Why do Emergency Doctors have a reputation of being "dumb"?

[InterestedinEM]

Every rotation I've been on they all rail on ER docs as being not too bright. They say this is the specialty where the less intelligent med students go. Surely I'm not the only one who has experienced this.

Do you guys think it is jealousy or something else.

---

Members don't see this ad.

 

[Tiger26]

Every rotation I've been on they all rail on ER docs as being not too bright. They say this is the specialty where the less intelligent med students go. Surely I'm not the only one who has experienced this.

Do you guys think it is jealousy or something else.

it could be because a few of them have the tendency to ask basically the same question as has been discussed for the last week or so in the tread titled "too smart for EM" that is a few threads down from the top . . . .

 

[RustedFox]

I dunno. I for one was smart enough to recognize that endless rounding and the whole idea of 'call' is really unappealing.

 

[RxnMan]

Every rotation I've been on they all rail on ER docs as being not too bright. They say this is the specialty where the less intelligent med students go. Surely I'm not the only one who has experienced this.

Do you guys think it is jealousy or something else.

Funny. I thought endless sub-specialization made it easier because you had less to learn. Dumb me.

 

[J ROD]

it could be because a few of them have the tendency to ask basically the same question as has been discussed for the last week or so in the tread titled "too smart for EM" that is a few threads down from the top . . . .

 

[J ROD]

Every rotation I've been on they all rail on ER docs as being not too bright. They say this is the specialty where the less intelligent med students go. Surely I'm not the only one who has experienced this.

Do you guys think it is jealousy or something else.

knows something about alot, expert on nothing.....

 

[Homunculus]

Every rotation I've been on they all rail on ER docs as being not too bright. They say this is the specialty where the less intelligent med students go. Surely I'm not the only one who has experienced this.

Do you guys think it is jealousy or something else.

i think it's selection bias and/or ignorance. older attendings and people who come from areas where the ED is full of non-EM trained providers (ex-surgeons, ex-FP's, NP's, graduates with only internship) will have an opinion that the ED is "dumb". it also varies according to location. our ED now is staffed with more EM boarded docs-- previously we had an IMG with no residency, an ex-surgeon, and a few other castaways. it was kind of like the land of misfit toys. now things are better, but back then i saw all kinds of weirdness come out of there. if that were my primary experience with the ED for a decade or two, i'd probably think same as some of the people you mention. but i've been fortunate enough to be close to the process and know a few ED folks (like kungfufishing) who could have done anything but chose EM because it fit them and they had a passion for it.

i don't think you'll find any junior attendings or "new" staff espousing the "dumb er doc" mentality. there will still be some ignorant ones out there, but that's true of anything. regardless, i wouldn't let it effect your career choice.

--your friendly neighborhood ED observing caveman

 

[docB]

Every rotation I've been on they all rail on ER docs as being not too bright. They say this is the specialty where the less intelligent med students go. Surely I'm not the only one who has experienced this.

Do you guys think it is jealousy or something else.

To be brutally honest it's because when someone creates work for you it's easy to hate them. It's really easy to nitpick over whatever they did before they sent the patient to you. Since most internists, surgeons, hospitalists, critical care docs, etc. get all their unplanned, unpre-approved and uninsured patients from the ED, well, there you go.

I can say this with authority as I routinely consider many of my primary care, nursing home and other community colleagues who send patients to the ED to be *****s when I'm cleaning up their mess.

The difference is that in med school you get one rotation in 4th year to get exposed to how the stupidity and laziness of the rest of the medical world contributes to the workload of the ED and you get the other side of the story in every other rotation.

 

[kungfufishing]

The next doc to see the patient is the smartest. Medicine also attracts an unusual set of personalities, in case you hadn't noticed.

 

[SoCuteMD]

It's easy to know everything when you get to work off the front line's information, results, and mistakes.

Also, pretty much everyone knows more about THEIR specialty than EM docs known about their specialty...which is fine since that's the way it should be. You won't see the pediatrician I&Ding an abcess (at least not the ones I know), the surgeon diagnosing a STEMI and activating the cath lab, or the anesthesiologist making a dispo plan for the 90 year-old fall-down-go-boom who is fine but just can't go home.

I was actually told by a chief resident at my local peds program that what makes our community hospital scary for the pedi residents is that the kids come up from the ED with their workups in progress and that they have to THINK about what to do for the kid. Um...so you are pediatricians and you are scared by having to diagnose and treat illness in a kid? Sounds like your problems are bigger and closer to home than the ED!!

 

[deleted65604]

A more representative statement would be... "ER docs are too conservative." Being conservative is what causes a lot of work for other specialties. When you get out into private practice, the PCP's want to send most chest-pain home, most TIA's home, and most "abdominal pain of unknown etiology, but wants to be admitted" kind of crap.

THEY want YOU to take medicolegal responsibility for the low-risk stuff so they can sleep at night. You too would hate the ER doctor that consistently admits EVERY chest pain (I try to). When the yield on chest pain admits starts approaching 20%, you would get irritated too.

