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It seems that just about every med student interested in EM has there own fantasy of what their future life in EM will be like.

While these fantasies are often based on some truth, they are quite often based on an equal amount of BS.

What misconceptions irk you the most? What were the biggest realizations/disappointments/pleasant surprises you had when you first made it to the real world of EM?

seriously, so many med students have their heads in the clouds when it comes to EM, quite often myself included, EM provides the opportunity for a lot of personalization and malleability, and the temptation to take that idea of EM to far and to the extremes of possibility are often too strong to resist. Knock our heads down to earth.
 

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Wow! Where to begin? There are so many. Let's start with a big one, money. Not your money, their money. Meaning that too many EM hopefuls and residents think that being in EM will happily isolate them from ever having to worry about the business aspects of medicine. Not so.

As "contract docs" EPs are more saddled with financial and cost issues than other docs. True we don't have to run an office but trust me running an EM group is just as daunting and often becomes just as big an enterprise. When hospitals need to cut back they will subject you to "utilization review" which translates to "order less stuff."

I've seen guys who come in and vow that they won't be subject to any financial concerns when it comes to their practice. They get beat down pretty quick.

Take home rule: Nowhere in medicine, including EM, can you hide from the influence of the almighty dollar.
 

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Nnnnoooooooo!!! Let me hang on to my fantasies! All day shifts, 3 days a week, big pay, not having to work holidays . . . oh wait, I'm describing dermatology:laugh::laugh:
 
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Medical students overestimate:
-number of thoracotomies
-number of chest tubes
-number of traumas
-excitement of trauma management
-excitement of laceration repair
-overall excitement of department
-competitiveness of specialty
-salary

Medical students underestimate:
-number of vag bleeders to be seen
-number of EKGs to be read
-number of cases of vague abdominal pain to work-up
-difficulty of work
-difficulty of switching shifts
-thoroughness of typical work-ups
 
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Ceez

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Wow! Where to begin? There are so many. Let's start with a big one, money. Not your money, their money. Meaning that too many EM hopefuls and residents think that being in EM will happily isolate them from ever having to worry about the business aspects of medicine. Not so.

As "contract docs" EPs are more saddled with financial and cost issues than other docs. True we don't have to run an office but trust me running an EM group is just as daunting and often becomes just as big an enterprise. When hospitals need to cut back they will subject you to "utilization review" which translates to "order less stuff."

I've seen guys who come in and vow that they won't be subject to any financial concerns when it comes to their practice. They get beat down pretty quick.

Take home rule: Nowhere in medicine, including EM, can you hide from the influence of the almighty dollar.

and we should never shy away from the business aspect of medicine! i went to b-school and my classmates were always working on ways to take advantage of business naive doctors
 
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deleted109597

Just by reading the threads, you can see the overestimations.
Trauma
Program prestige

Underestimations are tougher.
Such as..you really need to have reasons to do what you're doing, not just winging it.
How thick your skin needs to be.
 

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I've been doing this about two years post residency....

and sometimes I'm at work saying "$hit, I am seeing absolutely nothing emergent, this sucks...." then three hours later a BS chest pain ended up with a saddle embolus, the abdominal pain is actually ovarian cancer, an ectopic rolls through the door, etc. Sometimes the work is monotonous, but if you sit back, usually every shift you'll have a patient or two that was pretty darn interesting and quite nice and, well, kind of what you went to med school for.

Another thing that I noticed as an attending last year, was brought up by our mighty mod Spyderdoc a few years ago. I kind of got into a funk, and wans't sure if I wante dto stay in EM or not (yes, this was me, making great $ and working not quite so much), but then realized it was only because I was so used to doing a new rotation every month (med school -> residency for 7 years, every 1st of the month you got to do a new rotation and was on a different locatino). So, as an attending, that never changed. Took me a few weeks to get over the fact that I will be in the ED only, and have absolutely no idea where L&D, the MICU, teh SICU, the psych floor, the ortho floor, etc, is in the hospital, that really the only places I need to know are the ED, the physicians dining room, and the parking lot.

That actually took me by surprise the most.

Q
 
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I've been doing this about two years post residency....

and sometimes I'm at work saying "$hit, I am seeing absolutely nothing emergent, this sucks...." then three hours later a BS chest pain ended up with a saddle embolus, the abdominal pain is actually ovarian cancer, an ectopic rolls through the door, etc. Sometimes the work is monotonous, but if you sit back, usually every shift you'll have a patient or two that was pretty darn interesting and quite nice and, well, kind of what you went to med school for.

