How can you know if you like EM because you like the specialty or because you just get to do a lot as a med student?

[Doctor_Strange]

M3 here. Been interested in EM for some time now. With VSAS around the corner, I need to seriously decide whether or not I should pursue EM. One thing I've been thinking about as of late is if my interest in the field right now has been a function of the fact that I have been able to do a lot during my shifts (I've done 15 shifts), such as H&Ps, present to attendings, updating patients on results, and helping with ultrasound or some minor procedure. To phrase another way, I think EM is popular among med students (myself included) because it's one of the few specialties that during a rotation the student is actually relied upon and can really act like a doc in some ways. In the back of mind, I wonder if the things that are exciting me now will wear off as an attending in my 40s. Will I still have that enthusiasm to walk into a room and determine the origin for a patient's abdominal pain? In contrast, another specialty that I am considering is anesthesiology, and outside of doing intubations, the med student really observes and reads their pocketbook to try to learn about the case at hand. So, to me, I may not have enjoyed it as much only because I am not relied upon for the patient's care in the OR. I may be getting cold feet since I am basically deciding my entire future over the next few months, but I want to make sure I go into EM for the right reasons.

Any residents or physicians care to comment on my thought process? I totally own up to feeling anxious about diving into EM, but I don't want to be a PGY-2 and regretting my decision...

Thanks in advance!

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[Birdstrike]

I have to say, the question in the thread title is a very good question.

 

[miacomet]

Agreed, I was just thinking how wise the question is.

I don't think you can know, completely. Picking a specialty is in many ways a shot in the dark and as @Birdstrike has elucidated previously, EM can be uniquely unforgiving. It's just really hard to know where you will be in life at fifty and what you will want then.

Try and rotate at a community shop. Try and find mirrors of yourself- a female role model if you are a woman, for example, or someone who has a job you would want. Ask them what they do/don't like about their job. Try and write out where you see your life in ten or twenty years. Will endless nights, weekends, and holidays affect family life, if you want a family? How well do you tolerate night shifts now? If you have any problem with them, run.

Things that lead to longevity/happiness in EM:
-tolerance for night shifts- if you are a lark, look at anesthesia; EM loves owls
-not being a primary caregiver for children
-interest in living in an "undesirable" area
-early identification of a niche
-ability to save early and hard so you can exit soon
-stay-at-home spouse/partner
-tolerance for lack of control at work/chaos
-ability to multitask
-interest in/talent for admin
-tolerance for uncertainty in career, work, schedule

There are more. In restrospect I would have chosen anesthesia, hands down. But that doesn't mean you should. Best of luck, and I wish more students would, or could, approach their decision-making this way.

 

[ace_inhibitor111]

Agreed, I was just thinking how wise the question is.

I don't think you can know, completely. Picking a specialty is in many ways a shot in the dark and as @Birdstrike has elucidated previously, EM can be uniquely unforgiving. It's just really hard to know where you will be in life at fifty and what you will want then.

Try and rotate at a community shop. Try and find mirrors of yourself- a female role model if you are a woman, for example, or someone who has a job you would want. Ask them what they do/don't like about their job. Try and write out where you see your life in ten or twenty years. Will endless nights, weekends, and holidays affect family life, if you want a family? How well do you tolerate night shifts now? If you have any problem with them, run.

Things that lead to longevity/happiness in EM:
-tolerance for night shifts- if you are a lark, look at anesthesia; EM loves owls
-not being a primary caregiver for children
-interest in living in an "undesirable" area
-early identification of a niche
-ability to save early and hard so you can exit soon
-stay-at-home spouse/partner
-tolerance for lack of control at work/chaos
-ability to multitask
-interest in/talent for admin
-tolerance for uncertainty in career, work, schedule

There are more. In restrospect I would have chosen anesthesia, hands down. But that doesn't mean you should. Best of luck, and I wish more students would, or could, approach their decision-making this way.

The factors that lead to longevity in EM match me to a T. I’m very concerned about the growing oversupply though. Wondering how much that should affect my decision.

 

[kaygeebee]

in the same position as OP, really love and enjoy EM and i think i'm a great fit for the field. but not too sure about how i'll feel in 20 years. i came into medical school wanting to do EM and now that the time has come to officially plan for the future, i have some (relatively minor but still present) doubts. other options include OB and anesthesia which also come with their own serious cons. it's tough

 

[Doctor_Strange]

in the same position as OP, really love and enjoy EM and i think i'm a great fit for the field. but not too sure about how i'll feel in 20 years. i came into medical school wanting to do EM and now that the time has come to officially plan for the future, i have some (relatively minor but still present) doubts. other options include OB and anesthesia which also come with their own serious cons. it's tough

What do you view as cons for anesthesiology out of curiosity?

