The "Backup" Specialty

[AmoryBlaine]

**Continuing a trend of semi-controversial topics (with more to come -- I clearly am not working right now).**


On SDN, in the hospital, and at my medical school I have met six different types of people interested in/applying to EM.

1. The Genuine - Those who absolutely prefer EM to all other fields, who have considered other options, who have met the stresses and deemed them (hopefully) tolerable, and who try to have a serious understanding of emergency care and it's place in the larger system of healthcare.

2. The Idiots - Those who have filled out ERAS and are interviewing in EM and who still seem to have only the vaguest idea of what exactly EM docs do. In case I am accused of creating a straw-man I have at least n=2, one person who said they were going into EM "because they loved trauma so much" and another who said that she "could only deal with really sick patients, ambulatory stuff just pisses me off."

3. The Backups - Those who are applying to something else as their first choice but "also really like EM" and so wish to use our specialty as a backup.

4. The Fearful - Those who have a passion for another field (often GSurg) but decide it's just too much to handle and so apply to EM.

5. The Latecomers - Those who train for awhile in something else and then switch into EM.

6. The Prospective Latecomers - Those who plan to train in something else, see if they can handle it, but say "if it doesn't work out I'll just do EM."


Maybe this is no big deal, maybe it is a function of the youth of specialty and it's fairly pay/time ratio. I tend to think it is a big deal. I often find myself a little irked at the thought of working alongside a group of people who include especially #2, 3, 4 and 6.

I am mainly curious to hear input from the attendings/residents. Do you feel like you meet Idiots, Backups, and Fearfuls on the interview trail? Does it denigrate the seriousness of the specialty that it seems to be a fall back option for relatively so many people? Do you notice a difference in quality among residents who trained in another field for 1-2 years (either positive or negative)?

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[waterski232002]

It doesn't make a difference how a person got into the specialty of emergency medicine, as long as they respect themselves, their profession, work hard, and treat others professionally. That is what ultimately earns respect.... not whether they initially wanted to be a surgeon or whether they used EM as "a back-up".

Who cares... I only care about the end product.

 

[EM_Rebuilder]

I think one of the large problems for EM as a whole (if you call it a problem?) is the viewpoint that many older doctors still have, and gets passed to many new doctors is that anybody can work in the ED and it continues to be a 'catch all' for doctors that did not like what else they were doing..... I am doing a pediatric ambulatory month right now; I was working with a very old peds guy at a private like clinic. He asked who I was, I tell him an Emergency Medicine intern, he asked oh what is your specialty. I told him Emergency Medicine again and then he asked how many years I had worked 'down there'. I told him again I was an intern and just worked two months in the ED. I honestly do not think he realizes that EM is a real specilalty, and I think that many elder private doctors do not... We changed the subject; I still dont think he understood who I was....

Unfortunately, it will still be many years until we can push people who are not EM trained out of the EM field. Once the ED is filled with EM physicians and our current peers move up ranks and are educated that there are EM physicians...things will change somewhat. I have heard estimates of 2020, but who honestly knows... I think by then, we will have larger EDs filled...but its unlikely we ever fill EVERY 'ER' in America with EM trained people, so there will almost always be a subset of people working in the one horse town 'true to the term' Emergency ROOM.

One way or another, EM and the ED will always be a catch all... remember S**T runs downhill and there is a reason why we are always at the ground level.

 

[nymbarra]

**Continuing a trend of semi-controversial topics (with more to come -- I clearly am not working right now).**


On SDN, in the hospital, and at my medical school I have met six different types of people interested in/applying to EM.

1. The Genuine - Those who absolutely prefer EM to all other fields, who have considered other options, who have met the stresses and deemed them (hopefully) tolerable, and who try to have a serious understanding of emergency care and it's place in the larger system of healthcare.

2. The Idiots - Those who have filled out ERAS and are interviewing in EM and who still seem to have only the vaguest idea of what exactly EM docs do. In case I am accused of creating a straw-man I have at least n=2, one person who said they were going into EM "because they loved trauma so much" and another who said that she "could only deal with really sick patients, ambulatory stuff just pisses me off."

3. The Backups - Those who are applying to something else as their first choice but "also really like EM" and so wish to use our specialty as a backup.

4. The Fearful - Those who have a passion for another field (often GSurg) but decide it's just too much to handle and so apply to EM.

5. The Latecomers - Those who train for awhile in something else and then switch into EM.

6. The Prospective Latecomers - Those who plan to train in something else, see if they can handle it, but say "if it doesn't work out I'll just do EM."


