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ER Medicine....to specialize or not to specialize

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Gooser2019

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Colleagues! As a 4th year student, I've been struggling with what I want to do after graduation. A little background...

A couple years ago I thought I really wanted to be a surgeon. After gaining some experience with board-certified surgeons and surgical practice, I gained a lot of respect for the discipline, but ultimately realized it wasn't something I wanted to spend my life doing. I still assumed I would pursue some specialty of some kind in the end, be it cardiology, internal medicine, etc. After working in an emergency and referral hospital over the past year, and currently being on my ICU/Emergency rotation (and LOVING it), I have totally fallen in love with emergency medicine and have no question this is what I want to do with my career. The conflict now is whether I should pursue ECC board certification or be an ER vet at a hospital, no board certification.

Despite always assuming I was going to move forward with specialty medicine, my mindset is something that has also evolved over the last year. I've gotten to the point where I've realized life is painfully short and I'm ready to start living. Be that traveling the world with my husband, having lazy days off, having the time to stroll around a farmer's market or art festival, etc (while being full aware ER med comes with overnights and weekend work, which I'm cool with) I'm not so confident specialization is for me anymore, but I want to know I can have a good career being an emergency vet without it.

The ER vets I work with are great doctors who are really good at what they do, and they are not specialized, just enjoy emergency medicine. What are your thoughts and/or experiences with ER med, and if going through putting life on hold is really worth it in the end for what I'd like to do?

Thanks all!
 

CalliopeDVM

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can have a good career being an emergency vet without it.
Yes! There are many, many emergency clinics around the country that don't hire ACVECC specialists, or not exclusively specialists. If your goal is to work in emergency medicine but not necessarily further the field of, or be on the cutting edge of, critical care, I would say don't specialize. Especially if you are considering the possibility of starting a family, because even though night and weekend work can work well in a relationship, I don't think it can be really satisfying in a life with young children.

Also remember that you can pursue a residency (if you change your mind) after working in the field for a few years - it's not an irreversible decision if you choose not to do it now.
 

Minnerbelle

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This one's an easy one. If you know you like emergency, then do an internship at a good program with a busy ER. That's really good enough for most ER receiving jobs. Then if you decide you want further training (most people don't need it) you can decide if an ER specific internship is something you want to do vs ECC residency. Honestly unless you want to be a criticalist, you don't need an ECC residency. Though your chances of an 8-5 job is much higher as a criticalist if that's what you want. At some point along the way, if you decided you wanted to change paths you can do that easily.
 

jmo1012

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I agree with finding a good internship with good, mentored ER shifts and time with critical care specialists. Also try to ask the residents at your school why they are doing the residency, and talk to some ER docs about why they chose that route.

I'm about to be a 3rd year resident (!!:wideyed:). I wanted to do the residency because I really, really enjoy pathophysiology and having a more significantly in depth understanding of physiology and medicine. It does not matter how much you read or how much CE you attend, this really cannot be (fully) achieved outside of a residency with strong mentorship. I also don't like emergency work. At all. I enjoy stabilizing something critical, managing patients in an ICU, and dealing with the most critically crashing patients, but I do not enjoy the more mundane vomiting for a day, torn nail, laceration, etc. I don't enjoy how unpredictably busy that makes me and how it takes away from other truly sick patients. The reality is that I may end up working some combo of ER, but right now the set up at the practice my residency is at is what i would ideally like to achieve. I also did a residency because I want to work a day job. The above 8-5 hours as a day CC job are a little bit of a stretch, but most CC people work 3-4 10-12 hour day shifts a week. ER people work similarly, but a lot of the ER shifts are swing or overnights.

Internship and residency are going to steal a solid 4 years of your life. Theres no way around how intensive and time consuming these programs are. They have to be. You have to learn, read, and achieve so much in a finite period of time. People have families and friendships and things outside of work, but it is really, really hard to make it a reasonable balance. It is hard to make it to special family and friend occasions. I cannot fathom being pregnant during those 4 years and dealing with the long hours and stress and strain. Its tough for many people to even maintain a healthy, happy relationship with a significant other. If you are feeling the pressures of life now as a student, you may very well not want to stick it through another 4 years of grueling training. I went into it happy to make the sacrifices and not wanting to focus on other things in life. As I'm nearing the end and am exhausted, I am starting to realize I want more to life than work. Fortunately for me, I just have 1 year left, but it still feels like forever in some aspects. I do genuinely think this is the hardest specialty residency for the above reasons, and because we don't work "normal" hours and then just have on call. ECC residents generally work all the shifts and weekends. Some weeks and places quality of life is better than others, but even then, you are still often working when most of the world is not. My surgery and neuro friends came in close second because they had a ton of on call and patients in the hospital to care for every day, but they still generally had more freedom to do things during normal hours with normal people.

