Why is EM more fun than IM???

[Primate]

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No, really? So much of what you do in the ED (I'm doing my req. rotation now and am having the most fun of any clerkship yet) is IM, you'd think that there'd be more overlap. IM was interesting, I suppose, but EM is just so much more fun. Knowing IM is cool, but doing it? Well, let's just say it's not for this monkey.

Do most of you in EM really like time in the Units or on the ward? Did you like IM but just wanted more of a shift work job? I suppose I'm most curious about whether EM is more a specialty of IM or a different field that incorporates IM. My experience is the latter, but is the difference I'm experiencing real and does it last for a career?

It almost seems that you get all the variety of family practice, all the jazz of trauma, and all the benefits of a 30 hr work week.

WHAT AM I MISSING HERE?

 

[NinerNiner999]

There are three Major reasons I prefer EM over IM (They are very similar in many aspects):

1. No rounding (in the time it takes for morning rounds to finish on one patient, I can have labs read, CT's and other imaging completed and maybe have the patient admitted).

2. No Call with faced paced shifts. There is no call in EM, which is great because it keeps you fresh to work when you do (and believe me - you do).

3. Full variety of everything I studied in medicine. I'm not restricted to the same patients every day, and there is almost endless variety in cases as they come to the ED.

There are several other minor reasons to consider it as well: Less restriction and more autonomy with your patients, no overhead in private practice, the ability to set your own hours, and constant barrage of unique medical conditions that require immediate attention and a more creative use of my acquired skills.

I think you've touched on the nuts and bolts of the field, but also consider that there are many more procedures to be done in EM and the critical experience is unique in that the patients you manage are right off of the street, for the most part. In short - pick up your Pathology book, critical care book, Trauma protocol, and throw everything clinical you can think of in between - then you have EM.

The IM "equivalent" of Emergency Medicine would be being a hospitalist - but again, that's strictly IM.

 

[ckent]

I can answer that question from an IM perspective. EM is *very* differen then IM. I actually thought that I would enjoy my EM rotation, but I actually found it remarkably dissatisfying. As an EM doctor, unless you call patients at their homes (which I did on a number of occassions as part of our course and also to learn), you have essentially no follow up. So you never really see the end point of the patient, all you know is that you discharged them from your ER in stable condition. Some days, I'd like to know if the patient that I sent home with chest pain really did have GERD. The EM mentality is a vastly different then your IM mentality. In the EM, it's all about ruling out what's going to kill your patient and offering temporary solutions to your patient. I had one patient that I started to order iron studies on because he was being admitted for anemia, and the EM resident told me that I could, but he didn't think that it was necessary. And at other hospitals, a lot of EM docs shoot their patients up with abx before drawing blood cultures (at our hospital, I think that our ID docs did a pretty good job of discouraging that practice so the EM docs all know to write the orders for blood cultures first. usually). If you ask to order an ANA or coag studies for a patient (as I did), you will be told not to. If a patient has knee pain and you can't figure it out but you've ruled out the dangerous stuff, you send him home with some codeine and tell him to follow up with their primary care doctor. An EM resident explained it to me by citing a study, which apparently shows that EM doctors spend less on working up patients and less on therapy for patients then IM docs working in the EM with equivalent or better outcomes. It's interesting because so many people use ER's as their primary care place, but I don't think that they really aren't being adequately worked up or treated by the newer ER docs they are training these days. I don't think that there's anything wrong with that either, it's the health care system's fault and not the EM physicians, since it really isn't efficient for people to be going to EM's as their primary care source. I definitely do think that the two specialties have diverged far enough that you shouldn't have too many IM doc's working in ER's in the future to keep cost down and because they aren't as good at stabilizing/ruling out deadly conditions, and you shouldn't have any ER docs doing primary care work in the future because they aren't trained to.

