why is EM more comp than IM?

[ALTorGT]

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Hi
Just wonderin...with IM after doin 3 years + fellowship in something like Cards/GI or something else thats procedural, interesting and varied, you can have a cushy private practic lifestyle making 300K plus and with cards - I see on www.cardiologyjobsonline.com that 1M plus is possible in midwest.

Why is it that IM is relatively non competitve compared to EM where there are few private practice opps, income is limited by shift work and longer term...u cant really be an EM physician doin night shifts at 55+.

So...whats the deal..pls. explain someone.

Thanks.

 

[Renovar]

Originally posted by ALTorGT
Hi
Just wonderin...with IM after doin 3 years + fellowship in something like Cards/GI or something else thats procedural, interesting and varied, you can have a cushy private practic lifestyle making 300K plus and with cards - I see on www.cardiologyjobsonline.com that 1M plus is possible in midwest.

Why is it that IM is relatively non competitve compared to EM where there are few private practice opps, income is limited by shift work and longer term...u cant really be an EM physician doin night shifts at 55+.

So...whats the deal..pls. explain someone.

Thanks.

Advantage of EM is that everything is quick, to the point, and very few hours where you waste (ie. no t.i.d. rounding) when you are working, and work fewer hours overall, for similar pay as IM attendings who works more overall hours. You can work fewer shifts when you dont feel like it, and work more if you do. No gay call is nice too. Some IM attendings left their beeper on their car when they go home from work.

For a private IM general internist to make 300k a year (or cards making even more), you need to bust your ass, and you can't practice in big metropolitan areas. Pretty much the way that's possible these days is to go to a town of 5k people where there are only 2 other IM docs (or you are the ONLY cardiologist) and a county hospital within an hour drive. You'll work q3 calls and 120 hour weeks in Podunkville, that's what it takes to make 300k as an IM doc. In popular metropolitan areas, such as California cities, IM internists averages out to low-mid 100's, i've even heard some start at 100 flat.

If you are talking fellowship-IM like cards of GI, then you are talking 3 more years of training which starts to add up. And the real money-maker subspecialties, like Cards, GI or allergy are extremely competitive. Each program easily considers 30-40 applicants for every spot in these money specialties. Now we are talking pretty rough competition. More down-to-earth and less competitive stuff like ID, geriatrics and nephro are not very big in terms of ringing up the cash, and wont add too much to the earning power of a generalist IM attending.

 

[rirriri]

Originally posted by ALTorGT
Hi
Just wonderin...with IM after doin 3 years + fellowship in something like Cards/GI or something else thats procedural, interesting and varied, you can have a cushy private practic lifestyle making 300K plus and with cards - I see on www.cardiologyjobsonline.com that 1M plus is possible in midwest.

Getting a Cardiology or GI fellowship is VERY competitive. IM may be less competitive than EM, but the 2 IM fellowships you mentioned are VERY tough to get into.

 

[Scrubbs]

Also, in terms of residency, EM has limited spots - 127 programs in the country. I couldn't tell you how many IM programs there are, but I guarantee its way more than 127

 

[DrQuinn]

EM is competitive because:

Lifestyle is much better than general IM and most of the IM subspecialties, especially cards/pulmonology (others with good lifestyles are allergy/immunology, nephrology).

Pay is much better than what the majority of internists make (starting EM between 180-220, I know several residents who pulled offers of 250+ in suburban areas).

When you're done, you're done. No pager. No call. You work 3 12 hour shifts a week and you're done. No rounding, no nurse calls at 2 AM for Ativan.

And as for being 55+ and working in the ED, that was an issue I was concerned about in college as well. I asked the ED attendings where I worked as an orderly if they would transition into FP or something else as they got older... all of them (most in their 40s or 50s) said to me "Hell no, EM is what I've been trained to do and I will do it until the end."

The "quote" of the average burnout rate in EM being 10 years is old. The EM profession is young... with most of the EM residencies being less than 20 years old. Before EM was an actual specialty, you had OB/GYNs, ENTs, FPs, IM, GSs working in the ED... they were not formally trained in Emergency Medicine... so their burnout rate was much higher.

Now, you have people like myself, and Scrubbs who knew what EM is all about, know what we are getting into, and love it. We are being trained by the people that write the textbooks and were formally trained themselves. There will be no surprises to us when we are out on our own. Burnout probably won't be as big an issue for us than people who weren't trained in EM.

