Rising PGY-2 in IM, and I still get some FOMO about EM...

[Doctor_Strange]

I had my whole application as a MS4 geared towards EM. I eventually dual-applied to IM as well because I was considering whether or not I would enjoy certain sub-specialties, like Heme-Onc or Cardiology. Now that I am almost done with intern year, I do not think I can stomach more training and if it were to be hospitalist vs EM, I think I'd rather do EM since they are both shift work and not to mention I still feel like I miss the ED. I told myself, initially, that going IM and even being a hospitalist, would provide for a longer career, but so far I don't really enjoy general medicine that much.

Anyways, I know the doom and gloom of EM. I read the report and even as a M4 I was concerned about the job marker (I had one PD tell me, "You will be competing with PAs for jobs in the future"), so future employment is not something I minimize, but the adage of "enjoying what you do, you will never have worked a day in your life" has taken a lot more meaning for me since I do not enjoy what I do right now...

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[skougess]

My advice is stop romanticizing it. I’m sure IM is a poop sandwich. EM is also a poop sandwich. Don’t trade one poop sandwich for another. Go to work and get your check.

 

[BoardingDoc]

I had my whole application as a MS4 geared towards EM. I eventually dual-applied to IM as well because I was considering whether or not I would enjoy certain sub-specialties, like Heme-Onc or Cardiology. Now that I am almost done with intern year, I do not think I can stomach more training and if it were to be hospitalist vs EM, I think I'd rather do EM since they are both shift work and not to mention I still feel like I miss the ED. I told myself, initially, that going IM and even being a hospitalist, would provide for a longer career, but so far I don't really enjoy general medicine that much.

Anyways, I know the doom and gloom of EM. I read the report and even as a M4 I was concerned about the job marker (I had one PD tell me, "You will be competing with PAs for jobs in the future"), so future employment is not something I minimize, but the adage of "enjoying what you do, you will never have worked a day in your life" has taken a lot more meaning for me since I do not enjoy what I do right now...

Find a fellowship that you want to do. Look at your IM residency as a box you need to check in order to actually do said fellowship. I only ever seriously considered EM and EP when I was a med student. I will say that 3 years of EM vs 3 of IM + 3 of cards + 1-2 of EP made the decision to do EM a lot easier. Knowing what I know now, I may not have made the same decision. The primary thing keeping me from saying I 100% would have done EP if I had to do it again is that I have something of a unicorn job. If I were some of my co-residents who weren't as lucky, I'd definitely rather have done EP.

 

[Doctor_Strange]

Find a fellowship that you want to do. Look at your IM residency as a box you need to check in order to actually do said fellowship. I only ever seriously considered EM and EP when I was a med student. I will say that 3 years of EM vs 3 of IM + 3 of cards + 1-2 of EP made the decision to do EM a lot easier. Knowing what I know now, I may not have made the same decision. The primary thing keeping me from saying I 100% would have done EP if I had to do it again is that I have something of a unicorn job. If I were some of my co-residents who weren't as lucky, I'd definitely rather have done EP.

Cards is something that made me decide to forgo EM for IM. Gen Cards is good enough for me. But even getting into Cards may require a 1 year of chief year or hospitalist or some other buffer. The road is long. I have to tell myself if I stay with IM that it will be worth it in the end...

 

[Angry Birds]

I had my whole application as a MS4 geared towards EM. I eventually dual-applied to IM as well because I was considering whether or not I would enjoy certain sub-specialties, like Heme-Onc or Cardiology. Now that I am almost done with intern year, I do not think I can stomach more training and if it were to be hospitalist vs EM, I think I'd rather do EM since they are both shift work and not to mention I still feel like I miss the ED. I told myself, initially, that going IM and even being a hospitalist, would provide for a longer career, but so far I don't really enjoy general medicine that much.

Anyways, I know the doom and gloom of EM. I read the report and even as a M4 I was concerned about the job marker (I had one PD tell me, "You will be competing with PAs for jobs in the future"), so future employment is not something I minimize, but the adage of "enjoying what you do, you will never have worked a day in your life" has taken a lot more meaning for me since I do not enjoy what I do right now...

I will go against the grain and say that you should look for an opening in an EM program for a PGY-1 spot. There were 200+ open positions. Have at it.

Honestly, I would still have done EM over IM, even with all the gloom and doom that is projected. But, alas, I have a cush job. They still exist. But they might not into the future. I suspect 20 years from now this job may not exist. Or it might bounce back a bit. Or not.

