I can't see myself enjoying anything but EM. Is the job market *that* sketchy?

[Lynx zwo drei vier]

MS-4 taking a research year, so I've finished my clerkships but ERAS is a year away. My dream is EM in a big city with lots of uninsured people, lots of drug ODs, and lots of gun violence.

I loved every minute of EM. I looked forward to every shift, and I felt satisfied after each one (it helped that I'm in one of the cities that I'd want to practice in). I also liked stroke consult on Neuro and the CRC on Psych, but that's because both had the ED's intensity. I also liked IP Peds, and I know that Peds-EM fellowships exist, but I've read that their match rates are low. And I liked Trauma Surg, but TBH I don't think I'm a strong enough applicant for a GenSurg residency.

I know about EM's current supply-demand mismatch. But every mentor (not just in EM) has told me to apply based on what I loved (and that people used to say that path/gas/rads were gonna get killed by AI, or CRNAs, or offshoring to India). In a way, now feels the best time to apply EM. If people are still panicking next year I'll have a great shot at matching somewhere that I'd wanna practice in. And by the time residency and fellowship are done, might the job market might self-correct?

If it matters, I'm a vet. So I'll be graduating with almost no debt (🇺🇸=❤️), and I can afford to take risks than many students can't.

---

Members don't see this ad.

 

[JacobMcCandles]

You’re in a glorifying mindset. Soon, you’re going to be frustrated at the uninsured treating you as their primary care for minor complaints. You’re going to be frustrated with not being able to get them follow up for anything. You’re going to be frustrated with seeing the same people OD and then get upset at you if you give them too much narcan. You’re going to be frustrated seeing that a majority of people who get shot typically get shot for a reason and that reason usually falls back on them. You’re going to be especially frustrated when you see the same person who has been shot before.

 

[thegenius]

MS-4 taking a research year, so I've finished my clerkships but ERAS is a year away. My dream is EM in a big city with lots of uninsured people, lots of drug ODs, and lots of gun violence.

Oh good lord. Ready to practice primary care without primary care training? Ready for entitlement at its worst?

I loved every minute of EM. I looked forward to every shift, and I felt satisfied after each one (it helped that I'm in one of the cities that I'd want to practice in). I also liked stroke consult on Neuro and the CRC on Psych, but that's because both had the ED's intensity. I also liked IP Peds, and I know that Peds-EM fellowships exist, but I've read that their match rates are low. And I liked Trauma Surg, but TBH I don't think I'm a strong enough applicant for a GenSurg residency.

I know about EM's current supply-demand mismatch. But every mentor (not just in EM) has told me to apply based on what I loved (and that people used to say that path/gas/rads were gonna get killed by AI, or CRNAs, or offshoring to India). In a way, now feels the best time to apply EM. If people are still panicking next year I'll have a great shot at matching somewhere that I'd wanna practice in. And by the time residency and fellowship are done, might the job market might self-correct?

Oh good lord.

If it matters, I'm a vet. So I'll be graduating with almost no debt (🇺🇸=❤️), and I can afford to take risks than many students can't.

Oh good lord. Dear Jesus!

 

[CliveStaples]

I like Emergency Medicine. I'm still intellectually stimulated by undifferentiated patients, and I like being around learners which is why I moved from community practice to academics last year. I have a good job that compensates me appropriately for the work I'm doing in light of the investment I put in.

However, I know I am in the minority. The ED carries a lot of the burdens of our dysfunctional medical system. We spend more time risk stratifying the chronically ill than we spend on true acute care and critical care medicine. In my state/region, jobs are still available and compensation I think is reasonable, even at local CMG shops, but I know that has a high probability of going away in the next several years as more people accept moving to "flyover country" in the pursuit of better wages.

As a medical student, I really enjoyed my trauma surgery rotation. A good, happy chief resident told me only to pursue general surgery if it was the only way I could see myself happy with my career. He understood that while he was making the right choice for himself, he knew the downsides (the opportunity cost of the training, the lifestyle afterward, strain on family, etc.) meant that for the majority of people, it was not the right choice, regardless of how enjoyable the OR and trauma bay were. Emergency Medicine is likely going to become like that. The downsides of our field (nights, weekends, holidays, lack of ownership in our practices, economic factors from increasing supply to outpace demand) will mean that many in our field are going to recommend that you only do this if you cannot see yourself happy in a different specialty, like anesthesia, family medicine, general surgery, critical care medicine, etc.

But I still like Emergency Medicine, and I want other people to like it too.

 

[RustedFox]

JESUS CHRIST, STOP!

Anyone else want to point out the glaringly obtuse statements in the OP before I do?

Please? I'm tired.

 

[DeadCactus]

The EM job market is unlikely to rebound to it's unsustainable precedent of neurosurgeon wages with an easy to get job in any city after a 3 year residency. You will likely be able to get a job in the rough geographic area you want for a salary a little better than primary care in that area. I wouldn't enter the specialty if you're not willing to move to a traditionally undesirable location or do a fellowship if the worst fears about the job market come to fruition.

I'm not here to talk people into or out of emergency medicine. I would encourage you to abandon the "can't see myself enjoying anything but [blank]" mindset. There's so much variability between jobs in any field. Explore what you really want out of your career in terms of more concrete outcomes and then explore what specialties can get you there. Most people will find there are many specialties that could get them what they want and that gives you more room to weigh the pros and cons of a specialty.

 

[GonnaBeADoc2222]

Sigh.