Another thing that I noticed as an attending last year, was brought up by our mighty mod Spyderdoc a few years ago. I kind of got into a funk, and wans't sure if I wante dto stay in EM or not (yes, this was me, making great $ and working not quite so much), but then realized it was only because I was so used to doing a new rotation every month (med school -> residency for 7 years, every 1st of the month you got to do a new rotation and was on a different locatino). So, as an attending, that never changed. Took me a few weeks to get over the fact that I will be in the ED only, and have absolutely no idea where L&D, the MICU, teh SICU, the psych floor, the ortho floor, etc, is in the hospital, that really the only places I need to know are the ED, the physicians dining room, and the parking lot.

That actually took me by surprise the most.

Q

Even though I loved being in the ED for 2 straight mos, I still think this will be the toughest part for me! :laugh:
 

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Hot nurses everywhere...

Da*n 'ER'
 
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enfuegoEP

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Medical students overestimate:
-number of thoracotomies
-number of chest tubes
-number of traumas
-excitement of trauma management
-excitement of laceration repair
-overall excitement of department
-competitiveness of specialty
-salary

Medical students underestimate:
-number of vag bleeders to be seen
-number of EKGs to be read
-number of cases of vague abdominal pain to work-up
-difficulty of work
-difficulty of switching shifts
-thoroughness of typical work-ups

Great post. I spent 3 months rotating through 3 different ED's and this has been my experience. Fortunately for me after all three months I couldn't imagine doing anything other than emergency medicine.
 
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Classmates who were looking to go into EM because "Hey, this should be great! It's shift work and you only work a few hours a week!" Plus, if you get into a bind, you can just call the Specialists."

They're in for a rude awakening. :p
 
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I'm PGY3 in a 4 yr osteopathic ER residency. I'm not sure if it's the same in allopathic schools but in osteopathic schools, most of them at least, you couldn't do an ER rotation until your 4th year of med school. Which means unless you're absolutely certain you're applying for ER, you might be preparing to do sub-i on other specialty and find out you love ER..... and it's kinda too late by then. Hopefully they could change this policy.
What i didn't know and should know as a student: Business of medicine is top of my list. 14 months to go and i still have no clue how to look at contracts, malpractice insurance. We don't do patient satisfaction score at my hospital (we see almost only no insurance or medicaid pts).... that's going to be a new thing when i get out. The amount of primary care medicine you're gonna see (majority!) tons more than the traumas.
 
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docB

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What misconceptions irk you the most? What were the biggest realizations/disappointments/pleasant surprises you had when you first made it to the real world of EM?

One thing that gets everyone when they start out as a green attending is when they realize how much of the job isn't about medicine. The biggest learning curve is about the systems and processes at your particular hospital. Who admits this, what type of patient can go to what floor, will radiology do rectal contrast or not, can you get an MRI at 2am, and so on. It's harder than any other hospital you've learned because there are no senior residents you can stick to to teach you. You pretty much learn this one through trial and error.
 
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AmoryBlaine

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One thing that gets everyone when they start out as a green attending is when they realize how much of the job isn't about medicine. The biggest learning curve is about the systems and processes at your particular hospital. Who admits this, what type of patient can go to what floor, will radiology do rectal contrast or not, can you get an MRI at 2am, and so on. It's harder than any other hospital you've learned because there are no senior residents you can stick to to teach you. You pretty much learn this one through trial and error.

Good point, but would that be specific to EM? I imagine this is bad in pretty much any field of medicine although it might be a little more pronounced in EM since we deal with so many different services/departments.
 

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I would say in academic em, most of it is what people expect, not being slow as a snail and killing 85% of your patients.

I would say the difficulty of being able to sail on the river of bureaucracy to the never ending sea of political bull**** without capsizing is vastly underestimated.
 

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Good point, but would that be specific to EM? I imagine this is bad in pretty much any field of medicine although it might be a little more pronounced in EM since we deal with so many different services/departments.
True. But as a hospital based specialty we are more at the mercy of these issues than docs who spend much of their time in their clinic where they have more control (and overhead and business headaches but more control) over such things.
 
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theCamel

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and we should never shy away from the business aspect of medicine! i went to b-school and my classmates were always working on ways to take advantage of business naive doctors

please expand on this!
 
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roja

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I am in Dublin right now and one of my colleagues gave a great lecture to the medical students here.

One point he made was the the most commen misconception is that as an EMP, you don't have to worry about the 'business' of medicine. Even in academia, I deal with it alot!
 
