Why you shouldn't do EM

[cyanide12345678]

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I'm sitting here contemplating whether I should tun in my 90 day notice for my first attending job and find something better. I'll probably suck it up and finish my contract but being an attending is hard. I've been trained very well, but some aspects of emergency medicine just suck. I wish the following were things I had paid more attention to when I was choosing a specialty.

1) A large number of US patients just absolutely suck. You can smile all you want, greet people nicely, go all out and try to help them as much as possible, they will still find reason to complain. And the hospital really only cares about their patient satisfaction scores. Guess what, you didn't give someone dilaudid for the headache that they wanted? They can still complain and if you don't have a good medical director, that complaint will get back to you. That dental pain had to wait for 30-40 minutes because you were in with a critical patient? Doesn't matter. A good 40-50% of patients are mostly self centered, all that matters is them. The remaining are alright.

2) Administration for the large part sucks - That ultrasonographer with a 2 year education thinks that torsion study was unnecessary because they didn't want to come in over night? Great - They also complain to the administration. The admin will then get back to you and question you. Well...a young female with vomiting and L adnexal pain female needs an ultrasound - I'm an ER doctor. I don't just say "its probably pain from the cyst". I'm trained to have a low miss rate. The dental pain had to wait 30 minutes and now you're being questioned again by admin as to why this person was unhappy? Every damn stupid complaint - if your admin sucks will come back to you.

3) 5-10% of your patients are a**hol*s. Enjoy being yelled at by crazy patients? Great, the ER is perfect for you. Ever been called a terrorist because of your muslim name ? Yup...that's our patient population. Just smile and take it.

4) Half of your nurses will suck. Half of your nurses will be amazing, they will save your ass, they will identify critical patients and immediately grab you. Value those nurses. The other half will be lazy, inexperienced, and just terrible. You'll chase them for a full set of vitals, you'll ask them repeatedly to put the pulse ox in the chart. You'll ask them repeatedly if the 2nd troponin was drawn, after the 3th 4th time that you will ask, it will finally get done.

5) ER is EXTREMELY high liability - Things present weirdly already - there is no textbook answer in emergency medicine. The chances of missing something are damn high. The litigative environment in the US just absolutely sucks. I was named in a lawsuit as a resident when I did 0 patient care, just responded to a code blue, didn't even run it because the cardiology fellow was running it. My name was on the chart as "other people present" on the code sheet. I got named. It took 1 year and 2 months to get dismissed for a case where I didn't even matter. Have fun getting sued when that 80 year old comes in with asystole and family is vindictive and just wants a payout.

6) ER can be unsafe medicine. There will be plenty of times in your career where you will think things are unsafe. 15 patients dropped in within 1 hour and 30 minutes in your single coverage shop? Many of them are sick? Great, good luck. The unpredictability of the ER can make things unsafe occasionally when you can have several hours of no patients and then all of a sudden within 2 hours half of your entire day average volume just pop in during that time. My FM wife has a schedule - 5 patients don't just drop in together in 1 minute (but it happens far too often in emergency medicine)

7) Circadian rhythm switches will suck and will slowly eat your health away. Obesity, HTN, HLD are all associated with shift work disorder.

8) For the most part, unless you're in a SDG, you will have no control over hiring and you will very likely be supervising midlevels who you believe are incompetent. And guess what? It's still your license they practice under 🙂 When they miss something, it's on you. And when those 10 patients drop in at the same time together, you may not get the chance to review everything that they did.

9) some consultants are good and do their job, some are terrible and will degrade you.

This doesn't even begin to talk about reimbursement cuts, future uncertainty with influx of new grads, increasing mlp creep etc.

 

[southerndoc]

Every specialty and every other career has its own set of problems.

Regarding #5, you might want to consider moving to a state with liability protection or advocating your legislators to pass such legislation in your own state.

As for the others, we all feel your pain.

 

[STEMI_voy]

Lol too late

 

[cyanide12345678]

Every specialty and every other career has its own set of problems.

Regarding #5, you might want to consider moving to a state with liability protection or advocating your legislators to pass such legislation in your own state.

As for the others, we all feel your pain.

Can't wait to move to Texas. Just waiting on my wife to end residency.

Med students don't hear these issues. All they hear about are the consultants, the nights, and the holidays.

 

[gamerEMdoc]

Med Students dont get rude patients? I disagree, tons of med students bring that up in an interview when asked about the downsides of the field. Nearly everything you’ve listed (other than supervising midlevels) are common answers when I interview students for residency about the downsides of EM.

I talk to a ton of students who weigh the good with the bad, have decent perspective and still choose to do EM. I dont think this is some big secret we are hiding from people.

I would say for the most part, most people go into EM in part because of the flexibility the shift work gives them and the lack of call, and they just accept the rude behavior bc the benefit to them outweighs the risk. Granted the circadian changes certainly can screw up your days off, but the popularity of EM has exploded with women in the past decade, at least in part because of flexibility and family commitments. No one forces anyone to work 16 shifts a month. You can work 8 shifts and still make a decent living. EM, from a scheduling standpoint, is one of the most flexible fields. You can work as much or as little as you want depending on what is going on in your life.

 

[deleted859535]

Counterpoint for the same audience:

Most specialties have to deal with ass*oles. All specialties have problems -- pick which problems you can best deal with relative to the benefits of the specialty. EM statistically pales in comparison to multiple surgical specialties in terms of liability, where as previously stated, the state in which you practice affects this greatly. And yes, carefully choose your practice environment to limit having to deal with ridiculous complaints / overly entitled non-emergencies / etc. EM is a hard enough job as it is. Go where you best fit for what you want.

