ER versus IM

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Hi. I would like to ask about the differences between the 2 specialties. But not about why I should go into a specialty, but why would they want me or somebody else? So the question is what are the differences in how competitive programs choose the right candidate? I understand that competitive programs look for a higher step1, LOR,etc. But what are some things(about a student's personality or whatever) that could make you undesirable or give you a red flag in ER but make you a great internist or vice versa?
 
J DUB said:
EM personalities are more laid back and cool folks. Can handle stress well and multitask great.

IM is more a person that loves detail and followup. IM folks are more boring to me.
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Thank you. Have you met any weird/odd people that thrive in either specialty? What is their schtick?
 
Talk to an IM doc. Talk to an ER physician. They'll give you the best perspectives.
 
The entire thought process is totally different. EM folks are "treat 'em and street 'em". They don't really care about the pathophysiology, WHY things are going wrong, or how long to prescribe antibiotics for this nasty osteomyelitis or what bugs are potentially there. They know empiric treatments for the most part and don't care beyond "what is the first dose of antibiotics". They don't care about sensitivities to drugs, side effects of long term treatment, or maximizing patient's functional capacity. They care about "what do I need to do RIGHT NOW to get this person stable enough for the floor or out the door"?

IM folks think about longer term. They treat empirically and then trim after sensitivities come back. They consider functional capacity. If you put someone on IV only antibiotics, how do you manage that? hospital? nursing home? PICC line? infusion center? what about long term management of chemo related diarrhea? how about the effects of metformin on renal function? considering xigris for sepsis? vent settings based on ABGs? exactly WHY does this 32 year old person have cardiomyopathy anyway and how should that best be handled???????

Basically, EM fixes the immediate threats and then turfs to IM. EM doesn't care WHY, they just fix the NOW. IM finds out WHY and deals with any NOW things that come up along the way (such as hemorrhagic anemia, pancreatitis, wound dehiscence caused by odd bacteria, renal failure needing dialysis, cardiac dysrhythmias caused by electrolyte disturbances secondary to high ostomy output, etc.). IM folks wonder what happens to their patients afterwards. EM folks see a repeat customer and say "you AGAIN? NOW what?"

If you are a WHY personality, then IM is a better fit. If you are a NOW personality, then EM is a better fit.

Now having said that, the programs look for those things. Are you a decision maker or a puzzle builder? Can you make rapid decisions (and make the right ones) or do you need more time? Do you like procedures or not? do you think about your patients when you go home or not? can you swing your shifts on a moment's notice? Can you juggle 12 patients at one time or do you want to think about only 6? Do you thrive on chaos and sorting out the mess or do you like it neat and tidy? Programs look for that "fit" of a personality into the specialty more than anything else.
 
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ShyRem said:
The entire thought process is totally different. EM folks are "treat 'em and street 'em". They don't really care about the pathophysiology, WHY things are going wrong, or how long to prescribe antibiotics for this nasty osteomyelitis or what bugs are potentially there. They know empiric treatments for the most part and don't care beyond "what is the first dose of antibiotics". They don't care about sensitivities to drugs, side effects of long term treatment, or maximizing patient's functional capacity. They care about "what do I need to do RIGHT NOW to get this person stable enough for the floor or out the door"?

IM folks think about longer term. They treat empirically and then trim after sensitivities come back. They consider functional capacity. If you put someone on IV only antibiotics, how do you manage that? hospital? nursing home? PICC line? infusion center? what about long term management of chemo related diarrhea? how about the effects of metformin on renal function? considering xigris for sepsis? vent settings based on ABGs? exactly WHY does this 32 year old person have cardiomyopathy anyway and how should that best be handled???????

Basically, EM fixes the immediate threats and then turfs to IM. EM doesn't care WHY, they just fix the NOW. IM finds out WHY and deals with any NOW things that come up along the way (such as hemorrhagic anemia, pancreatitis, wound dehiscence caused by odd bacteria, renal failure needing dialysis, cardiac dysrhythmias caused by electrolyte disturbances secondary to high ostomy output, etc.). IM folks wonder what happens to their patients afterwards. EM folks see a repeat customer and say "you AGAIN? NOW what?"

