Is EM for me?

[policymaker]

Lately I've been thinking about going into emergency medicine. The nature of the work as well as the shift-based schedule appeal to me. The problem is, I don't particularly want to take care of the homeless and alcoholics, so that rules out big urban hospitals. What are suburban emergency departments like? Should I rule out EM because I want to avoid certain populations?

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[Sessamoid]

Lately I've been thinking about going into emergency medicine. The nature of the work as well as the shift-based schedule appeal to me. The problem is, I don't particularly want to take care of the homeless and alcoholics, so that rules out big urban hospitals. What are suburban emergency departments like? Should I rule out EM because I want to avoid certain populations?

Homeless are less common in suburban and rural settings, but drunks can be found in all areas and all economic classes. Rich drunks can be worse than poor ones. Drunk people of all social classes drive at night, too.

Here's the kicker. It's hard to get jobs at rich suburban hospitals because nobody wants to leave those jobs. This will vary some with geography, but in general it's true.

If you absolutely cannot tolerate dealing with the dregs of society on a fairly regular basis, then perhaps this isn't the right specialty for you. Depending on how strong the aversity is for you, you may not even make it through residency. Residency programs typically serve inner-city, urban jungles. Some exceptions exist (UC Irvine and Scott and White come to mind), but not many.

What about the medical aspects of EM did you like? Because for lifestyle, there are other specialties that offer shift work or something similar. Anesthesia, pathology, internist/hospitalists, physiatry... the list is actually pretty long.

 

[policymaker]

What about the medical aspects of EM did you like? Because for lifestyle, there are other specialties that offer shift work or something similar. Anesthesia, pathology, internist/hospitalists, physiatry... the list is actually pretty long.

I like the immediacy of it. Someone comes in with a problem, you fix it and the person is all better again. I realize this is a very simplistic view of the specialty, but I think I'm more of an instant gratification person than one who enjoys treating chronic diseases. Together with the idea that once you leave the office you are free to pursue your own life, EM definitely is appealing to me.

 

[DrScott]

I'm with policymaker. There are so many aspects of Emergency Medicine that interest me but I am concerned about the 'lowlife' factor. I just don't know if I want to deal with that. I don't want to help some drunk driver who raps himself around a light pole.

One solution that minimizes the 'lowlife' factor is Pediatric ER. However, I have heard that you have two more years of training with a potential drop in income.

If there is anyone on here that could give me an idea of the percentage of 'lowlife' patients in a busy Level 1 ER, that would be helpful. Every specialty I look at has it's pros and cons but it seems like the majority of ER falls into the pros category with the exception of dealing with 'less desirables'.

Scott

 

[roja]

Low life? Low life? You have *got* to be kidding me. I would suggest that both of you seriously reconsider EM. If by 'lowlife's' you mean individuals who are poor or homeless, disinfranchised, then, yup, you are goign to see alot of these. In any field. Except maybe plastic surgery (and you will see these 'low lifes' during your surgical residency) or dermatology.

If this is truly your attitude towards patients, then ER is definately NOT the place for you. Unlike private practice, EMTALA ensures that *all* patients get treated in the ER. Period. And carrying around an attitude like this can be dangerous. Yes, sometimes homeless and/or drunks are annoying. however, if you automatically dismiss them, you will get burned over and over (not to mention the purely unethical aspect of this).

Drunks, homeless, dinguses... they all get sick. You have to gaurd against bias and deal.

If you don't want to help some patient because you don't like the choices they have made, I would say you should seriously reconsider your career in medicine.

 

[DrScott]

My viewpoint is not an uncommon one. Everytime I post something on here people read into it and make assumptions. Lowlife does not mean poor or homeless. I am talking about people(rich or poor) that are in the emergency room due to questionable practices like drunk driving.

And please don't lump the OP with me. I used the term low life, not the OP. Leave him out of this.

And yes, I don't want to help some people that make decisions that I do not agree with. I don't want to help a drunk who just killed a family. This is a common and understandable reaction, it doesn't make a person unethical or insensitive.

As I stated before, this is the biggest reason I do not want to do ER. This would be much less a concern with pediatric ER but would increase in frequency with the older kids.

Scott

 

[Febrifuge]

There are two major mental/ emotional skills that are invaluable to an Emergency Physician: one, you need to maintain your own personality and "to thine own self be true" throughout your work (in a positive and professional way of course) and two, you have to leave your own predjudices and moral judgements out of it.

If you can't do both at the same time, then don't work in EM. I agree with Roja above.

 

[roja]

My viewpoint is not an uncommon one. Everytime I post something on here people read into it and make assumptions. Lowlife does not mean poor or homeless. I am talking about people(rich or poor) that are in the emergency room due to questionable practices like drunk driving.

And please don't lump the OP with me. I used the term low life, not the OP. Leave him out of this.

And yes, I don't want to help some people that make decisions that I do not agree with. I don't want to help a drunk who just killed a family. This is a common and understandable reaction, it doesn't make a person unethical or insensitive.