 

[gamerEMdoc]

Counterpoint for the same audience:

Most specialties have to deal with ass*oles. All specialties have problems -- pick which problems you can best deal with relative to the benefits of the specialty. EM statistically pales in comparison to multiple surgical specialties in terms of liability, where as previously stated, the state in which you practice affects this greatly. And yes, carefully choose your practice environment to limit having to deal with ridiculous complaints / overly entitled non-emergencies / etc. EM is a hard enough job as it is. Go where you best fit for what you want.

Yes. Rude consultants are rude to nurses and other docs who consult them as well. Rude patients are rude to their doctors. It is what it is. Many of the interpersonal issues go accross fields. Our issue is we cant fire people, we cant deny them care. But dealing with rude patients and/rude families is hardly an EM centric thing. Neither is legal liability. Nor is being busy.

Medicine is hard, dealing with people, including other docs, is hard. Our societies behavior is terrible to one another. This isnt an EM thing, this is a 2020 working with the American public thing. Ask a waiter how fun their job is.

All in all, taking the good with the bad, I still would go to med school again if I was 22 again. I still would go into EM. Ive had a really rewarding 10 year career so far. Are there days when I get frustrated with everything? Yes, of course. This job is hard, very hard. But in the end you can make a difference, you get paid well, and I still enjoy it. Would I rather be gaming or golfing than work? Absolutely. But thats why they pay me.

 

[Porfirio]

Many first time attendings quit their first job within the first year. That is ok.

If I remember right, you are high pay, nocturnist, in single coverage.

 

[WildcatS11]

Many first time attendings quit their first job within the first year. That is ok.

If I remember right, you are high pay, nocturnist, in single coverage.

If that’s true... then man, you should’ve known what you’re getting into! You chose a tough gig in order to reap the perceived benefits.

I wouldn’t trade EM for anything, personally.

 

[cyanide12345678]

Many first time attendings quit their first job within the first year. That is ok.

If I remember right, you are high pay, nocturnist, in single coverage.

Yup. Now that I'm debt free, considering a pay cut for a better life.

Several of my full time nurses who were established and knew what they were doing have left. Ridiculously short staffed lately, they have stopped bothering filling up those open nursing shifts. There new nurses they are hiring have never been in an ER, are slow as hell and i literally have to ask for vitals multiple times. Plus, volumes have gone higher while team health has pretended that volumes are lower and reduced MLP hours. They've hired a new mlp who is family medicine and doesn't know crap about EM and works in a clinic. His work up for a 60+ yo with epigastric pain radiating to the chest was "pepcid and home" until i was like "are you kidding me"????

All those things were getting to me after some very tough shifts. Then yesterday i got an email from my director regarding a complaint from an ultrasound tech who didn't deem my ovarian torsion study appropriate. Her problem is she had to come in at 2 am to do it. It's unacceptable when someone without a medical degree tried to decide what appropriate medical care is. A young female with pelvic pain, vomiting, Adnexal tenderness and known history of cysts which is a risk factor for torsion is an ultrasound. But if the study comes negative, all of a sudden it was unnecessary and the tech is sending emails to my medical director because she came in. So absolutely unacceptable.

And it all just annoyed me. The hospital has a staffing issue, they are short on techs, who get pissed when they come in over night and then in the days. But that doesn't mean my order was inappropriate. So if I'm being asked to order something judiciously, then that's crap, i will do what is the safest thing for the patient and i refuse to have someone dictate medical care when they don't know the nuances of medical care and their job is simply to get pictures. My medical director agrees with my points, but i don't think this sort of silliness should even be brought up to me when the core issue is a hospital staffing issue. I'll happily transfer a patient to the rival hospital next time so i don't have to call someone in 😉

Anyway... I've been fairly annoyed. If this person was going to deem appropriateness of medical care, she should have gone to medical school and then done a residency.

 

[cyanide12345678]

I truly liked my job until these staffing issues

 

[RoyBasch]

Yup. Now that I'm debt free, considering a pay cut for a better life.

Several of my full time nurses who were established and knew what they were doing have left. Ridiculously short staffed lately, they have stopped bothering filling up those open nursing shifts. There new nurses they are hiring have never been in an ER, are slow as hell and i literally have to ask for vitals multiple times. Plus, volumes have gone higher while team health has pretended that volumes are lower and reduced MLP hours. They've hired a new mlp who is family medicine and doesn't know crap about EM and works in a clinic. His work up for a 60+ yo with epigastric pain radiating to the chest was "pepcid and home" until i was like "are you kidding me"????

All those things were getting to me after some very tough shifts. Then yesterday i got an email from my director regarding a complaint from an ultrasound tech who didn't deem my ovarian torsion study appropriate. Her problem is she had to come in at 2 am to do it. It's unacceptable when someone without a medical degree tried to decide what appropriate medical care is. A young female with pelvic pain, vomiting, Adnexal tenderness and known history of cysts which is a risk factor for torsion is an ultrasound. But if the study comes negative, all of a sudden it was unnecessary and the tech is sending emails to my medical director because she came in. So absolutely unacceptable.

And it all just annoyed me. The hospital has a staffing issue, they are short on techs, who get pissed when they come in over night and then in the days. But that doesn't mean my order was inappropriate. So if I'm being asked to order something judiciously, then that's crap, i will do what is the safest thing for the patient and i refuse to have someone dictate medical care when they don't know the nuances of medical care and their job is simply to get pictures. My medical director agrees with my points, but i don't think this sort of silliness should even be brought up to me when the core issue is a hospital staffing issue. I'll happily transfer a patient to the rival hospital next time so i don't have to call someone in 😉

Anyway... I've been fairly annoyed. If this person was going to deem appropriateness of medical care, she should have gone to medical school and then done a residency.

I used to work at a hospital similar to this. The only answer is to leave this job.

 

[Backpack234]

Cyanide, didn’t you just post about being debt free? I remember you saying happiness is overrated. Please go back and reread that thread. Happiness is huge. Take some time and think about what would create that the most for you then take action. If that means quitting your job and finding another one, that’s ok. If it means fighting admin and standing up for yourself, also ok but be careful. If it means taking up photography or (like me) blogging, also ok.

