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EM & Orthopods

Discussion in 'Emergency Medicine' started by Willamette, Mar 31, 2004.

  1. Willamette

    Willamette Good with a bo-staff
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    Hey Guys,

    I wanted to run something by you guys that I heard the other day from a current EM resident. To get to the point the resident (a really nice guy) said that he chose EM over Ortho because he felt that they (orthopods) didn't really know very much about medicine. He said he was loathe to "forget" most of what he had learned during medical school in order to become an orthopaedist. He didn't make any of the snide jokes about bonecrunchers (i.e. "to be an orthopod you need to be as strong as an ox and half as smart" or "what're the toughest 3 years in an orthopods life? 4th grade"), and opined that they are usually "really good at what they do." Now, I'm a person that really has taken a "generalist" approach to much of my life. I like knowing something about lots of things, and I enjoy quite a variety of leisure-time pursuits. In fact, I've often found myself identifying with one of RAH's many dictums that "Specialization is for insects." As such, the two medical specialties that most appeal to me are Emergency Medicine and Family Medicine. However, I have recently taken an interest in ortho, but am worried that SPECIALIZING in the musculoskeletal system will make me unhappy. Any thoughts on the subject are certainly welcome. Thanks!

    Willamette
     
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  3. Kalel

    Kalel Membership Revoked
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    All specialties have residents and faculty who have negative comments to make about other specialties. I can't think of a specialty out there (except maybe neurosurgery?) which doesn't have it's "stereotypes", including EM and FP by the surgeons. I wouldn't let any of that sway your decision making process, since you will always be able to find someone out there who says that your specialty is "incompetent". If they bother you, you can always ignore/avoid them.
     
  4. bobdobaleena

    bobdobaleena Junior Member
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    i went through the ortho vs. EM dilemma myself this year. i did 8 weeks of ortho electives and 8 weeks of EM electives before i made a decision. i had letters of rec from both fields and even applied to both fields through ERAS. i ended up turning down my ortho interviews and only going to my EM interviews. i realized during my second ortho elective that it wasn't for me. i like the OR, i like the procedures, i like the outcome of the orthopedic procedures, but i, like your friend, hated the idea of losing everything i've worked so hard to learn. many of the residents prided themselves on being unable to work-up chest pain, or run a code or read a CXR or interpret lab data. this totally turned me off. if you think you may like the field, do an away elective and give it a shot. also, if you really enjoy the OR and can't see yourself doing something where you're not spending time in the OR, think about general surgery.....much more intellectual and many many opportunities to work with very sick patients. you have time next year to check out a couple fields if you're still not clear whick way you want to go.....good luck.
     
  5. roja

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    I never really went through hthe ortho vs EM dilema. I did want to do ortho for a while, but while I loved teh OR I ahted clinic.

    It also, despite stereotypes, takes a large degree of intelligence.
    My father is an ortho and is exceptionally smart. Even in ortho, a basic understanding of medicine is necessary as many of your patients will not have isolated ortho problems.

    Just like in EM where we know a lot about trauma and a lot about emergency medicine, we don't have the detailed knowledge of an ortho or whatever. Of course, there are fellowships, andthere is always the continued pursuit of fields you find interesting. (we hhave an em attending who is incredibly knowledgeable about ortho stuff)

    Also, all those damn eponems... eeeeeeeeeek
     
  6. Freeeedom!

    Freeeedom! Senior Member
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    I was all about ortho for years 1 and 2 in med school...until the smartest and coolest guy I met was an EM doc. He had fun and enjoyed his work. Made the switch rather quickly.
     
  7. Willamette

    Willamette Good with a bo-staff
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    Yeah, the ED guys at our hospitals are really cool too. This "coolness" seems to extend from the attendings, through the residents, and even into the students who show the most interest in EM. One major difference that I have seen in ortho is that, while the attendings and residents are awesome, MOST of the students who are really interested in ortho are self-serving jerks. This CERTAINLY DOES NOT pertain to all of them. In fact, I like a couple of them quite well. But there are a few that I wouldn't even trust to give me the right directions to an interest group meeting. I went to a small undergrad where the "premed mentality" was practically non-existent, but when I imagine said mentality, it's now these "jerks" that come to mind.

    Willamette
     
  8. beyond all hope

    beyond all hope Senior Member
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    Any speciality you do will emphasize some of what you learned in medicine school to the exclusion of others. More general specialities like IM, Peds, EM, FP are more like med school, more focused specialities like Ortho are nothing like med school.