One last comment. I think pretty poorly of ECC specialty internships. When I was applying for residencies and worrying I wouldn't match, I looked in all of the available programs that year (dozens and dozens). When it came down to it, all but 1 or 2 were primarily poorly paid ER jobs that had minimal exposure to the ECC specialists. My take away was crappy hours for crappy pay with not a lot of formal learning to be gained. I think a good rotating internship with good mentored ER time is an excellent step for a new graduate, but just don't think theres a big benefit for a specialty ECC internship to make you a better residency candidate. Not in the way you get the repetitive exposure and learn how to echo as a cardio specialty intern, or constant exposure of performing a solid neuro exam and interpreting neuro diagnostics with a neuro internship. Maybe I'm wrong, but I just don't think theres tons of valuable experience to be gained from a specialty ECC internship as opposed to working as a real ER doctor. Why not work better hours and earn a real salary? :shrug:
 

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I agree with finding a good internship with good, mentored ER shifts and time with critical care specialists. Also try to ask the residents at your school why they are doing the residency, and talk to some ER docs about why they chose that route.

I'm about to be a 3rd year resident (!!:wideyed:). I wanted to do the residency because I really, really enjoy pathophysiology and having a more significantly in depth understanding of physiology and medicine. It does not matter how much you read or how much CE you attend, this really cannot be (fully) achieved outside of a residency with strong mentorship. I also don't like emergency work. At all. I enjoy stabilizing something critical, managing patients in an ICU, and dealing with the most critically crashing patients, but I do not enjoy the more mundane vomiting for a day, torn nail, laceration, etc. I don't enjoy how unpredictably busy that makes me and how it takes away from other truly sick patients. The reality is that I may end up working some combo of ER, but right now the set up at the practice my residency is at is what i would ideally like to achieve. I also did a residency because I want to work a day job. The above 8-5 hours as a day CC job are a little bit of a stretch, but most CC people work 3-4 10-12 hour day shifts a week. ER people work similarly, but a lot of the ER shifts are swing or overnights.

Internship and residency are going to steal a solid 4 years of your life. Theres no way around how intensive and time consuming these programs are. They have to be. You have to learn, read, and achieve so much in a finite period of time. People have families and friendships and things outside of work, but it is really, really hard to make it a reasonable balance. It is hard to make it to special family and friend occasions. I cannot fathom being pregnant during those 4 years and dealing with the long hours and stress and strain. Its tough for many people to even maintain a healthy, happy relationship with a significant other. If you are feeling the pressures of life now as a student, you may very well not want to stick it through another 4 years of grueling training. I went into it happy to make the sacrifices and not wanting to focus on other things in life. As I'm nearing the end and am exhausted, I am starting to realize I want more to life than work. Fortunately for me, I just have 1 year left, but it still feels like forever in some aspects. I do genuinely think this is the hardest specialty residency for the above reasons, and because we don't work "normal" hours and then just have on call. ECC residents generally work all the shifts and weekends. Some weeks and places quality of life is better than others, but even then, you are still often working when most of the world is not. My surgery and neuro friends came in close second because they had a ton of on call and patients in the hospital to care for every day, but they still generally had more freedom to do things during normal hours with normal people.

One last comment. I think pretty poorly of ECC specialty internships. When I was applying for residencies and worrying I wouldn't match, I looked in all of the available programs that year (dozens and dozens). When it came down to it, all but 1 or 2 were primarily poorly paid ER jobs that had minimal exposure to the ECC specialists. My take away was crappy hours for crappy pay with not a lot of formal learning to be gained. I think a good rotating internship with good mentored ER time is an excellent step for a new graduate, but just don't think theres a big benefit for a specialty ECC internship to make you a better residency candidate. Not in the way you get the repetitive exposure and learn how to echo as a cardio specialty intern, or constant exposure of performing a solid neuro exam and interpreting neuro diagnostics with a neuro internship. Maybe I'm wrong, but I just don't think theres tons of valuable experience to be gained from a specialty ECC internship as opposed to working as a real ER doctor. Why not work better hours and earn a real salary? :shrug:

I've only known people who did specialty ER internships mostly for desire to do ER receiving and getting more surgical Training, not so much to get critical care experience or as a stepping stone for residency, and at least they seemed really happy with their experiences. Usually the people who did rotating internships who wanted to continue ER work, but didn't get much cutting experiences with emergency surgeries. Is it not helpful? I would imagine it depends a lot on the program itself as well.