But I think most of us can empathize with what you’re dealing with

 

[bravotwozero]

3) 5-10% of your patients are a**hol*s. Enjoy being yelled at by crazy patients? Great, the ER is perfect for you. Ever been called a terrorist because of your muslim name ? Yup...that's our patient population. Just smile and take it.

If somebody did this to me at our ED, they'd be labelled as belligerent and verbally abusive, and kicked out of the ED. We have a zero tolerance policy with regards to this kind of behavior from patients, and there's a plaque saying this in every patient room. We've even sent patients straight to jail if anyone got assaulted.

 

[cyanide12345678]

Cyanide, didn’t you just post about being debt free? I remember you saying happiness is overrated. Please go back and reread that thread. Happiness is huge. Take some time and think about what would create that the most for you then take action. If that means quitting your job and finding another one, that’s ok. If it means fighting admin and standing up for yourself, also ok but be careful. If it means taking up photography or (like me) blogging, also ok.

But I think most of us can empathize with what you’re dealing with

Yes, debt free. Maybe that's why I'm less willing to put up with things and more willing to get a lower paying job now. But it may mean a 50-100k paycut, that's a lot of money. I still need to build assets and net worth, that requires a high income.

Just curious, what's the name of your blog?

 

[cyanide12345678]

If somebody did this to me at our ED, they'd be labelled as belligerent and verbally abusive, and kicked out of the ED. We have a zero tolerance policy with regards to this kind of behavior from patients, and there's a plaque saying this in every patient room. We've even sent patients straight to jail if anyone got assaulted.

Thankfully never been assaulted. But been asked maybe 6-10 times if I'm related to a certain ex world dictator because of the same last name 😛

Someday to screw with people i think I'll start saying yes 😛

 

[GeneralVeers]

Personal insults or threats against me are grounds for immediate discharge from the ED. I end discussion with them, and have security escort them out. It's not worth one second of your time arguing or having any more discussion with these people.

 

[deleted1027621]

Personal insults or threats against me are grounds for immediate discharge from the ED. I end discussion with them, and have security escort them out. It's not worth one second of your time arguing or having any more discussion with these people.

How do you chart on these folks? Do you wait at all for any work up that is not resulted?

 

[GeneralVeers]

How do you chart on these folks? Do you wait at all for any work up that is not resulted?

In general these people don't have a medical emergency and are there for secondary gain. If I believe that, I chart as such using words like "belligerence, shouting, insulting" directly on the chart. I won't officially discharge them until any pending labs are back, but I certainly won't talk to them again.

The worst one I had was in South Texas. An entitled older white guy came in, with A-fib RVR (in the 130's) and chest pain. Right from the start he began name-dropping his cardiologist in Houston, and demanding that I talk to him before ordering any meds or tests. When I told him I wasn't going to do that, he began berating me, and stating that I "knew nothing", and that he wanted to see someone else. I told him I was going to admit him to the hospital and walked out of the room. I ordered all the meds, labs, etc and didn't go back in the room once. I called the hospitalist to admit him. The idiot patient ended up signing out AMA after the hospitalist talked to him and left.

If I truly think they might have a medical emergency, I let them AMA or elope rather than have a confrontation with them.

 

[Porfirio]

If patients ask me to call their other physician, I always tell them the truth. Their other physicians can’t help them right now.

 

[RustedFox]

An entitled older white guy came in, with A-fib RVR (in the 130's) and chest pain. Right from the start he began name-dropping his cardiologist in Houston, and demanding that I talk to him before ordering any meds or tests. When I told him I wasn't going to do that, he began berating me, and stating that I "knew nothing", and that he wanted to see someone else. I told him I was going to admit him to the hospital and walked out of the room. I ordered all the meds, labs, etc and didn't go back in the room once. I called the hospitalist to admit him. The idiot patient ended up signing out AMA after the hospitalist talked to him and left.

This. All day at my primary job site.

"OK BOOMER"

 

[Dr.CCM]

You have to remember that the ER brings a lot of people on their worst day. But, it also brings in a lot of people who are not disincentivized to stop abusing it. It brings in a lot of the worst parts and most uneducated and entitled parts of our society. Inpatient medicine does block some of these problems but not all. I don’t find these issues nearly as bad in the ICU (it’s usually other issues) and if they can talk they can probably go to step down soon lol, maybe consider fellowship.

 

[Birdstrike]

I'm sitting here contemplating whether I should tun in my 90 day notice for my first attending job and find something better. I'll probably suck it up and finish my contract but being an attending is hard. I've been trained very well, but some aspects of emergency medicine just suck. I wish the following were things I had paid more attention to when I was choosing a specialty.

1) A large number of US patients just absolutely suck. You can smile all you want, greet people nicely, go all out and try to help them as much as possible, they will still find reason to complain. And the hospital really only cares about their patient satisfaction scores. Guess what, you didn't give someone dilaudid for the headache that they wanted? They can still complain and if you don't have a good medical director, that complaint will get back to you. That dental pain had to wait for 30-40 minutes because you were in with a critical patient? Doesn't matter. A good 40-50% of patients are mostly self centered, all that matters is them. The remaining are alright.

2) Administration for the large part sucks - That ultrasonographer with a 2 year education thinks that torsion study was unnecessary because they didn't want to come in over night? Great - They also complain to the administration. The admin will then get back to you and question you. Well...a young female with vomiting and L adnexal pain female needs an ultrasound - I'm an ER doctor. I don't just say "its probably pain from the cyst". I'm trained to have a low miss rate. The dental pain had to wait 30 minutes and now you're being questioned again by admin as to why this person was unhappy? Every damn stupid complaint - if your admin sucks will come back to you.