    I'm sorry, but the stereotype of orthopods is often true. It's not that orthopods are dumb, but it's not exactly an intellectual field. Neither is EM, BTW, but at least EM involves a bit more brain-crunching. As for knowing how to run a code or work up chest pain, that seem important to you now but after awhile it's just part of the job.

    Most orthopods do not know how to read an EKG, but then again neither do most surgeons, optho, psychiatrists, pathologists, etc. Then again, don't ask an IM doc to rule out a calcaneal fracture, or even look for a posterior fat pad sign...:)

    If you're looking for an intellectual field, neither EM nor Ortho are probably what you're looking for. They're both action specialties - you find a problem and fix it. Think about IM, Neuro or Psych if you want really challenging mindwork. Avoid FP unless you really like clinic, or you're planning on working in the middle of nowhere.
     
  9. The White Coat Investor

    The White Coat Investor AKA ActiveDutyMD
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    RE: Ortho not being an intellectual field....that's really a generalization. The amount of anatomy that must be known (hmmm....seems like that was something taught in med school) is incredible just to plan an approach for any ORIF. The ability to recognize which ortho problems are surgical and which are not requires a fair bit of intellectual ability, something that is shared by both Ortho and EM docs. Granted, ortho requires a lot of manual skills, and they do pride themselves on obtaining consults for sore throats, but don't be swayed by the orthopod/carpenter arguments into thinking it requires no brain power at all.
     
  10. bobdobaleena

    bobdobaleena Junior Member
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    i would argue that of all the fields in medicine, ortho is the one field where you could succeed without ever going to medical school. take a smart guy off the street who is great with his hands and put him through 6 years of intense training.....there you go....an orthopod. the anatomy is not very difficult (hey watch out for the infrapatellar branch of the saphenous nerve) and can be very easily learned. a very skilled cabinet maker, for instance, would make a great orthopod.
     
  11. I am interested in learning more about ortho, is there an ortho forum? I was unable to find it.

    Thanks :horns:
     
  12. frog4brooke

    frog4brooke Member
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    I just did a month of Ortho expectibg all of the stereotypes to be true, but I was pleasantly surprised! (It could be differnt in the community-this was academics).

    These GUYS were smart and nice. Many of the conferences I went to were very helpful and intellectual.

    I agree there is a lot of the "fix it" mentality in EM and Ortho-(Which I personally like). The ortho clinics still involve a lot of "Chronic" problems or rechecks. Also I like using my stethoscope-none of those guys even carried one anymore :)

    Have fun, enjoy your 4th year. Rotations in EM and Ortho will only help you in the end.

    F4B
     
  13. anonymousEM

    anonymousEM Senior Member
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    while rotating on the trauma service I got a consult for a postop (from an IM NAIL) ileus by ortho on a trauma pt with isolated ortho issues (hmm, you the surgeon, want me the ED resident to handle this POST OP issue?). It's not that ortho can't handle their issues or aren't smart enough (check out most of their step 2 scores...they DID learn something in med school) Most knew how to read EKGs and CXRs and work up chest pain, they just don't want to now and often manage to get medicine to admit anyone who might need the slightest bit of attention outside of the OR and postop checks while admitted....
     
  14. banner

    banner Senior Member
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    Perhaps, ortho people just don't have all this guilt about having to use everything they learned in medical school. Guilt is s silly reason to do anything.

    Ortho guys are more than capable of learning chest pain stuff. The thing is is that they don't want to. They went into orthopedics to operate and address very mechanical problems. And that is what they do... If they liked managing cholesterol, DM, or chest pain, they would have went into IM. If they wanted to manage glycogen storage diseases or strokes, they would have went into neuro.

    Lots of other specialists know nothing about orthopedics, but nobody holds it against them. No one complains that the internist is stupid because he wasn't comfortable setting the Colles fracture.

    These guys just want to fix bones. They don't want to know everything or be able to answer all their families stupid questions.

    I'm not an orthopod, but I respect what they do. And if they can make $300K/year doing carpentry knowing nothing, good for them.
     
  15. Febrifuge

    Febrifuge Grizzled Old Newcomer
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    I agree completely. However, I think it might be something about the EM personality; your example about the Colles fracture is a good one to illustrate what I mean.

    I was doing my ER Tech thing last week (nothing fun, just putting labels on blood vials and calling various pagers, mostly) for an MVC pt with multiple fxs... somebody went for the Hare traction splint, and a little voice deep in my nascent EP-like brain wanted to say "hey, cool, I know how to do that. Let me in there! I'll do it!" Maybe an internest would be happy to not have to set a busticated femur; I couldn't say, 'cuz I don't seem to have that mindset.