 

[mikecwru]

Originally posted by ckent
I can answer that question from an IM perspective. EM is *very* differen then IM. I actually thought that I would enjoy my EM rotation, but I actually found it remarkably dissatisfying. As an EM doctor, unless you call patients at their homes (which I did on a number of occassions as part of our course and also to learn), you have essentially no follow up. So you never really see the end point of the patient, all you know is that you discharged them from your ER in stable condition. Some days, I'd like to know if the patient that I sent home with chest pain really did have GERD. The EM mentality is a vastly different then your IM mentality. In the EM, it's all about ruling out what's going to kill your patient and offering temporary solutions to your patient. I had one patient that I started to order iron studies on because he was being admitted for anemia, and the EM resident told me that I could, but he didn't think that it was necessary. And at other hospitals, a lot of EM docs shoot their patients up with abx before drawing blood cultures (at our hospital, I think that our ID docs did a pretty good job of discouraging that practice so the EM docs all know to write the orders for blood cultures first. usually). If you ask to order an ANA or coag studies for a patient (as I did), you will be told not to. If a patient has knee pain and you can't figure it out but you've ruled out the dangerous stuff, you send him home with some codeine and tell him to follow up with their primary care doctor. An EM resident explained it to me by citing a study, which apparently shows that EM doctors spend less on working up patients and less on therapy for patients then IM docs working in the EM with equivalent or better outcomes. It's interesting because so many people use ER's as their primary care place, but I don't think that they really aren't being adequately worked up or treated by the newer ER docs they are training these days. I don't think that there's anything wrong with that either, it's the health care system's fault and not the EM physicians, since it really isn't efficient for people to be going to EM's as their primary care source. I definitely do think that the two specialties have diverged far enough that you shouldn't have too many IM doc's working in ER's in the future to keep cost down and because they aren't as good at stabilizing/ruling out deadly conditions, and you shouldn't have any ER docs doing primary care work in the future because they aren't trained to.

I'm not going to get into an IM vs EM pissing match, but on the issue of cxs and abxs, please realize that EM physicians do understand that you "should" get cxs before abxs, but there are certain situations where prolonging abxs to get a good test may be of detriment to the pt. This is usually not a big hassle with blood cxs, but comes into play alot with abx before a spinal tap. You don't let the patient die in order to identify the organism. (And you have some time before abx screw up CSF studies anyway.) Lots of hospitals now have time goals for door to abx for pneumonia, etc.

It's a very different mentality. Don't assume that because an ER doc doesn't do it, that (s)he doesn't understand the medicine. Hopefully, at least some of the ER docs took you aside and told you more than just telling you "no" when you requested a test. Usually you get a "no" because the test won't change the patients management, or because of the setting of the ED, you can't provide the immediate f/u (e.g, paps and HIV testing).

mike

 

[roja]

Em is very different from other fields. The notion that one is 'better' than the other is ridiculous, and not really worth the time to get into.

I was incredibly dissatisfied with IM. It didn't fit my personality. I didn't want to tweak HTN meds, DM meds, and I didn't want to wait days for labs to awnser a question. But I am very thankful that there are people out there that do.

IM functions on creating a broad differential of what is wrong with your patient with the most common or likely first and then prioritizing downward.

EM functions very differently. We try and make sure that there is nothing life threatening (or something dangerous enough to come into the hospital) going on. What is exactly causing the back pain? I don't really need to know.

And EM is much *MORE* than IM. There is definately IM that is a part of it, but there is also pediatrics, OB/gyn, ortho, cardiology, psych, trauma, general surgery, anesthesia..... I got interested in EM after I was almost done with my entire 3rd year. I liked a little bit of everything that I had done but nothing so much that I wanted to do it soley. In EM, I get a nice variety, I get to diagnos a lot of patients (though many I don't) and I get a nice life. It also just suits my personality. In EM, you have to be able to multitask. You have to not mind thinking quickly and you have to balance a number of patients.

Its certainly not a subset of IM. And most of my IM friends *hate* EM. And vice versa.

And many EM programs don't have IM floor months. (two ICU months are required by the ROC for certification.. but no floor months).

 

[Freeeedom!]

Quick question...when in the WORLD has a blood culture changed the clinical course of a patient except for the sickest of patients admitted to the ICU. I have not seen a single study, in fact more to the contrary, where cultures (when not contaminated!) add almost NIL to the treatment of pneumonia or any non immunocompromised adult. They simply do not change the course of treatment of those patients not admitted to the ICU.

Remember, when ordering tests in the ED, they are considered STAT...when do you actually need a STAT ANA? This imposes considerable cost to the patient...we are spending OTHER PEOPLES MONEY.
I try to make that point to the IM residents that come down and begin ordering tests in order to take the shotgun approach. ED laboratory tests are MORE expensive than floor tests.