3) 5-10% of your patients are a**hol*s. Enjoy being yelled at by crazy patients? Great, the ER is perfect for you. Ever been called a terrorist because of your muslim name ? Yup...that's our patient population. Just smile and take it.

4) Half of your nurses will suck. Half of your nurses will be amazing, they will save your ass, they will identify critical patients and immediately grab you. Value those nurses. The other half will be lazy, inexperienced, and just terrible. You'll chase them for a full set of vitals, you'll ask them repeatedly to put the pulse ox in the chart. You'll ask them repeatedly if the 2nd troponin was drawn, after the 3th 4th time that you will ask, it will finally get done.

5) ER is EXTREMELY high liability - Things present weirdly already - there is no textbook answer in emergency medicine. The chances of missing something are damn high. The litigative environment in the US just absolutely sucks. I was named in a lawsuit as a resident when I did 0 patient care, just responded to a code blue, didn't even run it because the cardiology fellow was running it. My name was on the chart as "other people present" on the code sheet. I got named. It took 1 year and 2 months to get dismissed for a case where I didn't even matter. Have fun getting sued when that 80 year old comes in with asystole and family is vindictive and just wants a payout.

6) ER can be unsafe medicine. There will be plenty of times in your career where you will think things are unsafe. 15 patients dropped in within 1 hour and 30 minutes in your single coverage shop? Many of them are sick? Great, good luck. The unpredictability of the ER can make things unsafe occasionally when you can have several hours of no patients and then all of a sudden within 2 hours half of your entire day average volume just pop in during that time. My FM wife has a schedule - 5 patients don't just drop in together in 1 minute (but it happens far too often in emergency medicine)

7) Circadian rhythm switches will suck and will slowly eat your health away. Obesity, HTN, HLD are all associated with shift work disorder.

8) For the most part, unless you're in a SDG, you will have no control over hiring and you will very likely be supervising midlevels who you believe are incompetent. And guess what? It's still your license they practice under 🙂 When they miss something, it's on you. And when those 10 patients drop in at the same time together, you may not get the chance to review everything that they did.

9) some consultants are good and do their job, some are terrible and will degrade you.

This doesn't even begin to talk about reimbursement cuts, future uncertainty with influx of new grads, increasing mlp creep etc.

I feel you, bro, I really do. All I can say is, there’s a lot of lies being told out their.

 

[TooMuchResearch]

Your name is Cyanide Hitler?

Thankfully never been assaulted. But been asked maybe 6-10 times if I'm related to a certain ex world dictator because of the same last name

Someday to screw with people i think I'll start saying yes 😛

 

[cyanide12345678]

You have to remember that the ER brings a lot of people on their worst day. But, it also brings in a lot of people who are not disincentivized to stop abusing it. It brings in a lot of the worst parts and most uneducated and entitled parts of our society. Inpatient medicine does block some of these problems but not all. I don’t find these issues nearly as bad in the ICU (it’s usually other issues) and if they can talk they can probably go to step down soon lol, maybe consider fellowship.

I'm done with training. I've already spent too many years on education. If i wanted to take the pay cut of being an icu attending, i would rather work at a shop with 10k volume and a chill life.

3 year opportunity cost of fellowship is about a million dollars. No thank you.

 

[GeneralVeers]

Your name is Cyanide Hitler?

I'm gonna say Palpatine. He's one of the lost grandchildren

 

[TooMuchResearch]

You're right, Cyanide probably isn't his real name.

Palpatine Hitler.

It's certainly unique.

I'm gonna say Palpatine. He's one of the lost grandchildren

 

[thegenius]

How do you chart on these folks? Do you wait at all for any work up that is not resulted?

I used to feel the way you do DaKitty...how you do r/o an EMC in these patients.

I now realize that virtually none of them are even close to having an EMC, and in the VERY VERY small percentage of the time they might find a lawyer and make a claim against you under the EMTALA statue, then the hospital is just going to have to eat it. (EMTALA claims are usually against hospitals and not physicians, but not always).

It's gotten much easier for me to say "That's it, i'm discharging you!" And I walk out and say in a loud, but non-yelling voice "Nurse can you please summon security to room 16 for me?"

NOTHING makes a nurse move faster than that! Love it.

 

[miacomet]

Med Students dont get rude patients? I disagree, tons of med students bring that up in an interview when asked about the downsides of the field. Nearly everything you’ve listed (other than supervising midlevels) are common answers when I interview students for residency about the downsides of EM.

I talk to a ton of students who weigh the good with the bad, have decent perspective and still choose to do EM. I dont think this is some big secret we are hiding from people.

I would say for the most part, most people go into EM in part because of the flexibility the shift work gives them and the lack of call, and they just accept the rude behavior bc the benefit to them outweighs the risk. Granted the circadian changes certainly can screw up your days off, but the popularity of EM has exploded with women in the past decade, at least in part because of flexibility and family commitments. No one forces anyone to work 16 shifts a month. You can work 8 shifts and still make a decent living. EM, from a scheduling standpoint, is one of the most flexible fields. You can work as much or as little as you want depending on what is going on in your life.

With the market tightening, it's pretty hard to get an 8 shift a month gig, and I'd imagine it will only get harder. And the fewer shifts you work, the higher percentage are nights and weekends, for the most part. At our shop moonlighters get only nights, weekends, and holidays. It can actually be pretty inflexible. And plenty of groups require back-up or sick call.

 

[thegenius]

I'm sitting here contemplating whether I should tun in my 90 day notice for my first attending job and find something better. I'll probably suck it up and finish my contract but being an attending is hard. I've been trained very well, but some aspects of emergency medicine just suck. I wish the following were things I had paid more attention to when I was choosing a specialty.

1) A large number of US patients just absolutely suck. You can smile all you want, greet people nicely, go all out and try to help them as much as possible, they will still find reason to complain. And the hospital really only cares about their patient satisfaction scores. Guess what, you didn't give someone dilaudid for the headache that they wanted? They can still complain and if you don't have a good medical director, that complaint will get back to you. That dental pain had to wait for 30-40 minutes because you were in with a critical patient? Doesn't matter. A good 40-50% of patients are mostly self centered, all that matters is them. The remaining are alright.