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I am in Dublin right now and one of my colleagues gave a great lecture to the medical students here.

One point he made was the the most commen misconception is that as an EMP, you don't have to worry about the 'business' of medicine. Even in academia, I deal with it alot!

How does it come into play in EM practice Roja? I'm learning (MS1).
 

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"Took me a few weeks to get over the fact that I will be in the ED only, and have absolutely no idea where L&D, the MICU, teh SICU, the psych floor, the ortho floor, etc, is in the hospital, that really the only places I need to know are the ED, the physicians dining room, and the parking lot."

then the realization hits....in the immortal words of one of my attendings, " the purpose of the rest of the hospital is to support the emergency dept".
 

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There is no field of medicine that isn't touched by the business of medicine. Billing, reimbursements, consultants, etc etc all have an affect in EM
 
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I was recently elected the president of my school's EM student association. In the previous two weeks, I have had 6 first and second years approach me to ask about the shift work side of EM. None of them could grasp the concept that they could get sued, work nights, and be constantly tired---even though EM is supposedly a lifestyle specialty. I really wish that students would at least be willing to read up on the field more than tossing around the overused phrase "We work hard. We play hard." I think the recent openings in PGY-2 spots across the country demonstrate that quite a few people have no idea what they're getting into. It's a shame given the number of qualified applicants who had to miss out on this wonderful field. For now, I point everyone to Rules of the Road. I then say, "Once you're done reading the whole book, then come back to me and tell me that you want to join the EMSA."

As far as the advice about learning business skills, I think that statement could be applied to all fields. Even the hospitalists need to know about proper coding and billing. I wonder why medical schools don't offer a 4th-year elective in medical business.
 

EM2BE

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I was recently elected the president of my school's EM student association. In the previous two weeks, I have had 6 first and second years approach me to ask about the shift work side of EM. None of them could grasp the concept that they could get sued, work nights, and be constantly tired---even though EM is supposedly a lifestyle specialty. I really wish that students would at least be willing to read up on the field more than tossing around the overused phrase "We work hard. We play hard." I think the recent openings in PGY-2 spots across the country demonstrate that quite a few people have no idea what they're getting into. It's a shame given the number of qualified applicants who had to miss out on this wonderful field. For now, I point everyone to Rules of the Road. I then say, "Once you're done reading the whole book, then come back to me and tell me that you want to join the EMSA."

As far as the advice about learning business skills, I think that statement could be applied to all fields. Even the hospitalists need to know about proper coding and billing. I wonder why medical schools don't offer a 4th-year elective in medical business.

I'm intrigued. But on doing a search, there are lots of links to different Rules of the Roads. Can you post a link to the correct version?

Also, is there an elective during residency one can take for medical business?

Thanks!!!!!!
 

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I was recently elected the president of my school's EM student association. In the previous two weeks, I have had 6 first and second years approach me to ask about the shift work side of EM. None of them could grasp the concept that they could get sued, work nights, and be constantly tired---even though EM is supposedly a lifestyle specialty. I really wish that students would at least be willing to read up on the field more than tossing around the overused phrase "We work hard. We play hard." I think the recent openings in PGY-2 spots across the country demonstrate that quite a few people have no idea what they're getting into. It's a shame given the number of qualified applicants who had to miss out on this wonderful field. For now, I point everyone to Rules of the Road. I then say, "Once you're done reading the whole book, then come back to me and tell me that you want to join the EMSA."

As far as the advice about learning business skills, I think that statement could be applied to all fields. Even the hospitalists need to know about proper coding and billing. I wonder why medical schools don't offer a 4th-year elective in medical business.

And by "elected", you mean co-president unopposed i think.
 

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It seems that just about every med student interested in EM has there own fantasy of what their future life in EM will be like.

While these fantasies are often based on some truth, they are quite often based on an equal amount of BS.