As for the original question...because EM docs simply have the time to enjoy life! We have virtually no overhead costs and our net income is substantial. I love it!

Keep on rockin in the free world.

 

[jazz]

I had one patient that I started to order iron studies on because he was being admitted for anemia, and the EM resident told me that I could, but he didn't think that it was necessary. And at other hospitals, a lot of EM docs shoot their patients up with abx before drawing blood cultures (at our hospital, I think that our ID docs did a pretty good job of discouraging that practice so the EM docs all know to write the orders for blood cultures first. usually). If you ask to order an ANA or coag studies for a patient (as I did), you will be told not to.

you've hit the nail on the head.

we don't do a complete workup in the er because we don't have time or the resources. i understand the need to send iron studies and prior to transfusion if the cause for anemia is not obvious, but at the same time the results take a long time to come back and do not affect our management. we may not order ANA studies but the patient is being admitted and at most hospitals those studies take a few days so they would not affect management of the patient. our goal in the er is to see many patients, stabilize the critically ill ones, and send the chronic problems home with follow up. the er is not designed to provide good primary care and those individuals who come to the er for primary care are misusing resources. at the same time, the er is not designed for prolonged workups. that is why patients are admitted. i actually think that everything sent from the er is billed at a higher rate because it is considered emergent. therefore, in a broader health care perspective, it probably is more cost efficient to order ANA, TSH, etc studies form the floors.

I actually thought that I would enjoy my EM rotation, but I actually found it remarkably dissatisfying

As an EM doctor, unless you call patients at their homes (which I did on a number of occassions as part of our course and also to learn), you have essentially no follow up

people who enjoy em do not usually enjoy im and vice versa. i like em b/c i like seeing a variety of patients, i don't like managing long term problems (adjusting hypertension medications, chronic ulcers secondary to diabetic neuropathy). a lot of us follow up the patients we admit and see how they do in the unit, floor, etc. at the same time, it is not an uncommon practice to call people up at home and follow up with them especially if there is a concern (complicated lac with high risk of infection, for instance).

 

[jazz]

Freeeedom!

just want you to know that i was typing my response when you posted yours. glad to see you confirmed my suspicion that ed studies and labs are more expensive. didn't want to make you think that i don't read all the posts and just repeat things....

 

[ckent]

Originally posted by Freeeedom!
Quick question...when in the WORLD has a blood culture changed the clinical course of a patient except for the sickest of patients admitted to the ICU. I have not seen a single study, in fact more to the contrary, where cultures (when not contaminated!) add almost NIL to the treatment of pneumonia or any non immunocompromised adult. They simply do not change the course of treatment of those patients not admitted to the ICU.

Well, I hope that no one misconstrued my post to be negative towards people who want to do EM, I didn't mean that at all. I was just pointing out as many other users have pointed out that the personalities of people who like IM and the people who like EM is usually pretty different. And regarding the issue of blood cultures, *please* get them before starting antibiotics. If you suspect endocarditis but failed to get blood cultures, you are obligated to treat for 4-6 weeks of IV antibiotics. That can mean 4-6 weeks of having an IVDA complaining about heroin withdrawl and every ache and pain in the world (geez these people love to yell about CP at 3 AM), arguing with the nurses and smoking in the bathroom every morning while sitting on the medical service because there are no sub-acute beds. Getting a specific organism often helps guide your therapy as well, in terms of choosing antibiotics with less toxicity or a narrower spectrum antiotic so your patient doesn't develop VRE in his stool forcing you to gown up everytime you want to go into the patients room. See, this is exactly what I was talking about how EM and IM docs often have very different perspectives on patient care issues, especially since many EM programs don't require general floor months. For an EM doc, once they are out of the door and onto the floor, they are not your problem anymore. But for IM docs, it can be really frustrating if the EM doc isn't thinking about the patient's long term care. Most EM docs at my school aren't like that, but I've heard complaints (yes, I know, everyone likes to rag on IM, EM, FP, psych, etc) from other hospitals. I suspect that it used to be different when IM docs were the ER docs in the past. I do agree that EM docs have to know much more then IM docs too.