Q, DO

 

[ALTorGT]

hi
quinn..what bout outpatient clinics and being health care counsellor - lose weight, exercise, get off your ass, explaining to people of IQs <100 the importance of not eating Krispy Kreme for breakfast lunch and tea....I hate all those aspects of Physician life...which made surger more attractive. ......... so what bout EM vs Surgery?

 

[DrQuinn]

Well said, Cuts.

I like your opinions. I share most of them. We down in the ER love what we do (most of us, anyways). We're not burnt out, tired of running here and there... we are advocates of our patients and treat them (for the most part) and street them if we can. If we think a patient needs admission, we call Medicine.

I'm on ward medicine now, and I see how every internist HATES the ED. They think we're incompetent, they think we just like to bug them. My resident does whatever he can to block any admissions that come to us. Why? Not because our patient list is too long (we have 6 patients, with one resident, two interns, and a third year student). But because he's lazy.

Anywyas, in the ED, if the waiting room is full, or empty, I'll still be in the same mood. Working my 12 hour shift as best I can, having fun, talkign to the nurses/EMTs/police/trauma transport, etc, laughing, talkign about going out for a drink...

where as when I'm on wards, its "crap we have to go down to the ER, the go*dam ER!, now we have to go down and see what the hell they want."

*sigh* Such is the life on wards at my hospital.

Q, DO

 

[DrQuinn]

Originally posted by ALTorGT
hi
quinn..what bout outpatient clinics and being health care counsellor - lose weight, exercise, get off your ass, explaining to people of IQs <100 the importance of not eating Krispy Kreme for breakfast lunch and tea....I hate all those aspects of Physician life...which made surger more attractive. ......... so what bout EM vs Surgery?

In EM, stabilization is key.

However, it takes one minute to explain to a patient why it is important to control their blood pressure. Probably less than one minute. Here's what I say:

"If we, as doctors, decreased evreyone's blood pressure by 10 mmHg, we would cut down on the # of strokes in the United States by 50% A majority of hte patients can drop their blood pressure by losing weight and exercising. If that doesn't work, most people need only one pill to control their blood pressure, others need a few more."

Literally, that shouldnt' take more than one minute. One minute of patient education is worth billions in $ saved via primary prevention.

If your aversion to patient education is that vast where you wish to avoid it all together, join Cuts in rads or do Psych.

Q, DO

 

[DigableCat]

Originally posted by Renovar
No gay call is nice too.

hmm...I wonder what this would entail???

 

[doc05]

Originally posted by Dr. Cuts


5) Prestige. EM = moderate-to-high. IM = low


[/B]

I have to disagree on this one. In academia at least, EM is pretty low-prestige compared to medicine.

 

[neutropeniaboy]

Originally posted by Dr. Cuts

All this is very interesting to read; nevertheless, I have much more respect for IM physicians than EM physicians. The only bright EM physicians I have met are the ones that are EM/IM or EM/Peds. They actually have a remote concept of what long term care means and what the impact of what they do means.


1) IM = care for GOMERS, EM = turf GOMERS to IM


"Care for" is the operative phrase.


2) EM is arguably the premier lifestyle gig. Residency's not too bad either. IM residency is 3 years of slave labor, and life as an Attending is not too much better.


I'll give you that one.


3) I know of more than a few CRNA's that earn more than IM Attendings. The only IM docs that make decent money are Interventional Cards and GI, and they work like surgeons. Although EM plateus around 300-350K, an ER doc can tailor exactly how much he wants to work and how much money he wants to make.


I know of a few CRNAs that make more money than EM docs as well. What's your point, really? Anybody can make more than anybody. And this bit about an EM physician tailoring "exactly" how much he wants to work and make...ha!


4) Flexibility. An EM doc can up and move anywhere and get a job. An IM doc is stuck.


IM docs are not "stuck." There are sick people everywhere. Yes, there are saturated areas, but this is the same for any field.


A friend of mine told me of an EM doc he knows that works 10 back-to-back shifts in Seattle, then leaves for the remainder of the month to chill out with his family in Hawaii. Any IM docs you know do that?


Yeah, I hear all EM jobs are like that...and starting, too!


5) Prestige. EM = moderate-to-high. IM = low


This is obviously the view the public has of EM physicians compared to IM physicians...but, I suppose in the end, that is all that matters, right? And it's based upon false pretenses. I mean, every EM physician does sternotomies and oversews torn ventricles just like Dr. Carter, right??


6) Esprit de Corps. Most EM residents are bright and love what they do--they are a great bunch of colleagues. Compare that with most disgruntled IM residents who constantly have that "What the hell am I doing here?" look on their faces.