I CT'd a guy the other day that I was almost positive would be normal, (symptoms of gastroenteritis), because his abomen continued to be tender in the right lower quadrant. CT showed appendicitis, which I couldn't deny looking at the CT myself. Got his appendix out and the path was normal. Stool grew out salmonella. In hindsight, I shouldn't have done the CT.

But I'd rather do that than pull what one of my (respected) FP colleagues did, and not CT an abdominal pain and have the dude go home and present at another hospital shortly thereafter with a bowel obstruction, ischemic colon, and end up with a colostomy.

To catch all emergencies, we have to pull the fire alarm a lot of times when there isn't a fire. That is going to piss people off from time to time and make them think you don't know what you are doing.

 

[gman33]

Is the reason for "pulling the fire alarm so often" better patient care or to protect from lawsuits?
Probably some of both, in my mostly uniformed opinion.

 

[tegs15]

Is the reason for "pulling the fire alarm so often" better patient care or to protect from lawsuits?
Probably some of both, in my mostly uniformed opinion.

Remember that many if not most lawsuits are issued due to a perceived harm, real or imagined. Thus being more conservative in most cases is also better patient care at the individual patient level, the one 55yo male with a NSTEMI that suffers a poor outcome is only a statistic to us and the lawyers but to him its really life or death.

 

[docB]

Is the reason for "pulling the fire alarm so often" better patient care or to protect from lawsuits?
Probably some of both, in my mostly uniformed opinion.

Both. But that's the system in which we work and live. And so do all the other doctors which is why they don't just immediately discharge the patients we admit and why they send so many patients to the ED in the first place.

Remember that many if not most lawsuits are issued due to a perceived harm, real or imagined. Thus being more conservative in most cases is also better patient care at the individual patient level, the one 55yo male with a NSTEMI that suffers a poor outcome is only a statistic to us and the lawyers but to him its really life or death.

I would argue that it's not (despite what I said above). I think that the med mal crisis actually makes everyone's care worse. It stifles clinical judgement and the ability to tailor care to individuals. It leads to overuse of diagnostic tests and the morbitity associated with those tests and the morbidity associated with the false positives.

 

[wook]

It leads to overuse of diagnostic tests and the morbitity associated with those tests and the morbidity associated with the false positives.

 

[Tesla MD]

To answer the OP, I think part of it is also that our first question on a patient encounter is "Where is this guy going?" and if the answer involves being admitted, we're partially checked out because we only need to know why and if the answer is going home, we're partially checked out because we only need to figure out what should be done to facilitate that. We think the hardest when we don't know where they should go. So let's say you have a medically interesting patient with some kind of renal failure, and they're going to medicine inpatient. Medicine may have lots of academic and interesting thoughts and tests and whatnot, but we (or, at least, me) have stopped caring unless there's a concern for current life threat.

And also the thing about more work.

 

[goodoldalky]

Every rotation I've been on they all rail on ER docs as being not too bright. They say this is the specialty where the less intelligent med students go. Surely I'm not the only one who has experienced this.

Do you guys think it is jealousy or something else.

Good responses in this thread, let me add just one thought:

No matter what field you choose to practice in, there will be physicians and persons in other fields with low/negative opinions about your field and the work you do. This seems to be partially because each field generally creates a certain amount of work for the other fields and it's partially just human nature, but try these on for size:

Surgeon: Just a robot. Does the operations they are told to do. Can barely think, but wanted to do surgery so they could boss people around and have a napoleon complex.

Pediatrician: Too scared to want to treat anything more severe than a cold with any regularity.

Psychiatrist: Weird. Needs a psychiatrist.

Ortho: Meathead.

Anesthesia: Lazy.

Primary Care: Does an awful job providing primary care. They're the reason healthcare is collapsing and the ER is swamped.

Derm: Pimple popper, M.D.

Radar/Path: Can't talk to a patient, barely a "real doctor".


Of course, none of these things are true. The only truth is that medicine is a community and patients routinely bounce from one field to the next, as though they are all creating work for each other. The ER is no different, and is where any patient who needs urgent care from any field needs goes first. With certain people, this leads to a negative attitude. Ultimately, no matter what field you choose, someone can be negative about it if they want to.

Pick a field because you WANT to. Don't choose or avoid a field based on what others think of it. You have to be happy with it, because you'll get ragged on from time to time no matter what it is.

 

[notinkansas]

Probably has to do with the degree of bogus consults they call to avoid lawsuits. Example: Nursing home pt c/o leg pain, affected leg might be a little swollen, no fractures. Foot a little cooler than the other one, palpable pulses > call vascular surgery consult.

At least this is an easy consult. "Palpable PT and DP, no vascular surgery intervention needed, will sign off"

But each specialty can tell of bogus consults. Combine that with what seems to be the tendency to get the full panel of labs on every pt and liberal use of CT scanning - I believe this is really the epitomy of defensive medicine. Your tax dollars at work!