 

[BCE]

I think you need to make a clear distinction between which groups of patients need blood cultures. I would take multiple cultures on a ? endocarditis, but I wouldnt take any on a CAP, pyleo or cellulitis. - for those later 3 there is good evidence that +ve BC's dont alter treatment or outcome - so we dont bother.

BCE

 

[Coleman]

Re: bcx and abx
I have actually hear a wide variety of times (in hours) necessary for abx to clear a bcx, meaning, if you give abx ___hours before you draw bcx, you can still grow out bacteria. Often, many of my IM attendings pointed out that there was no need to "rush" because it took 4 hours or 6 hours, depending on who was speaking. Does anyone have a good article to give me some insight on this. Both bcx and csf clearing time would be great if you know them.

re: em vs. im
I enjoy the medicine of IM, and honestly, if you don't, you would have a hard time in EM. I have heard a great quote passed down from residents above me that we see the "first 15 minutes of every disease". Lately, with overcrowding and nursing shortages and medicare spending cuts, I have changed this to the first "6 hours" of each disease, but regardless that is not the point.

I chose EM because it requires me to be an excellent doc for peds, adults, and geriatrics in both IM and surgical emergencies. That is why I went to medical school. There is no such thing as a patient who is too complicated for the ED. That is what I love about it. Also, just my personal preference, it killed me ordering tests and labs on IM patients and then waiting til the next day at pre-rounds to get the answers. I am a born and bread EP and am not used to waiting more than 3 hours at max.

 

[edinOH]

I always try to think about the probable hospital course/work-up for a patient when I see them in the ED. For instance, if a pt is anemic with no immediately obvious source, I'll go ahead and order the iron studies before transfusion since I realize that the IM team will most likely be needing those at a later date. Same with choice of abx and cultures.

It is easy to just look at the pt. from the ED point of view, but I think I'm practicing better medicine when I take a moment to consider the long-term management of the pt.

The reasons I love EM and really dislike IM is the rounding. I have a pretty short attention span. I like that I can see someone, do as much as I can for them, and then hand them off for someone else for all the "detail work". I realize some people find it satisfying to follow a pt for days or weeks while their diagnosis and course becomes clear. I find it excruciating.

 

[DrQuinn]

Originally posted by edinOH
The reasons I love EM and really dislike IM is the rounding. I have a pretty short attention span. I like that I can see someone, do as much as I can for them, and then hand them off for someone else for all the "detail work". I realize some people find it satisfying to follow a pt for days or weeks while their diagnosis and course becomes clear. I find it excruciating.

Amen. You guys have it easy, though, when I'm on my off-service rotatoins, and when we round, I am stuck on the 8th floor of Tampa General Hospital overlooking a picturesque view over downtown Tampa and Tampa Bay... not fun for rounding and trying to pay attention.

Q, DO

 

[Primate]

The thing that got me about IM, and this is related to the dislike for rounding, was that we only spent a very small amount of time with the patient (a few minutes pre-rounding) and then a WHOLE lot of time rounding (work rounds without even going into the rooms, then attending rounds in a conference room), followed by several hours of arranging tests/etc and then a quick peek at the patient and off to home/call and admitting another - and that's only on the day of admission. Like I said, IM is interesting (to me - I'm not into pissing matches of EM v. IM, which are just silly, just which is more enjoyable *for me*) but less satisfying the way I've seen it practiced here. I've, ironically, had way more patient contact during EM than IM.

How's it go. . . Degustabus non disputum est (my Lating is SOOOO rusty, but you need the occassional pretentious quote 😉 ).

Of course, looking out at W. Philly during rounds did help with the concentration - not quite as scenic as Tampa I suppose.

 

[Sessamoid]

Ditto on the short attention span here. When I was in medical school, I actually managed to fall asleep standing up while on neurosurgery rounds. Sure didn't win any brownie points that that day. 🙂

 

[Samoa]

Regarding cultures after antibiotics, it's probably true that it takes several hours after administration for the antibiotic to reach its peak effect. It depends on the antibiotic. However, peak *levels* of an IV antibiotic in the blood are reached almost as soon as the infusion is completed. Therefore, a culture obtained at any time after antibiotic infusion will contain enough antibiotic to inhibit subsequent bacterial growth, or else will not contain sufficient viable bacteria to generate a positive culture. The antibiotic cannot be removed at that point, so the culture will be negative, even if bacteria were still present in large numbers at the time of the draw. If the bacteria is resistant, has intermediate sensitivity or has inducible resistance to the antibiotic you selected, you may still get a positive culture if you draw it several hours after administration. But it introduces a significant and sometims insurmountable confounding variable any time you administer antibiotics prior to the culture.