Let me tell you a great story of a 3rd year EM physician who was treating a total laryngectomy patient of mine who came in with shortness of breath. He put a fask mask on her and started administering albuterol nebs and put taped gauze on her stoma! And let me tell you about the EM attending who consulted us for a small amount of epistaxis and the woman had a damn Lefort I fracture.

Yes, EM residents seem to need above average USMLE scores to enter these residencies, but they must dumb down fairly quickly.


7) Work environment. The ER is a cool place to hang out... you see and experience a lot of cool stuff. Compare that with Telemetry or the ICU in Medicine.


OK. The ER is kinda cool. But, so is the SICU.

 

[DrQuinn]

Nboy-

Let me tell you about the Surgical Intern on his ED rotation who will be a PGY-2 in ENT next year who DC'd a patient from the ED with an epidural hematoma... luckily the patient came back in 20 hours complaining of paraplegia from the compression. Gee, I guess he forgot to actually LOOK at the INR that was ordered that was 7.2.

Yeah, ENT applicants are supposedly the "best and the brightest" but they sure have a narrow differential once they get their acceptance letter.

Q, DO

 

[1996]

Originally posted by Dr. Cuts
EM blows IM for many reasons. A few off the top of my head...

5) Prestige. EM = moderate-to-high. IM = low

I have to disagree with this one as well. After much interactions with residents and attendings from different fields (from IM to surgery and other subspecialties), EM is pretty low on the list when it comes to prestige. The respect and prestige for IM would be more variable (pretty high for subspecialists such as cardiologists and on the lower side for primary care IM). However, even a non-subspecialist primary care IM generally receives more respect from collegues from other specialties than an EM physician does. Jokes about mistakes and oversights by EM physicians are frequently heard in any department that I rotated through. Opinions regarding diagnoses and management from IM physicians, especially subspecialists, are more highly regarded and respected around the hospital than those of EM physicians. I was always taught, in any service, that tests/exams done and diagnoses made in the ER should be disregarded when I admit a patient, mostly because you "can't trust what they do in the ER."

Many of my friends are going into EM. They cited many of the reasons listed by you as the reason why they chose EM (shift work, good life style, etc.). However, they almost unanimously say that the one negative thing about EM, one that they really have to get over, is the low prestige and respect associated with the field.

 

[dharmabum7]

although i have only worked at a few hospitals, its seems like everywhere i go, the ER docs are dogged for being so crappy...the work ups are very half assed...half the time the reason for admission is questionable...

now i realize theoretically that there must be good er docs out there but why does it seem that many seem to be so inept...is it because some of the docs were not trained in ER in residency and transitioned into it?

i give you lifestyle is certainly better in ER. hands down.
but you must be willing to give up a "meaningful" relationship with the patient...

if is not important to you, then go for ER. definately there is a need for acute care...but half of what you deal with will be social admits/primary care for the uninsured....

you can still get a good lifestyle in medicine depending on what you choose to do...and from what i hear the money is out there...

 

[DrQuinn]

Originally posted by 1996
I have to disagree with this one as well. After much interactions with residents and attendings from different fields (from IM to surgery and other subspecialties), EM is pretty low on the list when it comes to prestige. The respect and prestige for IM would be more variable (pretty high for subspecialists such as cardiologists and on the lower side for primary care IM). However, even a non-subspecialist primary care IM generally receives more respect from collegues from other specialties than an EM physician does. Jokes about mistakes and oversights by EM physicians are frequently heard in any department that I rotated through. Opinions regarding diagnoses and management from IM physicians, especially subspecialists, are more highly regarded and respected around the hospital than those of EM physicians. I was always taught, in any service, that tests/exams done and diagnoses made in the ER should be disregarded when I admit a patient, mostly because you "can't trust what they do in the ER."

Many of my friends are going into EM. They cited many of the reasons listed by you as the reason why they chose EM (shift work, good life style, etc.). However, they almost unanimously say that the one negative thing about EM, one that they really have to get over, is the low prestige and respect associated with the field.

You are more right than Dr. Cuts about the prestige. Many doctors poo-poo the ED... remember that we are working in a fishbowl with everyone else around us... (especially lawyers). We often have limited history and no old records to go on...

I think Dr. Cuts was probably referring to the romanticism of EM compared to the rest of medicine... thanks to Trauam: Life in the ER and ER.

Q< DO

 

[Kiwi MD]

Wow, what an interesting discussion.