 

[cyanide12345678]

Oh cool you want drug overdoses. Some regret the overdose, a fairly large number just gets upset that you ruined their high, and a surprisingly high number can’t even wait 2 hours of their life even if you try to explain to them multiple times that narcan runs out and they can end up not breathing again and they need to be watched. We are not worth 2 hours of their time after having saved their lives most of the time.

The uninsured population usually is okay, some of them who are not super users of ERs might even be appreciative. But they are far in between, a majority are super users of the ER….oooo you got a wood splinter, go to the ER. You have a rash that i literally can’t even see, oh great go to the ER. Oh you have a runny nose and cough that started 2 hours ago, great -_- i wish Medicaid had a $10 copay. It would weed out so much silliness from the ER.

Either way, if that’s the choice you’ve made, Good luck. I wish these forums were as grim 6 years ago when i was deciding on specialty, i would have made a better choice. Im sure in 10 years you will regret this choice. But hey…. Then it will be too difficult to switch so you’ll just have to suck it up and live with your choice - sort of like what I’m doing 😂

 

[Franzd'Epinay]

I guess I’ll be the lone voice saying go for it…

BUT:

Start working on your exit plan now. Maybe for you that’ll be doing electives in sports med/pain/clinical informatics/crit care to have a good CV to apply for a fellowship outside of the ED. Maybe that’ll mean networking with people in pharma/tech/consulting to leave medicine altogether. Maybe that’ll mean becoming financially literate so you can retire early. Or maybe it’s doing all of the above.

Either way, you want to be prepared for when you burn out or can’t get a good job. And if that never happens, good for you, at least you’ll be able to advice the huge number of your colleagues who do want out.

 

[CajunMedic]

I got into med school with the sole purpose of doing EM. Much Like you, I couldn't see myself doing anything else. (did almost switch to psych, ironically.) Before med school, I worked EMS in a large city in the south with all the OD's, GSW's, medicaid patients, etc. you could desire. Completed my residency in a hospital system where I spent a lot of time in the kind of place you're wanting to train in. It was good training, but guess what? It. Gets. Old.

Narcanning someone just so they can leave AMA and come back 2 hrs later unresponsive. Taking a cell phone from the methed out guy masturbating and watching porn at ear splitting volumes. Getting yelled at by the chronic inebriate because you haven't had time to get them another turkey sandwich on their 3rd visit of the day. Waiting room that looks like Jonestown, the morning after. Watching a tweaker roll in their own crap in the waiting room. GSW's become routine. The Entitled Boomer that somehow got lost on the way to the other campus that is just horrified at the patient and staff population and spends the entire visit bitching and demanding pain meds for their hangnail. As one of my chief residents said: "It steals your soul"

I can't lie, I do still love Emergency Medicine. But, I also accept the truths that myself, and others above have said and are realistic about them. I got lucky and landed a decent gig after my CMG job fell through. I get to teach EM residents and med students in a community hospital. I have a fairly decent patient population with the occasional OD and GSW. My best advice: be realistic and have a backup plan and exit strategy.

 

[GassYous]

big city with lots of uninsured people, lots of drug ODs, and lots of gun violence

What? Why? Sounds terrible

 

[ER BlueBlood]

What? Why? Sounds terrible

Sounds like New Orleans or BR to me lol

 

[CoolDoc1729]

MS-4 taking a research year, so I've finished my clerkships but ERAS is a year away. My dream is EM in a big city with lots of uninsured people, lots of drug ODs, and lots of gun violence.

I loved every minute of EM. I looked forward to every shift, and I felt satisfied after each one (it helped that I'm in one of the cities that I'd want to practice in). I also liked stroke consult on Neuro and the CRC on Psych, but that's because both had the ED's intensity. I also liked IP Peds, and I know that Peds-EM fellowships exist, but I've read that their match rates are low. And I liked Trauma Surg, but TBH I don't think I'm a strong enough applicant for a GenSurg residency.

I know about EM's current supply-demand mismatch. But every mentor (not just in EM) has told me to apply based on what I loved (and that people used to say that path/gas/rads were gonna get killed by AI, or CRNAs, or offshoring to India). In a way, now feels the best time to apply EM. If people are still panicking next year I'll have a great shot at matching somewhere that I'd wanna practice in. And by the time residency and fellowship are done, might the job market might self-correct?

If it matters, I'm a vet. So I'll be graduating with almost no debt (🇺🇸=❤️), and I can afford to take risks than many students can't.

I felt the same as you before residency. After residency I specifically looked for a non trauma center because while I still enjoy working with the urban population, trauma is really boring after a certain number when you’re not the one doing definitive management .. the trauma surgeons are. And at least 10 years ago, at my residency program they were going to a shift work trauma surgery setup.. idk if this is common but I’m sure you could find something.
Don’t get me wrong, myself personally I do not regret doing EM rather than general or trauma surg… but if my priority was trauma I would have leaned more that way. We order blood and fluids and pan scan and then after the commotion there’s 6 more belly pains to see 🤦🏻‍♀️

 

[Frazier]

I did EM for the majority of my pre-med shadowing and EM was one of my major pulls to attending med school. I did EM early during my MS3 year, followed by several EM electives and away rotations. I did EM residency. And now I do not do EM at all. As the others said above: many of the things that are appealing early in training lose their luster, then new things you haven't even thought of yet start to be grating. Worked out great in my case as it was a gateway to my subspecialty. Nonetheless, as your terminal field: choose carefully.