    EM is all about doing lots of different cool stuff. Ortho people do some cool stuff. I respectfully submit that maybe it seems a little odd to EM people that Ortho people don't want to do more kinds of cool stuff. It may be just that simple.
     
  16. banner

    banner Senior Member
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    Great. Sounds to me like you're on the right track.

    The best reason to do something is because you like it and it makes you happy.

    I think finding a specialty is more of a gestalt than breaking it down into its components.

    I am always wary of people who attack other specialties (which happens a lot in medicine). Much of the time, they are insecure with their own decision to go into whatever specialty. They make themselves feel better by cutting on everthing else.

    When you boil down a lot of the cross-specialty criticism, it usually sounds pretty stupid. Often resembles making fun of somebody because they like chocolate ice cream.
     
  17. Ex-fix

    Ex-fix Junior Member
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    Many people believe that orthopedist are clueless about basic medical management. Most orthopedist are 100% capable of handling many of the things we consult for. We just don't feel like handling it.

    Orthopedics is one of the hardest specialties to match. You can't take any old guy off the street and train him/her to be a orthopedist. Not only do you have to learn the biomechanics of the musculoskelteal system the biology behind the prosthesis we put in.

    Spending many hours in the ED with many ER residents, I personally fell that ER physicians are under trained. THese are the doctors that I believe should have a general knowledge about every filed. For example, orthopedics compromises about 20-35% of what ED docs will see. However, most ED programs have rotations that equate to 2% of their training. Much of their training is spent on learning triage, rather than true medical care.

    Any MS4 can diagnose and treat most acute MI, sore throats, and belly aches. How many MS4 can perform TKA, THA, femoral/tibial nailings, and habdle their complications. Probably none. Why spend a residency already learning what you already know. Use residency to enhance your educational and medical skills.
     
  18. beyond all hope

    beyond all hope Senior Member
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    It's not that orthopedists are dumb. However, after 20 years of only doing surgery, most ortho guys forget how to read EKGs, manage complex medical patients, etc. It's not just that they don't want to: senior orthopods don't know anymore. Just like as an EM doc I'll probably forget how to manage chronic medical problems.

    As for EM being undertrained in ortho, I think it's true and not true. Certainly I don't feel very well trained in ortho, and I wish we had a few more rotations to shore up my knowledge. However, EM docs really don't need to know all the specifics: we just diagnose, reduce, splint and refer to your clinic the next day.

    As for the tired argument of ER docs being glorified triage nurses, that only makes sense for the people who don't understand the fine arts of stabilization, disposition, and managing the flow of the ER. These are not as simple as you may believe.
     
  19. Willamette

    Willamette Good with a bo-staff
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    What do you mean by "disposition and managing the flow of the ER?"

    Willamette
     
  20. Apollyon

    Apollyon Screw the GST
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    Rapid recognition of sickness and health. "Treating and streeting" who you can, getting "two for the price of one" from radiology (like ultrasounds, when you have to call the tech in from home), dealing with female abdominal pain (>90% of the time getting a pelvic exam, which is a real figure, vs. the "20-35%" figure of orthopedics for EM (a vastly inflated percentage)), with positioning, especially when the patients have to be rotated through rooms that can handle a pelvic exam appropriately, keeping your drunks (if that's a part of your patient base) segregated to sleep it off, seeing a patient, formulating your plan, ordering what you need, seeing the next patient while the first one "cooks", and so on, finding time to sew up someone's lac, and having the feel for whether to use lidocaine or bupivicaine (if you think you'll be called away)...that sort of thing.
     
  21. beyond all hope

    beyond all hope Senior Member
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    Not to detract from Apollyon's explanation, but I think it may be difficult for non-ER docs to understand. Traditional medicine tends to focus on the individual patient, diagnosis and treatment of disease.

    In Emergency medicine, the whole ER is your patient. You have to treat the sickest patients immediately, while not letting the worried well wait too long. Flow is important - send the well patients out to clinics or PMDs so you have room and resources to treat your sickies.

    You treat mostly treat symptoms, not diseases, because you are working on limited information. Diagnosis is not important, stabilization (normalization of vital signs and patient comfort) and disposition (will the patient go home, stay in the hospital, go immediately to surgery or the ICU?) are key.

    Traditional medicine is not fixed in time: you have all the resources of room to think and contemplate a condition, pick the exact treatment that will help the patients. EM is firmly fixed in time: you have limited amounts of it, and it is a precious resource to be used wisely. If you take a half hour on a H&P for the little old lady who's weak and dizzy, your drunk will go into DTs and die in the next room. Time management, like seeing another patient while the first one's labs are cooking, is essential.