In my own experience, in New Zealand, Emergency Med was one of the least competitive specialties and also one of the least prestigious. Kind of a Jack of all trades, master of none, thing.

Is it just me, or are salary discussions also irritating some other members in this forum? Really! If you wanted to make money, you would have probably made much better bank choosing a different career and putting the same effort into it than it took to get through residency and medical school. If money is your main motivation ( and considering how the most competitive programs also ironically have the highest salary figures for the year in Iverson's and Salary.com), get ready for a huge surprise, because it fluctuates, it WILL change depending on where the government decides to implement cuts next. If anything, I would dare to suggest that the highest paying jobs currently are most at risk of being the next target for cost cutting. And soon, like general surgeons came to realize, your income statement won't be the thing that keeps you happy.

As far as internal medicine goes, I have generally found internists to be the more humble of our species, considering the vast amount of knowledge they have stored away. They tend to be less showy, and don't really get off on going around promoting their god-like qualities! " Oh well, today, I just extended Mr Xs life by ten years by starting him on an ACE-inhibitor, and then I avoided a massive lethal stroke in Mrs S by giving her some warfarin for her Atrial fibrillation!"

I don't know about most folks, but I tend to appreciate a bit of humility, and being treated with more respect by internists compared with orthopods or general surgeons. Ever wondered why that may be? Perhaps a reflection of a happy working environment?

 

[ERMudPhud]

Ah the great why do all ER doc suck debate rears its ugly head once again.

A few reasons why even the best of us will sometimes seem incompetent to the bigger heads that will see the patients next.

1. We have a very limited time to do our best to figure out what is wrong with the patient and do something about it plus we are focusing on many patients at once. Despite that I think our admitting diagnosis is probably right a respectable if not perfect percentage of the time. If it hasn't already been studied (I'll look and see what I can find) it should be. It would be an easy chart review to pull the charts of say every patient admitted to the MICU and look at the ED diagnosis versus the MICU diagnosis and determine the percent agreement etc...

2. Admittedly we are probably not THE EXPERTS on anything. Everybody knows more about their pet organ system or problem than we do or they better if they're the SPECIALIST.

3. Everybody else gets 20/20 hindsight. You will always be open for second guessing if you are the first to see and treat the patient. 24 hours later after more results are in and everyone has had a chance to take a deep breath and think long and hard about the problem, then discuss it with assorted subspecialist who should know more (see above) its easy to piss on the first person to see the patient. If you are the last person to see the patient there really isn't anyone to piss on you....unless you screw up and send the patient home when you shouldn't have. Then the lowly ER doc gets to deal with your problem all over again but there probably won't be anyone he can complain to.

A little ENT story for neutropenia boy. Man comes to ED with food impaction in esophagus. Impaction is high in esophagus so not really in GI's domain. ENT takes him to OR for rigid esophagoscope and chicken mcnuggetectomy. Can't get ahold of McNugget so rams it through to stomach and admits patient to floor. All night long multiple calls to ENT resident (PGY2 or 3 I can't remember) by nurses for chest pain, rising fevers, falling BP etc. Resident calls in orders for fluids, pain meds, antibiotics, but never sees patient. In A.M. during rounds ENT attending recognizes gravity of situation despite ENT resident's nonchalant attitude toward whole thing. Patient taken emergently to OR by thoracic surgeon for second McNuggetectomy from mediastinum and then to SICU for prolonged ugly septic course. ENT resident assigned remedial reading on sign/symptoms/seriousness of esophageal rupture. True story, I was the SICU resident.

As I said before, can't we all just get along. There a good docs and bad docs in every field. It isn't the field that makes them good or bad.

 

[neutropeniaboy]

Originally posted by QuinnNSU
Nboy-

Let me tell you about the Surgical Intern on his ED rotation who will be a PGY-2 in ENT next year who DC'd a patient from the ED with an epidural hematoma... luckily the patient came back in 20 hours complaining of paraplegia from the compression. Gee, I guess he forgot to actually LOOK at the INR that was ordered that was 7.2.

Yeah, ENT applicants are supposedly the "best and the brightest" but they sure have a narrow differential once they get their acceptance letter.

Q, DO

A couple of thoughts:

1) That's pretty bad.
2) It's also pretty bad that his senior resident and attending didn't catch it either and sign off on the d/c.
3) Intern. They're all stupid.
4) Intern. They need supervision.
5) Again, that's pretty bad.

--

The biggest bone I have to pick with EM physicians is that they assault all these patients with all kinds of studies and labs, and when they happen to pick up something, they all pat each other on the backs for discovering something which entailed no application of any sort of clinical accumen.