 

[Lynx zwo drei vier]

I like Emergency Medicine. I'm still intellectually stimulated by undifferentiated patients, and I like being around learners which is why I moved from community practice to academics last year. I have a good job that compensates me appropriately for the work I'm doing in light of the investment I put in.

However, I know I am in the minority. The ED carries a lot of the burdens of our dysfunctional medical system. We spend more time risk stratifying the chronically ill than we spend on true acute care and critical care medicine. In my state/region, jobs are still available and compensation I think is reasonable, even at local CMG shops, but I know that has a high probability of going away in the next several years as more people accept moving to "flyover country" in the pursuit of better wages.

As a medical student, I really enjoyed my trauma surgery rotation. A good, happy chief resident told me only to pursue general surgery if it was the only way I could see myself happy with my career. He understood that while he was making the right choice for himself, he knew the downsides (the opportunity cost of the training, the lifestyle afterward, strain on family, etc.) meant that for the majority of people, it was not the right choice, regardless of how enjoyable the OR and trauma bay were. Emergency Medicine is likely going to become like that. The downsides of our field (nights, weekends, holidays, lack of ownership in our practices, economic factors from increasing supply to outpace demand) will mean that many in our field are going to recommend that you only do this if you cannot see yourself happy in a different specialty, like anesthesia, family medicine, general surgery, critical care medicine, etc.

But I still like Emergency Medicine, and I want other people to like it too.

I think a lot of this is region-dependent, but so much of what people are saying about EM's downsides (ungrateful patients, frequent flyers, dealing with the broken system, getting abused, patients constantly AMA'ing) could be said about what hospitalists have to deal with as well.

 

[Lynx zwo drei vier]

I felt the same as you before residency. After residency I specifically looked for a non trauma center because while I still enjoy working with the urban population, trauma is really boring after a certain number when you’re not the one doing definitive management .. the trauma surgeons are. And at least 10 years ago, at my residency program they were going to a shift work trauma surgery setup.. idk if this is common but I’m sure you could find something.
Don’t get me wrong, myself personally I do not regret doing EM rather than general or trauma surg… but if my priority was trauma I would have leaned more that way. We order blood and fluids and pan scan and then after the commotion there’s 6 more belly pains to see 🤦🏻‍♀️

Yeah, but look on the bright side: you don't have to spend 4 days rounding on those 6 belly pains.

 

[Pigg-O-Stat]

I'm eight years out, and I still wouldn't choose any other specialty. Ignore all the noise, and do EM.

 

[cyanide12345678]

I'm eight years out, and I still wouldn't choose any other specialty. Ignore all the noise, and do EM.

What sort of place do you work at?

Good for you for practicing during the golden years of emergency medicine when y’all were getting hundreds of recruiting emails and routinely being offered $300+/hr.

The future is not the same as your past.

 

[cyanide12345678]

I think a lot of this is region-dependent, but so much of what people are saying about EM's downsides (ungrateful patients, frequent flyers, dealing with the broken system, getting abused, patients constantly AMA'ing) could be said about what hospitalists have to deal with as well.

Both EM and hospitalist medicine have some of the highest burn out rates for good reason.

They are definitely more lifestyle friendly and career longevity promoting specialties out there.

 

[Pigg-O-Stat]

I've taken a huge paycut over the past few years, and the job is more demanding than ever. But I'd still take EM over any other specialty, hands down.

 

[AlmostAnMD]

OP just shows no one can really convince someone to not walk off a cliff.

It's like telling someone not to join a cult. Except none of us can get out while telling others not to join.

Then, in 10 years, OP replies to a similar post with a familiar warning and the cycle continues.

 

[qwerty89]

You’re in a glorifying mindset. Soon, you’re going to be frustrated at the uninsured treating you as their primary care for minor complaints. You’re going to be frustrated with not being able to get them follow up for anything. You’re going to be frustrated with seeing the same people OD and then get upset at you if you give them too much narcan. You’re going to be frustrated seeing that a majority of people who get shot typically get shot for a reason and that reason usually falls back on them. You’re going to be especially frustrated when you see the same person who has been shot before.

No. He's different.

 

[RustedFox]

Duuuude.

You think that EM is so cool and that you "can't see yourself doing anything else" because for that rotation or two that you had...

Ready?

You were a tourist.

You were very, VERY largely shielded from the absolute soulsucking ****show that is EM.

This is a thread full of current EM attendings, with hundreds of cumulative years under our belts.

We're all telling you this a mistake for a reason.

 

[Lynx zwo drei vier]

I guess I’ll be the lone voice saying go for it…

BUT:

Start working on your exit plan now. Maybe for you that’ll be doing electives in sports med/pain/clinical informatics/crit care to have a good CV to apply for a fellowship outside of the ED. Maybe that’ll mean networking with people in pharma/tech/consulting to leave medicine altogether. Maybe that’ll mean becoming financially literate so you can retire early. Or maybe it’s doing all of the above.

Either way, you want to be prepared for when you burn out or can’t get a good job. And if that never happens, good for you, at least you’ll be able to advice the huge number of your colleagues who do want out.

I agree with all of this. Never go through life without a Plan B.

 

[Lynx zwo drei vier]

Duuuude.

You think that EM is so cool and that you "can't see yourself doing anything else" because for that rotation or two that you had...

Ready?

You were a tourist.

You were very, VERY largely shielded from the absolute soulsucking ****show that is EM.