 

[kaygeebee]

What do you view as cons for anesthesiology out of curiosity?

It could possibly be boring, i actually like running in the ED. I don't care much for cardio/pulm physiology, putting it lightly. Also the midlevel creep issue, which seems unavoidable nowadays.

that being said, i have my elective in anesthesia coming up later this month so i'll know for certain soon enough!

 

[luckycccc]

On a practical level, EM requires structured away rotations and anesthesia doesn't. You could set up an EM away rotation, give it your all, and see how you feel about it. If it goes well-you have a SLOE, and if it doesn't then you still learned something and it doesn't matter. Meanwhile try to also schedule an anesthesia rotation early at your home school so you can compare the two.

They are definitely very similar specialties, and I think personally I would enjoy either. We have such fatalism about choosing specialties but I think for an enthusiastic person with a genuine passion for medicine there are many things you could enjoy. For both EM and anesthesia you do a ton of procedures, you are an "anonymous doctor" without long term follow up, you move efficiently and for the most part work stays at work and there is little call.

For me I love all of the patients in the ED and then variety of problems they present with. Anesthesiologists are much more specialists than generalists and they love to be queen/king of the airway. I would miss showing up to problems I'd never seen before and trying to figure out a solution if I did anesthesia.

Also it's probably poor consolation, but there are many people who hate the ED despite the opportunities so a baseline interest is probably promising.

 

[ShockIndex]

Ask yourself 2 very simple questions:

1) What kind of doctor do you want to be?
2) What kind of patients do you want to treat?

If your answer is, “I want to be a doctor in the emergency department who helps people no matter their problems,” then community or academic EM can be an outstanding career.

If your answer is, “I want to be a doctor in the emergency department who treats emergencies,” then EM may be a good career but you may struggle depending on the practice environment.

If your answer is, “I want to be a doctor in the emergency department who treats really sick people,” then you likely have a problem because what you want is not going to mesh with reality.

 

[RustedFox]

What do you view as cons for anesthesiology out of curiosity?

Do you like being verbally berated by surgeons for things that are their own fault?

 

[Doctor_Strange]

On a practical level, EM requires structured away rotations and anesthesia doesn't. You could set up an EM away rotation, give it your all, and see how you feel about it. If it goes well-you have a SLOE, and if it doesn't then you still learned something and it doesn't matter. Meanwhile try to also schedule an anesthesia rotation early at your home school so you can compare the two.

They are definitely very similar specialties, and I think personally I would enjoy either. We have such fatalism about choosing specialties but I think for an enthusiastic person with a genuine passion for medicine there are many things you could enjoy. For both EM and anesthesia you do a ton of procedures, you are an "anonymous doctor" without long term follow up, you move efficiently and for the most part work stays at work and there is little call.

For me I love all of the patients in the ED and then variety of problems they present with. Anesthesiologists are much more specialists than generalists and they love to be queen/king of the airway. I would miss showing up to problems I'd never seen before and trying to figure out a solution if I did anesthesia.

Also it's probably poor consolation, but there are many people who hate the ED despite the opportunities so a baseline interest is probably promising.

Yeah, luckily I did a 2 week anesthesiology rotation and have another elective coming up soon. I've also done about 2 weeks in the ED as well. Both at a community hospital in a pretty urban location. I feel like I have a good sense of both specialties, and they appeal to different parts of my personality I feel. I actually think EPs not at an a academic center don't do nearly as many procedures as most think, at least not in my experience.

My preclinical years were PBL based, and I always enjoyed problem solving a patient with a diagnosis that would be revealed at the end of the case. That is pretty much every patient in the ED. I learn something new each shift. The realist in me thinks that eventually the undifferentiated patient won't be as exciting as it is right now as a M3.

Edit: And yeah, I am planning my 4th year audition rotations around EM. If I fall out of favor, I'll go anesthesiology -- I am hoping to get more clarity over the next few weeks though!

 

[ShockIndex]

Yeah, luckily I did a 2 week anesthesiology rotation and have another elective coming up soon. I've also done about 2 weeks in the ED as well. Both at a community hospital in a pretty urban location. I feel like I have a good sense of both specialties, and they appeal to different parts of my personality I feel. I actually think EPs not at an a academic center don't do nearly as many procedures as most think, at least not in my experience.