As I stated before, this is the biggest reason I do not want to do ER. This would be much less a concern with pediatric ER but would increase in frequency with the older kids.

Scott

My statements apply to *both* your 'lowlifes' and the OP's drunk/homeless statement and thus, stand.

Your stance is a dangerous one, not only for EM but for ANY doctor. Your *reaction* may be understandable but your DUTY as a physician is to treat the sick. Regardless of your field or your personal beliefs. If you can't check your own morality, for your patients health, than you absolutely don't belong in the ER.

and really, where are you going to draw the line? Withholding HIV meds because someone engaged in promiscuous sex? Not treat a Lung CA patient because they smoked?

No one *wants* to have to treat someone who has done something horrible. But its your DUTY. Especially in the ER. If you can't check your own morality at the door and it endangers a patient's life, then you don't belong in the ER.

 

[RichL025]

Right on, Roja!

From another poster:

I just don't know if I want to deal with that. I don't want to help some drunk driver who raps himself around a light pole.

Did the person who wrote the above (or any of you reading it who were nodding your heads in agreement) ever know anyone who EVER drove drunk? Face it, most people have at one point in their life. For most of them, it was a stupid high-school thing, no one got hurt, and the drunk driver eventually wised-up and stopped doing it.

Think back to high school. I'm SURE you knew someone who drove after a few too many drinks. Now imagine if that person had wrecked their car. How would YOU have felt if, when accompanying your friend to the hospital, the ER doc had rolled his eyes and said he hated taking care of lowlife drunks?

Good people make stupid decisions sometimes. Yes, bad people do too <g>, but the difference is, it's not our place to judge them.

If you found yourself agreeing with the above quoted assertion, PLEASE do not consider a career in emergency medicine. Because even if I happen to be a clean-cut non-drunk, non-druggie type of guy, how do I know you're not going to judge me in some other way, and conclude that _I_ don't really deserve your best efforts? Maybe you have a thing against white anglo-saxons or something? I dunno. But if you are bothered enough by it that you need to make value judgements, perhaps you should consider a different line of work.

And if you really believe this:

I don't want to help some drunk driver who raps himself around a light pole.

You should re-consider medicine altogether. I'm hoping that was just hyperbole.

Just my 2 cents, hope I didn't offend.

 

[medic170]

My statements apply to *both* your 'lowlifes' and the OP's drunk/homeless statement and thus, stand.

Your stance is a dangerous one, not only for EM but for ANY doctor. Your *reaction* may be understandable but your DUTY as a physician is to treat the sick. Regardless of your field or your personal beliefs. If you can't check your own morality, for your patients health, than you absolutely don't belong in the ER.

and really, where are you going to draw the line? Withholding HIV meds because someone engaged in promiscuous sex? Not treat a Lung CA patient because they smoked?

No one *wants* to have to treat someone who has done something horrible. But its your DUTY. Especially in the ER. If you can't check your own morality at the door and it endangers a patient's life, then you don't belong in the ER.

Great post.

I wanted to mention something to you folks.

You are a doctor, not a Judge and not a Diety.
Therefore, it is NOT your job, or really even your right, to judge people, leave that to the Judges, the Juries, and especially to God. Just worry about doing YOUR job. Who are you to judge people anyway? Lose the holier than thou attitude, you don't know the whole story with any patient, and like what was said before, where do you stop? If you want to judge people, join a Jury, become a Judge, or become a God.

 

[kungfufishing]

...wow....

1. Regardless of which specialty you end up in, which population do you expect to serve during residency?

2. The attitude your post displays is actually somewhat common in the ED, but only when dealing with consultants who are worried about getting paid/trying to avoid getting out of bed/ trying to avoid "lowlifes" or getting their hands dirty. The reality is that in EM, you end up being the "lowlife's" advocate.

3. As an EP, you are required to see/treat all comers. This aspect is actually somewhat appealing, aside from the smell. But even if you go into something else, you are paid to be a Doctor, not to pass judgement.

Ultimately, I would say that you will probably find lowlifes in your practice no matter what you go into (found in all socioeconomic strata). Good luck.

 

[policymaker]

I have created a monster.

First off, I agree with all the above posters that as a doctor it's your job to take care of patients no matter who they arer. If a so-called "lowlife" (whatever that means) comes into my office I of course will treat them. Having said that, I'd rather not have to do this on a regular basis. It's like people who choose not to go into oncology because they don't want their job to be taking care of cancer patients, not because they think cancer patients should not be treated. Likewise, I don't want my job to be taking care of homeless people. I have a lot of respect for those of you who do, but it's not what I want to do. Hence my original question: Can I choose certain settings to practice EM, or is EM the same everywhere and I should just consider another field?

 

[roja]

policymaker- You didn't create a monster. EM is one of the last fields that has to hold this ideology sacred. Often EM is the last advocate for the homeless, disinfranchised patients.