 

[thegenius]

I would do EM also. At the end of the day we are allowed to say "no."

Sometimes it's hard to say "no." But we can.

No to narcotics
No to worknotes
No to the 5th CT in 2 months
No to treating your chronic pain
No to the demand to call a consult
No for a second opinion
The list goes on

 

[Birdstrike]

I had my whole application as a MS4 geared towards EM. I eventually dual-applied to IM as well because I was considering whether or not I would enjoy certain sub-specialties, like Heme-Onc or Cardiology. Now that I am almost done with intern year, I do not think I can stomach more training and if it were to be hospitalist vs EM, I think I'd rather do EM since they are both shift work and not to mention I still feel like I miss the ED. I told myself, initially, that going IM and even being a hospitalist, would provide for a longer career, but so far I don't really enjoy general medicine that much.

Anyways, I know the doom and gloom of EM. I read the report and even as a M4 I was concerned about the job marker (I had one PD tell me, "You will be competing with PAs for jobs in the future"), so future employment is not something I minimize, but the adage of "enjoying what you do, you will never have worked a day in your life" has taken a lot more meaning for me since I do not enjoy what I do right now...

EM is the toughest job in Medicine. I have mad respect for anyone still practicing it. EM doctors, nurses and PAs are true unsung heroes of society.

However, the job market situation is nothing compared to the chronic circadian rhythm dysphoria caused by the random, rotating shift work of EM. There are many subspecialties of IM that allow you to have a normal life. In EM they're rare. EM offers a much greater likelihood of being trapped in a chronically dysphoric state of feeling constantly jet-lagged, with PTSD from helpless horrors you can't unsee. IM offers many avenues to easily avoid all of that.

Do you want to work at 3 am on your favorite holiday and have no sleep the night before having to be awake and present for important family events one third of the time for the next 30 years? Also, you'll be dealing with all that while being constantly gaslit while being told 'we have it easy' and if you don't feel that way, 'you're the problem.'

EM is meaningful work, but it takes a big toll.

 

[Ho0v-man]

In a few months you’ll be telling interns to do a lot of the stuff you currently hate. You have several threads going about switching into like 4-5 different specialties. Sounds like severe grass is greener syndrome. Intern year just sucks.

 

[bronx43]

I had my whole application as a MS4 geared towards EM. I eventually dual-applied to IM as well because I was considering whether or not I would enjoy certain sub-specialties, like Heme-Onc or Cardiology. Now that I am almost done with intern year, I do not think I can stomach more training and if it were to be hospitalist vs EM, I think I'd rather do EM since they are both shift work and not to mention I still feel like I miss the ED. I told myself, initially, that going IM and even being a hospitalist, would provide for a longer career, but so far I don't really enjoy general medicine that much.

Anyways, I know the doom and gloom of EM. I read the report and even as a M4 I was concerned about the job marker (I had one PD tell me, "You will be competing with PAs for jobs in the future"), so future employment is not something I minimize, but the adage of "enjoying what you do, you will never have worked a day in your life" has taken a lot more meaning for me since I do not enjoy what I do right now...

I don’t romanticize IM. I wish I would have done something else (mainly rads). But, compared to EM, I think you’re better off.

Gen cards is a good gig especially if you stick with academia and have fellows take your call. Even outpatient subspecialties like heme onc, endo, rheum aren’t terrible if you find the right gig. Working 36 clinic hours with banker hours is honestly the best you can do in terms of lifestyle. Pay is variable but the money is out there if that’s your goal.

 

[Angry Birds]

In a few months you’ll be telling interns to do a lot of the stuff you currently hate. You have several threads going about switching into like 4-5 different specialties. Sounds like severe grass is greener syndrome. Intern year just sucks.

Good detective work here. I did not know this. If that is the case, then I would not encourage a switch. Intern year sucks. Having done a Transitional Year myself--with tons of IM--all I can say is that it even got better near the end of the first year.

 

[Robotic Wis-Hipple]

In a few months you’ll be telling interns to do a lot of the stuff you currently hate. You have several threads going about switching into like 4-5 different specialties. Sounds like severe grass is greener syndrome. Intern year just sucks.

This 100%.