If you are a WHY personality, then IM is a better fit. If you are a NOW personality, then EM is a better fit.

Now having said that, the programs look for those things. Are you a decision maker or a puzzle builder? Can you make rapid decisions (and make the right ones) or do you need more time? Do you like procedures or not? do you think about your patients when you go home or not? can you swing your shifts on a moment's notice? Can you juggle 12 patients at one time or do you want to think about only 6? Do you thrive on chaos and sorting out the mess or do you like it neat and tidy? Programs look for that "fit" of a personality into the specialty more than anything else.
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👍👍👍
 
sylvanthus said:
Sooo, what about those hybrids out there who want to do both?
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There's a lot of overlap, or at least there is in my opinion. I like the ED and I like hospital medicine (especially the ICU) - also the boring ER cases, which are MOST of the patients honestly, are very similar to out-patient medicine patients (though often at 1:30 in the AM in a less responsible patient population). I bet an ED physician does more pelvics than I would as an internist any day of the week.

Though, and I've said this before, as an IM trained guy, doing fellowship, that unless two criteria are met either 1) you want to save the world one primary care patient at a time (this is your life's dream) or 2) you want to do fellowship in an IM subspecialty, don't do IM, do ER.

I think if I were to do it all over again, I'd go the ER, followed by Critcal Care fellowship route. I'm happy with the he way I've done things overall and I do also get to do pulmonary medicine (and possibly sleep if I was to do an extra year), which is cool because I like pulm and bronchs, but I don't know . . . It'd be a nice way to make a living splitting your time doing shifts in the ED or ICU . . . maybe the grass is always greener. 😀
 
J DUB said:
EM personalities are more laid back and cool folks. Can handle stress well and multitask great.

IM is more a person that loves detail and followup. IM folks are more boring to me.
Click to expand...

Given the burnout rates in EM, I am not so sure this is true. I still have yet to meet an ED attending older than 50, and I have worked in 3 large ED's.
 
cowme said:
Given the burnout rates in EM, I am not so sure this is true. I still have yet to meet an ED attending older than 50, and I have worked in 3 large ED's.
Click to expand...

Agreed. I've only met 1 EM doc >50, but I'm quite sure he was on something...
 
jdh71 said:
There's a lot of overlap, or at least there is in my opinion. I like the ED and I like hospital medicine (especially the ICU) - also the boring ER cases, which are MOST of the patients honestly, are very similar to out-patient medicine patients (though often at 1:30 in the AM in a less responsible patient population). I bet an ED physician does more pelvics than I would as an internist any day of the week.

Though, and I've said this before, as an IM trained guy, doing fellowship, that unless two criteria are met either 1) you want to save the world one primary care patient at a time (this is your life's dream) or 2) you want to do fellowship in an IM subspecialty, don't do IM, do ER.

I think if I were to do it all over again, I'd go the ER, followed by Critcal Care fellowship route. I'm happy with the he way I've done things overall and I do also get to do pulmonary medicine (and possibly sleep if I was to do an extra year), which is cool because I like pulm and bronchs, but I don't know . . . It'd be a nice way to make a living splitting your time doing shifts in the ED or ICU . . . maybe the grass is always greener. 😀
Click to expand...

That is one of the options I am weighing most......I liked the time I spent in the ICU...especially MICU. I thought about doing EM for 10-15, then flipping over to ICU or just Urgent Care. Either way I would be happy....🙂
 
cowme said:
Given the burnout rates in EM, I am not so sure this is true. I still have yet to meet an ED attending older than 50, and I have worked in 3 large ED's.
Click to expand...

Well, the age thing is someting totally different and I dont really believe the whole burnout thing. Maybe a little.

the ER can be a stressful place with the cases that come in and you got to have a person that handle that and multitask well.
 
cowme said:
Given the burnout rates in EM, I am not so sure this is true. I still have yet to meet an ED attending older than 50, and I have worked in 3 large ED's.
Click to expand...

we have 2 attendings over 50 in our community ER.......

and several in their 40's..........

