EM vs IM

[orthoguy]

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I am a lost 3rd year getting ready for 4th year planning and all of the joy that it brings and I am stuck deciding b/w EM and IM. It seems to me that IM would be more cerebrally challanging but ER would be a lot of fun with a nicer more flexiable lifestyle.

Any advice from any of you?

 

[deleted6669]

EM probably offers the more flexible lifestyle. no call. no patient panel. flex time options, for example you could work 10 out of 14 days and be off the rest of the month with pay without using any vacation time. more variety in em to include trauma, gyn, and kids. if you really want to focus on the care of sick elderly patients and not much of anything else than IM is the field for you. I am a little biased, but you could not pay me enough money to practice IM
also, not a whole lot of ortho in IM, ORTHOGUY🙂

 

[EidolonSix]

I just finished an ER rotation in my residency. It could be a lot of fun but it does grind you down seeing and treating so many people who are not sick, never getting to the bottom of problems and often being dumped on by outside physicians. The variety was good however, with a bit of surgery, ortho, basic medicine and peds rolled in to one. Frankly, ER seems like running a busy clinic for poor people interrupted with occ. periods of excitement. I found the knowledge of my ER attendings to be adequate, but far from mind boggling, unlike many IM/ IM subspecialty attendings who seem to benefit both an understanding of acute issues as well as chronic issues and the complex interplay between diseases and the patients.

IM has its own problems...the burden of caring for the sickest patients, dumps from surgical services who believe than *any* medical problem is justification for transfer and the everpresent reality that despite your best efforts, your patient often get worse. The plus side...subspecialties, the variety combined with depth (you'd be hard pressed to find a specialty that requires such a commanding knowledge of physiology and pathophysiology), meaningful relationships with some patients (some of my VA patients I consider friends). Subspecialties offer some lifestyle differences. Hospitalists also enjoy some of the benefits of ER medicine in terms of flexibility. Remember to though that it is much better to spend 80 hrs doing something you love than 40 hrs doing something you hate. You'll be a better doctor for it.

 

[smackdaddy]

burnout is higher in er as is liability.
people use the er (in places) as their clinic, so you are attempting to practice (the field of) medicine without the same training that internists, orthopods, etc get.
like the other guy (but different), you couldn't pay me to do er.

 

[DrWBD]

I had the same dilemma of choosing between EM and IM when I started my 4th year. IMHO if you are considering EM, it's to your advantage to get exposure as early as possible in your 4th year, b/c EM is still much more competitive than IM. Plus you can get letters of recommendation from EM program directors in time for your ERAS application, which you should definitely have when applying.

 

[Apollyon]

Originally posted by smackdaddy
people use the er (in places) as their clinic, so you are attempting to practice (the field of) medicine without the same training that internists, orthopods, etc get.

EM physicians are experts in resuscitation and rapid recognition of illness and health. Clinic medicine has a lot of preventive stuff - and I never once gave a pt in the ED a referral for breast clinic or mammography, routine diabetic eye care, foot care, guaiac cards, or routine colonoscopy.

Your moderately withering criticism of EP's doesn't look at the flipside- ever see an orthopod or IM doc run a code, vs. an EM doc? IM codes in teaching hospitals are noted for one thing - being "charlie foxtrots" (CF's).

 

[ryryguy]

ever see an orthopod or IM doc run a code, vs. an EM doc? QUOTE]

At OSUMC in Tulsa, IM runs codes all the time.

 

[gro2001]

IM codes in teaching hospitals are noted for one thing - being "charlie foxtrots" (CF's).

((disclaimer: med student, AND going into EM of all things))

I am not sure that's a fair statement. I saw codes by IM (at teaching hospitals) that were supremely well run and ones that were CFs. Likewise with EM. And with peds. And surgery. I don't have percentages of well vs poorly run codes for each speciality, and maybe there is a significant difference one way or the other, but there is nothing that makes it inherently likely for an IM physician to be worse at running a code than an EM physician. EPs may see more codes/month but both specialities see sick people and both rotate through ICUs. Also, I would make the argument that number of codes attended/run may not be the strongest determinant of how well a physician runs a code. It's not quite like a procedural skill.

 

[jdh71]

The dead should stay dead. You've all seen the movie about that happens when the dead live? Zombies. Why would any of you want that?

 

[gutonc]

Nice useless necrobump. Don't do this again. I mean it.

Also, pretty much every code, even the ones which are perfectly run, is a clusterf*** in the end. In the ED (or the OR) they run the code, get ROSC, get the tube and ship them to the MICU where they soon die (on somebody else's service).

In IM, we know they're going to die and it's going to be on our service, so we do the same thing (get ROSC and drop the tube) but then they croak on our service anyway (just like they would have in the prior scenario). The only difference is that, in the first scenario, somebody (EM, Gas, Surg) gets to look like a hero with IM as the goat, while in the latter IM is the goat from the start. Outcome is the same in either case but perspective means a lot.

 

[Apollyon]

Damn - 8 year bump! Damn!