Maybe this is no big deal, maybe it is a function of the youth of specialty and it's fairly pay/time ratio. I tend to think it is a big deal. I often find myself a little irked at the thought of working alongside a group of people who include especially #2, 3, 4 and 6.

I am mainly curious to hear input from the attendings/residents. Do you feel like you meet Idiots, Backups, and Fearfuls on the interview trail? Does it denigrate the seriousness of the specialty that it seems to be a fall back option for relatively so many people? Do you notice a difference in quality among residents who trained in another field for 1-2 years (either positive or negative)?

Amory,

I think while we may have had some conflicting views before, I really appreciate the thought that you put into your threads.

Like you said there is a spectrum of personalities that go into EM, but overall, we have a good diverse crowd in EM. Compared to, say, ortho or OB/GYN, not to pick any fights.

Perhaps the "genuine" group can be split between community and academics, but that's finer detail stuff that you could probably find in any specialty.

I am myself more of an introspective person and I appreciated seeing other people in EM who were that way. One thing that irks me is the view that EM is for the 'cowboys' of medicine, which kind of draws the #2 crowd, but I wouldn't go as far as to give that label. (I mean, that's like saying that ortho is a bunch of jocks, but clearly that is denigrating and totally inaccurate, as they're some of the smartest guys on the block.) And I think EM is made of some of the brightest cookies out there, another reason that hooked me.

For a presentation, I actually looked into why people choose various specialties, and how they view it over the next ten years, post-residency etc. Think of it as a Venn diagram- you have students in one circle, residents in another overlapping circle, and attendings in another circle. In each there is an intersecting area, and in each there are no areas of overlap. For example, students will be able to understand a certain part of residency that makes them more likely to pick that specialty, but will certainly understand less of the practice outside of residency. Then there are the unknown areas, those that you won't know about until you are actually there.

The bottom line is that there is no specific personality that goes into EM, and psychologically speaking (ie, the psych lit on decisions and future 'happiness') you will be happy no matter what specialty you chose. I will give you some citations if you are interested.

As to your point about working with some types of coworkers, etc., I think that is relatively minor considering that everyone has to have tough skin and be efficient to go into EM, and that you will gladly call one another comrades after a tough day seeing the most needy in healthcare.

We all choose specialties based on the patients, the medicine, and the lifestyle. For me, the balance that you see in EM--along with the coolest people--is what makes it the best (can I get a holla?).

 

[EM_Rebuilder]

Amory,

I think while we may have had some conflicting views before, I really appreciate the thought that you put into your threads.

Like you said there is a spectrum of personalities that go into EM, but overall, we have a good diverse crowd in EM. Compared to, say, ortho or OB/GYN, not to pick any fights.

Perhaps the "genuine" group can be split between community and academics, but that's finer detail stuff that you could probably find in any specialty.

I am myself more of an introspective person and I appreciated seeing other people in EM who were that way. One thing that irks me is the view that EM is for the 'cowboys' of medicine, which kind of draws the #2 crowd, but I wouldn't go as far as to give that label. (I mean, that's like saying that ortho is a bunch of jocks, but clearly that is denigrating and totally inaccurate, as they're some of the smartest guys on the block.) And I think EM is made of some of the brightest cookies out there, another reason that hooked me.

For a presentation, I actually looked into why people choose various specialties, and how they view it over the next ten years, post-residency etc. Think of it as a Venn diagram- you have students in one circle, residents in another overlapping circle, and attendings in another circle. In each there is an intersecting area, and in each there are no areas of overlap. For example, students will be able to understand a certain part of residency that makes them more likely to pick that specialty, but will certainly understand less of the practice outside of residency. Then there are the unknown areas, those that you won't know about until you are actually there.

The bottom line is that there is no specific personality that goes into EM, and psychologically speaking you will be happy no matter what specialty you chose. I will give you some citations if you are interested.

As to your point about working with some types of coworkers, etc., I think that is relatively minor considering that everyone has to have tough skin and be efficient to go into EM, and that you will gladly call one another comrades after a tough day seeing the most needy in healthcare.

We all choose specialties based on the patients, the medicine, and the lifestyle. For me, the balance that you see in EM--along with the coolest people--is what makes it the best (can I get a holla?).

I'll give you a whoo whoo!