This is a thread full of current EM attendings, with hundreds of cumulative years under our belts.

We're all telling you this a mistake for a reason.

Asking you seriously: what are the biggest soulsucking of the job that students don't see?

 

[Apollyon]

Asking you seriously: what are the biggest soulsucking of the job that students don't see?

The recurrent social problems for which you don't have a toolbox. Likewise, the personality disorders: the first time, they're fascinating. But, you're then ready for the movie to be over. The next time, it's like a torn fingernail.

Then, there's the self-made problems, the bad choices, which people come in for, too late, and want a pill to fix it. TV commercials for "ask your doctor about this drug for cancer", while good for their business, makes me (EM, at that) get into an uncomfortable position. I would like to say, "that drug isn't even for your type of cancer".

Then, there's the demanding, ungrateful group who can't "adult", well, if at all.

Wash, rinse, repeat.

 

[Mount Asclepius]

Asking you seriously: what are the biggest soulsucking of the job that students don't see?

Then, there's the demanding, ungrateful group who can't "adult", well, if at all.

This is the vast majority of it that most other specialists and normal society don’t see. A huge percentage of American’s (and some percentage worldwide) can’t ‘adult.’

70-80% of patients we see in the ED are discharged.

Some of these people are helped with an ED visit like receiving a splint and reduction of a closed fracture. Some are worried well presenting to the ED with a reasonably valid visit for chest pain.

Some maybe should have gone to their PCP instead. They might even have a decent reason like urgent cares were closed or their PCP couldn’t get them in. They still could have likely waited.

A large percentage though just can’t ‘adult.’ The ones that hurt the most are the many that didn’t even need to see a physician at all. Example of countless: Dye from wet sock discolors foot of average adult. Comes off with alcohol swab. Patient didn’t realize came from same colored sock. Discharge. Rinse and repeat. 🤦‍♂️

 

[Lynx zwo drei vier]

The recurrent social problems for which you don't have a toolbox. Likewise, the personality disorders: the first time, they're fascinating. But, you're then ready for the movie to be over. The next time, it's like a torn fingernail.

Then, there's the self-made problems, the bad choices, which people come in for, too late, and want a pill to fix it. TV commercials for "ask your doctor about this drug for cancer", while good for their business, makes me (EM, at that) get into an uncomfortable position. I would like to say, "that drug isn't even for your type of cancer".

Then, there's the demanding, ungrateful group who can't "adult", well, if at all.

Wash, rinse, repeat.

But besides rads and path, is there any specialty that doesn’t deal with this?

 

[Apollyon]

But besides rads and path, is there any specialty that doesn’t deal with this?

Other specialties are hidden upstairs and you have to be buzzed in to get to them. Our door is - literally - open 24/7. And you don't have to pay! Nope, not even a cent. What could go wrong?

 

[GatorCHOMPions]

Asking you seriously: what are the biggest soulsucking of the job that students don't see?

But besides rads and path, is there any specialty that doesn’t deal with this?

The complete lack of control of workplace conditions is the biggest source of burnout imo. Unpredictable volume surges, doc/nurse/tech staffing shortages, and being mandated to see everything and anything that walks through the door is what separates EM from the rest of the pack. Oh and you don’t have the slightest bit of control of your schedule with most jobs. Those random Tuesdays off are nice when you’re 28 but not sexy at 38 when you realize you’re working 50% of weekends and missing dinner with family 1/3rd of the time for the rest of your career. We haven’t even touched on the circadian disruption. You’re right that “difficult” patients exist in all specialties, but for the vast majority there is a filter before they get to you. Initially by the naive medical student the above may be seen as a strength to EM (“I was made for this, I am making a difference, I am a badass”, etc.) but after a while the reality sets in.

 

[Rekt]

Asking you seriously: what are the biggest soulsucking of the job that students don't see?

Literally everything. You don't experience EM as a med student.

I did five aways and residency was still nothing like being a med student.

When you have your cute clipboard and pen, meticulously seeing a patient I had already seen 3 more plus argued with a hospitalist and a consultant.

Med students rarely have to talk to hospitalists/consults. If you do, it's the "nice one" or it's an easy admit. And they just have some sweet summer child pitty on you if you do end up talking to them. Gloves are off as a resident and attending. You don't experience the daily pushback and lazy ass consultants and being the middle man between them.

When I send you off to do the lac, I have a moment of fleeting appreciation but then remember that without fail a horrible lac will completely brick me later outside mid-level hours. it immediately becomes your most hated procedure.

When I give you that intubation or central line that will be a highlight of why you love EM but even at high acuity places it's still uncommon. Especially with mostplaces just doing peripheral pressors or letting the CCM "provider" do it upstairs. Plus bipap hfnc continues to save the day. These are some of your highlights of fourth year. As a resident/attending you won't even remember them once you get home because of everything else slowly destroying your soul.

Interesting? Puzzles? When you're going through your med student ddx thinking of unicorns and zebras after your thorough presentation, I knew what 3-8 click boxes for this patient I was already going to click based off the CC and triage note. Listening to the patient is a formality. If anything it almost always decreases what I was going to order. Sure you eventually get some things that might be truly interesting, but that's not a good thing. All it means is multiple phone calls to people who don't want to work and likely transfer depending on where you're at and you'll like run into "we're at capacity" road blocks. Consultants don't want interesting so everyone is going to try as hard as possible to block a consult. "Send to X quaternary care center" that's probably full. Interesting doesn't pay. Why waste time with intellectual thought as a consultant when routine procedures/consults pay the same or more. etc etc.