Because of EMTALA, it is highly unlikely that you will never have to deal with this in the ED. Granted, once you finish residency, you can go to a smaller community and probably not have to deal with homeless individuals on a regular basis.

but realize, no matter where you are, there is NO filter to the ED. Everyone comes. Everyone gets treated. There is no screening, there is no 'fallout' (ie patients don't fail to show up for thier 'followup').

If your really unsure, rotate through a community ED and an Urban ED (to find out if you can handle it for the duration of residency) and see what you think. But realize, to be safe, you will have to hammer out any bias that might be present. (something EVERYONE has to work at.)

 

[sunnyjohn]

Low life? Low life? You have *got* to be kidding me. I would suggest that both of you seriously reconsider EM. If by 'lowlife's' you mean individuals who are poor or homeless, disinfranchised, then, yup, you are goign to see alot of these. In any field. Except maybe plastic surgery (and you will see these 'low lifes' during your surgical residency) or dermatology.

If this is truly your attitude towards patients, then ER is definately NOT the place for you. Unlike private practice, EMTALA ensures that *all* patients get treated in the ER. Period. And carrying around an attitude like this can be dangerous. Yes, sometimes homeless and/or drunks are annoying. however, if you automatically dismiss them, you will get burned over and over (not to mention the purely unethical aspect of this).

Drunks, homeless, dinguses... they all get sick. You have to gaurd against bias and deal.

If you don't want to help some patient because you don't like the choices they have made, I would say you should seriously reconsider your career in medicine.

Febrifuge and Roja may be right...

 

[USAF MD '05]

Right on, Roja!

From another poster:


Did the person who wrote the above (or any of you reading it who were nodding your heads in agreement) ever know anyone who EVER drove drunk? Face it, most people have at one point in their life. For most of them, it was a stupid high-school thing, no one got hurt, and the drunk driver eventually wised-up and stopped doing it.

Stole my thunder, Rich!
I was a crazy ass kid. I drove drunk with cars full of my equally drunk high school friends. I like to think I've matured out of the lowlife phase, but there have been occasions since childhood when I have gotten home and thought, "I was stupid to drive tonight. I'm not drunk, but I am probably a little impaired."
Thankfully those occasions are a thing of the past, and I have discovered the freedom and relaxation that a DD or cab brings. ( Now that I'm married with kids, I rarely get out for a beer at all!) I'm also a ******* lowlife motorcycle rider. I'm not one of the consultants who stand over a horrible MVC crash and talk about what a ***** the guy was. Blah, blah, donorcycle, blah. I IDENTIFY with these people. I give them compassionate care and I thank God that I'm not in their shoes. To err is human, and all that jazz.
Granted, repeat offenders are a different story. It is hard to frustrating to see the same faces for the same stupid actions over and over. Many times, however, the events that bring the patients through the ED doors are lifechanging. Some will not repeat, and have us to thank for their second chance at life.
In summary, all this to me says that medicine may have been the wrong choice for you, but EM should be crossed off your list, like yesterday.
Steve

PS- Your definition of lowlifes will be found in any field in medicine. What about the 350 pound guy in the Cardio clinic who gets a cheeseburger on the way home, the COPDer that smokes around his O2 line, the pregnant teenager (G5P2A3) who continues to drink and drug, the HIV positive guy infecting partners at random, or the idiot ER doc who keeps giving you stupid consults all night long? You will have to deal, one way or the other. We see 'em first in the ED, but we farm them out to everyone.

 

[RichL025]

Thanks, Steve.

I'm a motorcycle rider also... those demon sportbikes! Another great analogy (although I don't ride too crazy, and wear full protective gear).

 

[Koko]

It's reassuring to see people speak up about the need to treat everyone appropriately and do your best not to let your prejudices influence the care you provide. On rotations I have seen discouraging interactions and comments made all too frequently. We're all human and bring our prejudices to the bedside, and sleep deprivation doesn't help, but I think it's vital to remember how sacred our role is in society.

My first real challenge in this vein was taking care of a belligerent, foul-mouthed racist who had prominent swastika tatoos on both hands. I remember having to consciously make an effort to be non-judgmental and treat him as I would any other pt on our service.

I'm not interested in piling on or pretending to be holier than thou, but our role in society is unlike that of any other individual. We can't be judgmental or discriminatory in how we treat our patients or we risk losing the trust that is essential to the practice of medicine.

Peace.

 

[USAF MD '05]

Thanks, Steve.

I'm a motorcycle rider also... those demon sportbikes! Another great analogy (although I don't ride too crazy, and wear full protective gear).

It's cruisers for me, but I'm not so hot with the protective gear!!

 

[doc05]

it's pretty obvious that the OP shouldn't go into EM. he displays the mentality of a dermatologist.

 

[iatrosB]

it's pretty obvious that the OP shouldn't go into EM. he displays the mentality of a dermatologist.

 

[RichL025]

It's cruisers for me, but I'm not so hot with the protective gear!!

Wellllll, I'd be a liar if I said I always wear all the proper gear . Always a helmet, though (even in Fla when they dropped their helmet law)

 

[waterski232002]

And yes, I don't want to help some people that make decisions that I do not agree with. I don't want to help a drunk who just killed a family.