Having 4 days off a month, and being an intern just sucks. It’s almost over. If you try to swap into EM it’s the same time commitment as it would be to do a chief year in IM. You currently are in control of your destiny in IM. If you want cards you can have it, if you want to pick a lifestyle field like allergy or endocrinology you can, or if you want a 7 day on 7 day off hospitalize gig you can.

Intern year sucks. Don’t reset and get a new poop sandwich when you’ve only got a few bites left of your current one.

 

[Doctor_Strange]

I appreciate the responses. I do have severe grass is greener syndrome. Medicine is not as fulfilling as I initially thought as a medical student. But more than that, I always thought I would find a specialty or job that would make me be a "live to work" kind of person. Not that life is just work, but that work can bringing meaning to one's life if that makes sense. I look at my old man, he works in academic Peds and I still remember him telling me as a high school student, "I have never worked a day in my life." That is how much satisfaction you got from his work. I wanted that. So far, I do not feel that at all and when I look into the looking glass I fear maybe I won't get that from IM (who is to say I would get it from EM though? So I recognize the dissonance in my thinking).

Anyways, I will continue to mull it over. I have multiple LORs from med school and have several emails in draft mode that I could send to multiple programs at my institution. I have not done so just because, like others have said, perhaps it is intern year blues.

 

[thegenius]

I appreciate the responses. I do have severe grass is greener syndrome. Medicine is not as fulfilling as I initially thought as a medical student. But more than that, I always thought I would find a specialty or job that would make me be a "live to work" kind of person. Not that life is just work, but that work can bringing meaning to one's life if that makes sense.

For the most part, none of medicine is like this. The system is not set up for you to "help" people. We really have this sick two-tiered system in the US:
1) for those who have insurance, for the most part they pay an arm and a leg for subpar service. They are not incentivized to use it.
2) for those who have little-to-no insurance, they suck the life out of doctors and demand care because the system allows them to access it for free.

I wish I was a doctor 50 years ago. Patients weren't nearly as complex, they respected doctors and a doctor then could probably make a difference.

Nowadays, most of medicine is shifting risk to the next doc, along with an uncompromising mindset that Americans take little responsibiltity for their own health outcomes and yet still demand that their doctors fix them.

At least, that's what my ER experience is like.

This is why I pound my fist on the table insisting that people pay to access a doctor. Enough with using insurance for non-catastrophic care. I'm fully aware that there will be a large percentage of docs out of work, and a sizable percentage of people who can't afford to see a doctor (although prices will come down), yet we have this untenable system now that just gets worse, and worse, and worse....
and worse...
and worse...

Then medicine will be like everything other item or service in society. e.g. buying and owning cars, homes, electronics, going to restaurants, etc.

 

[Tenk]

I appreciate the responses. I do have severe grass is greener syndrome. Medicine is not as fulfilling as I initially thought as a medical student. But more than that, I always thought I would find a specialty or job that would make me be a "live to work" kind of person. Not that life is just work, but that work can bringing meaning to one's life if that makes sense. I look at my old man, he works in academic Peds and I still remember him telling me as a high school student, "I have never worked a day in my life." That is how much satisfaction you got from his work. I wanted that. So far, I do not feel that at all and when I look into the looking glass I fear maybe I won't get that from IM (who is to say I would get it from EM though? So I recognize the dissonance in my thinking).

Anyways, I will continue to mull it over. I have multiple LORs from med school and have several emails in draft mode that I could send to multiple programs at my institution. I have not done so just because, like others have said, perhaps it is intern year blues.

One thing I’ve learned over the years is that it’s more the patient than the specialty that will affect your day and overall attitude. For instance, if I have a lot of people during a shift that thank me for helping them and are nice I actually feel pretty satisfied. If I see a bunch of people who yell and curse at me, I’m just over it. The actual medicine part becomes really routine after a few years.

 

[thegenius]

One thing I’ve learned over the years is that it’s more the patient than the specialty that will affect your day and overall attitude. For instance, if I have a lot of people during a shift that thank me for helping them and are nice I actually feel pretty satisfied. If I see a bunch of people who yell and curse at me, I’m just over it. The actual medicine part becomes really routine after a few years.

Yea once you get to know your field, it's pretty cut and dry. I can't remember the last time I struggled with a decision. A true medical decision where my actions dictate the outcome. Because at the end of the day, EM is pretty easy. Secure the airway and keep the BP elevated. That's all you really have to do. Keep the patient alive long enough to make sure someone else can try to save their life.