Sure you can work up interesting things or look for zebras but after your LPs with pressures and full CNS MRI w/wo, your atypical lab test that's a send out anyway (and you'll lose the MRN and forget to follow up anyway), whatever you're wasting time on (that 99% chance will be normal), your bosses will wonder why you're the slowest doc with the worst metrics.

Literally a book could be written on why it's an extremely poor choice. Haven't even touched on all of it. The metrics. The drug addicts. The demanding googlers. The dozens of daily old people with nothing wrong except weakness, realistically familial abandonment and depression. Admins. CMGs. Hospitalists. Consultants. Being the punching bag for everyone outside the ED. Being the "dumbest doc in the hospital". All we do is "CT everything". "Hey could you get a CT of xyz before coming upstairs". Lazy partners. Understaffing. Resource shortages. Phone calls. Scheduling. Charting. Charting. Charting. Charting. AMAs (just kidding, ama is the best thing to ever happen on shift). etc etc etc


It all comes down to what I'll call "THE DREAD". You'll have your own. I bet many are similar to me. You can't experience this as a med student. The dread is what it sounds like. There's almost ALWAYS something on your board that you're dreading. For me it's a patient currently undergoing workup that I know the whole time is going to be a very difficult disposition. The dread sits there chipping away at your soul all shift. As soon as you finally resolve the dread. There's another one. Then another. Then maybe you go home on time. Probably not though. Then on your next shift there's the dread. Staring at you all shift. Whatever it is for you, it'll be there.

 

[GatorCHOMPions]

It all comes down to what I'll call "THE DREAD". You'll have your own. I bet many are similar to me. You can't experience this as a med student. The dread is what it sounds like. There's almost ALWAYS something on your board that you're dreading. For me it's a patient currently undergoing workup that I know the whole time is going to be a very difficult disposition. The dread sits there chipping away at your soul all shift. As soon as you finally resolve the dread. There's another one. Then another. Then maybe you go home on time. Probably not though. Then on your next shift there's the dread. Staring at you all shift. Whatever it is for you, it'll be there.

Should make a DREAD Thread and either sticky it or keep it alive so we can just refer to it when this topic invariably comes up each week. “Go see the DREAD Thread”.

 

[Lynx zwo drei vier]

Other specialties are hidden upstairs and you have to be buzzed in to get to them. Our door is - literally - open 24/7. And you don't have to pay! Nope, not even a cent. What could go wrong?

Fair point lol. I guess every FM doc or private-practice psychiatrist sees patients who are at least functional enough to know that they need a doctor.

But being dumb doesn’t disqualify you from getting healthcare, and sometimes the inability to act like a grown-up leads to interesting pathophysiology. There are the IVDU patients who’ve already ruined their veins, start getting creative about where they inject, and present with Lemierre’s. There are people who were too embarrassed to see a doctor for their pilonidal disease/perianal abscesses/etc and come in after trying home I&Ds. There’s the occasional patient who gets shot, doesn’t seek immediate attention because he doesn’t wanna show up on law enforcement’s radar, and finally comes in, bullet still in thigh, because the pain/fever/stench have gotten too bad to ignore.

And sometimes people are just sadly in denial. One such case was a guy who didn’t follow up on his HIV diagnosis for 3 years because he couldn’t accept it (and came from a culture where homosexuality is taboo). Without giving away specifics, his findings were hair-raising.

 

[Lynx zwo drei vier]

Literally everything. You don't experience EM as a med student.

I did five aways and residency was still nothing like being a med student.

When you have your cute clipboard and pen, meticulously seeing a patient I had already seen 3 more plus argued with a hospitalist and a consultant.

Med students rarely have to talk to hospitalists/consults. If you do, it's the "nice one" or it's an easy admit. And they just have some sweet summer child pitty on you if you do end up talking to them. Gloves are off as a resident and attending. You don't experience the daily pushback and lazy ass consultants and being the middle man between them.

When I send you off to do the lac, I have a moment of fleeting appreciation but then remember that without fail a horrible lac will completely brick me later outside mid-level hours. it immediately becomes your most hated procedure.

When I give you that intubation or central line that will be a highlight of why you love EM but even at high acuity places it's still uncommon. Especially with mostplaces just doing peripheral pressors or letting the CCM "provider" do it upstairs. Plus bipap hfnc continues to save the day. These are some of your highlights of fourth year. As a resident/attending you won't even remember them once you get home because of everything else slowly destroying your soul.

Interesting? Puzzles? When you're going through your med student ddx thinking of unicorns and zebras after your thorough presentation, I knew what 3-8 click boxes for this patient I was already going to click based off the CC and triage note. Listening to the patient is a formality. If anything it almost always decreases what I was going to order. Sure you eventually get some things that might be truly interesting, but that's not a good thing. All it means is multiple phone calls to people who don't want to work and likely transfer depending on where you're at and you'll like run into "we're at capacity" road blocks etc etc.

Sure you can work up interesting things or look for zebras but after your LPs with pressures and full CNS MRI w/wo, your atypical lab test that's a send out anyway (and you'll lose the MRN and forget to follow up anyway), whatever you're wasting time on (that 99% chance will be normal), your bosses will wonder why you're the slowest doc with the worst metrics.