My personal experience as a GP who does a lot of shelter/community medicine is that I've gotten to cut a ton of emergency surgeries without any internship so I've considered it overrated. That being said, the people I know who have done them have been super happy, so I've taken their word for it.

Huh... my impression was that the criticalists in private practice around me have pretty sweet hours (I'm pretty sure the two I consult with are weekday day jobs - though I think you're right about the 4 day longer shifts... though that's not that different than many GP jobs), so I thought that was achievable. Maybe that perception is skewed.
 

jmo1012

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I've only known people who did specialty ER internships mostly for desire to do ER receiving and getting more surgical Training, not so much to get critical care experience or as a stepping stone for residency, and at least they seemed really happy with their experiences. Usually the people who did rotating internships who wanted to continue ER work, but didn't get much cutting experiences with emergency surgeries. Is it not helpful? I would imagine it depends a lot on the program itself as well.

My personal experience as a GP who does a lot of shelter/community medicine is that I've gotten to cut a ton of emergency surgeries without any internship so I've considered it overrated. That being said, the people I know who have done them have been super happy, so I've taken their word for it.

Huh... my impression was that the criticalists in private practice around me have pretty sweet hours (I'm pretty sure the two I consult with are weekday day jobs - though I think you're right about the 4 day longer shifts... though that's not that different than many GP jobs), so I thought that was achievable. Maybe that perception is skewed.
Hmm I guess if it gave you good surgical mentorship it may be worth it, but the few people I've known to do them were in cheap labor positions

I hope there are cc peeps out there with better lives, but a vast majority I know either have to walk away from patient care and deal with that compromise and sacrifice (which when you are dealing with truly critical things may be a huge trade off) or have tough quality lives. Im nervous.
 

Minnerbelle

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Hmm I guess if it gave you good surgical mentorship it may be worth it, but the few people I've known to do them were in cheap labor positions

I hope there are cc peeps out there with better lives, but a vast majority I know either have to walk away from patient care and deal with that compromise and sacrifice (which when you are dealing with truly critical things may be a huge trade off) or have tough quality lives. Im nervous.

Bingo on the less patient care thing. Super sweet schedule, but less patient care. Sure they have some cases, but more on the consulting for the trenchie doctors and managing the ER/ICU end of things. Well I guess that's the same with many professions. The "interesting hands on" stuff tends to be for the worker bees with less optimal schedules. The more admin type stuff you do, the better the schedule.
 

Ashgirl

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Colleagues! As a 4th year student, I've been struggling with what I want to do after graduation. A little background...

A couple years ago I thought I really wanted to be a surgeon. After gaining some experience with board-certified surgeons and surgical practice, I gained a lot of respect for the discipline, but ultimately realized it wasn't something I wanted to spend my life doing. I still assumed I would pursue some specialty of some kind in the end, be it cardiology, internal medicine, etc. After working in an emergency and referral hospital over the past year, and currently being on my ICU/Emergency rotation (and LOVING it), I have totally fallen in love with emergency medicine and have no question this is what I want to do with my career. The conflict now is whether I should pursue ECC board certification or be an ER vet at a hospital, no board certification.

Despite always assuming I was going to move forward with specialty medicine, my mindset is something that has also evolved over the last year. I've gotten to the point where I've realized life is painfully short and I'm ready to start living. Be that traveling the world with my husband, having lazy days off, having the time to stroll around a farmer's market or art festival, etc (while being full aware ER med comes with overnights and weekend work, which I'm cool with) I'm not so confident specialization is for me anymore, but I want to know I can have a good career being an emergency vet without it.

The ER vets I work with are great doctors who are really good at what they do, and they are not specialized, just enjoy emergency medicine. What are your thoughts and/or experiences with ER med, and if going through putting life on hold is really worth it in the end for what I'd like to do?

Thanks all!
Depending on where you are looking for a job, it is also another possibility to get an ER job straight out of school without an internship (which is what I did). There are places that won't hire you without one, but personally, as a newlywed and as someone who wanted a full salary right outside of school... It was sooo worth it (for me, mind you) to look around until I found a busy specialty hospital with great mentorship that would hire me. If you think you want to be boarded though, you will definitely have to do an internship first.
 