I think EM being a relatively young specialty makes this an issue too.
 
cowme said:
Given the burnout rates in EM, I am not so sure this is true. I still have yet to meet an ED attending older than 50, and I have worked in 3 large ED's.
Click to expand...
I heard this "burn out" is amyth, and that would make sense considering EM didnt come about till 1980 and probably didnt start training more then a few till much later then that. (Apparently FMs took care of the ED).
 
PinkIvy08 said:
Agreed. I've only met 1 EM doc >50, but I'm quite sure he was on something...
Click to expand...

I think the age of the specialty is part of this, since it did not become a true specialty until the 70s.
 
jdh71 said:
There's a lot of overlap, or at least there is in my opinion. I like the ED and I like hospital medicine (especially the ICU) - also the boring ER cases, which are MOST of the patients honestly, are very similar to out-patient medicine patients (though often at 1:30 in the AM in a less responsible patient population). I bet an ED physician does more pelvics than I would as an internist any day of the week.

Though, and I've said this before, as an IM trained guy, doing fellowship, that unless two criteria are met either 1) you want to save the world one primary care patient at a time (this is your life's dream) or 2) you want to do fellowship in an IM subspecialty, don't do IM, do ER.

I think if I were to do it all over again, I'd go the ER, followed by Critcal Care fellowship route. I'm happy with the he way I've done things overall and I do also get to do pulmonary medicine (and possibly sleep if I was to do an extra year), which is cool because I like pulm and bronchs, but I don't know . . . It'd be a nice way to make a living splitting your time doing shifts in the ED or ICU . . . maybe the grass is always greener. 😀
Click to expand...
Whoa, back up there. If I want to be a GI or Pulmonary doctor, I can do ER and then do my fellowship? I've never heard of that before. I thought the only way to do a Cardio fellowship or whatever is to go through IM. Or are you just referring to sub-specialties like critical care or toxicology?
 
Alvarez13 said:
Whoa, back up there. If I want to be a GI or Pulmonary doctor, I can do ER and then do my fellowship? I've never heard of that before. I thought the only way to do a Cardio fellowship or whatever is to go through IM. Or are you just referring to sub-specialties like critical care or toxicology?
Click to expand...

he's saying don't do IM unless you love primary care OR you wanna subspecialize.

If you fit into neither category then do EM instead
 
Alvarez13 said:
Whoa, back up there. If I want to be a GI or Pulmonary doctor, I can do ER and then do my fellowship? I've never heard of that before. I thought the only way to do a Cardio fellowship or whatever is to go through IM. Or are you just referring to sub-specialties like critical care or toxicology?
Click to expand...
theres a few places that let you do a fellowship in Critical care after EM....pretty sure you cant do GI or cardio after EM.
 
winkleweizen said:
theres a few places that let you do a fellowship in Critical care after EM....pretty sure you cant do GI or cardio after EM.
Click to expand...

yeah you DEFINITELY cannot do GI or cards after EM.

EM has the following specialties: critical care, toxicology, peds EM, sports medicine, ultrasound, hyperbaric, international medicine... might be others but i'm blanking at the moment...
 
Alvarez13 said:
Whoa, back up there. If I want to be a GI or Pulmonary doctor, I can do ER and then do my fellowship? I've never heard of that before. I thought the only way to do a Cardio fellowship or whatever is to go through IM. Or are you just referring to sub-specialties like critical care or toxicology?
Click to expand...

I guess my syntax was a little odd, but I meant unless you're interested in subspecialty or really, really, really love primary care, don't do IM.

The only way to do cards or GI is through IM, and if you want to do those specialties, you'll have to go through IM. EM can do an IM critical care fellowship, as well as gas or surgery critical fellowship, BUT IM is the ONLY route that will allow an EM trained doc to sit for boards and be certified as a critical care physician.
 
WhateverMang said:
EM has the following specialties: critical care, toxicology, peds EM, sports medicine, ultrasound, hyperbaric, international medicine... might be others but i'm blanking at the moment...
Click to expand...

Actually, EM doesn't have it's own critical care fellowships. Though, you may find spots through gas, surgery, or IM critical care programs.
 