 

[GassYous]

Yea once you get to know your field, it's pretty cut and dry. I can't remember the last time I struggled with a decision. A true medical decision where my actions dictate the outcome. Because at the end of the day, EM is pretty easy. Secure the airway and keep the BP elevated. That's all you really have to do. Keep the patient alive long enough to make sure someone else can try to save their life.

That basically sounds like my life

 

[sylvanthus]

Dude intern year in IM blows, hang in there, itll get better.

 

[Angry Birds]

Good luck my man

 

[JustAMedStudent99]

Yea once you get to know your field, it's pretty cut and dry. I can't remember the last time I struggled with a decision. A true medical decision where my actions dictate the outcome. Because at the end of the day, EM is pretty easy. Secure the airway and keep the BP elevated. That's all you really have to do. Keep the patient alive long enough to make sure someone else can try to save their life.

Do you think the easiness of EM will allow midlevels to take over the field eventually?

 

[sylvanthus]

Do you think the easiness of EM will allow midlevels to take over the field eventually?

They are already on their way to doing so.

 

[larpleston]

Yea once you get to know your field, it's pretty cut and dry. I can't remember the last time I struggled with a decision. A true medical decision where my actions dictate the outcome. Because at the end of the day, EM is pretty easy. Secure the airway and keep the BP elevated. That's all you really have to do. Keep the patient alive long enough to make sure someone else can try to save their life.

I think no matter what you do you get so many reps in that it's eventually easy. EM's only 3 years so I agree it's pretty easy in that sense, but I think any specialty is eventually going to be rote once you become an expert. I think we get so much disrespect in EM that we internalize it, but does a surgeon who spends 60% of their time doing appys, lap choles and lipoma excisions really have a more intellectually simulating job? I'm not so sure they or anyone else does (excluding clinical researchers). Gone are the days of human experimentation when doctors could puzzle through problems and constantly discover and invent things. Medicine is a trade now.

 

[RustedFox]

Do you think the easiness of EM will allow midlevels to take over the field eventually?

Yeah. It's so easy that they screw it up all the time.

Take that in any direction you want and it still holds true.

 

[Kryptocoin]

If you absolutely hate IM, then bail out now. I honored IM as an M3 but couldn't stomach spending 3yrs rounding and writing progress notes. For all the shortcomings I have with EM (and there are quite a few), I can work as little as or as much I want. No place will hire you to work four days/month as a hospitalist. In EM, it's very plausible to cut back and pick your shifts.

Your PD is only half right. You'll also be competing with mid-levels for hospitalist jobs.

The problem with EM is not innate but rather outside forces controlling the specialty. Very soon, there'll be nowhere to hide. Most of medicine will become infected with the disease of corporatization. EM is just a good test subject.

 

[eefen]

I think you are on a good path. Intern year sucks, especially in IM where you tend to be a note-writing, order-entering, page-returning scut monkey. As you progress through residency you should be able to take more of a senior role where you can zoom out a bit and focus on the big picture in addition to having more cush consult rotations.

If you love emergency medicine after the next year, as someone who transitioned from EM to CCM and is currently finishing fellowship, I would say that (for me at least) CCM has much of what I thought I loved about EM in the first place while avoiding much of what I grew tired of.

Stabilize critically ill patients. Procedures. Broad field. Potential for shift work. Occasional medical conundrums/interesting cases. Can have meaningful interactions with patients/families over a period of a few days. Interesting physiology and chance to experiment (in a good way) as you sort through a muddled presentation. Get to be "expert" in a cool field.

And with CCM, once the patient's social or chronic issues > acute medical issues = transfer to floor. You never have to whip out a speculum again if you don't want to, accept a patient who should have just stayed home, etc. You can have a good working relationship with other services - you send patients out to them, but also help them when they are in a pinch. For me, that "feels" better than EM where every phone call I made was to give someone more work. And I'm still very early in all this, but I tend to enjoy what I do on a daily basis, even if my hours are currently much longer than what they were in EM. There's just a different pace and the hours at the hospital are usually less exhausting.

Pay, at least for me, will also be more than what was probably realistic for EM in the geographic area I want to live. Though compensation varies with time and shouldn't primarily drive your decision.

It has its downsides, too. Relatively longer hours. Shift work and all that entails, though less variable than EM tends to be and my job will be primarily days. Encroachment of midlevels/larger HCA-style groups. No real opportunity for outpatient practice as an exit strategy. Etc. And who knows, maybe I'll be regretting things years down the road.