What misconceptions irk you the most? What were the biggest realizations/disappointments/pleasant surprises you had when you first made it to the real world of EM?

seriously, so many med students have their heads in the clouds when it comes to EM, quite often myself included, EM provides the opportunity for a lot of personalization and malleability, and the temptation to take that idea of EM to far and to the extremes of possibility are often too strong to resist. Knock our heads down to earth.
:laugh: Yes,I guess some of us do find ourselves in some sort of fairy tale world and our heads in the clouds.The misconception that irks me the most?Hmmm...In my opinion most students think that every case walking in to the emergency room is going to be a patient that has chopped his finger off while cutting onions,or someone that has swallowed a thumbtack...Blood guts and gore kind of cases.But really c'mon,lets be realistic here.:rolleyes:Probably the most common patients that walk in to the ER have a simple cold or migraine and jump to conclusions thinking that it is something worse than what it really is,although we have to think worst case scenario."Knock your heads down to earth."Eventually most of us come back down to earth and pull our heads out of our butts.:DSadly I haven't hit that point yet...he he:smuggrin:
 
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ERdoc2b said:
Hmmm...In my opinion most students think that every case walking in to the emergency room is going to be a patient that has chopped his finger off while cutting onions

this month has been a ton of that for me.....although i'm doing a hand surgery specialty month now!

what i think people underestimate the most about things is that for every 1 really cool case, you've got 10-20 not cool cases that piss you off....but even more than that, people underestimate the total volume of paperwork needed to get through a day. from pink slips to transfer crap to t-sheets and order forms and chest pain pathway paperwork and NIHSS paperwork and coroner forms....it just goes on and on and on.
 
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deleted109597

Honestly, if 10-20 cases really piss a person off for every 1 that is "cool", then it is the wrong field and headed towards the fabled early burnout. Remember, back pain still pays the bills. Plus, an added benefit is that this particular patient has a low chance of acutely dying on you, unlike some of the others. EM is boredom punctuated by moments of terror. However, you can make the boredom fun.
 
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Nice to hear the pre-med input telling me what my career as an EM doc will be like! Let's keep it coming!
 

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Nice to hear the pre-med input telling me what my career as an EM doc will be like! Let's keep it coming!

I think a lot of cases can also be misdiagnosed if it is early in the disease process. I mean usually all the emergent cases are taken care of, like someone coming in with hypotension and sat of 80% will get studies done to make sure its not pulmonary embolism or whatever you think from clinical exam...but someone with hyperthyroidism that is not in storm, but comes in for nonspecific complaints may not be iniitally diagnosed as that...sent home thinking they have something else and then seen at some time again when the diagnosis is more clear.

On that points, if some clinician can pick up a disease syndrome before another one (not that he/she is better); they may see more 'cool cases'....

so what i'm saying is maybe the more you know the earlier you may pick up on something and your 'cool numbers' may be higher....just an opinion.
 
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I am not just being contrary but I want to sort of dispel the counter-myth that EM is all non-urgent complaints. I see about 20 patients per shift and while 15 of them range from the real-but-routine to the sublimely ridiculous, three of the rest are real emergencies and the other two are full-blown, better-remember-all-the-doses-of-critical-medication-kind-of-things.

Last night I had a pediatric seizure/respiratory arrest and a full-blown unstable V-tach with the works.
 
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roja

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So true! I have had days where in one hour had to manage a cardiac arrest, a hypoglycemic-hypothermic-ams and a SVT with chest pain
 

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And then you (and me one day) get a pt like my sister that has a sz in the waiting room, nurse freaks out, she comes out of it, but made high priority. Then had another one while waiting for the doc for them to find out they didn't have a peds intubation and/or mask around (she stops breathing, and they didn't seem to like that part).
 

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I can be whatever I want to be on the Internet... including a busty bisexual female who recently got out of a relationship and is looking to get even with my cheating boyfriend.

I am concerned that my ERAS application won't be matching up to yours in a few years when I am applying...:laugh:
 

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This is an excellent thread. It's so easy for med students such as myself to hear all of the wonderful things about the specialty from well-meaning folks...While the harsher negative aspects are often underplayed.

Here's one expectation that I'd like to explore: we hear so much about shiftwork being a bonus of the field ("Look Ma, no pager!").

Yet I'm sure that it's not necessarily the case. Anyone (resident, attending) willing to explore the downsides a bit more? I for one am okay w/shiftwork if it stays regular, i.e., working a consistent series of overnights. But how realistic is it to think that we'll ever have that kind of control over our schedules?

For background, when I was in the Marines and deployed, I often worked 12-14h shifts (mostly overnight) for months on end. While not ideal, I grew to love it in a perverse way. Yet something tells me that it's not the same with EM. Thoughts?
 
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AmoryBlaine

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This is an excellent thread. It's so easy for med students such as myself to hear all of the wonderful things about the specialty from well-meaning folks...While the harsher negative aspects are often underplayed.

Here's one expectation that I'd like to explore: we hear so much about shiftwork being a bonus of the field ("Look Ma, no pager!").

