EM Vs IM

[randommedstu]

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anyone else having a problem deciding between these two fields? which specialty do you think has a better lifestyle?

 

[tkim]

EM vs hospitalist = no difference in lifestyle.

 

[KissMyAsthma98]

I am also having a hard time!! EM has a much better lifestyle, but I feel like IM is more academic and intellectual- more time to think about and solve complex problems. It seems crazy to me though to give up a 30 hr/week schedule for a 100+ hr/week schedule. I'm confused!!

 

[gutonc]

I am also having a hard time!! EM has a much better lifestyle, but I feel like IM is more academic and intellectual- more time to think about and solve complex problems. It seems crazy to me though to give up a 30 hr/week schedule for a 100+ hr/week schedule. I'm confused!!

So...an EM attending tells you there's no difference in lifestyle and you follow that up with an imaginary 30h EM schedule compared to an imaginary 100+h IM schedule?

I will grant you that EM residents have a generally easier schedule (when not on off-service rotations) than most IM residents have (although IM residents don't have to do trauma and ortho rotations which blow goats). But this is neither universally true, nor particularly relevant when you consider that this is <10% of your working life.

As an attending, to make a huge generalization, your average EM schedule over the course of 2 weeks would be 6-8 shifts of 9-12 hours (depending on group and hospital). The average IM hospitalist schedule is probably 7 days (in a row or separated) probably 12-14 hours a day. So the EM attending will work 72-ish hours over 2 weeks and the IM attending will work 84-ish. So yes, that's 12 more hours (6h/week) for IM, but not the 70+ you quoted (which was sheer crazy talk).

Also, keep in mind that most IM hospitalist schedules are much more predictable than EM attendings. In hospitalist work, the shifts are usually 7 days (or 7 nights if that's how you roll) in a row, all with the same hours. Over the course of 2 weeks, an EM attending may work two 7a-4p shifts, get a day off, work two 3p-1a shifts, have 3 days off, work three graveyard shifts, have two more days off and then repeat some crazy combo of the above.

Choose the medicine you want to practice. You can make the schedule work for you no matter which one you choose.

 

[Reddpoint]

With IM you can definitely have a good lifestyle either as a hospitalist or working in primary care for a big group. You will not work 100+ hours as a resident or attending in IM (unless you specialize in cards and want to make a 7 figure salary).

Make you decision based on the type of medicine you feel comfortable practicing. As an IM doc, I could not stand the superficial nature of the ER. You triage patient to home vs admit and never see if what you did was right or not. You also deal with so many people who are completely pissed off because they have been waiting for 6+ hours to see a doctor. I really do not see how people do not burn out from EM. Now I know that the ER doctor likes to point out that even if they have an annoying patient they get to sign them out at the end of their shift whereas a hospitalist will have to deal with them until they are discharged. Its a fair point but I definitely feel that every shift in the ER will have a number of abusive patients whereas the hospitalists do not constantly have to deal with terrible patients. Just remember that there is much more flexibility in any field in medicine than is apparent to you as a 3rd year medical student. Choose which field you like better and shape your career to you own goals.

 

[Apollyon]

Make you decision based on the type of medicine you feel comfortable practicing. As an IM doc, I could not stand the superficial nature of the ER. You triage patient to home vs admit and never see if what you did was right or not.

Not always true - in fact, I get a lot of feedback (both from the doctors, and from the nursing supervisor, who has the list and knows what is going on).

You also deal with so many people who are completely pissed off because they have been waiting for 6+ hours to see a doctor. I really do not see how people do not burn out from EM.

Again, not always true - working in a busy city hospital, people can wait 6+ hours - but it is rare that that person has anything but a trivial problem. As for not burning out, it's because people know what they're getting into, and their training is geared towards it (versus people in the past that were trained in something that had elements of EM, but also wide swaths of things they weren't taught - like the IM doc and anything traumatic - fractures, lacerations, MVCs, and the surgeon with almost anything medical, for very broad stereotypes).