 

[DrQuinn]

Originally posted by neutropeniaboy
A couple of thoughts:

1) That's pretty bad.
2) It's also pretty bad that his senior resident and attending didn't catch it either and sign off on the d/c.
3) Intern. They're all stupid.
4) Intern. They need supervision.
5) Again, that's pretty bad.

1). Yup.
2). We dont' have senior residents in our ED. And a lot of the times the attendings let the interns do the DC instructions and follow the initial evaluation. It was actually as issue an later on the ED attending said the intern told him the INR was normal. Although the intern never admitted to anything...
3). Yup.
4). Yup.
5). Yup.

Everyone loves to BM on the ED... I refer to ERMDPHD's post.

Q, DO

 

[Molly Maquire]

3) ""I know of more than a few CRNA's that earn more than IM Attendings. The only IM docs that make decent money are Interventional Cards and GI, and they work like surgeons. Although EM plateus around 300-350K, an ER doc can tailor exactly how much he wants to work and how much money he wants to make.""



Actually, I have to quibble with these salary figures. From the data I have seen, the only EM doctors who make $300,000-350,000 work in tiny towns in the middle of nowhere.

I think in any decent-sized city, EM probably plateus at around $200,000, not much different than you can make as a hospitalist. And a hospitalist works a set number of shifts, just like an EM doc (although I am not sure how the number of hours and lifestyle compares).

 

[Kiwi MD]

ERMudPhud's post is excellent. I never did think of Emergency Med that way, so my trap is shut. For now.

 

[docB]

Hmmm... This kind of turned into a retread of that "Why I hate ER docs" post that has been festering on the EM board. One thing I'll say in favor of EM is that based on recent discourse we are much less bitter and resentful than many other specialties.

 

[Derek]

Just a quick point about the Surical Intern going into ENT who sent the patient home with a elevated INR and epidural hematoma.

This sort of thing will happen to each one of us at some point in our practice. Not because we are lazy, don't care about the patients, or that we are too focused on just our specialty, but rather because we as docs are humans and as humans we will error.

Even the best docs you can think of have missed and missed big.

It is better to walk in humility and be thankful that none of us were there that day to pick that patient up, because it could have been any one of us in those shoes.

 

[ALTorGT]

Arrr...so much anger..so much hate...chill peoplez..chill
all i asked was why, given the fact that in the US a lot of the demand for specialities is driven by the compensation one can expect at the end of training, is it that EM is more comp than IM? thats it. And I rec'd clarification for it.

EM pays more, quicker with a lot more certainity than slaving in IM hoping to get a Cleveland IC Card fellowship along with every other top 1% stud from Ivy League Med schools.

And really..medicines just medicine..Its just a job just like any other. no biggie. A docs a doc. Who cares what specialist. Theres nothing extra special about ENT when compared to Cards, when compared to Rads. Who cares whats more prestigious. Youre all docs already...........do garbage collectors argue about whether its better to be the person outside the truck picking up recyclable materials or the one inside operating the robot arm.......grow up the whole lot of you.
Jeez.
😱

 

[Sessamoid]

Originally posted by Molly Maquire

I think in any decent-sized city, EM probably plateus at around $200,000, not much different than you can make as a hospitalist. And a hospitalist works a set number of shifts, just like an EM doc (although I am not sure how the number of hours and lifestyle compares).

A little personal experience. I was offered multple jobs in major metro areas that started around 200K in EM straight out of residency, including the one I'm working at now. In some areas, that obviously won't be the case (e.g. most of California), but all the Texas cities paid pretty well, as did all the Florida cities I looked at. Also consider that the hospital I work at now has the worst payer mix in the county, and I know I could make more at some of the other area hospitals.

 

[sweetfynesse]

Originally posted by ERMudPhud
Ah the great why do all ER doc suck debate rears its ugly head once again.

A few reasons why even the best of us will sometimes seem incompetent to the bigger heads that will see the patients next.

1. We have a very limited time to do our best to figure out what is wrong with the patient and do something about it plus we are focusing on many patients at once. Despite that I think our admitting diagnosis is probably right a respectable if not perfect percentage of the time. If it hasn't already been studied (I'll look and see what I can find) it should be. It would be an easy chart review to pull the charts of say every patient admitted to the MICU and look at the ED diagnosis versus the MICU diagnosis and determine the percent agreement etc......


I think another interesting study would focus on the percentage of admitted ER patients with bogus diagnosis per IM that get d/c'ed within 24 hours, or better yet 10-12 (the same amt of time we have on shift) of admission because IM is certain that these patients don't need any additional work-up.