2) Administration for the large part sucks - That ultrasonographer with a 2 year education thinks that torsion study was unnecessary because they didn't want to come in over night? Great - They also complain to the administration. The admin will then get back to you and question you. Well...a young female with vomiting and L adnexal pain female needs an ultrasound - I'm an ER doctor. I don't just say "its probably pain from the cyst". I'm trained to have a low miss rate. The dental pain had to wait 30 minutes and now you're being questioned again by admin as to why this person was unhappy? Every damn stupid complaint - if your admin sucks will come back to you.

3) 5-10% of your patients are a**hol*s. Enjoy being yelled at by crazy patients? Great, the ER is perfect for you. Ever been called a terrorist because of your muslim name ? Yup...that's our patient population. Just smile and take it.

4) Half of your nurses will suck. Half of your nurses will be amazing, they will save your ass, they will identify critical patients and immediately grab you. Value those nurses. The other half will be lazy, inexperienced, and just terrible. You'll chase them for a full set of vitals, you'll ask them repeatedly to put the pulse ox in the chart. You'll ask them repeatedly if the 2nd troponin was drawn, after the 3th 4th time that you will ask, it will finally get done.

5) ER is EXTREMELY high liability - Things present weirdly already - there is no textbook answer in emergency medicine. The chances of missing something are damn high. The litigative environment in the US just absolutely sucks. I was named in a lawsuit as a resident when I did 0 patient care, just responded to a code blue, didn't even run it because the cardiology fellow was running it. My name was on the chart as "other people present" on the code sheet. I got named. It took 1 year and 2 months to get dismissed for a case where I didn't even matter. Have fun getting sued when that 80 year old comes in with asystole and family is vindictive and just wants a payout.

6) ER can be unsafe medicine. There will be plenty of times in your career where you will think things are unsafe. 15 patients dropped in within 1 hour and 30 minutes in your single coverage shop? Many of them are sick? Great, good luck. The unpredictability of the ER can make things unsafe occasionally when you can have several hours of no patients and then all of a sudden within 2 hours half of your entire day average volume just pop in during that time. My FM wife has a schedule - 5 patients don't just drop in together in 1 minute (but it happens far too often in emergency medicine)

7) Circadian rhythm switches will suck and will slowly eat your health away. Obesity, HTN, HLD are all associated with shift work disorder.

8) For the most part, unless you're in a SDG, you will have no control over hiring and you will very likely be supervising midlevels who you believe are incompetent. And guess what? It's still your license they practice under 🙂 When they miss something, it's on you. And when those 10 patients drop in at the same time together, you may not get the chance to review everything that they did.

9) some consultants are good and do their job, some are terrible and will degrade you.

This doesn't even begin to talk about reimbursement cuts, future uncertainty with influx of new grads, increasing mlp creep etc.

Hey man, I hear what you are getting at. Maybe your particular job sucks. We all know a lot of docs

I work 16-17 times a month. If I were to rate my happiness at the end of a shift, this is my monthly breakdown:

1 (miserable) - 1 shifts
2 - 2 shifts
3 (just a job, not happy, not sad) - 9 shifts
4 - 2 shifts
5 (very happy) - 2 shifts

Most of the time I'm happy. The shifts where I'm miserable seem to have a common theme: either I'm calling 25 consults and I can't get some of them to do what I want them to do, I'm constantly fighting with the inpatient Hospitalist team, or I have 3-4 patients who are dispo difficult. I occasionally get real a**holes but they don't seem too difficult to dispo.

Regarding
#1: I'm getting better and better saying "I'm sorry I don't know what you have, and it's not an emergency. I'm sorry the ER can't help you." The patients babble and complain on-and-on and I just say "I hear ya. I'm sorry. ER doctors are not trained to treat this problem."

#2: I really don't have any problem with Admin. They have never complained about me that I know of. Maybe 1/year (I did an EMTALA violation once and I got a slap on the back of my hand, but even then the hospital tried to defend me even though I was in the wrong.) I used to work for TH, now our group is part of the hospital foundation.

#3: Yea I get those, but they are usually not all that bad to dispo. Occasionally they are, but I bet all medicine does except for those with cash pay. Even then, some people pay cash and are a**holes.

#4: I'd say 2/3 are good, 1/6 suck and 1/6 are excellent. Not a bad breakdown.

#5: Statistically ER is in the middle of liability. It's about 1 lawsuit in 40,000 charts.

#6: Yup it can be, but thankfully we get so many bozos that it's rare you get 3 critical people at once (where I work at least).

#7: Yup prob the worse part of ER

#8: Even when I was part of a CMG (TH), we had control over who we hired and fired. I'm surprised to read that that situation is not necessarily the norm?

#9: Yup, same for all fields.

 

[Old_Mil]

I'm sitting here contemplating whether I should tun in my 90 day notice for my first attending job and find something better. I'll probably suck it up and finish my contract but being an attending is hard. I've been trained very well, but some aspects of emergency medicine just suck. I wish the following were things I had paid more attention to when I was choosing a specialty.

1) A large number of US patients just absolutely suck. You can smile all you want, greet people nicely, go all out and try to help them as much as possible, they will still find reason to complain. And the hospital really only cares about their patient satisfaction scores. Guess what, you didn't give someone dilaudid for the headache that they wanted? They can still complain and if you don't have a good medical director, that complaint will get back to you. That dental pain had to wait for 30-40 minutes because you were in with a critical patient? Doesn't matter. A good 40-50% of patients are mostly self centered, all that matters is them. The remaining are alright.