Now I know that the ER doctor likes to point out that even if they have an annoying patient they get to sign them out at the end of their shift whereas a hospitalist will have to deal with them until they are discharged. Its a fair point but I definitely feel that every shift in the ER will have a number of abusive patients whereas the hospitalists do not constantly have to deal with terrible patients.

That is saying the same thing: "docs in the ED will have bad patients, and hospitalists will have bad patients" - higher frequency but lower duration in the ED, lower frequency but higher duration on the floor.

Just remember that there is much more flexibility in any field in medicine than is apparent to you as a 3rd year medical student. Choose which field you like better and shape your career to you own goals.

True, true, true. I thought I liked IM until I did it (for a prelim year) (and I was good at it), and then found my true calling.

 

[Dirt]

This thread wins in my book.

👍👍

 

[NaughtyGirl]

Both are great fields. Hospitalists and ER physicians make about the same amount of money.

The big difference in my mind are working the graveyard shift. All ER physicians work nights. Hospitalists with Nocturnalists in the group work set hours during the day.

Not working the night shift is a big tie breaker in my book.

 

[blight]

Both are great fields. Hospitalists and ER physicians make about the same amount of money. .

Is this really true?

 

[gutonc]

Is this really true?

Can be. Median salaries are probably pretty similar but the tail on the EM salary curve is probably a little bigger and longer than on the hospitalist salary curve.

 

[docscience]

just offering my thoughts on this debate as I recently had to wrestle with this decision:

- obviously the setting matters...you may have some quiet night ER shifts in a smaller town. in a big major city, forget it, you will definitely have patients to see all night long...you definitely will be working! Also, ER @ the VA is a different beast than the ER at a Level 1 Trauma center.

- pros for ER: shift work, don't have to worry about patients after shift, another physician/team takes care of the patient.
- cons for ER: as pointed out you will have to work NIGHTS, don't know what happens to your patients if you consult/no continuity of care, most patients are admitted to another service, can't work in IM/do IM fellowship

- pros for medicine: no night shift if you are a hospitalist (vs. nocturnist), continuity of care, opportunity to specialize, can always moonlight in the ER***
- cons for medicine: not as many procedures and "adrenaline"/first care medicine, long floor pts, more social issues?

just some naive thoughts

***someone correct me if i am wrong/are can give a good summary of moonlighting rules/opportunities

 

[ILEMres]

With IM you can definitely have a good lifestyle either as a hospitalist or working in primary care for a big group. You will not work 100+ hours as a resident or attending in IM (unless you specialize in cards and want to make a 7 figure salary).

Make you decision based on the type of medicine you feel comfortable practicing. As an IM doc, I could not stand the superficial nature of the ER. You triage patient to home vs admit and never see if what you did was right or not. You also deal with so many people who are completely pissed off because they have been waiting for 6+ hours to see a doctor. I really do not see how people do not burn out from EM. Now I know that the ER doctor likes to point out that even if they have an annoying patient they get to sign them out at the end of their shift whereas a hospitalist will have to deal with them until they are discharged. Its a fair point but I definitely feel that every shift in the ER will have a number of abusive patients whereas the hospitalists do not constantly have to deal with terrible patients. Just remember that there is much more flexibility in any field in medicine than is apparent to you as a 3rd year medical student. Choose which field you like better and shape your career to you own goals.

EM physicians don't triage pt's at all. We work them up to a diagnosis prior to admitting to you. All the pertinent labs and procedures are done before you see them. You have the easy part, "Pt admitted for sepsis" give antibiotics. We have the hard part - pt comes in with unspecific sx and we have to sort it out. And of course put the central line in, a-line, do the LP, do all the hard work for you and we do it in no time. You IM and surgery folks need to stop dissing EM docs.