 

[Bostonredsox]

EM physicians are experts in resuscitation and rapid recognition of illness and health. Clinic medicine has a lot of preventive stuff - and I never once gave a pt in the ED a referral for breast clinic or mammography, routine diabetic eye care, foot care, guaiac cards, or routine colonoscopy.

Your moderately withering criticism of EP's doesn't look at the flipside- ever see an orthopod or IM doc run a code, vs. an EM doc? IM codes in teaching hospitals are noted for one thing - being "charlie foxtrots" (CF's).

Not all of us in the IM world are poor at running codes 🙁 Lots of recusitation in the ICU and most of us intensivists (still a few years from now for me I know) were at one point in our training, internists.

 

[Gastrapathy]

The dead should stay dead. You've all seen the movie about that happens when the dead live? Zombies. Why would any of you want that?

The thread or the topic of the thread?

+1 for both.

 

[ranmyaku]

At my two hospitals, the ER essentially calls IM to run the codes. If they have an arrest in route to the hospital, they overhead page 'code blue' prior to patient arrival so the IM team is in the ER when they arrive. Also, if the patient codes in the ER, they call code blue and then when I walk in the door they are like 'see ya later' patient is yours. We have actually complained to admin about this. Additionally, rarely do the patients have central lines placed in the ER. The caveat is that we do not have an EM residency program, so maybe if we did things would be a lot different.

 

[jdh71]

At my two hospitals, the ER essentially calls IM to run the codes. If they have an arrest in route to the hospital, they overhead page 'code blue' prior to patient arrival so the IM team is in the ER when they arrive. Also, if the patient codes in the ER, they call code blue and then when I walk in the door they are like 'see ya later' patient is yours. We have actually complained to admin about this. Additionally, rarely do the patients have central lines placed in the ER. The caveat is that we do not have an EM residency program, so maybe if we did things would be a lot different.

necromany is a crime punishable by burning at the stake

 

[bravotwozero]

necromany is a crime punishable by burning at the stake

Will you be doing the honors?

 

[jdh71]

Will you be doing the honors?

Did you really stop by a stupid necrobump and respond to a joke in an attempt to try and start some shiz? I just want to make sure I'm completely understanding the current situation. 🙂

 

[bravotwozero]

Did you really stop by a stupid necrobump and respond to a joke in an attempt to try and start some shiz?

yes....😛

 

[jdh71]

yes....😛

noted

 

[Tedebear]

Here is the big difference.

Although both make over $200K out of residency.

Hospitalists sleep in their own bed every night (most hospitalists groups have nocturnalists that cover nights exclusively).

ER physicians work night shifts. You will never be able to get out of working nights as a ER physician.

 

[Tedebear]

EM probably offers the more flexible lifestyle. no call. no patient panel. flex time options, for example you could work 10 out of 14 days and be off the rest of the month with pay without using any vacation time. more variety in em to include trauma, gyn, and kids. if you really want to focus on the care of sick elderly patients and not much of anything else than IM is the field for you. I am a little biased, but you could not pay me enough money to practice IM
also, not a whole lot of ortho in IM, ORTHOGUY🙂

Not so fast emedpa.

Hospitalists have no call (12 hour shifts) and have better hours than ER. Work 7am-7pm via one week on and one week off. Don't carry pagers outside of their 7am-7pm shifts. Plus starting salaries are over $210,000 and you still get 26 weeks off.

ER physicians work nights and staggered shifts. Working night shifts is tough as you get older.

Therefore, I would say that Hospitalists have a better schedule than ER because it is a fixed schedule not staggered shifts. Plus you don't have to work night shifts. Both specialties don't have call with pagers either.

 

[countthestars]

How much would a hospitalists working in New York City (I'm about Manhattan, Queens or Brooklyn) be able to make and what kind of hours would they be putting in?

 

[jdh71]

looks like we've brought back to life a special kind of undeadthread

we'll need some major powerful juju to keep this one dead

 

[tkim]

Hospitalists sleep in their own bed every night (most hospitalists groups have nocturnalists that cover nights exclusively).

Plus you don't have to work night shifts.

Not at my hospital. And not at a lot of other hospitals. For what you say to be true, there are an almost equal amount of hospitalists that exclusively work nights. Can it be true that 50% of hospitalists prefer to be nocturnists? I find that hard to believe.

http://todayshospitalist.com/index.php?b=articles_read&cnt=105

"One of the downsides of working with nocturnists is the limited supply of physicians willing to work nights.

When Sanjiv Panwala, MD, was looking for work as a nocturnist three years ago, he says hospitalist groups were bending over backwards to accommodate him. "More people are trying to get nocturnists," says Dr. Panwala, now one of two nocturnists at Providence St. Vincent Medical Center in Portland, Ore., "but there just aren't enough people willing to do it.""

http://www.acphospitalist.org/archives/2008/12/cover.htm

"There's a reason Dr. Sabharwal spoke in the past tense, though. Although he was one of the first to document the nocturnist trend, in a first-person piece in The Hospitalist in 2005, his hospital has since given up on its nocturnist program.