 

[Sessamoid]

Originally posted by sweetfynesse

I think another interesting study would focus on the percentage of admitted ER patients with bogus diagnosis per IM that get d/c'ed within 24 hours, or better yet 10-12 (the same amt of time we have on shift) of admission because IM is certain that these patients don't need any additional work-up. [/B]

If you're going to do that, then you ought to study those that get discharged by the internist only to bounce back the ER within 24 hours. Don't think it doesn't happen.

FYI, a good number of the admits are only supposed to be in for 24 hours, depending on the diagnosis. CP r/o MI's and hypoglycemias come instantly to mind. Bad asthma attacks that need some time for the steroids to kick in, also.

 

[vulcanrider]

I think one of the main conflicts is the difference in philosophy between EM and other specialties. In EM the philosophy is "think worst first". In other specialties the luxury of time allows "what is most likely". In other words the short of breath tachycardic 38 year old female has a PE until proven otherwise in EM, but most likely is dehydrated from inadequate PO will at poolside today. Questionable admissions are no fun from either side in my experience. The EM physician doesn't want to miss serious disease and the IM/FP physician doesn't want the extra work that admissions cause. I really don't see a solution to this conflict during residency -- I hope that out in the "real world" my consults will appreaciate the business ( on paying patients, on non payers well they don't really matter anyway 🙄 )

 

[sweetfynesse]

Originally posted by Sessamoid
If you're going to do that, then you ought to study those that get discharged by the internist only to bounce back the ER within 24 hours. Don't think it doesn't happen.

FYI, a good number of the admits are only supposed to be in for 24 hours, depending on the diagnosis. CP r/o MI's and hypoglycemias come instantly to mind. Bad asthma attacks that need some time for the steroids to kick in, also.

again, those (24 hour r/o ACS, asthma exacerbation, etc) wouldn't fall under bogus complaints--right. and trust me, i know the amount of people that bounce back to the er after im discharge...although, i would say that many of the bounce back patients just simply don't understand the nature of their illness.

trust me, we get a lot of ER bounce backs too when the patients read their discharge papers that say if the pain comes back or whatever happens again, come back to the ER. its kinda ridiculous the things some patients come back with, yet in some cases its simply because they don't get enough reassurance and aren't properly educated on their disease process...just yesterday, i had an 8 day old infant with reflux secondary to over feeding, who came into the ER twice because every time he ate, he got "white junk" in his mouth when they laid him down....

but as for the bogus complaints, it would be nice to see how many were discharged prior to additional work up by im....

 

[ERMudPhud]

It occurred to me last night that this recurring debate about the merits of emergency medicine keeps being answered the same way. It always seems to be about money, lifestyle, turf the gomers, and a bit of adrenaline. I don?t fully agree with that list so here is my list of the top reasons to do EM.

1. Be the first doctor to see a problem, start from scratch and figure out what is wrong and what to do about it. Think of each patient as your own personal detective novel. When you do get the diagnosis you have the satisfaction of knowing that you and you alone figured it out. When you?re wrong you learn something.
2. Test yourself against the huge scope of medical practice. In many ways we and the family practitioners are the last of the true generalists. Sure there is security in specializing in the diagnosis and treatment of problems in a single layer of cells in the eye or a single joint in the leg but there is nothing like trying to bite off and chew as much as you can swallow. There is comfort and satisfaction in knowing that you can handle (if only in the short term) almost anything that will walk through your door.
3. See everyone regardless of ability to pay. We are the only specialty given this mandate by the government. Everyone else can choose to see whom they want and refuse to see others. Its actually liberating because since you can?t ask about ability to play it quickly becomes a nonissue and you see and treat everyone without thinking about their ability to play. The only time I care is if I am choosing medications and the patient is paying for meds out of pocket or when I am trying to arrange followup. Despite EMTALA, followup for uninsured patients is a pain. The first question most specialists ask me is what is their insurance. Interesting that other EM physicians never ask me that when I am transferring a patient to their facility. So much for the stereotype of the money-grubbing lifestyle ***** ED doc.
4. Save lives and make a difference. Sure the majority of my patients don?t really need an ER and plenty of the really sick ones die no matter what. All it takes is one ?save? , one kid shown the dangers of STD?s or alcohol, or even one truly grateful patient to make your week.
5. Interact with and learn from specialists in every field. The best part of residency was working with and learning from all my fellow residents. You make a point of discussing physical findings, workup, and differential with all your consultants so you can do a better job each time. I have friends now in virtually every field in every hospital in town. They know that I usually know what I am talking about when I call them and I know that they?ll listen to me.
6. Ok, finally the lifestyle thing. The chance to pursue other things in your life. I work full time doing immunology research and still get to take my daughter to the park or zoo in the afternoon if I want to. Other colleagues in town climb mountains in the Himalayas, work for overseas relief groups, work with FEMA, started an internet company, started a biotech company, or just spend time with their families. Nothing wrong with any of that.