 

[ILEMres]

EM physicians don't triage pt's at all. We work them up to a diagnosis prior to admitting to you. All the pertinent labs and procedures are done before you see them. You have the easy part, "Pt admitted for sepsis" give antibiotics. We have the hard part - pt comes in with unspecific sx and we have to sort it out. And of course put the central line in, a-line, do the LP, do all the hard work for you and we do it in no time. You IM and surgery folks need to stop dissing EM docs.

oh and for a field of medicine that is considered nothing more than the case managers (consult cardiology for the sinus tach, consult GI for the nausea, consult neuro for the confusion, consult surgery for the belly pain) come on guys - seriously?! Trying to diss EM docs... You know what I do w/ a belly pain? I put an Ultrasound on them, I diagnose them bedside, and the only reason we admit to IM docs is because we can't keep them in the ED. Triage my *****..

 

[gutonc]

oh and for a field of medicine that is considered nothing more than the case managers (consult cardiology for the sinus tach, consult GI for the nausea, consult neuro for the confusion, consult surgery for the belly pain) come on guys - seriously?! Trying to diss EM docs... You know what I do w/ a belly pain? I put an Ultrasound on them, I diagnose them bedside, and the only reason we admit to IM docs is because we can't keep them in the ED. Triage my *****..

You know you're arguing with a med student, right? The rest of us ignored his (ignorant/conceited) post and moved on. You'd be wise to do the same.

 

[ILEMres]

You know you're arguing with a med student, right? The rest of us ignored his (ignorant/conceited) post and moved on. You'd be wise to do the same.

Oh. I did not know that. Why in the heck is he talking like he knows whats up then?? UGH! Well, it makes more sense now... Thanks! 😀

 

[SeekerOfTheTree]

You know I have always wondered, can you apply to both IM and ER or do you have to pick one specialty to apply to for matching?

I am hungry.

 

[randommedstu]

Both are great fields. Hospitalists and ER physicians make about the same amount of money.

The big difference in my mind are working the graveyard shift. All ER physicians work nights. Hospitalists with Nocturnalists in the group work set hours during the day.

Not working the night shift is a big tie breaker in my book.

i think that EM docs make a considerable amount more $$.

in your opinion, what is specialty is more tiring and has more burnout?

 

[Reddpoint]

You know you're arguing with a med student, right? The rest of us ignored his (ignorant/conceited) post and moved on. You'd be wise to do the same.

Sorry I didnt update my status, Im a IM resident. I can only speak for the ED at my program but its a 50/50 shot that I even have a vague diagnosis by the time I come to the ED for an admission. I cannot count the times Ive come down to find my CHF patients with hypotension after getting 3L of fluids for "sepsis" with a JVP to their forehead. At least at my program the ED is more concerned with determining whether to admit vs dc than making a diagnosis. That may be less true at a community program.

 

[JoyfulMD]

EM physicians don't triage pt's at all. We work them up to a diagnosis prior to admitting to you.

All the pertinent labs and procedures are done before you see them. You have the easy part, "Pt admitted for sepsis" give antibiotics. We have the hard part - pt comes in with unspecific sx and we have to sort it out. And of course put the central line in, a-line, do the LP, do all the hard work for you and we do it in no time. You IM and surgery folks need to stop dissing EM docs.

Maybe in your hospital but not where I am. We put in the lines (sometimes right in the ER). We make the diagnoses (ED is sometimes correct).

 

[Reddpoint]

One more thing to add. I believe that the ED docs are very good at what they do its just a different type of medicine than IM. Many times when there is a straight forward diagnosis it can be made quickly in the ED. However, what I would argue the interesting part of internal medicine is the more difficult diagnosis that cannot be made in the 6-8 hours a patient sits in the ED. If a 50 y/o patient comes into the ED with three days of dyspnea and infiltrates on their CT scan they might have CAP. However just because they are started on ceftriaxone and admitted does not mean that is the correct diagnosis. That person might end up having an ILD, eosinophilic PNA, cancer etc. You cannot figure that out in the ED. Its not what the ED is designed to do nor should it be expected to.

 

[Super Mario]

I enjoyed both rotations as a med student and considered both as a career choice. Both EM and IM often involve working up undifferentiated patients and coming up with differential diagnoses so I don't think its unexpected to like both fields.