Literally a book could be written on why it's an extremely poor choice. Haven't even touched on all of it. The metrics. The drug addicts. The demanding googlers. The dozens of daily old people with nothing wrong except weakness, realistically familial abandonment and depression. Admins. CMGs. Hospitalists. Consultants. Lazy partners. Understaffing. Resource shortages. Phone calls. Scheduling. Charting. Charting. Charting. Charting. AMAs (just kidding, ama is the best thing to ever happen on shift). etc etc etc


It all comes down to what I'll call "THE DREAD". You'll have your own. I bet many are similar to me. You can't experience this as a med student. The dread is what it sounds like. There's almost ALWAYS something on your board that you're dreading. For me it's a patient currently undergoing workup that I know the whole time is going to be a very difficult disposition. The dread sits there chipping away at your soul all shift. As soon as you finally resolve the dread. There's another one. Then another. Then maybe you go home on time. Probably not though. Then on your next shift there's the dread. Staring at you all shift. Whatever it is for you, it'll be there.

Wait, consultants were nice to medical students at your school? Getting berated is the norm for us here, on both EM and IM.

 

[Rekt]

Wait, consultants were nice to medical students at your school? Getting berated is the norm for us here, on both EM and IM.

See ya in 4 years.

 

[GonnaBeADoc2222]

The complete lack of control of workplace conditions is the biggest source of burnout imo. Unpredictable volume surges, doc/nurse/tech staffing shortages, and being mandated to see everything and anything that walks through the door is what separates EM from the rest of the pack. Oh and you don’t have the slightest bit of control of your schedule with most jobs. Those random Tuesdays off are nice when you’re 28 but not sexy at 38 when you realize you’re working 50% of weekends and missing dinner with family 1/3rd of the time for the rest of your career. We haven’t even touched on the circadian disruption. You’re right that “difficult” patients exist in all specialties, but for the vast majority there is a filter before they get to you. Initially by the naive medical student the above may be seen as a strength to EM (“I was made for this, I am making a difference, I am a badass”, etc.) but after a while the reality sets in.

Lack of control is a huge one for me.

I have zero hiring / firing power over what stupid-*** lowlevel they choose to hire and present to me.

I have zero hiring / firing power over what murderous nurses they bring in.

Other systems issues I cannot control: stocking of supplies; patients not being undressed; geographic placement of COVID+ patients within the department; physician / nursing call outs; random lack of subspecialty coverage on any given day; EMS / nursing initiated stroke / trauma / medical alerts; CT delays.

After awhile you start to feel superfluous to the actual operations of the department, and instead like just a billing machine - this is not a good feeling. It's the feeling of not mattering, that your voice is unheard, that you are invisible.

Honestly factors like pay, support staff, volume, etc., could all stay the same, and if they just changed the PERCEPTION of hearing physician concerns, my job experience would improve greatly.

 

[VA Hopeful Dr]

Fair point lol. I guess every FM doc or private-practice psychiatrist sees patients who are at least functional enough to know that they need a doctor.

But being dumb doesn’t disqualify you from getting healthcare, and sometimes the inability to act like a grown-up leads to interesting pathophysiology. There are the IVDU patients who’ve already ruined their veins, start getting creative about where they inject, and present with Lemierre’s. There are people who were too embarrassed to see a doctor for their pilonidal disease/perianal abscesses/etc and come in after trying home I&Ds. There’s the occasional patient who gets shot, doesn’t seek immediate attention because he doesn’t wanna show up on law enforcement’s radar, and finally comes in, bullet still in thigh, because the pain/fever/stench have gotten too bad to ignore.

And sometimes people are just sadly in denial. One such case was a guy who didn’t follow up on his HIV diagnosis for 3 years because he couldn’t accept it (and came from a culture where homosexuality is taboo). Without giving away specifics, his findings were hair-raising.

Not always. The biggest advantage we have is control. Someone shows at at my office, they get dismissed and can't come back. Someone is habitually noncompliant, they can be dismissed. I decide how many patients I see per day. If I'm really busy, I can stop taking new patients. I can turn people away at need. If my kid gets sick, I just call the office manage and she cancels my patients for the day.

The second biggest advantage is scheduling. I work banker's hours. No night, no weekends, no holidays. Lunch breaks are a thing.

Traditionally, EM made up for this by making way more money than primary care. This is starting to change. EM is getting less lucrative and primary care is becoming more so.

I can't speak for everyone, but all the "interesting pathophysiology" becomes way less interesting as time goes on. Plus, its time consuming. For example, I saw a new diagnosis crohn's disease patient a few weeks ago. Brand new to the area, had been diagnoses 3 weeks ago in another state but moved before she could start treatment. GI appointments here take 2-3 months. So I read up to make sure I was starting the right treatment, got her in with GI, had a long talk about symptoms that should warrant and ED visit, the whole shebang. Felt pretty proud of myself when she left cheered up since there was a solid plan in place.

Then I noticed that I'm now a hour behind.

 

[CoolDoc1729]

Yeah, but look on the bright side: you don't have to spend 4 days rounding on those 6 belly pains.