These are my personal reasons. A certain amount of money is nice but there are lots of ways to make money and only so many that will make you happy. Prestige is nice but ephemeral and anyway you make your own prestige. Turf the gomers might be a relief sometimes but isn?t really very rewarding. Procedures can be fun and lucrative but the truth is most procedures that we do are monkey work. They take a certain amount of practice and physical dexterity but not a lot of intellect- you could teach a monkey to do many of them. In the end it?s the intellectual and psychosocial rewards that will keep me going back into the ED every weekend,

Feel free to use any of the above in your application essays

 

[ERMudPhud]

Originally posted by neutropeniaboy

The biggest bone I have to pick with EM physicians is that they assault all these patients with all kinds of studies and labs, and when they happen to pick up something, they all pat each other on the backs for discovering something which entailed no application of any sort of clinical accumen.

My residency program did some of the first research on cost effective ED testing. We were continually challenged during rounds to justify every test we ordered and we're forced to cancel any we couldn't justify. Typically when we admitted the patients the admitting residents be they of the medical or surgical persuasion would have a whole list of things that they couldn't believe we hadn't ordered. CBC's, ABG's, ESR's, LFT's CT scans etc... We could point to the literature documenting that the test they wanted had been proven to make no difference in subsequent decision making to no avail they still got ordered by the admitting teams. As residents we rotated with both the surgeons and the IM folks primarily in the units. The surgeons despite their disparaging comments about fleas tended to be the most egregious abusers of ordering huge panels of daily labs. I think they just needed all the number for their little worksheets for morning rounds.

What neutropenic boy and other EM bashing subspecialists forget is that turnabout can be a b*tch. Since we interact with virtually every specialty we are in a unique position to judge everyone. We know who is quick and smart when called for problems in the ED and who is slow, lazy, or stupid. We know who is an arrogant jerk and who is kind and conscientious. After all if you?re a jerk to us you?re probably a jerk to your patients. Most importantly we know whose complications, misadventures, and mismanagements keep showing up in the ED and whose patients always seem to do well. So, patients and more importantly other docs keep coming to us for referrals. Furthermore, the ED resident you are pissing on now might be referring the paying patients to your competition in a few years.

 

[ERMudPhud]

Here's a few studies. Unfortunately the best one is from Singapore and cynics will say that their system is different enough that our accuracy rates may be quite different. They found that the admitting diagnosis was correct in 77% of medical patients and around 90% of surgical patients. The other two articles focus on accuracy in specific problems: cardiac arrest and abdominal pain. One is from Italy and the other is from the U.S. In both cases I think the diagnostic accuracy was in the 80-90% range. So, three very limited studies but this could easily be fertile and fairly easy ground for someones residency research project. Really just a big chart review.

1: Kurkciyan I, Meron G, Behringer W, Sterz F, Berzlanovich A, Domanovits H,
Mullner M, Bankl HC, Laggner AN.
Accuracy and impact of presumed cause in patients with cardiac arrest.
Circulation. 1998 Aug 25;98(8):766-71.
PMID: 9727546 [PubMed - indexed for MEDLINE]

2: Kizer KW, Vassar MJ.
Emergency department diagnosis of abdominal disorders in the elderly.
Am J Emerg Med. 1998 Jul;16(4):357-62.
PMID: 9672450 [PubMed - indexed for MEDLINE]

3: Goh SH, Low BY.
Accident & emergency department diagnosis--how accurate are we?
Singapore Med J. 1996 Feb;37(1):24-30.
PMID: 8783908 [PubMed - indexed for MEDLINE]

 

[Mirror Form]

Originally posted by Kiwi MD

Is it just me, or are salary discussions also irritating some other members in this forum? Really! If you wanted to make money, you would have probably made much better bank choosing a different career and putting the same effort into it than it took to get through residency and medical school. If money is your main motivation ( and considering how the most competitive programs also ironically have the highest salary figures for the year in Iverson's and Salary.com), get ready for a huge surprise, because it fluctuates, it WILL change depending on where the government decides to implement cuts next. If anything, I would dare to suggest that the highest paying jobs currently are most at risk of being the next target for cost cutting. And soon, like general surgeons came to realize, your income statement won't be the thing that keeps you happy.