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ER vet here-started right out of school 21 years ago. I only work 3 days a week and make as much if not more than my friend's that work GP. I can't imagine working a regular job/5 days a week (or even 4). I am one that does not like to form bonds with clients and I do not want o see the same people over and over again (though I have been at the same EC for 20 years so I have seen many clients more than once).
We do have criticalists and they work way more hours and I doubt they make any more than I do (likely less as I have at least 10 years more experience and actually have to give them advice of what to do). They also don't do any surgeries which I find strange-I had to learn how to do all emergency surgeries (GDV, R/A, splenectomy, attack by dogs etc...). I personally would not waste time on a CC residency but some people want to get more into the why and how things happen.
I am tired of working the holidays but hopefully will partially retire in a few years and will not have to work any more!


If I had a large amount of debt I would definitely consider ER medicine as the pay is much better but yes the hours can suck. Many have come and gone as they cannot do the overnights or the long hours on the weekends. I prefer to get all of my hours squeezed in over a few days and have more time off. It is getting harder to work 12-14 hour shifts at my age but I see the light at the end of the tunnel. It helped that I started at 25 years of age. I know many vet students are older now and I can tell you as I get older the hours do get harder to deal with. There are exceptions-like my boss who is 60 and only needs about 6 hours of sleep a day/night-he is still going strong after 30 years. I definitely do not want to be working overnights at the age of 60!
 

DVMDream

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ER vet here-started right out of school 21 years ago. I only work 3 days a week and make as much if not more than my friend's that work GP. I can't imagine working a regular job/5 days a week (or even 4). I am one that does not like to form bonds with clients and I do not want o see the same people over and over again (though I have been at the same EC for 20 years so I have seen many clients more than once).
We do have criticalists and they work way more hours and I doubt they make any more than I do (likely less as I have at least 10 years more experience and actually have to give them advice of what to do). They also don't do any surgeries which I find strange-I had to learn how to do all emergency surgeries (GDV, R/A, splenectomy, attack by dogs etc...). I personally would not waste time on a CC residency but some people want to get more into the why and how things happen.
I am tired of working the holidays but hopefully will partially retire in a few years and will not have to work any more!


If I had a large amount of debt I would definitely consider ER medicine as the pay is much better but yes the hours can suck. Many have come and gone as they cannot do the overnights or the long hours on the weekends. I prefer to get all of my hours squeezed in over a few days and have more time off. It is getting harder to work 12-14 hour shifts at my age but I see the light at the end of the tunnel. It helped that I started at 25 years of age. I know many vet students are older now and I can tell you as I get older the hours do get harder to deal with. There are exceptions-like my boss who is 60 and only needs about 6 hours of sleep a day/night-he is still going strong after 30 years. I definitely do not want to be working overnights at the age of 60!

Why the heck would a criticalist do surgery? That's really not what the specialty encompasses. I've never seen a criticalist do surgery. Maybe I'm incorrect but all the ones I've seen monitor, treat and support the more intensive cases and post-op patients that need extra care. If they're doing surgery it takes them away from the patients that they need to be monitoring.
 
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TXvet

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Well, occasionally during the day we do have surgeries (we do not have a "surgeon" at this location). I also have to monitor critical/intense cases and post op patients AND find time to do surgery. After 4 pm and on the weekend we have no criticalist. I would think with all of their training they would be able to do this as well. I just think it is strange when you do an internship and residency in ER medicine that you don't learn how to do ER surgeries. My boss does do surgery but he did get board certified in ER medicine after he had been an ER vet for 10 years.I do find it frustrating if I have a surgery that needs to be done during the day and if my boss is out of town I have to refer somewhere else.
 

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For those of you who took work as an emergency vet (not intern) position right out of vet school. Did you find you were prepared enough for the position or do you find you have a good mentor/support system to help you ease into it?

We just started our fourth year now and emergency positions are something that I've been considering as a nice mix for me (been strongly considering a specialty for a while but can't decide what to specialize in as I like a lot of services and I would ideally like a decent pay check when I'm done). I don't mind the long hours or the nights and if I have to work on holidays I'm okay with that too especially since it means I avoid traffic ;)
 

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I did some relief in an "emergency clinic" (i.e. after hours clinic) in my first year after graduation, and I don't recommend it to anyone.....I feel lucky that the techs were able to help me and nothing horrible happened. I was not ready and in retrospect it was a mistake to have taken the job and I think I did a disservice to those clients and patients.

However, that was a small clinic in a small city with no referral options available even during the day, and there was no mechanism for new vets to learn anything except by their own mistakes, and I shouldn't have been hired either - it was no place for new grads. If you have a larger emergency clinic with multiple doctors on overlapping shifts, which I've seen working relief in emergency clinics in the last several years in bigger cities, I think a new grad would be able to handle things just fine.
 
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Ashgirl

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For those of you who took work as an emergency vet (not intern) position right out of vet school. Did you find you were prepared enough for the position or do you find you have a good mentor/support system to help you ease into it?