 

[roja]

I agree with edinOH, to a degree, it is important to think about the long term plan of your patient and treat appropriately. Fever in an IVDU or HIV pt, definate blood cultures before antibiotics.

Same for paincontrol. If its even a possibility of surgery or ortho, I avoid NSAIDS.

And despite the fact that the trend where I am is to not Guiac everyone who walks in, if I am admitting a pt, I guiac them because it is a proverbial pain in the rear to get it on the floors here.

There are a lot of studies I am asked to order prior to admitting and I have had to say no. For many reasons. but I found once I explained why I am not going to restick someone for bloods that can be drawn tomm, that is more expensive, etc, I haven't had a lot of problems.


And I don't agree that EM has to know a lot *more*. Its just different. Everyone in medicine has to know a lot. Each field just has to know what thier field is about. Course, EM is a *lot* more fun. 🙂

 

[beyond all hope]

I am biased, being EM, but I will try to explain it from an IM point of view.

EM is fun when you first start because everything seems new to you. Every patient has a different complaint, come from all ages and all walks of life, and everyone has a different story to tell. It seems very glamorous and exciting.

However, when you get a little bit more experienced, these all fall into only two categories.

1) Not sick ('worried well')
2) Sick

Not sick patients are treated symptomatically and given followup. In actuality, it matters very little how you treat them because they are going to be okay no matter what you do.

Sick patients are stabilized and admitted. These patients are challenging but in actuality there are only a few different kinds of resuscitation/stabilizations that we do. Mostly we try to keep the pressure and oxygenation up until someone comes to take over the patient. Actual treatments for sick patients in the ER (pericardiocentesis, chest tubes, defibrillation) are rare and usually only stopgaps to definative tx in the OR or ICU.

IM is more routine in that the patients are already stable once coming the foor and just need a diagnosis and medication adjustment. Clinic patients usually have a dx and just come for routine maintenance and/or whining.

Note that IM docs have much more leeway in choosing their careers after residency, whereas ER docs are always stuck in the ER.

Most people came into medicine thinking it's all about bringing people back from the brink of death, which is why ER is so attractive initially.

Those of us who stick with it do so not because it's exciting (after the first 100 resuscitions, they all seem kind of the same) but because we like the pace and the work itself. (and we hate call, rounding, working six days a week and treating only people over 70)

 

[edinOH]

Originally posted by beyond all hope
I am biased, being EM, but I will try to explain it from an IM point of view.

EM is fun when you first start because everything seems new to you. Every patient has a different complaint, come from all ages and all walks of life, and everyone has a different story to tell. It seems very glamorous and exciting.

However, when you get a little bit more experienced, these all fall into only two categories.

1) Not sick ('worried well')
2) Sick

Not sick patients are treated symptomatically and given followup. In actuality, it matters very little how you treat them because they are going to be okay no matter what you do.

Sick patients are stabilized and admitted. These patients are challenging but in actuality there are only a few different kinds of resuscitation/stabilizations that we do. Mostly we try to keep the pressure and oxygenation up until someone comes to take over the patient. Actual treatments for sick patients in the ER (pericardiocentesis, chest tubes, defibrillation) are rare and usually only stopgaps to definative tx in the OR or ICU.

IM is more routine in that the patients are already stable once coming the foor and just need a diagnosis and medication adjustment. Clinic patients usually have a dx and just come for routine maintenance and/or whining.

Note that IM docs have much more leeway in choosing their careers after residency, whereas ER docs are always stuck in the ER.

Most people came into medicine thinking it's all about bringing people back from the brink of death, which is why ER is so attractive initially.

Those of us who stick with it do so not because it's exciting (after the first 100 resuscitions, they all seem kind of the same) but because we like the pace and the work itself. (and we hate call, rounding, working six days a week and treating only people over 70)

When did you graduate from residency? Just curious.