Are you kidding me??? And you got into med school??? And I'm sure you are soooooo perfect and good... Comments like these really disgust me b/c you make it seem like you've NEVER done anything you've ever regret. You're talking about wanting to REFUSE treatment of a patient because of a PERSONAL disagreement! Remember what you're trained to do in medicine... criticism and judgement isn't it.

Furthermore, if you think this doesn't apply to every specialty in medicine than you're on crack. Look at the typical american... fat-ass gluttons, chain smokers, 300 lb diabetics who are non-compliant, than show up to the gen med service with a massive MI and need surgery for resection of that huge lung mass. Not to mention you've been riding them for the last 10 years to lose weight and quit smoking. You don't need to be homeless to be this patient. This is what fills up the general surgery and medicine floors! But these are the people that need your help the most... not your egotistical cynicism.

My statements apply to *both* your 'lowlifes' and the OP's drunk/homeless statement and thus, stand.

Your stance is a dangerous one, not only for EM but for ANY doctor. Your *reaction* may be understandable but your DUTY as a physician is to treat the sick. Regardless of your field or your personal beliefs. If you can't check your own morality, for your patients health, than you absolutely don't belong in the ER.

and really, where are you going to draw the line? Withholding HIV meds because someone engaged in promiscuous sex? Not treat a Lung CA patient because they smoked?

No one *wants* to have to treat someone who has done something horrible. But its your DUTY. Especially in the ER. If you can't check your own morality at the door and it endangers a patient's life, then you don't belong in the ER.

Well said Roja...

 

[bartleby]

You're kidding, right? Who do you think is bringing their snotty little kid to the ED at 3am?

One solution that minimizes the 'lowlife' factor is Pediatric ER.

I work in an inner city hospital and several community EDs in "nice" towns. What's the difference? The "dirtbags" drive nicer cars and use more expensive drugs in the 'burbs...

You're going to deal with plenty of people you'd rather not sit down and have a beer with after work. Get over it. If want to minimize your coversation time, consider anesthesia...

 

[MasterintuBater]

Boy, some of the regular EM preachers really got behind the pulpit on this one.

I carry my judgments and morals with me everyday, and find it impossible to check them at the front door of the hospital. That's what makes me different from the robots. We all carry our values with us, and they affect how we treat people, even if its subconscious or subtle and we do our best to suppress prejudicial actions. But anyone who has the ability to not pass judgment on anyone better check their pulse.

But I wish some of you long time posters who police this EM forum would have told me sooner that I shouldn't go into Emergency Medicine cause it's too late now!!!

 

[jazz]

I carry my judgments and morals with me everyday, and find it impossible to check them at the front door of the hospital. That's what makes me different from the robots. We all carry our values with us, and they affect how we treat people, even if its subconscious or subtle and we do our best to suppress prejudicial actions. But anyone who has the ability to not pass judgment on anyone better check their pulse.

"I don't think your clients belong in jail, but I don't get to make that decision! I represent the government of the United States without passion or prejudice,"

guess what movie this is from?

basically, your job as a physician is to treat the patient in front of you with the same standard of care. you may not agree with their lifestyle and you may not feel sympathy for them or their condition, but you MUST treat them and as roja put it, "If you can't check your own morality at the door and it endangers a patient's life"

as a GI doctor, you're going to see people who abused alcohol and/or IV drugs for a large portion of their life and now have cirrhosis and hepatitis and need their abdomen tapped all the time.

in ALMOST ever speciality, you will see people who have made decisions in the past or present that have compromised their health and/or the life of others. as a physician, you cannot spend your time judging individuals. your DUTY is to treat.

as stated earlier, as an ER physician you ARE your patient's strongest active. many of the individuals we are referring to have no primary care, access to primary care, etc and come to the ER for their medical care.

finally, to the OP, if you are looking to practice in a nice suburbn setting (which will not make you immune to the homeless and intoxicate), you will likely see fewer than in an inner city, county ER. however, realize that most training programs are in urban areas because these are the ER's where you will see sicker patients and trauma patients.

 

[typeB-md]

"I don't think your clients belong in jail, but I don't get to make that decision! I represent the government of the United States without passion or prejudice,"

guess what movie this is from?

basically, your job as a physician is to treat the patient in front of you with the same standard of care. you may not agree with their lifestyle and you may not feel sympathy for them or their condition, but you MUST treat them and as roja put it, "If you can't check your own morality at the door and it endangers a patient's life"

as a GI doctor, you're going to see people who abused alcohol and/or IV drugs for a large portion of their life and now have cirrhosis and hepatitis and need their abdomen tapped all the time.

in ALMOST ever speciality, you will see people who have made decisions in the past or present that have compromised their health and/or the life of others. as a physician, you cannot spend your time judging individuals. your DUTY is to treat.

as stated earlier, as an ER physician you ARE your patient's strongest active. many of the individuals we are referring to have no primary care, access to primary care, etc and come to the ER for their medical care.

finally, to the OP, if you are looking to practice in a nice suburbn setting (which will not make you immune to the homeless and intoxicate), you will likely see fewer than in an inner city, county ER. however, realize that most training programs are in urban areas because these are the ER's where you will see sicker patients and trauma patients.

blah blah blah... we get the point.

