Having spent some time in the ED third year in addition to being there with consulting and/or admitting services, I've seen how often someone gets a shotgun spread of labs and imaging with a consult to the appropriate service. Obviously a full H&P isn't done by the ED, but the documentation is often lacking or the history included there doesn't even address the patient's complaint. I know this offensive terminology to EPs, but there is a lot of triage medicine done there with a focus on disposition more than diagnosis. I realize this isn't the case all the time and that many patients do have an established diagnosis on admission, but I've become much more aware of how many are admitted with a "diagnosis" of chest pain or abdominal pain. I'm not hating on EM, I like it a lot. Just trying to decide which side I'd rather spend my time on.
Honestly, if you feel that sense of disdain or criticism for EM, you're probably not meant for it. The perspectives are completely different, along with the differential. Think about it... any idea how many patients we see in a 12 hour shift? If you worked a patient up in pure "IM" style with the ultra thorough H&P and 10 blood gases and pocket calculator out and FENA ordered from the lab... you'd certainly have a very thorough work up... and a lot of dead patients on your hands. While you're mentally masturbating, for lack of a better word, over non emergent issues, patients can be critical and/or dying.
That extra hour you took for the last 5 patients in asking them 10 extra questions that are non-relevant where a potential emergency is considered... well guess what... you left a stroke out in the waiting room, and damn if she didn't get put back right past the TPA window. Hey, at least you didn't shotgun the labs though (fast), and spent the extra time for a thorough H&P asking questions that don't change your management (slow). Meanwhile, you'll miss STEMIs, CVAs and all sorts of other stuff. EPs have to make fast decisions, with very limited information, in a very short time span, whilst managing multiple patients at once. That means that things get missed, but it's usually the stuff that doesn't change our management. The Mg and Phos and lipid panels and everything else can get ordered upstairs. Chest pain and abdominal pain are completely reasonable and "codeable" diagnoses. Honestly, most of us don't care what is causing the chest or abdominal pain once an emergency has been ruled out.
Acute renal failure is a great example. Take ARF 2/2 nephritic syndrome. I don't need to know exactly what type it is. ATN? AIN? IgAN? SLE? Who cares? They are in ARF and need admission and if they are stable... my job is done. The only thing I care about at that point is getting them out of the ED as quickly as possible to make room for the next patient so that I don't miss an emergency.
So.... the argument of "who makes the diagnoses" depends on the perspective. Do you like working up undifferentiated patients and being the first to diagnose the "big problem" going on, or do you enjoy the mental tail chasing over the next few days and playing humphrey bogart? There's no right or wrong answer.
I will say this though... most people that genuinely enjoy EM are, I've found, of a certain personality type. I've known very few that were "on the fence" so to speak about working in the ED. Honestly, if you kind of enjoy working the medicine wards and morning report, then you're probably more in tune with IM and trying to talk yourself into EM. Most of us that truly enjoy EM could think of no hell worse than ward medicine with...ugh...a pager.
I hated morning report, I hated rounding, I hated sitting still, I hated making small changes every day, I hated the lack of instant gratification for the majority of my medical management...and worst of all? I hated wearing a tie and shiny shoes all day long and spending hours talking about electrolytes and for the love of God did I hate being paged....
. You also need to like / be able to take the stress of deciding critical actions in a very short time span.
