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]

I posted this question several months ago, but wanted to get some more responses from fellow med students who are interested or will be pursuing emergency medicine. In a nutshell: I've been ruminating if my interest in the specialty has been a function of the fact that I have been able to do a lot during my shifts (have done 20 shifts), such as H&Ps, present to attendings, updating patients on results, and helping with ultrasound or some minor procedure -- basically being useful and involved in patient care beyond, say, retracting or endless rounding. To put 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 actually function as a physician in some minor ways, lest of which is being often times the first point of contact for a patient in the ED. In the back of mind, I wonder if the things that are exciting me now will wear off as an attending in my 40s or 50s. Will I still have that enthusiasm to walk into a room and determine the origin for a patient's abdominal pain? Will trying to gather a history from an elderly SNF patient who can't give a coherent history be mentally taxing?

For other EM-bound medical students or students who still are on the fence about the specialty, what are your thoughts? Do you have an reservations about pursuing EM?

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[sunshine859]

I was on the fence about EM and did really appreciate how involved I could get in patient's care in the ED. But after doing about as many shifts as you mention, I realized it was not for me: I couldn't imagine myself ordering another CT scan or talking to another drunk college student for the rest of my career. My school also had us switch between day and night shift a few times during the short rotation, which was the final straw for me. I would argue that still having a great deal of passion for EM after 20 shifts is a good sign that you have real passion. Have you had other rotations, like family medicine, where you function in a similar role in terms of seeing undifferentiated patients and helping with procedures? What about exposure to the less desirable aspects of EM such as frequent changes to sleep schedule?

 

[InternistDO]

I had the same feelings as you--my 3rd year EM clerkship was the first time I felt useful (who knows how true that was). I got to see patients by myself and then run the plan by the attending, suture, put in a central line, all the cool stuff. It took me two more rotations (my EM subis) to realize that while EM was fun, it wasn't going to keep me going for 10-20 years. I ended up switching to IM at the last minute.

A big thing for me was continuity with patients--not necessarily long term primary care continuity (though that's nice too) but also diagnostic continuity. EM is making a lot of rapid, big picture diagnoses but they're often incomplete because of the time constraints (and the fact that these diagnoses usually take days). The patient may come to the floor with a diagnosis of pneumonia and it may later be discovered that its pneumonia 2/2 endocarditis with septic emboli, for example. If that's interesting to you, maybe something like IM is more your speed. If it's not, then EM or gas might be more appropriate. What other specialties are you thinking of?

 

[Neopolymath]

So I need to preface this by saying that I am not an EM bound student, but I have had the same thoughts as you have regarding choosing a specialty and I view this dilemma as an internal conflict that can be obscured by external experiences that we often over-emphasize as students. I'm sure EM folks will offer specific experiences that you will identify with to help you. Only you can know whether you are over-selling how you felt or not.

I think we all enjoy most things in medicine when the situation is optimal. Preclinical mentors that make you excited about a field, rotations that live up to expectations, and the ability to be useful make students like us happy. I would argue that most people could see themselves doing several specialties in the ideal third year environment. My point isn't that this means you don't actually like EM. It's that every student is making some leap of faith when they pursue their field over another that they like slightly less. You might be happy in Pulm/CC or anesthesiology. Some students choose to then focus on the lifestyle, money, and job market as an attempt to use objective data to make the decision for them in these stalemates. They think that will somehow protect them from making a bad choice and provides comfort. Some say to pick the one that you genuinely enjoy the bread and butter cases of or the one with the 2 am problem that bothers you the least. These are all good ways to stratify specialties. The one problem with these methods is that they largely don't examine our own personalities. I think you need to examine what types of work make you tick in general and completely removed from medicine. What aspects of hobbies and previous jobs gave you satisfaction? Can you identify those same situations in EM?

Every single specialty's specific medical care will become almost completely routine for you as that is a byproduct of being a highly trained individual. I don't think you can use being less enthused by obvious work-ups when you are 50 as a reason to move away from EM. It must be noted though that the satisfaction of doing something well and excitement are two different things. I know a GS attending that says the biggest reward of his day is doing a 35 minute lap chole. It certainly doesn't make him excited like an open belly but the comfort and satisfaction is stronger than any other procedure he does.

You seem level-headed and exposed to the specialty so you likely know the drawbacks as well as the misconceptions about the field. That puts you ahead of most people. I would say that EM is one of the specialties with the best medical student exposure to the actual specialty as a trainee and attending in PP. I think that means there is less risk of not knowing what you are getting into. So I would say that if you enjoy EM and don't particularly feel strongly about other specialties, then why not? Most people don't have the luxury of knowing 100% if they made the right choice and most people turn out just fine despite some bitter people online.