Don't be so self-righteous, the people on this board are just being realistic. I don't know how it works for you Kiwi's, but the US grads have loans from both med school and college, usually over $100,000 worth. If you have $150,000 in loans when you finally start working at age 30 and only make $130,000 per year (before taxes), you're never going to pay them off! It's a lot easier to get those loans paid for before your kids go to college w/ a 200k EM salary and also plenty of oppurtunity to make more.

Furthermore, every physician job satisfaction survery I've ever seen demonstrates that job satisfaction for physicians is CLOSELY related to compensation. I have a feeling that if general surgeons got paid the same per hour as the gas-man, the general surgeons would be much happier then they are now. Or at least that's what the data would lead me to believe.

Originally posted by Kiwi MD
As far as internal medicine goes, I have generally found internists to be the more humble of our species, considering the vast amount of knowledge they have stored away. They tend to be less showy, and don't really get off on going around promoting their god-like qualities! " Oh well, today, I just extended Mr Xs life by ten years by starting him on an ACE-inhibitor, and then I avoided a massive lethal stroke in Mrs S by giving her some warfarin for her Atrial fibrillation!"

I don't know about most folks, but I tend to appreciate a bit of humility, and being treated with more respect by internists compared with orthopods or general surgeons. Ever wondered why that may be? Perhaps a reflection of a happy working environment?

It's true that orthopods are in general more arrogant then IM's. And as a medical student I agree that it can be pretty annoying. Although, I bet that if you rotated w/ the IM's at hopkins or mass general, you'd probably find just as much ego there as in many ortho departments. And in terms of a happy working environment, I've met very few orthopods who don't love their field. Whereas, many IM's I've talked to say they wished they'd gone into radiology.

 

[Kiwi MD]

Didn't mean to sound self-righteous, so I apologize if it came across that way.

Of course compensation is important, especially if you have a $150 000 loan. And yes, most of my friends and myself have loans around 100 to 150K. The question is...once it is paid off, will you still be happy with your choice of specialty?

Good luck to everyone making this important decision. May there be no regrets!

 

[unregistered]

If you want to talk strictly hours ER is pretty good, but the stress level after many many years has got to be high (esp. at a large urban hospital c overcrowding). Some ppl have it easy though, and work at small ER's in surburbs.

I think the one thing missing about ER is that you really don't get to ever know your patients well. IM's typically do since there is more longer interaction and follow-up. Of course some people want to avoid patients as much as possible.

But i think for those who enjoy long term interaction and fewer working hours/week, then become a psychiatrists or physiatrists.

 

[klite]

In response to the higher EM salaries, one FP doc mentioned to me that in the ER you will be paid more but have no equity in your practice, your salary is it. Certainly, thats not enough to bridge the gap in salaries, but something to keep in mind.

 

[edinOH]

Your equity is only as good as your ability to see pts. There really isn't such a thing as building up a "practice" anymore with a list of loyal pts who want to see you the doc exclusively. Managed Care has fixed that. The only equity you have is a building if you own one (but most rent) and some equipment that is rapidly depreciating or becoming obsolete, or both. Most people lease their equipment I think anyway. Othewise, the only equity you really "own" is your medical knowledge and your physical ability to treat and diagnose. There is no real inherent value to a medical practice anymore.

I would rather take the "extra money" you mentioned and invest it in myself and my family through investments outside of medicine.

 

[DrQuinn]

One thign that a lot of other non-EM attendings forget is that EM gives you a lot of time off (time off during the weekdays if you wish) to do other things with your money. You can sail, spend it golfing, or open up a business. I know several EM attendings who use some of their salary to run businesses during the week, which can supplement or surpass thier physician income.

Also, a lot of EMS systems pay pretty well to have someone be a medical director. Often times, these positions involve but a few hours a week (or month) and can pay 30k-100k a year, depending on the county/system.

Some EM attendings are also the "medical doctor online" for EMS counties, and this pays a substantial amount of $ per HOUR. I know several who do it their off-time (Just have to carry around a walkie-talkie and answer questions from paramedics). We're talking several hundred/thousand a shift.

You can't do many of these opportunities if you are work 50+ hrs a week at your office, as well as seeing your patients in the hospital, as well as dealing with the business of running your own practice.

Q, DO