Tenuously related question:
How hard is it to match the following IM programs as a DO with no ties to California: Cedars Sinai and Scripps Green?
Thank you.
 
sylvanthus said:
Hmmmm pretty sure there are em fellowships in critical care. IM people seem against it though.
Click to expand...

You would be wrong.

EM trained people can do a critical care fellowship, but EM does not have it's own critical care fellowships. And IM isn't against it, not in the least. IM is the only board to have offered EM trained people the opportunity to get a board certification following fellowship in an IM critical care fellowship program, anesthesia and surgery have not been as kind (though they will take the warm bodies into their fellowship programs, which all too often do not fill with their own people).
 
jdh71 said:
I guess my syntax was a little odd, but I meant unless you're interested in subspecialty or really, really, really love primary care, don't do IM.

The only way to do cards or GI is through IM, and if you want to do those specialties, you'll have to go through IM. EM can do an IM critical care fellowship, as well as gas or surgery critical fellowship, BUT IM is the ONLY route that will allow an EM trained doc to sit for boards and be certified as a critical care physician.
Click to expand...
No problem at all 😀. I was thinking how great it would be to do EM, burn out after a few years, and then get into pulmonary medicine. I've seen ER w/ ultrasound/radiology components which is also something cool.
 
Alvarez13 said:
No problem at all 😀. I was thinking how great it would be to do EM, burn out after a few years, and then get into pulmonary medicine. I've seen ER w/ ultrasound/radiology components which is also something cool.
Click to expand...

You should not go into EM expecting to burn out. If you are expecting to burn out then go into a different field. It's not worth putting yourself through that. Not to mention I'm not sure you can go from EM into pulmonary medicine just because you do a crit care fellowship. But jdh can answer that better than I can.
 
PinkIvy08 said:
Agreed. I've only met 1 EM doc >50, but I'm quite sure he was on something...
Click to expand...

They're maybe all at quiet community hospitals. I work with more than a few. There is only the rare, random serious trauma and they pay the younger doctors in the group extra to cover the night shifts.
 
I just got off of a very long ICU shift with a fellow that is EM residency, critical care fellow. He said he went that route b/c he hates clinic and doesn't like managing chronic diseases. The fellowship is through IM, and he's just a critical care fellow, no big scarlet E for EM on his coat or anything. He was well prepared to start and can moonlight picking up extra ED shifts, which is cool. He said he wanted to do EM/IM (there are a few combined programs) but since he did residency with the Air Force he had to do one or the other.

IMHO people in EM burn out b/c they go into it expecting to be dealing with a lot of trauma and very critical situations but end up staffing a large urgent care clinic b/c of the way americans access healthcare. The people I worked with that I could see burning out the fastest were the ones constantly saying "why the Fxxk doesn't this person just go to their PCP," and the more well adjusted people recognized that comes with the territory.
 
Alvarez13 said:
No problem at all 😀. I was thinking how great it would be to do EM, burn out after a few years, and then get into pulmonary medicine. I've seen ER w/ ultrasound/radiology components which is also something cool.
Click to expand...

Rendar5 said:
You should not go into EM expecting to burn out. If you are expecting to burn out then go into a different field. It's not worth putting yourself through that. Not to mention I'm not sure you can go from EM into pulmonary medicine just because you do a crit care fellowship. But jdh can answer that better than I can.
Click to expand...

Nope can't do pulm out of an ER residency - however, you could consider a combined 4 year EM/IM program (I think there are around 20 or so combined programs, check FREIDA), and then after that residency do a pulm/cc fellowship.
 
Mattchiavelli said:
The fellowship is through IM, and he's just a critical care fellow, no big scarlet E for EM on his coat or anything. He was well prepared to start and can moonlight picking up extra ED shifts, which is cool.
Click to expand...

You're very well prepared to do a crit care fellowship coming out of an ER residency. There's nothing particularly magical about doing IM (or surgery or gas for that matter) prior to critical care - of course every specialty will come to the fellowship with some areas of strengths compared to others, but everyone is up to snuff by the end.
 
For the record OP... the residency is called EM, not ER. Don't ever use that term with an EM doc because it'll just piss a lot of them off.
 