 

[Doctor_Strange]

I was on the fence about EM and did really appreciate how involved I could get in patient's care in the ED. But after doing about as many shifts as you mention, I realized it was not for me: I couldn't imagine myself ordering another CT scan or talking to another drunk college student for the rest of my career. My school also had us switch between day and night shift a few times during the short rotation, which was the final straw for me. I would argue that still having a great deal of passion for EM after 20 shifts is a good sign that you have real passion. Have you had other rotations, like family medicine, where you function in a similar role in terms of seeing undifferentiated patients and helping with procedures? What about exposure to the less desirable aspects of EM such as frequent changes to sleep schedule?

Interestingly enough, FM was one of the other few rotations where students where give a tremendous amount of flexibility and autonomy. I suppose though the workflow was not as engaging for me.

I did work several evening and night shifts which were a challenge. One weekend I did two night shifts, and it took the following Monday and Tuesday to return to some normalcy. I can see how that can quickly get old, but I guess I take the good with the bad. But then I think to my surgery rotation, for instance, where I literally did nothing. Just retract and maybe practice suturing. Maybe if I had a larger role I could be thinking about surgery as a possible specialty choice right now and not EM, I mean who knows.

 

[Doctor_Strange]

I had the same feelings as you--my 3rd year EM clerkship was the first time I felt useful (who knows how true that was). I got to see patients by myself and then run the plan by the attending, suture, put in a central line, all the cool stuff. It took me two more rotations (my EM subis) to realize that while EM was fun, it wasn't going to keep me going for 10-20 years. I ended up switching to IM at the last minute.

A big thing for me was continuity with patients--not necessarily long term primary care continuity (though that's nice too) but also diagnostic continuity. EM is making a lot of rapid, big picture diagnoses but they're often incomplete because of the time constraints (and the fact that these diagnoses usually take days). The patient may come to the floor with a diagnosis of pneumonia and it may later be discovered that its pneumonia 2/2 endocarditis with septic emboli, for example. If that's interesting to you, maybe something like IM is more your speed. If it's not, then EM or gas might be more appropriate. What other specialties are you thinking of?

My attending keeps the MRN #s of interesting patients and whenever there is down time will go to the EMR and f/u on those patients. He said he did this in residency since it helps him as an EM doc. It did cross my mind if he was doing this because he was being slightly unfilled with not knowing the actual diagnosis of a patient.

Unfortunately, due to COVID I only spent one week in the MICU. That's all the IM exposure I've had third year outside of rotating with a community-based hospitalist as my very first rotation (an elective). I also spent a month on a Geriatrics service which was like a quasi-IM rotation insofar as being treated as a resident, rounding on patients, and fielding calls from nurses. Collectively, those experiences did not resonate with me, but I admit the sample and even quality of those rotations could be deemed subpar. I've been debating trying to set up a Sub-I (if they even will be made available to me as a DO) in the fall to see if I can rule it in or out definitively.

You bring up a good point though about diagnostic continuity. I've actually never heard that phrase or heard it said in such terms. That's something I gotta reflect on I guess now. Part of me is okay not knowing what is definitively going on in a patient, and the other half of my brain is like ohhh I wonder if the adrenal insufficiency is 2/2 TB?!? I should say at least with the hospitalist I was with, often times the diagnosis was known outside of a few exceptions. Again, I only spent two weeks with him so not a great sample size by any means.

 

[Doctor_Strange]

So I need to preface this by saying that I am not an EM bound student, but I have had the same thoughts as you have regarding choosing a specialty and I view this dilemma as an internal conflict that can be obscured by external experiences that we often over-emphasize as students. I'm sure EM folks will offer specific experiences that you will identify with to help you. Only you can know whether you are over-selling how you felt or not.

I think we all enjoy most things in medicine when the situation is optimal. Preclinical mentors that make you excited about a field, rotations that live up to expectations, and the ability to be useful make students like us happy. I would argue that most people could see themselves doing several specialties in the ideal third year environment. My point isn't that this means you don't actually like EM. It's that every student is making some leap of faith when they pursue their field over another that they like slightly less. You might be happy in Pulm/CC or anesthesiology. Some students choose to then focus on the lifestyle, money, and job market as an attempt to use objective data to make the decision for them in these stalemates. They think that will somehow protect them from making a bad choice and provides comfort. Some say to pick the one that you genuinely enjoy the bread and butter cases of or the one with the 2 am problem that bothers you the least. These are all good ways to stratify specialties. The one problem with these methods is that they largely don't examine our own personalities. I think you need to examine what types of work make you tick in general and completely removed from medicine. What aspects of hobbies and previous jobs gave you satisfaction? Can you identify those same situations in EM?

Every single specialty's specific medical care will become almost completely routine for you as that is a byproduct of being a highly trained individual. I don't think you can use being less enthused by obvious work-ups when you are 50 as a reason to move away from EM. It must be noted though that the satisfaction of doing something well and excitement are two different things. I know a GS attending that says the biggest reward of his day is doing a 35 minute lap chole. It certainly doesn't make him excited like an open belly but the comfort and satisfaction is stronger than any other procedure he does.