    Let other docs with more time and patience make good diagnoses. Your CHFer is decompensating in the other room, your hand lac is still bleeding, your seizure patient is seizing, and your psychotic PCP user has just ripped out his restraints again.

    The ER is your patient. Treat your patient, doctor.
     
  22. southerndoc

    southerndoc life is good
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    For the most part, any specialty concentrates on that specialty at the exclusion of others. Orthopods do not concentrate on general medicine because they do not need it. What does it matter? As an orthopod, you usually aren't going to be asked to workup a patient with hemoptysis, blurred vision, or abdominal pain after ingesting a meal.

    Generalist physicians (internists, family practitioners, and even emergency physicians) study everything in every specialty at the exclusion of studying things in as much depth as a specialist would learn.

    So it goes both ways. You can learn all there is about a particular area (e.g., cardiology) at the exclusion of others (e.g., nephrology), or you can learn something about everything at the exclusion of learning it in depth.

    If ortho is what you want to do, then by all means, do it! Don't worry what other people think. Unfortunately, medicine is such a specialty that no matter which specialty you choose, there will always be someone making fun of your specialty... and you making fun of the other specialties.
     
  23. Neuron

    Neuron Aequanimitas.
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    Just nitpicking about your otherwise sensible post - it is impossible to learn cardiology to the exclusion of nephrology. And, incidentally, vice-versa. :)
     
  24. Ex-fix

    Ex-fix Junior Member
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    Most of these problems are handled by your consultants. Most ED physician figure out the right person to call. THat's the major issue with ED docs. They should focus on one problem at a time. The real ER is far from what you see on TV. ER docs are trained pretty well at the basics, however when making complex medical decisions they begin having problems. ER physicians are very good at the ABC's of medicine, however when it comes to jumping to E,F, or even to Z, they begin to have issues.

    Don't get me wrong. I believe ED docs are smart people. Many get into it for the shift work and good salary. However, I truly believe that after residency their education takes a nose dive.
     
  25. TheMightyAngus

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    Anyone interested in both EM and Ortho? Please share your thoughts.
     
  26. Febrifuge

    Febrifuge Grizzled Old Newcomer
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    Yes. As to my thoughts, right now they tend toward "mmm, chicken pot pie."

    But I think you meant that less literally. I don't know how relevant this is to your situation, but I'll be a PA. So I can work in both, if I'm still into both when I'm done with school. And as a tech, currently, I am capable of a bitchin' thumb spica.
     
  27. Dr.McNinja

    Dr.McNinja Nobel War Prize Winner
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    I was, but I don't dig surgery. Or follow up clinic. Or how long the residency is. Beyond that though...
     
  28. EctopicFetus

    EctopicFetus Keeping it funky enough
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    Why would someone dig this up from 2004 no less? Start a new thread. anyways.. IMO there are people who like the OR and/or clinic and there are those that dont..

    Anyways I think that helps separate the fields.
     
  29. Febrifuge

    Febrifuge Grizzled Old Newcomer
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    Old threads are awesome. I can actually see myself get progressively more jaded, inappropriate, and incoherent.
     
  30. Dr.McNinja

    Dr.McNinja Nobel War Prize Winner
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    At least this person actually used the search function, as we always yell at people to use.
     
  31. docB

    docB Chronically painful
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    :laugh: Yeah. Reading old stuff is like looking at my old yearbook photos. "Just look how much thinner, poorer and less bitter I was."
     
  32. docB

    docB Chronically painful
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    True enough. At least this proves the search function works.
     
  33. docB

    docB Chronically painful
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    Oh. And BTW how'd this dose of trollage get by unnoticed.
     
  34. kungfufishing

    kungfufishing Senior Member
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    what I dont get is how often those in other specialties assume I chose this job because of "time off' or "shift work" or "good money for the hours" etc.

    That stuff is nice, but honestly I just like the work. I catch myself thinking "I love my job" often. corny, but true.
     
  35. Hard24Get

    Hard24Get The black sleepymed
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    Yeah, seriously! Reminds me of the geriatrics attending (no less) that asked, "Can I pay you a compliment?" then said, "go into something more intellectual than EM" :mad: EPs are not stupid! In fact, no specialty is, ortho include. Can't we all just get along? :(
     
  36. EctopicFetus

    EctopicFetus Keeping it funky enough
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    Someone cue up Kumbaya.. We can hold hands together and let everyone know how we all get along!
     