2) Administration for the large part sucks - That ultrasonographer with a 2 year education thinks that torsion study was unnecessary because they didn't want to come in over night? Great - They also complain to the administration. The admin will then get back to you and question you. Well...a young female with vomiting and L adnexal pain female needs an ultrasound - I'm an ER doctor. I don't just say "its probably pain from the cyst". I'm trained to have a low miss rate. The dental pain had to wait 30 minutes and now you're being questioned again by admin as to why this person was unhappy? Every damn stupid complaint - if your admin sucks will come back to you.

3) 5-10% of your patients are a**hol*s. Enjoy being yelled at by crazy patients? Great, the ER is perfect for you. Ever been called a terrorist because of your muslim name ? Yup...that's our patient population. Just smile and take it.

4) Half of your nurses will suck. Half of your nurses will be amazing, they will save your ass, they will identify critical patients and immediately grab you. Value those nurses. The other half will be lazy, inexperienced, and just terrible. You'll chase them for a full set of vitals, you'll ask them repeatedly to put the pulse ox in the chart. You'll ask them repeatedly if the 2nd troponin was drawn, after the 3th 4th time that you will ask, it will finally get done.

5) ER is EXTREMELY high liability - Things present weirdly already - there is no textbook answer in emergency medicine. The chances of missing something are damn high. The litigative environment in the US just absolutely sucks. I was named in a lawsuit as a resident when I did 0 patient care, just responded to a code blue, didn't even run it because the cardiology fellow was running it. My name was on the chart as "other people present" on the code sheet. I got named. It took 1 year and 2 months to get dismissed for a case where I didn't even matter. Have fun getting sued when that 80 year old comes in with asystole and family is vindictive and just wants a payout.

6) ER can be unsafe medicine. There will be plenty of times in your career where you will think things are unsafe. 15 patients dropped in within 1 hour and 30 minutes in your single coverage shop? Many of them are sick? Great, good luck. The unpredictability of the ER can make things unsafe occasionally when you can have several hours of no patients and then all of a sudden within 2 hours half of your entire day average volume just pop in during that time. My FM wife has a schedule - 5 patients don't just drop in together in 1 minute (but it happens far too often in emergency medicine)

7) Circadian rhythm switches will suck and will slowly eat your health away. Obesity, HTN, HLD are all associated with shift work disorder.

8) For the most part, unless you're in a SDG, you will have no control over hiring and you will very likely be supervising midlevels who you believe are incompetent. And guess what? It's still your license they practice under 🙂 When they miss something, it's on you. And when those 10 patients drop in at the same time together, you may not get the chance to review everything that they did.

9) some consultants are good and do their job, some are terrible and will degrade you.

This doesn't even begin to talk about reimbursement cuts, future uncertainty with influx of new grads, increasing mlp creep etc.

While all these observations are true, there are a lot of jobs that just suck; probably the majority. Finding a good one is hard. I quit my first attending job two months into my contract. My second was good for about a year and a half and then got bad. I lingered for another year and a half hoping it would get better. My third was good but the family wouldn’t move. My fourth is good and has remained so for about a year. Hopefully it will remain so.

Have a low threshold to vote with your feet. Don’t take a job with a CMG. If you do, remember that all the money to pay for their administrative staff and corporate headquarters is coming out of your paycheck, your quality of life, or both.

 

[ShockIndex]

I'm done with training. I've already spent too many years on education. If i wanted to take the pay cut of being an icu attending, i would rather work at a shop with 10k volume and a chill life.

3 year opportunity cost of fellowship is about a million dollars. No thank you.

It all depends on how you feel about the actual practice of EM. Being cursed at by drunk rednecks, talked down to by the occasional consult (or resident), answering patient complaints, etc. were annoyances. I didn’t decide to go back and do a fellowship until I began to feel that the actual practice of EM had become a failed paradigm with an emphasis of kissing the ass of the “not sick at all” over the critically ill. Helping things limp along was not an option for me, and my wife/kid would not allow me to play soldier or cops and robbers any more which exhausted my other career options.

If dollars/hr and overall wealth accumulation are the metrics by which you judge a career, then it’s time to suck it up buttercup because EM is one of the most efficient means to that ends. However, if you get to the point where you still enjoy taking care of certain patient populations but can’t stand the system, then a fellowship may be the right thing to do because changing the doctor is infinitely easier than changing the system. You also stand a much greater chance of being sued if you find yourself hating patients like some forum members have described. How much is that worth to you?

For some, post-fellowship can be an much easier lifestyle than most EM attendings. Many CCM, interventional pain specialists, and palliative care attendings make similar salaries as EM without the nights and hassle (our CCM attendings rarely come in for overnights). So, make sure you are judging all of your options accurately as everyone will bring different skill sets to the table that impact their lifestyle should they choose to go back and get additional training.

 

[changeofheart2016]

As a radiology resident getting ready to graduate in 4 months, I just wanna say that burnout is not immune to you guys. People think radiology is a lifestyle specialty, but the truth is far from it. Keep fighting the good fight. Save as much as you can and retire early.

 

[RustedFox]

As a radiology resident getting ready to graduate in 4 months, I just wanna say that burnout is not immune to you guys. People think radiology is a lifestyle specialty, but the truth is far from it. Keep fighting the good fight. Save as much as you can and retire early.

Do you mean to say "exclusive" and not "immune"?

 

[deleted497653]

With the market tightening, it's pretty hard to get an 8 shift a month gig, and I'd imagine it will only get harder. And the fewer shifts you work, the higher percentage are nights and weekends, for the most part. At our shop moonlighters get only nights, weekends, and holidays. It can actually be pretty inflexible. And plenty of groups require back-up or sick call.