EM may be different but any other physician can and likely will turn patients away. If you think you can "check your morality at the door" well... that's pretty stupid. But just because you're saying to yourself "man, this is one stupid mother Fer" doesn't mean that you can't treat him.

you all act like god has sent you down as a messiah for the poor. most of the EM guys i know don't like working on someone who smells like they played in baby crap and then didn't shower for a month...BUT they treat them like they treat anyone else.

and a physician doesn't have the DUTY... he has the ABILITY to help people.

 

[Sessamoid]

But just because you're saying to yourself "man, this is one stupid mother Fer" doesn't mean that you can't treat him.

I'm with you there. I can't count the number of times I said that last night or something similar to it. They all get care that at least meets the standard of care. I don't always go out of my way to make them comfortable about it though.

and a physician doesn't have the DUTY... he has the ABILITY to help people.

Oops. Actually, the EP has a legal duty to at least try to stabilize any emergent medical conditions that walk through the door. Whether he actually has that ability is a different matter.

 

[MasterintuBater]

Neither the OP or anyone else is confused that physicians have a DUTY to treat. Everyone already knows this. It's not what the OP wanted to discuss. The OP never said he/she WOULDN'T treat the drunk, poor, alcoholic, crack head, whatever. He said he didn't WANT to. I don't want to either. Just part of the job. The OP wanted to find out if there were divisions of EM that minimized this less-than-desirable aspect of EM. In the midst of this, he unfortunately used the emotionally charged phrase "low-life" and now we've gotta listen to all this crap about duty and EMTALA and whatever. Everyone knows you gotta treat everybody the same. WE get it. But you don't have to set aside your judgments and values to do so. It's entirely possible to think someone's a low-life, pass judgment on them, hate their mothers for bringing them into the world, and still treat them with the same standard of care.

 

[Goose...Fraba]

man this is the first serious discussion Ive seen on the EM forum, I kind of miss hijacking the thread into where you can get the best burgers (....lets see if I remember correctly it was a double animal from in and out, right? )
Goose

 

[RichL025]

Masterintubater -

Neither the OP or anyone else is confused that physicians have a DUTY to treat.

Read the post by TypeB MD, above. There is at least _one_ person who thinks he doesn't have a duty to treat. I can only hope his use of the word "physician" instead of "EM physician" means he isn't one (or wasn't referring to them).

 

[typeB-md]

Masterintubater -

Read the post by TypeB MD, above. There is at least _one_ person who thinks he doesn't have a duty to treat. I can only hope his use of the word "physician" instead of "EM physician" means he isn't one (or wasn't referring to them).

yes, i guess i should've specified that EM physicians are the exception to my feelings. I understand the legal situation in the ER.

My comments are in regards to the fact that i hate everyone telling doctors that they need to cure everyone in every single situation and be mother theresa, servant of the masses. Physicians (other than emergency situations) should be able to use their discretion in treating individuals.

I want the training of a doc so that i can hopefully help those in need, not those who have the means and just refuse to put any effort forth. This is what i mean by DUTY vs. ABILITY.

 

[RichL025]

yes, i guess i should've specified that EM physicians are the exception to my feelings. I understand the legal situation in the ER.

My comments are in regards to the fact that i hate everyone telling doctors that they need to cure everyone in every single situation and be mother theresa, servant of the masses. Physicians (other than emergency situations) should be able to use their discretion in treating individuals.

I want the training of a doc so that i can hopefully help those in need, not those who have the means and just refuse to put any effort forth. This is what i mean by DUTY vs. ABILITY.

Fair enough. Just realize that society seems to be increasingly viewing health care as a right, not a service. They don't look at the 10+ years you spend as an indentured servant during your training, nor do they look at how much you have to pay in malpractice - all they see is your gross salary (or what they imagine it is) and expect that for that amount of money (that they imagine they have somehow contributed to), they deserve treatment from you.

I wouldn't be surprised if sometime in the near future something like EMTALA gets extended to other providers also, or else we all get swallowed up like the NHS in the UK, but that's another thread....

 

[DrScott]

Neither the OP or anyone else is confused that physicians have a DUTY to treat. Everyone already knows this. It's not what the OP wanted to discuss. The OP never said he/she WOULDN'T treat the drunk, poor, alcoholic, crack head, whatever. He said he didn't WANT to. I don't want to either. Just part of the job. The OP wanted to find out if there were divisions of EM that minimized this less-than-desirable aspect of EM. In the midst of this, he unfortunately used the emotionally charged phrase "low-life" and now we've gotta listen to all this crap about duty and EMTALA and whatever. Everyone knows you gotta treat everybody the same. WE get it. But you don't have to set aside your judgments and values to do so. It's entirely possible to think someone's a low-life, pass judgment on them, hate their mothers for bringing them into the world, and still treat them with the same standard of care.