I spent 7 years in one of the busiest community shops in NC between military deployments before heading off to academics for 7 more years. I did a ton more procedures in the community environment compared to academics.

Every state has a handful of community shops that sport 20-25% admission and more than 10% critical care rates. I highly suggest new grads seek these places out for just a year or two. Unfortunately, they are often very challenging patient populations or underserved areas that do not lend themselves to career longevity.

 

[TooMuchResearch]

I only have 5 of your bullet points. It was 7-8 when I started a few years ago. oomed:

Agreed, I was just thinking how wise the question is.

I don't think you can know, completely. Picking a specialty is in many ways a shot in the dark and as @Birdstrike has elucidated previously, EM can be uniquely unforgiving. It's just really hard to know where you will be in life at fifty and what you will want then.

Try and rotate at a community shop. Try and find mirrors of yourself- a female role model if you are a woman, for example, or someone who has a job you would want. Ask them what they do/don't like about their job. Try and write out where you see your life in ten or twenty years. Will endless nights, weekends, and holidays affect family life, if you want a family? How well do you tolerate night shifts now? If you have any problem with them, run.

Things that lead to longevity/happiness in EM:
-tolerance for night shifts- if you are a lark, look at anesthesia; EM loves owls
-not being a primary caregiver for children
-interest in living in an "undesirable" area
-early identification of a niche
-ability to save early and hard so you can exit soon
-stay-at-home spouse/partner
-tolerance for lack of control at work/chaos
-ability to multitask
-interest in/talent for admin
-tolerance for uncertainty in career, work, schedule

There are more. In restrospect I would have chosen anesthesia, hands down. But that doesn't mean you should. Best of luck, and I wish more students would, or could, approach their decision-making this way.

 

[TooMuchResearch]

We're in that range. Sick patient population. Our critical care billing is under 10%, but some of my colleagues really under chart it. Never a relaxing day at the office there.

I spent 7 years in one of the busiest community shops in NC between military deployments before heading off to academics for 7 more years. I did a ton more procedures in the community environment compared to academics.

Every state has a handful of community shops that sport 20-25% admission and more than 10% critical care rates. I highly suggest new grads seek these places out for just a year or two. Unfortunately, they are often very challenging patient populations or underserved areas that do not lend themselves to career longevity.

 

[miacomet]

I only have 5 of your bullet points. It was 7-8 when I started a few years ago. oomed:

I think this is a great point- these things change more than you realize they will.
Which 2-3 have disappeared?

 

[ShockIndex]

We're in that range. Sick patient population. Our critical care billing is under 10%, but some of my colleagues really under chart it. Never a relaxing day at the office there.

Places like that are an excellent proving ground for EM. I suggest that new grads seek them out since they often have diverse pathology and decent support such as double coverage, reasonable on-call speciality services, etc. These shops allow a new grad to settle into their practice style while testing their ability to manage flow and volume. After a few years, a seasoned EP can then go work out in the Boonies if they want where they are the only doctor for 100 miles.

 

[TooMuchResearch]

Tolerance for nights. Mostly I think because of the addition of more children and a less compatible spouse work schedule. Luckily do very few right now.

Tolerance for career/job uncertainty. I thought I had this, but reimbursement risk, contract risk, etc hangs over my head, and I can't get comfortable.

I also thought I might like admin stuff. My wife thinks that's funny and wants to know if I've ever met me. So I guess I didn't have that one.

I think this is a great point- these things change more than you realize they will.
Which 2-3 have disappeared?

 

[TooMuchResearch]

I had about a 50% admit rate tonight. The only iffy one was an older guy with a mild CHF exacerbation, sub 20% EF, looked pretty good but patient and family were worried about going home. Everyone else had an NSTEMI (probably real and not just myocardial injury), post op complication/infection, sepsis, DKA. Or some combo of the above.

Places like that are an excellent proving ground for EM. I suggest that new grads seek them out since they often have diverse pathology and decent support such as double coverage, reasonable on-call speciality services, etc. These shops allow a new grad to settle into their practice style while testing their ability to manage flow and volume. After a few years, a seasoned EP can then go work out in the Boonies if they want where they are the only doctor for 100 miles.

 

[miacomet]

Tolerance for nights. Mostly I think because of the addition of more children and a less compatible spouse work schedule. Luckily do very few right now.

Tolerance for career/job uncertainty. I thought I had this, but reimbursement risk, contract risk, etc hangs over my head, and I can't get comfortable.

I also thought I might like admin stuff. My wife thinks that's funny and wants to know if I've ever met me. So I guess I didn't have that one.