+1 I worked for one cmg that had bought out an sdg. Part of their deal was that new hires were assigned all overnight shifts. It sucked because the same site had other locums who refused overnights so if you were contract, you ended up with 6+ overnight(over 10pm).
It took CMGs sime time to get over the curve of unfilled shifts. Nowadays l, if you want locums, you work the unwanted shifts. Other than the newly out if residency, most locums are struggling doctors who might be in between jobs.
Getting part time gigs may get harder in a few years. Part time jobs are hard to get once you have an oversupply of doctors akin to other fields like pharmacy where you are basically forced to work full time(in my city)

...times are a’changing

 

[Frazier]

It all depends on how you feel about the actual practice of EM. Being cursed at by drunk rednecks, talked down to by the occasional consult (or resident), answering patient complaints, etc. were annoyances. I didn’t decide to go back and do a fellowship until I began to feel that the actual practice of EM had become a failed paradigm with an emphasis of kissing the ass of the “not sick at all” over the critically ill. Helping things limp along was not an option for me, and my wife/kid would not allow me to play soldier or cops and robbers any more which exhausted my other career options.

If dollars/hr and overall wealth accumulation are the metrics by which you judge a career, then it’s time to suck it up buttercup because EM is one of the most efficient means to that ends. However, if you get to the point where you still enjoy taking care of certain patient populations but can’t stand the system, then a fellowship may be the right thing to do because changing the doctor is infinitely easier than changing the system. You also stand a much greater chance of being sued if you find yourself hating patients like some forum members have described. How much is that worth to you?

For some, post-fellowship can be an much easier lifestyle than most EM attendings. Many CCM, interventional pain specialists, and palliative care attendings make similar salaries as EM without the nights and hassle (our CCM attendings rarely come in for overnights). So, make sure you are judging all of your options accurately as everyone will bring different skill sets to the table that impact their lifestyle should they choose to go back and get additional training.

Great post.

Going back in time, I would choose EM as my residency selection every time. But not to practice today's version of EM.

It is a superb launchpad of skills and knowledge for many subspecialties.

It's hard to beat the raw time off and hourly wages of EM. That said, for some, actually enjoying their daily work, purpose, and patient population is worth the 50-80k pay difference of doing something else in medicine besides grinding out shifts. It is nice to wake up in the morning and not dread the next 12 hours.

If trying to FiRE ASAP at any cost: EM 100%

If trying to enjoy your specialty, enjoy being a physician, and build a larger cumulative wealth (by being able to practice more than 10-15 years without serious consequences to your physical health, mental health, spiritual health, world-view, or family): fellowship

YMMV.

As an academic exercise, go ask a bunch of senior EM residents how long they plan to grind shifts or what their longterm goals are.

Then go ask the same thing to folks doing their chosen subspecialty.

There is a difference.

 

[miacomet]

Great post.

Going back in time, I would choose EM as my residency selection every time. But not to practice today's version of EM.

It is a superb launchpad of skills and knowledge for many subspecialties.

It's hard to beat the raw time off and hourly wages of EM. That said, for some, actually enjoying their daily work, purpose, and patient population is worth the 50-80k pay difference of doing something else in medicine besides grinding out shifts. It is nice to wake up in the morning and not dread the next 12 hours.

If trying to FiRE ASAP at any cost: EM 100%

If trying to enjoy your specialty, enjoy being a physician, and build a larger cumulative wealth (by being able to practice more than 10-15 years without serious consequences to your physical health, mental health, spiritual health, world-view, or family): fellowship

YMMV.

As an academic exercise, go ask a bunch of senior residents how long they plan to grind shifts or what their longterm goals are.

Then go ask the same thing to folks doing their chosen subspecialty.

There is a difference.

What subspecialties? Unlike IM, there appear to be few of much use.

 

[ShockIndex]

What subspecialties? Unlike IM, there appear to be few of much use.

The three that have the potential to change your entire patient population are CCM, interventional pain mgmt, and palliative care. Having said that, I have 3 colleagues who did sports med; one is currently a team physician for one of the country’s largest athletic programs (I think half of her FTE is just sports med, she also has teaching and other academic buydown); another graduated from my residency several years ahead of me and spent several years in the Browns organization (full time), and another is a physician for pro triathletes, power lifters, etc.

I choose CCM for several reasons that fit my academic and personal interests. I’m going to moonlight in my second year of fellowship, but will not set foot in traditional ED once I’m done...I can literally count the number of pelvics that I’ll do in my life on both hands.

 

[Frazier]

What subspecialties? Unlike IM, there appear to be few of much use.

Great majority of primary specialties have fewer paradigm-shifting fellowship options than IM.... derm, neuro, rad onc, obgyn, rads, PMR, gas, ortho, psych.

Paradigm shift options available to the EM-trained?
Addiction, Aerospace, CCM, Hyperbarics/wound, Occ Med, Palliative, Tox, Sports, Informatics.

There's 9 off top of my head which all certainly are of much use, have very unique patient populations/work environments, unique daily work bread and butter, different schedules, and lifestyles different than traditional grinding EM.

None of those interest a person? Well, what does? I doubt it is specializing in only the CV or GI system.

IM has about 14 fellowships (which include some of the above). That's more than 9, but how many Em docs do you think would pick nephrology if it was available through EM?

The fact GI and Cards (often mentioned in this subforum) aren't available EM fellowships is kind of moot. Most EM docs have no real interest in those fields besides the prospect of money... which brings us back to the earlier point, if money is the person's only interest then do EM and absorb the suck to reach FiRE if that is the goal.

Goal should be to find what interests them in a longterm and sustainable way, IMO.

$0.02

 

[ShockIndex]

Great majority of primary specialties have fewer paradigm-shifting fellowship options than IM.... derm, neuro, rad onc, obgyn, rads, PMR, gas, ortho, psych.

Paradigm shift options available to the EM-trained?
Addiction, Aerospace, CCM, Hyperbarics/wound, Occ Med, Palliative, Tox, Sports, Informatics.