Yet I'm sure that it's not necessarily the case. Anyone (resident, attending) willing to explore the downsides a bit more? I for one am okay w/shiftwork if it stays regular, i.e., working a consistent series of overnights. But how realistic is it to think that we'll ever have that kind of control over our schedules?

For background, when I was in the Marines and deployed, I often worked 12-14h shifts (mostly overnight) for months on end. While not ideal, I grew to love it in a perverse way. Yet something tells me that it's not the same with EM. Thoughts?


Here's how I conceptualize the issue of shiftwork:

**caveat: M4, not resident/attending and my EM experience is limited to 2 elective months.

Shiftwork is not an objective plus or an objective minus. First of all it is an absolute sine qua non for the practice of EM. While people might be pulling 24-36 hour shifts out in the hinterlands, it is neither safe nor practical to do so in a busy ED.

For those of us who like EM, shiftwork becomes a plus because it is EM. There is no other way to practice the specialty ethically or effectively. Medical students tend to speak of it as if it were equal to winning the lottery, to which I usually respond, "well, you could go into Pediatrics and get to sleep all night almost every night of your life." That also sounds pretty cool.

Alot of people hate shiftwork. It means that even as a 55 year old veteran you will be pulling the 10p-6a run with some regularity. It means that you can't duck out of the office to see the dentist in mid day. It means that when you are at work you are working, not sitting in conference, not on autopilot refilling BP meds. It also means that when you sign out you aren't anyone's doctor. I had a few IM interns tell me that they loved the medicine in the ED, but couldn't handle the shifts.
 
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I am one of those weird people who find the night shift preferable. For me it is a big thing because working in an office from 8-?, with or without the possibility of being called in again later in the evening, sounds like punishment.
These M3 and M4 rotations are killing me already so I can't wait for "the shift work" to become a reality. Hopefully, for my sake, people will want to change shifts with me so I can work all nights!!!:D
Otherwise I think my idea of what EM will be like is pretty on target.:)
 

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I am one of those weird people who find the night shift preferable. For me it is a big thing because working in an office from 8-?, with or without the possibility of being called in again later in the evening, sounds like punishment.
These M3 and M4 rotations are killing me already so I can't wait for "the shift work" to become a reality. Hopefully, for my sake, people will want to change shifts with me so I can work all nights!!!:D
Otherwise I think my idea of what EM will be like is pretty on target.:)

Same. I like shiftwork. From someone who has done uncapped call and worked for 38 hours with no sleep before, shiftwork with no call and no long post-call ward round is heaven. I don't mind doing nights at all. People always say that'll change when you have a family, but...will cross that bridge when it comes.
 

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I have 2 kids and still prefer nights! I work while they are sleeping and get home some days in time to have breakfast with them. I then sleep while they are at school and we have the early evenings together before I head into work and they head off to bed.
 
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Shiftwork, or specifically the transition from nights to days, can be pretty unpleasant. Not only the screwy sleep schedule which you and your spouse/partner/hooker will have to deal with but also the days where you may be physically awake but cognitively and motivationally are pretty far from it. Exercise helps reset my clock and I rotate ambien, benadryl, and lunesta prn.
 
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EM2BE

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I have heard that at non-academic EDs (the one I had seen anyway), if you request to work all nights, they let you have it. The longer you are there, the more options you have to pick first or second shift and even the days of the week. This was an ED in a town with around 400-500,000 people to serve, if not more. Plenty busy most of the time.
 

deuist

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There are several fields that allow shiftwork: anesthesiologists, some radiologists, hospitalists, and even part-time pediatricians who work for a busy practice. I don't know why EM is looked upon as if it is the only field that has shifts.
 

roja

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other fields: hospitalists (IM), peds hospitalists.


Regarding shiftwork: the key is to know thyself. I don't do well with nights. I have learned what allows me to shift easier. I have several friends who only work nights.

I don't know a single field of medicine that doesn't involve having to work some holidays, weekends.

the beauty of shifts? our PD just spent a month in brazil. He just pushed that months shifts to the first two months prior to that vacation. Just one of hundreds of examples.

I find it also easier from a family standpoint. sure, I work some weekends or holidays, but I also get to go alot more of my kids stuff and pick her up from school and drop her off alot more than my colleagues in other fields
 

Emedpa

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I work about 1/2 swings and 1/2 nights.
I prefer nights. this allows me to put my kids to bed, go to work, come home, have breakfast with kids, drive them to school, sleep, pick up kids, dinner with kids, repeat.
also we get a night differential and as everyone knows the better cases come in on night shift....
 
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