I'd say this is a pretty classic trajectory for perhaps even a majority of EM docs. Caveat emptor.

 

[alpinism]

I spent 7 years in one of the busiest community shops in NC between military deployments before heading off to academics for 7 more years. I did a ton more procedures in the community environment compared to academics.

Every state has a handful of community shops that sport 20-25% admission and more than 10% critical care rates. I highly suggest new grads seek these places out for just a year or two. Unfortunately, they are often very challenging patient populations or underserved areas that do not lend themselves to career longevity.

I’m just curious but was this Fayetteville?

Heard good things from multiple docs and sounds like they actually have some great pathology.

 

[ShockIndex]

I’m just curious but was this Fayetteville?

Heard good things from multiple docs and sounds like they actually have some great pathology.

No. It was Gaston Memorial / Carmont Regional. It had just over 100,000 visits and a reasonable trauma volume. However, it was in a poor, rough suburb of Charlotte with all of the problems that go along with that title (good ’ol boy Board, revolving door hospital leadership, unstable medical staff, etc.).

I would not consider Fayetteville (Cape Fear Valley Medical Center) a community shop since it has an EM residency. However, it is very busy with a high acuity. 10 years ago Fayetteville was a no-go and paying a fortune for locums. However, I’ve been told by a friend in the state EMS leadership that they really tried to turn things around and quality has improved. I’ve also worked peripherally with their faculty on chest pain outcomes research and they seem to have their act together for a shop that is not affiliated with a large university. Now, it along with Lumberton, and Camp Lejeune are supposedly doing a pretty good job taking care of sick, sick people with little resources along that eastern I-95 corridor. Lejeune has become a pretty busy level 3 since the closest other trauma centers are Vident/ECU and New Hanover/Wilmington which are more than an hour away.

 

[Tenk]

I think your job structure is more important than your specialty. The only reason I’m perfectly happy with EM is that I only work 12-14 days a month and only three of those days are nights. I also like my ED which helps. I have definitely worked in EDs though that I would never last long term. The same could be said for anesthesia. I’m sure there are anesthesia jobs out there I would love and those I would hate. I would look more at the common job structures of EM vs anesthesia and see which is more appealing to you long term. I’m a work hard, play hard type. Others aren’t.

 

[RustedFox]

I think your job structure is more important than your specialty. The only reason I’m perfectly happy with EM is that I only work 12-14 days a month and only three of those days are nights. I also like my ED which helps. I have definitely worked in EDs though that I would never last long term. The same could be said for anesthesia. I’m sure there are anesthesia jobs out there I would love and those I would hate. I would look more at the common job structures of EM vs anesthesia and see which is more appealing to you long term. I’m a work hard, play hard type. Others aren’t.

Quoted for truth .

I know Tenk in real life.
He is exemplary.

 

[Birdstrike]

M3 here. Been interested in EM for some time now. With VSAS around the corner, I need to seriously decide whether or not I should pursue EM. One thing I've been thinking about as of late is if my interest in the field right now has been a function of the fact that I have been able to do a lot during my shifts (I've done 15 shifts), such as H&Ps, present to attendings, updating patients on results, and helping with ultrasound or some minor procedure. To phrase another way, I think EM is popular among med students (myself included) because it's one of the few specialties that during a rotation the student is actually relied upon and can really act like a doc in some ways. In the back of mind, I wonder if the things that are exciting me now will wear off as an attending in my 40s. Will I still have that enthusiasm to walk into a room and determine the origin for a patient's abdominal pain? In contrast, another specialty that I am considering is anesthesiology, and outside of doing intubations, the med student really observes and reads their pocketbook to try to learn about the case at hand. So, to me, I may not have enjoyed it as much only because I am not relied upon for the patient's care in the OR. I may be getting cold feet since I am basically deciding my entire future over the next few months, but I want to make sure I go into EM for the right reasons.

Any residents or physicians care to comment on my thought process? I totally own up to feeling anxious about diving into EM, but I don't want to be a PGY-2 and regretting my decision...

Thanks in advance!

Early on, I abhorred boredom and the hands on stuff is why I was attracted to EM: Suturing, reducing fracture/dislocations, lines, traumas, intubations, chest tubes, joint aspirations, CPR, LPs and so on. It worked for me early in my career. Now I do Interventional Pain Medicine which also allows me to be hands-on: Fluoroscopy guided epidural steroid injections, nerve blocks, nerve ablations, joint injections, spinal cord stimulators, kyphoplasties, and others. It's less adrenaline inducing, but allows me to sleep at night, literally. EM wouldn't have worked for me during the second half of my career, and Pain wouldn't have worked for me in the first half. I was very lucky to be able to make that transition mid-career.