ShyRem said:
The entire thought process is totally different. EM folks are "treat 'em and street 'em". They don't really care about the pathophysiology, WHY things are going wrong, or how long to prescribe antibiotics for this nasty osteomyelitis or what bugs are potentially there. They know empiric treatments for the most part and don't care beyond "what is the first dose of antibiotics". They don't care about sensitivities to drugs, side effects of long term treatment, or maximizing patient's functional capacity. They care about "what do I need to do RIGHT NOW to get this person stable enough for the floor or out the door"?

IM folks think about longer term. They treat empirically and then trim after sensitivities come back. They consider functional capacity. If you put someone on IV only antibiotics, how do you manage that? hospital? nursing home? PICC line? infusion center? what about long term management of chemo related diarrhea? how about the effects of metformin on renal function? considering xigris for sepsis? vent settings based on ABGs? exactly WHY does this 32 year old person have cardiomyopathy anyway and how should that best be handled???????

Basically, EM fixes the immediate threats and then turfs to IM. EM doesn't care WHY, they just fix the NOW. IM finds out WHY and deals with any NOW things that come up along the way (such as hemorrhagic anemia, pancreatitis, wound dehiscence caused by odd bacteria, renal failure needing dialysis, cardiac dysrhythmias caused by electrolyte disturbances secondary to high ostomy output, etc.). IM folks wonder what happens to their patients afterwards. EM folks see a repeat customer and say "you AGAIN? NOW what?"

If you are a WHY personality, then IM is a better fit. If you are a NOW personality, then EM is a better fit.

Now having said that, the programs look for those things. Are you a decision maker or a puzzle builder? Can you make rapid decisions (and make the right ones) or do you need more time? Do you like procedures or not? do you think about your patients when you go home or not? can you swing your shifts on a moment's notice? Can you juggle 12 patients at one time or do you want to think about only 6? Do you thrive on chaos and sorting out the mess or do you like it neat and tidy? Programs look for that "fit" of a personality into the specialty more than anything else.
Click to expand...

Great post!!! Well said!!!
 
jdh71 said:
🙄

Most ER docs don't give a ****
Click to expand...

I'm speaking from experience, maybe you haven't run into that... I ran into one who took huge offense to it. I'm sure your "most ER docs" is just as poorly representative a sample as mine is.

All I'm saying is you can't be too careful.
 
ArcGurren said:
I'm speaking from experience, maybe you haven't run into that... I ran into one who took huge offense to it. I'm sure your "most ER docs" is just as poorly representative a sample as mine is.

All I'm saying is you can't be too careful.
Click to expand...

He is a fellow and doesn't have to give a crap over whether or not he pissess off an EM doc with an errant letter change. (I am an 3rd year EM resident for some perspective)
 
Rendar5 said:
He is a fellow and doesn't have to give a crap over whether or not he pissess off an EM doc with an errant letter change. (I am an 3rd year EM resident for some perspective)
Click to expand...

I'm aware of that... my original post was addressed towards the OP
 
jdh71 said:
You would be wrong.

EM trained people can do a critical care fellowship, but EM does not have it's own critical care fellowships. .
Click to expand...

Nope, you're the one who is wrong. There are several EM-only critical care fellowships out there. North Shore has one. Also, there are gas and surg programs that are taking EM residents for critical care training. You just can't take the board certification exam if you go this route.
 
ShyRem said:
The entire thought process is totally different. EM folks are "treat 'em and street 'em". They don't really care about the pathophysiology, WHY things are going wrong,

...

Lots more baseless libel ...
Click to expand...

IM doesn't care about clean underwear. They get a critical patient or an undifferentiated chief complaint and then $hit their pants. They don't care about the CLEAN UNDERWEAR. They get a little old lady with no veins who has a lower GI bleed and mess themselves when all that WHY knowledge goes out the window when they can't do a resuscitation. Just look at these situations usually turn out:

Patient with fever and altered mental status---patient spends one hour getting stabbed multiple times in the back. IM resident gets dirty underwear and then calls IR to save the day.

Patient in cardiac arrest---IM resident thumbs through one of his many pocket books and then gives the first orders: obtain blood pressure and give sodium bicarbonate. He will then go to the call room to change his underwear.