If one of them leaves without being seen I’ll be hearing about it for 4 days …

 

[RoyBasch]

I felt the same as you before residency. After residency I specifically looked for a non trauma center because while I still enjoy working with the urban population, trauma is really boring after a certain number when you’re not the one doing definitive management .. the trauma surgeons are. And at least 10 years ago, at my residency program they were going to a shift work trauma surgery setup.. idk if this is common but I’m sure you could find something.
Don’t get me wrong, myself personally I do not regret doing EM rather than general or trauma surg… but if my priority was trauma I would have leaned more that way. We order blood and fluids and pan scan and then after the commotion there’s 6 more belly pains to see 🤦🏻‍♀️

Agree. If you really love trauma, do general surgery, Ortho, NSG, or even anesthesia. They are the ones who do the real heavy lifting on trauma cases. Our role is more diagnostic and temporizing. The traumas we manage definitively are the ones where major injuries are ruled out.

 

[Arcan57]

Duuuude.

You think that EM is so cool and that you "can't see yourself doing anything else" because for that rotation or two that you had...

Ready?

You were a tourist.

Love that line. It radiates truth like a dark sun.

Once tourist season is over you'll be a right fielder/D-lineman/2nd line winger as a resident. An important but not mission critical part of a team that existed before you got there and will be there long after you leave. The majority of your teammates will be at least moderately competent at their job and you'll have a sense of mission (both personal and shared). Around this time you'll start realizing that chaos eventually becomes routine.

Then you become an attending and it's no longer a team sport. You're playing solo (even when you're in a shop with overlapping coverage). You're now managing a team you didn't hire and can't fire. Furthermore, the majority of your team is going to fall into 1 of 3 groups:

1) Experienced but burned out- They're spending their shift posting terrible Facebook memes, shopping Wayfair, or prophylactically writing up someone that's about to hold them accountable. They've seen it all and that includes too many terrible managers, shifts with 1/2 the nurses calling out, and C-suite budget cuts. They've figured out the exact minimum they can do without being fired but they (usually) show up. Enjoy the nasty grams as you fall out on time sensitive metrics because just because you ordered broad spectrum antibiotics doesn't mean they're going to get hung in the next 4 hours.

2) Green - they're young, enthusiastic and tend to be respectful/deferential towards you. They also somehow never started an IV in nursing school, take 30+ minutes to set up a drip, and don't recognize when a patient is decompensating. With a good nurse manager and appropriate staffing ratios, they're going to turn into superstars who exemplify the best in humanity. Unfortunately, these Padawans got the job because the nurse manager's personality disorder drove off all the experienced nurses and they're going to finish orientation and go right into a string of night shifts where it's just them and the charge nurse for 16+ patients. The ones who don't thrive on chaos will either burn out and become part of group 1, move to specials/PACU/cath lab, or read the room and move into the third group.

3) Merit badge- whether they wanted to be nurses and were smart enough to realize bedside nursing sucks or knew from the start that becoming an NP is so much cheaper and easier than going the MD route, these nurses are just passing through. They tend to be excellent nurses if you can get them to log off from their NP homework or preceptor request paperwork and do the job they're currently being paid for. They'll be gone within a couple of years, only to come back PRN because the market is oversaturated.


Throw in demotivating emails about missing metrics because you were too busy keeping someone alive to document their dementia risk, directors forwarding patient complaints without regard to validity, entrenched consultants that become abusive when asked to do their job, and the realization that the game is about making money not taking care of patients.

 

[bravotwozero]

Y’all are being trolled hard.

 

[GonnaBeADoc2222]

OP, I think it's worth realizing that even during the glory days of EM when people were literally rolling in money, we were still abused.

It's just that people were better able to rationalize it by saying "oh well I'm making $500 / hr for this shift, I can tolerate anything for 10 hours."

Now that wages are coming back down to Earth people are hearing their inner Gob Bluth say "I've made a huge mistake."

 

[oldtown]

It all comes down to what I'll call "THE DREAD". You'll have your own. I bet many are similar to me. You can't experience this as a med student. The dread is what it sounds like. There's almost ALWAYS something on your board that you're dreading. For me it's a patient currently undergoing workup that I know the whole time is going to be a very difficult disposition. The dread sits there chipping away at your soul all shift. As soon as you finally resolve the dread. There's another one. Then another. Then maybe you go home on time. Probably not though. Then on your next shift there's the dread. Staring at you all shift. Whatever it is for you, it'll be there.

Another thing about “THE DREAD” (love this, by the way)- it’s insidious, and eventually consumes you. We’ll call it “DREAD CREEP”. It starts out as Rekt describes it, that hard to dispo patient on shift.

Pretty soon, you start to realize that you’re going to have at least one of these on every shift, so THE DREAD will start on your drive in to work. After a while, it starts when you wake up the day of that 2pm-12am shift. Then the day before you have to work a shift.

Eventually, you finish a string of 4 or 5 shifts, and are off for the next 9 days, but THE DREAD sets in on your way home from that last shift, because you know that in 9 days, you have to do it again. And THE DREAD casts a tint on your vacation when you should be just relaxing and enjoying your time off.

 

[RustedFox]

Fair point lol. I guess every FM doc or private-practice psychiatrist sees patients who are at least functional enough to know that they need a doctor.

But being dumb doesn’t disqualify you from getting healthcare, and sometimes the inability to act like a grown-up leads to interesting pathophysiology. There are the IVDU patients who’ve already ruined their veins, start getting creative about where they inject, and present with Lemierre’s. There are people who were too embarrassed to see a doctor for their pilonidal disease/perianal abscesses/etc and come in after trying home I&Ds. There’s the occasional patient who gets shot, doesn’t seek immediate attention because he doesn’t wanna show up on law enforcement’s radar, and finally comes in, bullet still in thigh, because the pain/fever/stench have gotten too bad to ignore.