 

[Doctor_Strange]

Early on, I abhorred boredom and the hands on stuff is why I was attracted to EM: Suturing, reducing fracture/dislocations, lines, traumas, intubations, chest tubes, joint aspirations, CPR, LPs and so on. It worked for me early in my career. Now I do Interventional Pain Medicine which also allows me to be hands-on: Fluoroscopy guided epidural steroid injections, nerve blocks, nerve ablations, joint injections, spinal cord stimulators, kyphoplasties, and others. It's less adrenaline inducing, but allows me to sleep at night, literally. EM wouldn't have worked for me during the second half of my career, and Pain wouldn't have worked for me in the first half. I was very lucky to be able to make that transition mid-career.

And therein lies my anxiety! I'm a single guy right now, late 20s -- what interests me right now in medicine may be different than when I am in my 40s. I'd like to think it wouldn't change. And at the risk of painting with a broad brush, to me going with something like anesthesiology, which while comparatively could be viewed as less exciting or sexy, may be the smarter choice for my future me than going with EM.

I did follow along with your posts too -- do you think it will be easier, harder, or the same level of difficulty for future EPs who would like to make a mid-career change like you did to pain? I think the main obstacle probably for many docs is sacrificing a certian level of income and displacement for one whole year.

 

[Birdstrike]

And therein lies my anxiety! I'm a single guy right now, late 20s -- what interests me right now in medicine may be different than when I am in my 40s. I'd like to think it wouldn't change. And at the risk of painting with a broad brush, to me going with something like anesthesiology, which while comparatively could be viewed as less exciting or sexy, may be the smarter choice for my future me than going with EM.

I did follow along with your posts too -- do you think it will be easier, harder, or the same level of difficulty for future EPs who would like to make a mid-career change like you did to pain? I think the main obstacle probably for many docs is sacrificing a certian level of income and displacement for one whole year.

I couldn't even venture to guess whether it will be harder or easier to do a mid career change in the future, compared to when I did it 8 or 9 years ago. I just don't know. But there's no need to have anxiety over this. Either do EM and do a fellowship immediately after residency, so you can reduce your shifts ED shifts to a manageable level later on, or do something you're more sure will be a fit. I wouldn't recommend waiting until mid-career like I did. That just makes it that much harder to uproot everything and go back for a year. You can do it, and I did. But it's better if you don't wait.

 

[miacomet]

This is a great discussion. Specialty choice is at best an educated guess, and with the massive changes in healthcare coming down the pike, it's really hard to know what any of our jobs will be like in ten, much less twenty, years. EM does have some unique issues with burnout and less-than-ideal exit strategies and we are also looking at oversupply. But it's still a three year residency that pays well.

Medical students today, unlike baby boomers and X-ers, will need to cultivate a mindset of flexibility and openness to change; it's just less stable. Low debt and a frugal life will allow young docs to flex with the times, no matter what field they choose.

An interesting footnote- in the mid twentieth century, ID was considered a nearly obsolete field after the development of antibiotics. Then along came HIV, drug resistance and now coronavirus. You just never know how you, or the world, will change.

 

[emergentmd]

What you know when you are a med student will change when you are a resident will change when you are an early attending will change when you are in the middle of the attending will change at the end of your career will change depending on the flux of every specialty will change with 100 other factors out of your control.

This is why a good amount of attendings in all fields have low satisfaction but if you ask everyone of them, most would not change and do another job with the decrease in pay. So I guess most actually like their choice if the took a step back.

 

[Doctor_Strange]

What you know when you are a med student will change when you are a resident will change when you are an early attending will change when you are in the middle of the attending will change at the end of your career will change depending on the flux of every specialty will change with 100 other factors out of your control.

This is why a good amount of attendings in all fields have low satisfaction but if you ask everyone of them, most would not change and do another job with the decrease in pay. So I guess most actually like their choice if the took a step back.

I actually think this is something I needed to hear. I've been trying to figure out how I will think of my specialty choice when I am 50. Of course it's a fools errand but I am trying to be as introspective and honest about the kind of career and even life I want to live. Recently, though, I've begun to accept I need to go off what I feel now. It's interesting, though, it seems within my class many students are trying to compare and contrast different specialties their going into and it seems like an arms race to compare who will have it better at the end of the day. Again, it's silly, but I've overheard this kind of conversation more than a few times.