 

[GeneralVeers]

I think one of the large problems for EM as a whole (if you call it a problem?) is the viewpoint that many older doctors still have, and gets passed to many new doctors is that anybody can work in the ED and it continues to be a 'catch all' for doctors that did not like what else they were doing..... I am doing a pediatric ambulatory month right now; I was working with a very old peds guy at a private like clinic. He asked who I was, I tell him an Emergency Medicine intern, he asked oh what is your specialty. I told him Emergency Medicine again and then he asked how many years I had worked 'down there'. I told him again I was an intern and just worked two months in the ED. I honestly do not think he realizes that EM is a real specilalty, and I think that many elder private doctors do not... We changed the subject; I still dont think he understood who I was....

Not to get us off topic, but "Pediatric Ambulatory Rotation"? That must sucketh, and the relevance to our specialty is minimal.

 

[jbar]

I don't know, from the little of pediatric EM I've seen it strikes me that most of those patients would fall under "pediatric ambulatory." Ie the kid has a cold and either they don't have a pediatrician or are too worried about the 99F fever to see the doc in the morning. Those well baby check ups may not be super high yield, but I'd guess you get pretty good at telling sick from not sick, as opposed to in patient peds were everyone is some degree of sick.

 

[Drawing Dead]

I guess I have to agree and disagree with Amory at the same time. There were definately people, mostly from my school that I either met on the interview trail or just in casual discussion throughout the year that I could have placed in any 1 of the 6 catagories Amory laid out. I never worried though, becuase my plan was 1- attempt to match, 2- Scramble if no match, 3- No scramble, internship, apply again. Why? Because I love EM, and knew that's what I wanted to do. And yes, I got my 4th choice, while there were some people that filled the programs I ranked higher that made me say "They're doing EM?" or something else similar, but I blame myself more than anyone else. Whatever those programs were looking for, whether it was scores, or clerkship performance, or stronger interview, or whatever, they had more of it than me. And, I know that I'm going into EM next year, whether I chose it for the "right" or "wrong" reasons. I also know, that I can't control what my residency classmates do, or why they chose EM, that was up to the PD.

I guess, EM is still like the "diagnosis of exclusion" as far as career choice goes. The older docs went down to the ER when they were done with their specialty, and now there are newer ones choosing it when they feel like nothing fits. But, as long as they are capable, I don't mind them. I would rather work alongside someone half-heartedly in the field that is proficient, than someone who is an EM junkie who sucks. And who knows, that could be me. Because, like in any field, those who belong will stay, and those who don't will be weeded out. And from the looks of it, you matched, so don't worry about it. It will all work itself out in the end.

 

[southerndoc]

I think another category should be the Lifestyler -- those that only want to work half the month.

 

[Squad51]

The best description I have ever heard of EM is that we are the "Austraila of Medicine". What began as a place for cast-offs, GPs, and moonlighting residents has become a specialty in its own right. However, much like the former penal colony, there will always be those who feel they can "escape" to EM, insinuating it couldn't have changed that much from its origin. Much like the Aussies, we like it here and will always bristle at those whose motivation for practice is suspect. Again, like Austraila, the larger institution of medicine recognizes our contribution, much as the world recognizes the economic power of "down under", but there will also be those Britons (much like surgeons) who will never let them forget their origin.

 

[GeneralVeers]

Also like Australia, we talk with funny words and drink lots of beer.

 

[Drawing Dead]

Does wanting to be Australian become catagory number 8? I'd like to peg myself into that one, being that pretty much every single girl I've ever met, girlfriend included, finds an Australian accent sexy. Drawbacks would include going out like Steve Irwin or Heath Ledger though.

 

[EM_Rebuilder]

Not to get us off topic, but "Pediatric Ambulatory Rotation"? That must sucketh, and the relevance to our specialty is minimal.

Yes and no. Its actually part of the EM transitional year (2,3,4 program). On the plus side, I work from 9-11ish (AM on both of those numbers). WCC arent much fun, but I have actually seen a fair amount of derm this week. The att I work with is a derm guru so the other att grab him thus grabbing me to check them out. He submitted something to dermatlas with my name the other day.

Not the most productive month, but its a nice breather... and a week vacation later in the month.

 

[GeneralVeers]

Does wanting to be Australian become catagory number 8? I'd like to peg myself into that one, being that pretty much every single girl I've ever met, girlfriend included, finds an Australian accent sexy. Drawbacks would include going out like Steve Irwin or Heath Ledger though.

When Obama invokes universal care, and my salary is cut in half, I know where I'm moving to.

 

[EvoDevo]

I know for myself that the decision to do EM was a matter of figuring out who I am. Part of that process was realizing that I don't need to be a surgeon, and that I love both acuity and clinic. And after a good deal of shadowing, I've truly come to embrace the specialty. *shrug*

Also, my school doesn't have a home program so it was hard for a while to find EM mentors that I could truly model myself after.