And sometimes people are just sadly in denial. One such case was a guy who didn’t follow up on his HIV diagnosis for 3 years because he couldn’t accept it (and came from a culture where homosexuality is taboo). Without giving away specifics, his findings were hair-raising.

- but sometimes it feels like it should. Because now the whole world's irresponsibility and failure to adult now becomes your responsibility... and worse... your liability.

That's right... you can be (and I have been) sued because a patient is too dumb to know simple things about themselves that every reasonable person on earth could conclude "was their responsibility".

You said - "sometimes the inability to act like a grown-up leads to interesting pathophysiology", and EVERYONE here on this forum immediately wanted to punch you.

These people are the worst. Oh, and they complain to the adminstrators. They fabricate. They disrupt. If they're not your number-one risk, they're damn close.

Seriously, OP? Take this as best as you can: Eff you, dude. You have no idea what you're talking about.

 

[southerndoc]

I'm eight years out, and I still wouldn't choose any other specialty. Ignore all the noise, and do EM.

I have the same mindset.

What I don't get is all the negativity on here about EM. If people are that negative about it, they should find another career. I sure as heck would. I wouldn't want to be miserable and share my misery with other people and let it spill into other areas of my life.

Yes, EM has its problems, but I still enjoy helping people, teaching residents, doing cool EMS stuff, and no matter what people claim, getting paid quite well for it. No I may not be paid at the top 0.5% of the specialty nor make a baseball player's salary, but I'm not working for $15/hr and it pays the bills, allows me to do the things I want and buy the things I want, and to save for a good retirement.

 

[GassYous]

OP, I think it's worth realizing that even during the glory days of EM when people were literally rolling in money, we were still abused.

It's just that people were better able to rationalize it by saying "oh well I'm making $500 / hr for this shift, I can tolerate anything for 10 hours."

Now that wages are coming back down to Earth people are hearing their inner Gob Bluth say "I've made a huge mistake."

You've already committed and you're throwing good money after bad. Can't help it, that's just how the brain works.

 

[Mount Asclepius]

I have the same mindset.

What I don't get is all the negativity on here about EM. If people are that negative about it, they should find another career. I sure as heck would. I wouldn't want to be miserable and share my misery with other people and let it spill into other areas of my life.

Yes, EM has its problems, but I still enjoy helping people, teaching residents, doing cool EMS stuff, and no matter what people claim, getting paid quite well for it. No I may not be paid at the top 0.5% of the specialty nor make a baseball player's salary, but I'm not working for $15/hr and it pays the bills, allows me to do the things I want and buy the things I want, and to save for a good retirement.

I think it's the googly eye misperception of the field that irks those that have more experience. Many of us going into EM thought we vetted the field quite well and were still wrong regarding what it's truly like. I think setting realistic expectations is helpful for people. If they still can't imagine doing anything else other than EM despite all of its negative aspects, then maybe it is the right choice for them. Not saying I would have done it differently with 20/20 hindsight, but I definitely would have considered my other options a little more seriously. Venting is also a good form of release.

 

[RustedFox]

I have the same mindset.

What I don't get is all the negativity on here about EM. If people are that negative about it, they should find another career. I sure as heck would. I wouldn't want to be miserable and share my misery with other people and let it spill into other areas of my life.

Yes, EM has its problems, but I still enjoy helping people, teaching residents, doing cool EMS stuff, and no matter what people claim, getting paid quite well for it. No I may not be paid at the top 0.5% of the specialty nor make a baseball player's salary, but I'm not working for $15/hr and it pays the bills, allows me to do the things I want and buy the things I want, and to save for a good retirement.

It's pretty clear to all those here on the forum that you're doing EM because you're in academics and dig it. Oh, and you've stacked paper to the ceiling during the good years and thru a series of smart investments and now things in your world aren't like 99% of community EM.

 

[EctopicFetus]

Forget where we are today. When you finish residency and start working a job in summer of 2926 what will it look like. It’s a bad bad future that is predicted.
i think if you will be happy working without staff and supervising your CMG MLPs and making 150/hr with tremendous liability for their decisions then by all means.
if you think seeing high acuity patients and having time to actually manage them properly is in your future I would reconsider.
many of us have decent enough jobs for now. Is the future bright? No way. Look at all the recent info with insurers aggressively going after em pay. It’s mostly about CMGs but everyone will get cut. The CMGs have previously used insurers as an excuse to cut pay. Throw in the mid levels; the workforce issues and peer into the dark future. For anyone fresh out. Get your exit plans prepped.
the few semi decent jobs left (horrid location; decent work environment and decent pay) are filling as we speak. Once that’s full. Then what? When every job in Mississippi and Arkansas is full for $270-300/hr what comes next in a job market and job hunt. Not much will be left. Next is find the better cities and rates will drop there. Then the outlying cities of the good cities (1-2 hours out) then the crappy locations will see pay drop.
i like what i do. I would never advise my kids to do EM. No control and the factors above lead to a bleak future.

 

[southerndoc]

It's pretty clear to all those here on the forum that you're doing EM because you're in academics and dig it. Oh, and you've stacked paper to the ceiling during the good years and thru a series of smart investments and now things in your world aren't like 99% of community EM.

I wasn't affiliated with a residency until 5 years ago, and I still volunteer for plenty of shifts without residents (I still like to primarily see patients). I work every Thursday during conference day now that I'm in more of an administrative role instead of core faculty.