 

[deleted65604]

Do we order too many CT scans? Yes. But only in retrospect. In the past year I've probably ordered 400 CT scans. 50 had pathology that I was totally expecting. 340 were normal like I expected. 10 had crazy stuff that I never expected. (appendicitis, air in the portal system concerning for ischemic gut, kidney tumors, brain tumors, lymphadenopathy concerning for lymphoma, retro pharyngeal abscess, etc. I thank my lucky stars I got the exam on a lot of those folks.

In the past year I've ordered around 1200 cbcs and chem comps. Around 100, I got abnormal labs that I totally expected (anemia in a GI bleed). About 20 showed crazy results that I would never have imagined.

For example, a hemoglobin of 6.0 in a 60 year old lady with mild dyspnea on exertion, a pulse of 70 (not on a b-blocker) and SBP of 120, satting 98% on room air (unusual for the elevation I live at). How many times do you pick up a crazy low sodium on a weak and dizzy work-up on old folks? I've caught a couple of leikemias and lymphomas on WBC's (that is like a yield of 0.1%). Throw in a couple of wickedly high lipases on pancreatitis patients, and I have no problem with the low yield on lab testing that I have. How many lipases do you have to order to pick up a truly sick, needs to be admitted pancreatitis? I'd say around 100.

Missing one important diagnosis a month is not acceptable on a personal, or institutional level. If I missed that many important diagnoses a month, I would be out of a job and would have been sued at least 5 times by now.

Don't knock it until you've been in our shoes.

 

[Jeff698]

On the whole "ED orders too many CT scans" thing...

Why does it look like primary care doesn't order many CT scans? Because if they think there many be any role at all for a CT, they send them to the ED to get it. When it's positive, they look great and can say "I knew it!". When it's negative, they can sit back and say "silly ER doc orders too many scans".

Take care,
Jeff

 

[GeneralVeers]

It would be great if we could go back to the old-fashioned "return in 12 hours if not better" approach to vague abdominal pain, especially on young women.

Every week I see 10-12 young women with abdominal pain who end up having a negative pelvic exam, negative CT, and negative ultrasound.

If we could get litigation out of the way, it would be completely reasonable to discharge a female who was afebrile with a negative pelvic, and non-focal abdominal exam, and have them return in 12 hours for re-exam.

I think everyone over 50 and all males who present with pain (except for chronic cases) should get a CT scan before discharge.

Subjectively it seems that 50% of the women I see have no explanation for their abdominal pain after workup, whereas it's less than 10% in the male patients. The ration of female to male abdominal pain at my facility approaches 3:1, which results in many negative CT scans.

 

[EctopicFetus]

On the whole "ED orders too many CT scans" thing...

Why does it look like primary care doesn't order many CT scans? Because if they think there many be any role at all for a CT, they send them to the ED to get it. When it's positive, they look great and can say "I knew it!". When it's negative, they can sit back and say "silly ER doc orders too many scans".

Take care,
Jeff

Yep!!

 

[InterestedinEM]

Good responses all around.

I think I will deal with the reputation and try not to let it get to me.

Many thanks!

 

[omgwtfbbq?]

... in the end, it's YOUR career and it only matters how you feel about your work. Going into something you don't love because its a "smart" specialty (by whose standards?!) is just going to make you miserable. Don't let a reputation, and a false one at that, turn you away.

 

[leorl]

ER is a specialty that many don't understand, we have our own ways of doing things just like the other specialties, and many future specialists do not ever have rotations in ER during their residencies / fellowships.

The stigma many times comes because as ER physicians, you will most of the time be the "2nd best" management for a patient requiring admission. You can reduce a fracture, but you will still need to call the ortho consult for definitive management. You can start tpa and anticoagulants, but you will still need to consult the cardiologist / neurologist for definitive managements. And just like we oftentimes do not know that specific consultant's analities regarding x med vs. y med causing them to view us as "not as knowledgeable," they do not know our EM-specific protocols on certain illnesses.

Also, there are many times in the ED that a specific diagnosis cannot be made but you must admit for a) they really don't look good and something potentially serious is going on for which a discharge will be unsafe or b) there's no way in hell I'm going to get tangled up in a complaint / lawsuit for something that needs further workup so I'm admitting them and I don't give a rat's ass that you don't like it not to mention your service is supposed to be following but they haven't gotten any followup appts / investigations yet.

Our world is a lot different from any of the other specialties. They sometimes view our workups as being incomplete and constantly want you to add x lab or y imaging study, but honestly I don't give a damn when it's super busy and I have sickies all over my trauma bay / code area. Once I get my patient stable, they're coming up to your ICU / floor and if x test hasn't been done yet, YOU get off your lazy ass and do it yourself. And I also don't care that the patient I'm admitting for foot osteomyelitis doesn't have a chest xray, that's your stupid protocol not mine. So as you can see, this is where some antagonism comes in.

But a lot of comments we get from rotators is that "wow, you guys see tons of people and actually discharge loads." They see us as giving them more work that they think should have been done in the ER, but once they rotate through the ER, most of them realize we actually save them a lot of work. It's just that not everyone has to do an ER rotation. Our mentality is sometimes opposite that of other specialties.