Thank you for this insightful remarks/clarifications. Your words exactly capture the intent of my posts. I am the one that used the term 'lowlife' that got everyone excited, not the OP. I WOULD treat these patients in a professional and competent manner despite my feelings towards them. I am just concerned that this would eat at me over time.

Thank you everyone for your input. It is appreciated and helps to further rule out EM for me.

Scott

 

[ERMudPhud]

One solution that minimizes the 'lowlife' factor is Pediatric ER. However, I have heard that you have two more years of training with a potential drop in income.

Don't forget even "lowlifes" have kids so you are still going to have to deal with them. Plus some of the meanest, most self-destructive, "lowlifes" I've ever met were teenagers.

Maybe the way you can tell if EM is right for you is when you enjoy it so much that it doesn't matter what percentage of your patients are "scumbags" Even the biggest "lowlife" still probably had or has a family plus every so often they surprise you. When I worked in the inner city county hospital I would bet that >10% of the patients met my "scumbag" criteria and depending on each individuals practitioners threshold for scumbaggness that number could probably be as high as 50%. We used to write stop drinking/drugging on virtually every set of discharge instructions. One day a colleague wrote "PLEASE, stop drinking its killing you and us" on one chronics discharge instructions. We had seen him for Etoh, seizures, trauma, all kinds of stuff on a near daily basis. We didn't see him for months and then one day he showed up clean, sober, with a minor work comp related injury. We all started writing PLEASE on our discharge instruction after that. Now that I work in the burbs I would say that "scumbag" level is slightly lower but the "scumbag" phenotype has changed. The homeless addicts have been replaced somewhat by entitled, demanding, often drug seeking, worried well. Instead of being a smelly alcoholic who calls you a m----f----er they are yuppies who threaten to write a letter to the state medical board or sue you because you didn't see them quickly enough and refused to refill their oxycodone script for their chronic hangnail pain

All that being said, I do pass judgement on people but the only way the "scumbags" will know that they have crossed my "scumbag" cut off is that I am a lot less friendly to them. They still get the same care, partly because the law says that is what I have to do and partly because I can't really imagine doing things any differently. For me that is part of what I like about EM. I like the fact that we see all comers regardless of status or ability to pay. If you are a millionaire investment banker who just had way to much to drink and nearly killed a van full of kids I can treat you with the contempt you deserve while still making sure to find all the injuries you are to drunk to notice yourself. If you are homeless alcoholic who is polite and respectful to the rest of the ED staff I can treat you like the citizen you are instead of the "scumbag" the rest of the world sees.

 

[Energon]

Even a dermatologist or a plastic surgeon is not immune to treating evil doers "low life" patients. Eg. a dermie may have to treat a rash on a patient who threw his schlong into the wrong hole. A Plastic surgeon may have to give a future porn star a new set of titts..... so as you see, we are surrounded by low life's and it just better to accept it and just do your job, which is being a physician.

 

[roja]

Apris- A story from this weekend:


Our charge nurse came up to me and rambled on about giving me an 'emergent patient who wasn't emergent despite having just got a couple of people'. I said, sure. Walked over to where the patient was bieng triaged and asked the paramedics what was going on.

para: We found him face down a foot away from the subway platform in his own vomit, drunk.

me: alright, what did you do? (assessing a very unresponsive pt with a subtle r facial droop)

para: well, he was drunk so we gave him narcan.

me: did yhou give d50?

Para: no, he didn't have a line.

me: did you give glucagon?

para: no, he was drunk.

me: great.

So, despite the fact tthat he patient had NO aob (?on clothes) and the pt being very cold, he didn't get the STANDARD of care because a bias was in place.

Needless to say, the patient had a FS of 44 and a rectal temp of 94.

He DID have a history of IVDU and probably overdosed and possibly has a history of DM.

Thankfully, I didn't listen to my charge nurse or the paramedics. Adn despite the fact that this person has royally f&cked his life, he deserved the standard of care.

The paramedics and the nurse never INTENDED to give less care. If you asked them if they planned to give sub-optimal care they would be horrified.

And this is why this is a sacred cow in EM. You must be vigilant with judging others. Because often, when you carry around the bias, it leaks out and affects your behavior. Even if you don't INTEND to.

I would put in another story, but I jsut got off work and am to tired.

 

[Sessamoid]

Even a dermatologist or a plastic surgeon is not immune to treating evil doers "low life" patients. Eg. a dermie may have to treat a rash on a patient who threw his schlong into the wrong hole. A Plastic surgeon may have to give a future porn star a new set of titts..... so as you see, we are surrounded by low life's and it just better to accept it and just do your job, which is being a physician.

You're missing the point. As EPs, we're obligated by law to take what rolls in the door. A dermatologist has to treat NOBODY who doesn't pay her. Ditto for plastic surgeons, save for the few cases they get on call (assuming they even bother with call anymore).

If even the patient can pay, derms and plastics aren't obligated to treat them.

