read other articles that conclude that job satisfaction is highly correlated with autonomy, with employed physicians scoring the lowest, and those in private practice (specifically in physician-owned multispecialty groups) scoring the highest. I can attest to that myself. ;)
 
signomi said:
Come now, you must see all the articles/news about the death of primary care. In primary care we get 15 minutes per patient. Maybe 30 years ago they got an hour. Don't exaggerate.
Click to expand...

You must be referring to your clinic! You know... Those patients that you follow up on their BP meds or GERD symptoms. I've never seen an IM resident work up a new patient in the ED in under 1 hour (HPI, PE, checking records, looking at X-rays, writing orders). Even that would be fast.
 
Sorry to awaken the recently dead, but I am VERY irritated by the way specialties look dow on each other, particularly EM. I remember in my medicine rotation, EM was the reason we already knew the diagnosis before we went downstairs. Similarly, my surgery residents can say, "let's go see this guy with cholecystitis" and do a half-ass work-up - because it was already done by the ED. Then they're irritated b/c the ED didn't insert a foley for them when there are tons of patients in beds outside rooms and even more in the waiting room? They tell me I am too smart for EM - certainly I'm the only one smart enough among them to realize how much they take the EM docs for granted. I just feel like they are putting me down when they put EM down. :(
 
Hard24Get said:
Sorry to awaken the recently dead, but I am VERY irritated by the way specialties look dow on each other, particularly EM. I remember in my medicine rotation, EM was the reason we already knew the diagnosis before we went downstairs. Similarly, my surgery residents can say, "let's go see this guy with cholecystitis" and do a half-ass work-up - because it was already done by the ED. Then they're irritated b/c the ED didn't insert a foley for them when there are tons of patients in beds outside rooms and even more in the waiting room? They tell me I am too smart for EM - certainly I'm the only one smart enough among them to realize how much they take the EM docs for granted. I just feel like they are putting me down when they put EM down. :(
Click to expand...

Dear hard,

People who spend time putting others down are just unhappy. Ignore them. Livng well (as an EP) is the best revenge.

BKN
 
Hard24Get said:
Sorry to awaken the recently dead, but I am VERY irritated by the way specialties look dow on each other, particularly EM. I remember in my medicine rotation, EM was the reason we already knew the diagnosis before we went downstairs. Similarly, my surgery residents can say, "let's go see this guy with cholecystitis" and do a half-ass work-up - because it was already done by the ED. Then they're irritated b/c the ED didn't insert a foley for them when there are tons of patients in beds outside rooms and even more in the waiting room? They tell me I am too smart for EM - certainly I'm the only one smart enough among them to realize how much they take the EM docs for granted. I just feel like they are putting me down when they put EM down. :(
Click to expand...

Take away a surgery resident's (and any other over worked group of people) right to complain and you take away half their reason to exist. Just grin, tell them that you are stupider than they think and wouldn't have been able to hold a retractor in the same place for two hours so surgery was out. After all you gave up taking call every third night and getting yelled at by malignant attendings so you couldn't have been that bright anyway, right.;)
 
Thanks, everyone. I feel like ranting here keeps me from arguing too vehemently or bustin' Chuck Norris moves. I am particularly vulnerable now because I do my first official EM rotation after this, and am terrified that 1) suddenly I won't like it anymore, or worse 2) all EM docs will hate me. And I ain't got no back up specialty!!! :scared:



totalbodypain said:
Take away a surgery resident's (and any other over worked group of people) right to complain and you take away half their reason to exist. Just grin, tell them that you are stupider than they think and wouldn't have been able to hold a retractor in the same place for two hours so surgery was out. After all you gave up taking call every third night and getting yelled at by malignant attendings so you couldn't have been that bright anyway, right.;)
Click to expand...
 
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