EM Pros:
- In many ways, your job will be that of the ultimate generalist. You will learn to manage pregnant women, kids and trauma in addition to adult medical problems
- Lots of minor procedures like lacs, I&D, etc that you don't do quite as frequently in IM
- When you're done with your shift, you are truly done (no labs to follow up on, patients to contact, etc)

EM Cons:
- Frequent night shifts
- As Reddpoint alluded to, the ER is not the place to get to the bottom of a complex diagnosis. You will probably never realize the routine community acquired pneumonia you admitted actually had IPF, or the abdominal pain actually had hypercalcemia due to MEN1.
- No long-term patient relationships (I really underestimated how important this was as a medical student and even as an intern)

IM Pros:
- Numerous opportunities to specialize and tailor your job as you see fit. You can do shift work as a hospitalist, work 8-5 in a clinic as a PCP or rheumatologist, focus on advanced procedures (therapeutic endoscopy, interventional cards/pulm)... the list goes on (can even run an ER at a VA).
- Longer-term patient relationships
- Opportunity to get to the botton of complex cases and learn how to manage patients who haven't responded to the standard stuff in pocket medicine/up to date
- Far more structured opportunities and mentorship if you have any interest in a research-based career (although EM departments do conduct research, it is typically nowhere close to what IM departments have to offer)

IM Cons:
- Hospitalist: lots of paperwork, social issues. In practice (out of training) procedures often handed off to IR since they even a simple LP can take an hour and ruin your efficiency
- GI/Cards: often have to come in at night to scope a variceal bleeder or cath a STEMI or at least field calls and troubleshoot
- Any office based specialty: need to follow up on tests, share call (even if its home call in a field like oncology or endocrine or outpt primary care)

Income: this is actually difficult to compare because for one, IM has many subspecialties with very disparate pay. Also, the pay differs between IM subspecialities, between private practice vs academic (and type of academic), and region.

EM/IM:
There are 5-year programs that train you to do both, and I have met attendings who split their time between the wards and the ER. The flip side is the folks who trained in this combined track and now only practice in one field have essentially wasted 2 years of training/income.

 

[confuse]

I think you have to know what's important to you. Continuity of care is very important for me so EM is not an option. Having to spend hours dealing with social issues instead practicing medicine is what bothers me most about IM, but not as much as the lack of continuity of care of EM.

 

[Reddpoint]

Many med students feel like there are lots of "social issues" in IM because they work at academic centers. However if you were to work in the community at a private hospital ie Kaiser there would likely be relatively less social issues and more bread and butter. That being said you would probably have more rich patients which can be another headache. Med school does a bad job of showing the various practice options you have any specialty.

 

[badasshairday]

Many med students feel like there are lots of "social issues" in IM because they work at academic centers. However if you were to work in the community at a private hospital ie Kaiser there would likely be relatively less social issues and more bread and butter. That being said you would probably have more rich patients which can be another headache. Med school does a bad job of showing the various practice options you have any specialty.

The "social issues" are what turn me off. However I did realize it is the practice setting.

I did my first month of IM at the VA and they have (surprisingly) much less social issues than the academic hospital I am at this month. I think part of it is because everyone is covered at the VA so no issues in getting insurance/disability benefits/whatever for oxygen or continuity of care. Also making follow up appointments is a breeze at the VA because it is just an easy electronic consult and it is all done for you... no googling the PCP or whatever and calling them which is crap scutwork. Also they have the "Hoptel" at the VA which is a transition between hospital and hotel..... so at least we can boot them off of the medicine floor. Plus the have the geriatrics unit which makes it easier to get them off the medicine floor when they are waiting for assisted living things to fall through.

At the academic hospital peoples discharge can be slowed down because they have no insurance so we have to wait for social workers to work something out to get home oxygen and follow ups. Follow up appointments means looking up on google and waiting on hold to get to some shady clinic to schedule an appointment.

I assume community hospitals and HMO giants like Kaiser have MUCH less social headaches than big academic hospitals. Hence, I am still leaning towards IM big time these days. Probably do the hospitalist gig for a while then maybe subspecialize.