 

[GeneralVeers]

I'm starting as in intern in EM this Summer, but in school I had to rotate through the county ER, and I work approximately 40 hours per month (for pay) in a smaller community ER. In both places you end up treating distasteful people. Whenever I encounter someone who is problematic, I try to separate my personal opinion of them from my professional attitude.

Yes, I may detest the drug-seeking heroine addict with 6 kids and 2 ppd smoking habit, but I will see the patient, do any procedures necessary, and dispo the patient accordingly WITHOUT making any sarcastic comments or judgements about them.

This is a hard skill to use consistently, and sometimes it can be very trying.

I have seen staff both private practice and academic who still have not mastered this.

 

[LotaPower]

I have created a monster.

First off, I agree with all the above posters that as a doctor it's your job to take care of patients no matter who they arer. If a so-called "lowlife" (whatever that means) comes into my office I of course will treat them. Having said that, I'd rather not have to do this on a regular basis. It's like people who choose not to go into oncology because they don't want their job to be taking care of cancer patients, not because they think cancer patients should not be treated. Likewise, I don't want my job to be taking care of homeless people. I have a lot of respect for those of you who do, but it's not what I want to do. Hence my original question: Can I choose certain settings to practice EM, or is EM the same everywhere and I should just consider another field?

The nature of EM today prevents an answer to that question. Regardless of where you practice, you have no idea what's going to step into your door. For example, just because you're an EP in Hollywood, doesn't mean you're not going to run into a ""lowlife"". You may get 10 of those patients in a day and then not see one for 2 weeks. If that doesn't mix with you then you might want to consider doing somthing else where you're patient population is more predictable.

 

[Sessamoid]

For example, just because you're an EP in Hollywood, doesn't mean you're not going to run into a ""lowlife"". You may get 10 of those patients in a day and then not see one for 2 weeks. If that doesn't mix with you then you might want to consider doing somthing else where you're patient population is more predictable.

Umm... I practice in Hollywood, and there's no shortage of "lowlifes" here. Last night shift was at least 50% drunks. Drunks in fights, drunks who fell, drunks who crashed their cars, drunks who are just too drunk to stand, people getting hurt trying to stop fights between drunks, drunks who are drug-seeking, etc. Only ten drunks last night would have been nice.

 

[LotaPower]

Umm... I practice in Hollywood, and there's no shortage of "lowlifes" here. Last night shift was at least 50% drunks. Drunks in fights, drunks who fell, drunks who crashed their cars, drunks who are just too drunk to stand, people getting hurt trying to stop fights between drunks, drunks who are drug-seeking, etc. Only ten drunks last night would have been nice.

ok forget hollywood... but I hope you get my point

 

[bartleby]

I want the training of a doc so that i can hopefully help those in need, not those who have the means and just refuse to put any effort forth.

Are you pre-med? A med student? A resident? The reason I ask is that you are gonna be one pissed off and burned out guy/gal if you are irritated by any patients who have a) any responsibility for their illness or b) any sort of relapse or worsening of a chronic condition due to non-compliance. You are gonna be pissed off everytime you see someone with an MI who has modifiable risk factors (gee...about 90% of them)? Even docs and nurses have been found to be much less than even 85-90% complaint with meds and treatment... so how do you think the rest of the population is going to be? It's called human nature, and you'd better get used to it.

My comments are in regards to the fact that i hate everyone telling doctors that they need to cure everyone in every single situation and be mother theresa, servant of the masses.

I agree with you that people often have unreasonable expectations about what a physician in 2005 is going to be able to do for them (i.e. not take all their problems with one magic pill). This is a societal problem.

What is point of being a physician in your mind? A cool job for people who don't feel like becoming lawyers or investment bankers? We're supposed to "be the servant of the masses". Who else would we serve? The rich and famous? The reason we are professionals and get all the respect that we do is that we _care_. Yes, it does stink sometimes...but it is also kind of cool that we are society's safety net.

Let me also remind you that we are paid generously for our efforts...

 

[typeB-md]

I agree with you that people often have unreasonable expectations about what a physician in 2005 is going to be able to do for them (i.e. not take all their problems with one magic pill). This is a societal problem.

What is point of being a physician in your mind? A cool job for people who don't feel like becoming lawyers or investment bankers? We're supposed to "be the servant of the masses". Who else would we serve? The rich and famous? The reason we are professionals and get all the respect that we do is that we _care_. Yes, it does stink sometimes...but it is also kind of cool that we are society's safety net.

Let me also remind you that we are paid generously for our efforts...

I am MS1 and i agree that non-compliance is a fact of life. Maybe i'll become a pathologist

The point of being a physician in my mind is for the pursuit of knowledge. Even if i never practice a day in my life, an MD will allow me the knowledge to take care of myself and be somewhat "in the know" if i ever experience a medical situation. I don't ever want to go see a family doctor and wonder if s/he's pulling one on me. I don't ever want to go into a surgery unsure as to what may go on.

Even if i go into real estate or law after medical school, i will still be very well off because the MD degree is the best degree you can ever have in terms of usefulness and applicability.