Overall, though, I think you are on a good path. Get through intern year. See how you feel a few months from now. Consider a fellowship that gives you options - stay inpatient/procedures/work outpatient/join private groups/etc. Cards is a good option. A few extra years now (to a point) isn't all that bad in the face of a decades-long career.

Good luck.

 

[emergentmd]

Medicine is not as fulfilling as I initially thought as a medical student.
Glad you see that medicine is just a job. Great thing is it makes alot of money so you do a 20hr/wk job and still make twice as much as most Americans. Then you have 20+ hrs more a week doing what you like. If you like or love your job, then you are lucky. I have been fortunate to have a job I really like and make more money than I ever thought. But set your expectations to find a JOB that you can bear for atleast 20 hrs and manage your money.


I look at my old man, he works in academic Peds and I still remember him telling me as a high school student, "I have never worked a day in my life." That is how much satisfaction you got from his work. I wanted that.

Medicine has changed. Your dad predates me and likely had much more autonomy. I started attending 20 yrs ago and we had a considerable amount of control in our ER and admin rarely bugged us. That is not the same. Your dad would find it hard to have the same work environment.

Back in the day, your many docs had their own practice or employees with great control. Now you likely will have a boss giving you monthly metrics to meet. Our forefathers only had to deal with going to work, raking in the $$$$, then going home. Now we have to deal with admin, metrics, insurance headwinds, unreasonable pts, etc which is the majority of the stressors.

 

[thegenius]

Do you think the easiness of EM will allow midlevels to take over the field eventually?

Take over? No. The general problem with EM is we don't practice EM. We practice urgent care and primary care for the millions of forlorned who can't be a normal adult. So we see a bunch of nonsense that is not emergency medicine.

Eventually, if not already...midlevels will be able to see 75% of that.

We do shine when s**t is on the line though. Man a good ER doc is worth his or her weight in gold.

 

[Kryptocoin]

Take over? No. The general problem with EM is we don't practice EM. We practice urgent care and primary care for the millions of forlorned who can't be a normal adult. So we see a bunch of nonsense that is not emergency medicine.

Eventually, if not already...midlevels will be able to see 75% of that.

We do shine when s**t is on the line though. Man a good ER doc is worth his or her weight in gold.

I think obvious emergencies are actually the easier part of the job after some learning curve. Stroke, STEMI, Sepsis, Trauma----I can do that in my sleep. Most of these have been heavily protocolized by institutions anyway. Can easily become cookbook medicine.

The best EM docs are actually the ones that can discern subtle emergencies when dealing with BS all day. It's hard to diagnose something you don't know or not thinking about.

I once diagnosed a carotid dissection after a midlevel checkout a patient to me pending xrays that came in for neck pain. I walked into the room, and the patient's pain was out of proportion to exam. No history of trauma. WTH is an xray going to tell me? I ordered CTA, and yup, dissection.

 

[GassYous]

I think obvious emergencies are actually the easier part of the job after some learning curve. Stroke, STEMI, Sepsis, Trauma----I can do that in my sleep. Most of these have been heavily protocolized by institutions anyway. Can easily become cookbook medicine.

The best EM docs are actually the ones that can discern subtle emergencies when dealing with BS all day. It's hard to diagnose something you don't know or not thinking about.

I once diagnosed a carotid dissection after a midlevel checkout a patient to me pending xrays that came in for neck pain. I walked into the room, and the patient's pain was out of proportion to exam. No history of trauma. WTH is an xray going to tell me? I ordered CTA, and yup, dissection.

What was the cause? Chiropractic or something like marfans?

 

[Kryptocoin]

What was the cause? Chiropractic or something like marfans?

Neither. The only risk factor was HTN. Pt was in their 40s. Pt's well-dressed. Not a frequent flier. On exam, was tearful and writhing in pain. I trained at a county hospital, so I'm used to dealing with pain seekers that put on full histrionics, but this wasn't it. The pain was localized to a specific part of the posterior neck.

Even the CT tech asked if I was sure I wanted a CTA ( usually only ordered as part of stroke protocol), and I told him yes.

I think the take-home message is not to CTA everyone that shows up with neck pain. Unfortunately, that's normally what we see with NPs as they over-order tests to compensate for a lack of knowledge fund. Good EM docs order tests based on clinical gestalt and overall pretest probability. They don't teach those in cookbooks......ahem, textbooks.