The problem was recruitment. "Even with a significant salary differential, there was no interest from anybody," Dr. Sabharwal said. He understands his colleagues' reluctance, as his sleep schedule is still suffering the consequences of working as a nocturnist. "I haven't worked nights in a year and a half and I'm still not back to normal." "

 

[Bostonredsox]

Not at my hospital. And not at a lot of other hospitals. For what you say to be true, there are an almost equal amount of hospitalists that exclusively work nights. Can it be true that 50% of hospitalists prefer to be nocturnists? I find that hard to believe.

http://todayshospitalist.com/index.php?b=articles_read&cnt=105

"One of the downsides of working with nocturnists is the limited supply of physicians willing to work nights.

When Sanjiv Panwala, MD, was looking for work as a nocturnist three years ago, he says hospitalist groups were bending over backwards to accommodate him. “More people are trying to get nocturnists,” says Dr. Panwala, now one of two nocturnists at Providence St. Vincent Medical Center in Portland, Ore., “but there just aren’t enough people willing to do it.”"

http://www.acphospitalist.org/archives/2008/12/cover.htm

"There’s a reason Dr. Sabharwal spoke in the past tense, though. Although he was one of the first to document the nocturnist trend, in a first-person piece in The Hospitalist in 2005, his hospital has since given up on its nocturnist program.

The problem was recruitment. “Even with a significant salary differential, there was no interest from anybody,” Dr. Sabharwal said. He understands his colleagues’ reluctance, as his sleep schedule is still suffering the consequences of working as a nocturnist. “I haven’t worked nights in a year and a half and I’m still not back to normal.” "

From what I have seen that differential in day to night pay is so large that is has me considering straight 7 on 7 off nights for the first few years out of residency to help get the house/loan/carpayments down. Plus the kids are asleep at night anyway as they're all still very little.

 

[tkim]

From what I have seen that differential in day to night pay is so large that is has me considering straight 7 on 7 off nights for the first few years out of residency to help get the house/loan/carpayments down. Plus the kids are asleep at night anyway as they're all still very little.

You would be in high demand if you wanted to be a nocturnist, but if you decide you like the job, but after a few years wanted to switch to some days, I wonder how much resistance you would encounter? Something stipulated in the contract, I suppose.

 

[Bostonredsox]

You would be in high demand if you wanted to be a nocturnist, but if you decide you like the job, but after a few years wanted to switch to some days, I wonder how much resistance you would encounter? Something stipulated in the contract, I suppose.

I'm assuming that I would sign a contract for say 3 years of nocturnal 7p-7a, 7 on 7 off, at the end of which I could decide to reup my contract, and if the field hasn't changed, ask for more money, or opt out and take a day job somewhere else.

 

[tkim]

I'm assuming that I would sign a contract for say 3 years of nocturnal 7p-7a, 7 on 7 off, at the end of which I could decide to reup my contract, and if the field hasn't changed, ask for more money, or opt out and take a day job somewhere else.

I'd stick with a yearly 'evergreen' contract and work from there.

 

[Bostonredsox]

I'd stick with a yearly 'evergreen' contract and work from there.

can you elaborate on that I'm not exactly sure what you mean.

 

[tkim]

can you elaborate on that I'm not exactly sure what you mean.

Evergreen contracts are ones that automatically renew every year unless one or both parties want to change the terms of the contract. Prevents a lapse in contract coverage, and having to revisit/re-sign the contract every year.

Signing a three-year contract locks you into those terms for three years. Lots of things can happen during three years. If you want to be a nocturnist, you have the upper hand and should not lock yourself into a longer contract. You should have the opportunity to renegotiate your contract after working for a year to see if you're getting what you want/deserve.

 

[Bostonredsox]

ahh I got ya. I chose 3 years just for arguments sake, whether its a year or 3 I was just trying to say I would sign as a nocturnist for a particular duration and then revisit my options at the end of it. If I was making a killing and enjoyed it, I'd stay. If I didn't really love it I would ask for more money. And if I had made enough to get my bills under control and wanted to move at the end of the contract I'd take a new job.

 

[Tedebear]

Just love how people distort facts here.

The fact is that there are many jobs available without doing nights as a Hospitalist and there are very few jobs (if not zero) that preclude nights for ER physicians.

The reason is that Nocturalists are hired by hospitalist groups to cover nights. Look up nocturnalist on google.

Also hospitalists have fixed 12 hour shifts. ER shifts are staggered. You work 1st, 2nd, and 3rd shifts. Lack of control of hours is HUGE.

 

[gutonc]

Also hospitalists have fixed 12 hour shifts.

Not always true. The largest hospitalist group in this town has a whole variety of shifts (some 6s, 8s, 10s and 12s) with varying degrees of overlap depending on the time of day and varying responsibility (rounding, admits, consults) based on shift length.

The 12/12 7/7 model is common for hospitalists but not the only one. Likewise, there are plenty of small community EDs where they work single coverage (often with PA/NP assistance) split 12s.

 

[tkim]

Just love how people distort facts here.

Like you.

 

[jdh71]

this thread is the gift that keeps on giving

 

[Apollyon]

Yeah, just like herpes.