I don't like being told what to do and that's why I wanted to go into medical practice. But apparently this was a naive mentality as we are held to the standards of the supernatural. Take this terri shiave case for example...back when she first had the MI, her husband sued the doctor because he failed to adequately treat/diagnose the bulemia that lead to her K+ imbalance and ultimately the MI. Was the doctor supposed to hold her hand every minute of every day?

Hopefully things will change, but if they do not, it probably won't be that big of a deal. There's plenty of stuff out there that interests me.

 

[GeneralVeers]

I am MS1 and i agree that non-compliance is a fact of life. Maybe i'll become a pathologist

If you are like most other MS1s (I'm finishing MS4) then you really haven't had a lot of clinical experience yet. Before you make judgements about society in general, or career goals you should get through your clinical rotations. After doing EM, surgery, medicine peds, etc. you'll have a good idea of what "fits" for you, and what patient populations you like dealing with.

If it turns out that you don't like dealing with patients, then you should go into pathology, but I would suggest that medical school is probably not the best place to begin with if that's the case.

 

[Febrifuge]

If you are a millionaire investment banker who just had way too much to drink and nearly killed a van full of kids I can treat you with the contempt you deserve while still making sure to find all the injuries you are too drunk to notice yourself. If you are homeless alcoholic who is polite and respectful to the rest of the ED staff I can treat you like the citizen you are instead of the "scumbag" the rest of the world sees.

Exactly. When I said that the OP should leave the judgement out of it, I meant keep it to yourself, and don't let it change the course of your diagnosis and treatment. There's nothing holier-than-thou about it; I'm just saying, if you like to weild your predjudices like a blunt instrument and can barely mask your contempt for a good portion of your patients, you'd be miserable in EM.

 

[jazz]

I am MS1

The point of being a physician in my mind is for the pursuit of knowledge. .

I hope that there is some interest to practice. I hope that is just the MS1 talking. Or maybe I'm the jaded resident talking. But either way, I think that if you're going to medical school for the pursuit of knowledge and just so you feel like you're getting "scammed" then beware. The basic FP stuff you could probably get by reading about it in medical texts (since you obviously have a strong basic science knowledge base being an MS1) prior to seeing a doc. The really specialiazed stuff (new drugs in heart failure, pumps that deliver meds straight to the heart in end stage heart failure...) all that stuff is still being managed by specialisits.

Anyhow, I just read your comment and found it intriguing and I know you never asked for my opinion but going to med school and then possibily residency just for the pursuit of knowledge is a long and painful course. Either way, you should have some interest in practicing something (be it EM, IM, Surgery, Pathology, Derm, etc).

 

[typeB-md]

I hope that there is some interest to practice. I hope that is just the MS1 talking. Or maybe I'm the jaded resident talking. But either way, I think that if you're going to medical school for the pursuit of knowledge and just so you feel like you're getting "scammed" then beware. The basic FP stuff you could probably get by reading about it in medical texts (since you obviously have a strong basic science knowledge base being an MS1) prior to seeing a doc. The really specialiazed stuff (new drugs in heart failure, pumps that deliver meds straight to the heart in end stage heart failure...) all that stuff is still being managed by specialisits.

Anyhow, I just read your comment and found it intriguing and I know you never asked for my opinion but going to med school and then possibily residency just for the pursuit of knowledge is a long and painful course. Either way, you should have some interest in practicing something (be it EM, IM, Surgery, Pathology, Derm, etc).

it's not so much 'scammed' as i want the knowledge about myself and my family. i want to be able to suture up any wounds i get. i want to be able to self administer drugs and know their affects. it's a lot of information that i thinks is good stuff to know.

as far as if i don't practice, i will not be attending a residency in this case. just the 4 years, and i'll be 25 with an open mind and an MD in hand. but like has been pointed out, i'm only MS1 and have very far to walk yet.

 

[NeuroSync]

man this is the first serious discussion Ive seen on the EM forum, I kind of miss hijacking the thread into where you can get the best burgers (....lets see if I remember correctly it was a double animal from in and out, right? )
Goose

This thread definitely hit a nerve. I've never seen a serious conversation go on so long here. I think we found the chink in the armor (in a good way). The idea that everyone gets treated AND that it is best not to be too judgmental are some basic underlying principles that those going into EM hold dear.

Anyone have a fun new microbrew lately? I tried a "Cinder Cone Seasonal Red Ale" from the Deschutes Brewery in Bend Oregon that was pretty tasty! The tettnang and amarillo hops add a nice toffee flavor...

 

[WilcoWorld]

That NeuroSync guy seems to know a lot about alcohol...must be a drunk. As a regular on SDN's EM forum am I duty-bound to respond to him?

 

[NeuroSync]

That NeuroSync guy seems to know a lot about alcohol...must be a drunk. As a regular on SDN's EM forum am I duty-bound to respond to him?

Well, I'm good at reading lables, anyway. As for being a guy, hold on, let me check.... ummm, nope.