  37. iatrosB

    iatrosB trying not to kill anyone
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    :laugh:
     
  38. LanceArmstrong

    LanceArmstrong Level X Elite User
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    So we call this ortho resident to the ED to admit this old lady with a broken hip...he goes "this lady has new onset a fib, medicine has to admit, clear and manage her" the attending walks over to him looks at the EKG goes "no its just a noisy baseline and there's obviously a p wave in front of every QRS" the ortho resident squints at the ekg with a blank expression for about 30 seconds and goes - " i dont know nothing about that i just read the interpretation on top of the ekg" the attending looks at him and goes "i havent looked at the machine interpretation of a ekg in 10 years" :laugh:
     
  39. SoCuteMD

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    What do you call two orthopods trying to read an EKG?
































    A double blind study.
     
  40. ERMudPhud

    ERMudPhud Back for a visit
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    Like that hasn't been posted a few time here:rolleyes: :)
     
  41. step1

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    Ortho:
    -Contrary to many beliefs, Orthopedics is a very academically challenging field particularly from PGY1-3. For many residencies, it is a life dedication.
    -Resident-level texts in Ortho are of multiple volumes. For instance, Campbells is a 5-volume text with each volume the size of a Tintinalli. Rockwood & Green Fracture book is 3 volumes (inc Peds) - This is just the beginning. These and others are expected to be read to a significant degree if you want to do well on the in-service exam.

    Its like rejecting the Med School info in your brain learned over the last 4 years to do the Ortho School (Mayo actually has a 6-month medical school-Ortho experience incorporated in their residency).


    -Early Ortho's can manage medical disease, but are not up to date on latest treatments. Unless they go to Medicine CMEs (which they don't do), they will be outdated on latest drugs and trends for common diseases. And there isn't time for the motivated student to learn it.

    -At the attending level, many are uncomfortable using a stethoscope

    -You are usu not at front line of the hospital unless a big trauma case comes in. Even then Ortho's wait until the patient is stabilized before doing anything.

    -Orthos are stuck with floor work, some are chronic patients that stay for long periods that residents still need to see.

    -Surgeries may be fun but oftentimes residents have to 'fight' for them.
    Once you do get to operate, doing stuff like repeated TKA's can get old.

    -There is the prestige/ $$ aspect in Ortho- but the gratification of helping many patients in EM or FM may be more important to many.

    EM:
    Is more "Action Oriented" and demanding than Ortho, really!
    When you're on, you really are ON.
    (this is why you hear people talk about 'burn-out')

    -Shifts are only 8-12 hours because you are doing a lot more than waiting hours for the next OR room to open or finding X-ray technicians to shoot your reduction. Ortho is overall "slower".

    -You are always busy and 'needed' using medical knowledge and intuition to assess patients of all kinds.
    -you can competently manage practically any immediate situation that's thrown at you from every field, there is an exciting large variety of patients.

    -ER residents do get Ortho experience at trauma centers- initial evaluations, basic reductions, splinting, and more depending on what the hospital allows.
    -ER residents should learn some Ortho anatomy and basic classifications of fractures and injuries.

    -EM is a rapidly evolving field, more than any other. There are many opportunties for administrative, academic, or leadership roles.
    An EM trained physician can travel abroad and their skills are needed and well-received. Even exotic jobs like cruise-line physicians or airport physicians are now seeking EM-trained physicians only.

    -The importance of the ED is continuing to grow esp. with reimbursement cuts for admissions. ED's are becoming overcrowded and you may be expected to be knowledgeable and help out to some degree in managing patients who would be admitted to a specialty service.

    -You may be confident and comfortable treating patients if you were the only physician available in a small town.

    -EM is the reason why many of us actually decided to go to Med School in the first place. It meets many of our expectations in terms of the knowledge/experience gained, assessment of patients, and satisfaction from helping patients


    *if interested in Ortho, check out the Ortho Forums:
    http://www.orthogate.org/forums/

    *for EM, check out
    http://www.saem.org/saemdnn/
    http://www.acep.org/webportal
    http://www.aaem.org/index.php
    There are excellent Mentors available on the EM sites.
     
  42. J.J.

    5+ Year Member

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    I would love to be a trauma surgeon if I didn't have to be a surgeon!

    One of the above posters mentioned general surgery. I agree with him. If you love the OR, procedures and medicine, you can't go wrong with general surgery. If you love acute care and trauma, you can do a trauma fellowship and specialize in trauma and critical care. This allows you OR time as well as SICU pts who need very educated physicians who get to play with all the cool drugs, like "pressurs"

    JJ
     
  43. EctopicFetus

    EctopicFetus Keeping it funky enough
    10+ Year Member

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    Overall a real good post. Truth is we bash on each other and some people in all fields take this seriously. IMO we are all in it for the right reasons.
     
  44. TheMightyAngus

    5+ Year Member

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    Thanks! Just the kind of post I was looking for.
     

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