 

[AmoryBlaine]

I think another category should be the Lifestyler -- those that only want to work half the month.

Careful, that might be my next post!

 

[roja]

I know for myself that the decision to do EM was a matter of figuring out who I am. Part of that process was realizing that I don't need to be a surgeon, and that I love both acuity and clinic. And after a good deal of shadowing, I've truly come to embrace the specialty. *shrug*

Also, my school doesn't have a home program so it was hard for a while to find EM mentors that I could truly model myself after.

Couldn't find a mentor??????? *sniff* *cries*

 

[EM2BE]

I hope I will find a mentor next year...or I guess I'll just get the SDN community to mentor me

 

[EvoDevo]

Couldn't find a mentor??????? *sniff* *cries*

What I meant to say was "a mentor at my school."

 

[WallowaWanderer]

I often find myself a little irked at the thought of working alongside a group of people who include especially #2, 3, 4 and 6.

I think that while there are some people who fit well into one category or another, most are genuine or are a blend of different categories. I understand you're doing it for the sake of discussion, but it's hard to pigeon hole people just based on a something you heard them say on a stressful interview day.

I think, other than "the idiots," which there are few of, the variety of perspectives and routes to the field isn't necessarily a bad thing. Some who start out genuine end up not liking the field, and some who ranked it second behind another specialty really end up digging it. Like waterski said, as long as you work hard, treat people with respect, and contribute to the profession then you will be an asset.

We have far less of the "second choice" problem than most fields.

I think latecomers are especially valuable to any field because they bring an extra level of training and a different perspective.

I don't think the #2's stay that way for long. They realize that it's not all about all about the trauma bay and discover that trauma isn't all that exciting anyway. I'm sure most of them end up deciding they love EM, but for different reasons than they initially thought. Even though we do a lot of primary care, most of the patients I've seen on my rotations are way higher acuity than I would ever see in a primary care clinic. So I think wanting to see sicker patients is legitimate.

The lifestyle thing . . . that's tough. I actually think it's a legitimate reason to eliminate a specialty from your list. If you know you would be unhappy working nights and weekends, then EM would be a poor specialty choice even if you love the work. Likewise, if you love doing surgery but hate every surgeon you've met, then it might not be a good fit. This is a very personal decision and for some it is very difficult. But if you know that you wouldn't be happy in a given field because of X, even tough you like the work, I think it smart to rule it out.

Why shouldn't lifestyle play an important role in your specialty choice? After all, it is the rest of your life we're talking about! EM isn't an easy lifestyle, but it is a DIFFERENT lifestyle, and those differences can mean a lot. I know that for me, I didn't want to have an office, be tied to a pager, round in the hospital every morning before clinic, take call for my colleagues, and stay in my office till 9pm calling in refills. I didn't want to know what patients I was going to see every day and show up at work at the same time each morning.

You won't be working with the #6's because they will be in a different specialty, right?

Not everyone falls in love with a specialty and is 100% sure. A good friend of mine had a very hard time deciding. Does that mean she won't be as good of a doctor or a colleague? Knowing her, I don't think so.

Just my thoughts.

 

[southerndoc]

Careful, that might be my next post!

It applies to me. Mine is a combination of love for EM (was a paramedic for a while) and the lifestyle.

 

[MaddieMay]

I think another category should be the Lifestyler -- those that only want to work half the month.

My sister does this, so she can raise her children herself after they get home from school.

 

[Hard24Get]

I think another category should be the Lifestyler -- those that only want to work half the month.

hmmm, do I fit in that category since I want to do research half the time?

I should add that one thing my school is very good at is beating EM out of you. So I don't know anyone that fits these categories, cause they all change their minds

 

[I heart EM]

I think it's unfair to classify someone as an "idiot" based on one statement. I don't like ambulatory all that much, but what I don't like about ambulatory is the endless medication readjustment, and the waiting weeks to complete a workup. I don't mind the acute sick visits that show up in the ED (much). Does that make me an idiot? Is it possible that the trauma person could be quite happy attending in a place like MetroHealth or Shock/Trauma in Baltimore? I think your #2 category is a bit unfair, probably because I think I fit into the "I like sick patients" persona.

 

[iridesingltrack]

One of the things that I find interesting about the categories is that I think they could apply to any specialty; they do not seem exclusive to EM.

I know lots of people that fit a variety of these categories going into Int Med, Radiology, G Surg etc. Honestly, I'm not sure it matters, why, in as much as, how dedicated, once the decision is made.