You seem level-headed and exposed to the specialty so you likely know the drawbacks as well as the misconceptions about the field. That puts you ahead of most people. I would say that EM is one of the specialties with the best medical student exposure to the actual specialty as a trainee and attending in PP. I think that means there is less risk of not knowing what you are getting into. So I would say that if you enjoy EM and don't particularly feel strongly about other specialties, then why not? Most people don't have the luxury of knowing 100% if they made the right choice and most people turn out just fine despite some bitter people online.

Man, this was a quality comment with great insight -- appreciate it. With all this time off, I definitely will reflect on those questions you posed.

 

[Brules_Rules]

I agree with the previous comments here 100%. As a student that is also really interested in emergency medicine I've definitely struggled with the novelty of the specialty as a student vs the potential grind of a 20-30 year post residency career. I certainly don't want to cloud the decision any more for you, but one thing that I've definitely been grappling with recently is some of the major changes that EM as a specialty seems to be going through right now. Specifically, the ongoing proliferation of EM residencies, in conjunction with major increases in mid level creep and the preponderance of CMGs has me somewhat concerned about what the job will look like in 4 years when I'm completing residency. I definitely love the medical/procedural parts of emergency medicine as well as the undifferentiated patients, but I would be lying if I said that another major appeal wasnt the perceived relatively high salary (in relation to residency length) and flexible scheduling. While things like Medscape continue to paint a rosy picture, the reality that I've heard from many current attendings and graduating residents (even pre-COVID) is that the job market has become a lot tighter and that salaries (at least on the west coast) have come down. While the ED has been an awesome place to work and learn as a student, I've gotta wonder if I would be able to be put up with some of its shortcomings if I was stuck in the middle of nowhere, making the same salary as someone working in primary care 4 days a week on a normal schedule.

While emergency medicine isn't insulated from the changes occurring in healthcare on a large scale, specialties like anesthesia and CCM both provide a major procedural component, allow you to work with high acuity patients, and still (even in the midst of COVID) have phenomenal job opportunities and reasonable starting salaries, even in major cities (a quick peek at Gaswork job listings is pretty illuminating). Unfortunately, as you mentioned, the student experience in both critical care medicine and anesthesia is often pretty poor, despite the fact that these specialties seem to be very cerebral and engaging at a resident/attending level.

I definitely dont want this to sound like I'm ****ting all over EM (I'm still 90% sure I'll be applying into it this fall), but these are things that I definitely think are worth considering (and will still probably think about over the next couple of months) as I finalize my specialty choice. At the end of the day, I think the majority of students take a leap of faith when choosing a specialty. None of us can predict the future of a field and we're all working with limited and imperfect information when we make the decision. I'm definitely comforted by the fact that many happy and well adjusted attendings (even in surgical fields) have told me they had seriously considered other specialties, but are ultimately happy where they ended up.

 

[Doctor_Strange]

I agree with the previous comments here 100%. As a student that is also really interested in emergency medicine I've definitely struggled with the novelty of the specialty as a student vs the potential grind of a 20-30 year post residency career. I certainly don't want to cloud the decision any more for you, but one thing that I've definitely been grappling with recently is some of the major changes that EM as a specialty seems to be going through right now. Specifically, the ongoing proliferation of EM residencies, in conjunction with major increases in mid level creep and the preponderance of CMGs has me somewhat concerned about what the job will look like in 4 years when I'm completing residency. I definitely love the medical/procedural parts of emergency medicine as well as the undifferentiated patients, but I would be lying if I said that another major appeal wasnt the perceived relatively high salary (in relation to residency length) and flexible scheduling. While things like Medscape continue to paint a rosy picture, the reality that I've heard from many current attendings and graduating residents (even pre-COVID) is that the job market has become a lot tighter and that salaries (at least on the west coast) have come down. While the ED has been an awesome place to work and learn as a student, I've gotta wonder if I would be able to be put up with some of its shortcomings if I was stuck in the middle of nowhere, making the same salary as someone working in primary care 4 days a week on a normal schedule.

While emergency medicine isn't insulated from the changes occurring in healthcare on a large scale, specialties like anesthesia and CCM both provide a major procedural component, allow you to work with high acuity patients, and still (even in the midst of COVID) have phenomenal job opportunities and reasonable starting salaries, even in major cities (a quick peek at Gaswork job listings is pretty illuminating). Unfortunately, as you mentioned, the student experience in both critical care medicine and anesthesia is often pretty poor, despite the fact that these specialties seem to be very cerebral and engaging at a resident/attending level.

I definitely dont want this to sound like I'm ****ting all over EM (I'm still 90% sure I'll be applying into it this fall), but these are things that I definitely think are worth considering (and will still probably think about over the next couple of months) as I finalize my specialty choice. At the end of the day, I think the majority of students take a leap of faith when choosing a specialty. None of us can predict the future of a field and we're all working with limited and imperfect information when we make the decision. I'm definitely comforted by the fact that many happy and well adjusted attendings (even in surgical fields) have told me they had seriously considered other specialties, but are ultimately happy where they ended up.

Well, it's nice to know I'm not alone in reflecting on these issues. I agree, the current landscape of EM seems a bit foggy to predict, particularly in coastal/metro locales.