We just started our fourth year now and emergency positions are something that I've been considering as a nice mix for me (been strongly considering a specialty for a while but can't decide what to specialize in as I like a lot of services and I would ideally like a decent pay check when I'm done). I don't mind the long hours or the nights and if I have to work on holidays I'm okay with that too especially since it means I avoid traffic ;)
So I'm only 2 months in, but I personally feel like the mentorship I'm getting at my ER job is fantastic and I feel very supported and as prepared as I can be. If I need to discuss a case or have someone look at a patient of mine I have that option, and so far I always have another vet or at least specialists to talk to for cases, which is wonderful. I think if I was the only doctor on a shift it would be overwhelming, so I think hospital choice is super important for first time jobs.
 
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Nalra095

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So I'm only 2 months in, but I personally feel like the mentorship I'm getting at my ER job is fantastic and I feel very supported and as prepared as I can be. If I need to discuss a case or have someone look at a patient of mine I have that option, and so far I always have another vet or at least specialists to talk to for cases, which is wonderful. I think if I was the only doctor on a shift it would be overwhelming, so I think hospital choice is super important for first time jobs.

Hello, since you're class of 2018 I'm assuming this is your first job right after grad. Aren't most ER hospitals either looking for DVMs with some emergency experience or at the very least internship-trained grads? I'm curious as to how you were able to find an ER job without having either of these things?
 

Ashgirl

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Hello, since you're class of 2018 I'm assuming this is your first job right after grad. Aren't most ER hospitals either looking for DVMs with some emergency experience or at the very least internship-trained grads? I'm curious as to how you were able to find an ER job without having either of these things?
So I don't know the statistics, but personally, I looked into and got job offers for 4 emergency clinics without any experience without any trouble. Maybe it's a location thing (these were in 3 different states and 4 different sized cities), but I just looked into the ones that were stated they were new grad friendly/willing to mentor and found good luck. Then again, I was willing to travel and made sure to not apply to those who needed internships so maybe it only seemed easy. There are a great number of places who do require internships so really it probably just depends on where you want to go.
 
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VetMedSurvivalGuide

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Even though you become board certified in emergency and critical care, you might not end up doing both. Most criticalists I know did it for the critical care part of the job post-residency. As an internist, I considered an ECC fellowship after my medicine residency for that same reason. However, I would never be able to do the emergency part of things as I have zero interest in it.

I'd say you should (as mentioned above), talk to the ECC people at your school and see why they decided to do it. And then see if those reasons match some of yours. There are criticalists that do mostly ER work, others not at all. It's personal preference and obviously dependent on the practice they're in.

I agree with what said above re: ECC internships. You have to be very careful and really try to get more information on those. Some of these programs are literally created for cheap ER labor. In academia (and in some private practices), you truly end up with great training. ECC internships are usually pursued because one didn't match for residency and are trying to boost their application for next year's match.

As a board certified criticalist you'll have more leverage to choose your schedule (ie. no overnights) and, despite what was said above, you are more likely to get paid more. Keep in mind however that salary always depends on how people are paid. If paid on production and you multiple surgeries a day as an ER doctor, you might very well end up getting paid close or more. If you don't know what I mean by how you're paid, check the post on compensation on our blog. Bottom line, check in with ECC specialists and residents at your school!
 

Mattcj

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I think sticking to ER medicine without a board certification is totally okay. Most of the criticalists I worked with said they became boarded in order to get teaching positions in academia and residency programs so they can teach others in the field. The clinic I work for now has 5 ER doctors and none are boarded because they couldn't really afford to go 3 years of low-pay residency after vet school :p
 

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I think sticking to ER medicine without a board certification is totally okay. Most of the criticalists I worked with said they became boarded in order to get teaching positions in academia and residency programs so they can teach others in the field. The clinic I work for now has 5 ER doctors and none are boarded because they couldn't really afford to go 3 years of low-pay residency after vet school :p

I guess the question then would be, what is the salary gap of a non-boarded ER doctor vs a criticalist. I understand that there are other benefits as well such as daytime working hours for criticalists as opposed to overnights for ER docs(most of the time), etc. But in terms of just purely salary to salary, is it beneficial to go for residency?
 
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Mattcj

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I guess the question then would be, what is the salary gap of a non-boarded ER doctor vs a criticalist. I understand that there are other benefits as well such as daytime working hours for criticalists as opposed to overnights for ER docs(most of the time), etc. But in terms of just purely salary to salary, is it beneficial to go for residency?

Honestly, I would think so, especially if you find a place of employment that pays base salary AND production.
 
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