Post-op patient presents with fever---IM team scratches head while ordering multiple blood cultures and giving different antibiotic regiments. After one week of not being able to come up with a source, a nurse removes the bandage to reveal a wound infection. Defecation occurs.

Patient with elevated lactate level---IM intern consults surgery STAT on the order of his senior because the patient must obviously have mesenteric ischemia given the lactate. Surgery resident discovers a patient who is sitting comfortably in bed eating dinner without any GI complaints. Surgery resident then schools the IM intern on the differential diagnosis of elevated lactic acid. Intern cries in the bathroom and then changes underwear.

Patient develops tension pneumothorax while an inpatient---IM resident calls a rapid response and orders a portable chest x-ray just to make sure. A resident from another service happens to walk through the hall and needles the patient. The janitor has a real mess to keep up on this one.

Sadly, all of the above example are true stories. You can wax on and on about learning pathophys and how you're such a great doc for caring about the WHY, but in practice, IM ends up being nothing more than the hub for calling sub-specialists. The most disgusting and misguided statement I've seen on this board is "Internists can handle almost all medical complaints," except when it comes to children, obstetrics, or surgical disease of any kind.
 
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deuist said:
Nope, you're the one who is wrong. There are several EM-only critical care fellowships out there. North Shore has one. Also, there are gas and surg programs that are taking EM residents for critical care training. You just can't take the board certification exam if you go this route.
Click to expand...

If the board of emergency medicine had it's own "official" critical care program, then there would be a board certification. Emergency medicine does NOT have it's own critical care programs. From the Board of EM website it clearly has listed the fellowships associated with the ABEM and a subspecialty certification: Hospice/Palliative, Tox, Peds, Sports, Undersea/Hyperbaric.

So, sorry, you are clearly confused on this issue. Even if the North Shore program "only" takes ER residents, it's NOT an EM fellowship. Someone else, either IM, Gas, or Surgery is running that fellowship and training the ER guys in critical care.

(EDIT: I imagine this is little embarrassing for you, as it appears you are an ER resident who just got done running his mouth)
 
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jdh71 said:
So, sorry, you are clearly confused on this issue. Even if the North Shore program "only" takes ER residents, it's NOT an EM fellowship. Someone else, either IM, Gas, or Surgery is running that fellowship and training the ER guys in critical care.
Click to expand...

While you're busy researching the Internet, see the North Shore site. The program is clearly run by EM. I never said the fellowship was accredited through ACGME; I said that it exists.

My guess is that once ABIM starts certifying EM-trained docs, these EM-run programs will dissipate.

As an aside, SAEM maintains a list of EM fellowships, both accredited and unaccredited.
 
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deuist said:
While you're busy researching the Internet, see the North Shore site. The program is clearly run by EM. I never said the fellowship was accredited through ACGME; I said that it exists.

My guess is that once ABIM starts certifying EM-trained docs, these EM-run programs will dissipate.

As an aside, SAEM maintains a list of EM fellowships, both accredited and unaccredited.
Click to expand...

*sigh*

I was obviously talking about accredited fellowship. This should have been obvious. But I see what you did there, I'll give you a few technical points, but overall I think you lose by changing the topic of discussion and definition without letting anyone know. Which I think is more than a little intellectually dishonest, and generally a douchebag move, but, hey, this is the interwubz. I'm not sure what I can expect from a system of connected tubes.
 
jdh71 said:
Which I think is more than a little intellectually dishonest
Click to expand...

I'm not quite sure what is dishonest. You said that EM does not have fellowships in critical care. I pointed out a program that does. What is dishonest, however, is your earlier statement:

IM is the only board to have offered EM trained people the opportunity to get a board certification following fellowship in an IM critical care fellowship program
Click to expand...

Currently, ABIM is not allowing EM-trained docs to take the critical care boards. Although ABIM has said that it plans to open its boards in the future, that announcement was made 1.5 years ago and I have seen any progress in that direction.

The North Shore program and others like it may not be ACGME accredited, but they do prepare docs to take the European critical care boards, which has historically served as a back-door to getting credentialed. I'm not happier about the situation anymore than you, but that's the lot we're given.
 
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