Some of the coolest jobs in medicine start out with an EM residency. They include the current or past: Medical Director of NASA, NASA Astronaut (Jonny Kim is a EP, SEAL, and astronaut), Medical Director of the FBI, multiple FBI Operational Medicine Special Agents, Director of the National Transportation Safety Administration, Commander of Joint Special Operations Medical Command, Group Surgeon US Army Special Forces, Brigade/Regiment and Battalion (multiple) Surgeons for the 75th Ranger Regiment, Dean of USUHS, Medical Director of the White House Medical Unit, Medical Director of DOS Foreign Services, Medical Director of the CIA, Director of Rand Corp Healthcare Policy...you get the picture.

While all of these people earned less and worked more than just about any EP posting in this thread, they all had a f%^*ing blast...

 

[miacomet]

Some of the coolest jobs in medicine start out with an EM residency. They include the current or past: Medical Director of NASA, NASA Astronaut (Jonny Kim is a EP, SEAL, and astronaut), Medical Director of the FBI, multiple FBI Operational Medicine Special Agents, Director of the National Transportation Safety Administration, Commander of Joint Special Operations Medical Command, Group Surgeon US Army Special Forces, Brigade/Regiment and Battalion (multiple) Surgeons for the 75th Ranger Regiment, Dean of USUHS, Medical Director of the White House Medical Unit, Medical Director of DOS Foreign Services, Medical Director of the CIA, Director of Rand Corp Healthcare Policy...you get the picture.

While all of these people earned less and worked more than just about any EP posting in this thread, they all had a f%^*ing blast...

The average EM doc is probably not going to become head of NASA etc; most of the examples you listed lean heavily military/government, which is not everyone's passion or interest. You could also probably do these from a variety of fields, not just EM.

But I think the point for students is the same; EM is great if you can check out in 10 years and if you can find a niche. It's not a great field if you want a thirty year career, and I don't know anyone whoever dreamed of palliative care or occ med. And that you absolutely MUST have an exit strategy.

 

[Frazier]

I don't know anyone whoever dreamed of palliative care or occ med.

We are out here! While you're right there aren't tons of us. For the right person, the field is amazing.

Here is about 6 years worth of data on palliative fellowship graduate satisfaction. The percentages speak for themselves and to my knowledge unmatched in healthcare.

2014

2016

2018

 

[gamerEMdoc]

I’d do palliative care medicine in a heartbeat if I could no longer do EM.

 

[Cath Up]

We are out here! While you're right there aren't tons of us. For the right person, the field is amazing.

Here is about 6 years worth of data on palliative fellowship graduate satisfaction. The percentages speak for themselves and to my knowledge unmatched in healthcare.

2014
View attachment 296618

2016
View attachment 296619

2018
View attachment 296620

Thank you for your perspective.
How long can you be in an EM career before pursuing a palliative care fellowship? Do you anticipate it becoming more competitive?

 

[Frazier]

Thank you for your perspective.
How long can you be in an EM career before pursuing a palliative care fellowship? Do you anticipate it becoming more competitive?

At my interviews, there was everything from graduating EM PGY-3's, to EM PGY4 chiefs, to EM attendings that graduated >10 years ago.

The door is always open. 🙂

More competitive? Yes, with the appreciation that it is currently not competitive to match somewhere (of course, as with all specialties, the big names are going to be competitive). But, if the goal is simply to match and be a happy pallimed doc -- any accredited program will work out great. If we are talking more of the community-based programs in states which might not have a lot of people going out of there way to call home, then it is understandably easier. Given the nature of the work, it will never be one of the MOST competitive fellowships in medicine. But for the right person, it is certainly the most desirable.

 

[miacomet]

At my interviews, there was everything from graduating EM PGY-3's, to EM PGY4 chiefs, to EM attendings that graduated >10 years ago.

The door is always open. 🙂

More competitive? Yes, with the appreciation that it is currently not competitive to match somewhere (of course, as with all specialties, the big names are going to be competitive). But, if the goal is simply to match and be a happy pallimed doc -- any accredited program will work out great. If we are talking more of the community-based programs in states which might not have a lot of people going out of there way to call home, then it is understandably easier. Given the nature of the work, it will never be one of the MOST competitive fellowships in medicine. But for the right person, it is certainly the most desirable.

Did you always plan on EM--->Palli? Or did you burn out? Love to hear more about your journey.

 

[Frazier]

Did you always plan on EM--->Palli? Or did you burn out? Love to hear more about your journey.

Happy to write up a bit more detailed look at my path soon.

 

[miacomet]

Happy to write up a bit more detailed look at my path soon.

Awesome! Eagerly awaiting it....

 

[ShockIndex]

The average EM doc is probably not going to become head of NASA etc; most of the examples you listed lean heavily military/government, which is not everyone's passion or interest. You could also probably do these from a variety of fields, not just EM.

But I think the point for students is the same; EM is great if you can check out in 10 years and if you can find a niche. It's not a great field if you want a thirty year career, and I don't know anyone whoever dreamed of palliative care or occ med. And that you absolutely MUST have an exit strategy.

I think that you are overlooking posts #33 and 39 where I listed the more common options of CCM, palliative, sports med, etc. Those are the common options for “the average EP” but they require 1-2 years of extra training to become more than average. On the other hand, 17 years ago J.D. Polk was an average EP and one of my attendings when I was a resident. 15 years later spent busting his ass while taking a big pay cut and he is now the Medical Director for NASA. So, I suppose that becoming something more than average is a bit of a process.

This question of “how can I get out of EM or get a high paying side gig” has been discussed in multiple threads. Embedded within these discussions is undertone (not necessarily from you) of accomplishing this with nothing more than a 3 or 4 year EM residency. Here is the brutal truth - that almost never happens. EM residency from most programs makes someone an average EP and earns them the ability of working in an average community ED. That’s it. Anything beyond that is earned from hard work, talent developed before or after residency, and often a financial investment (aka, a pay cut). So, unless someone has developed some great skillset outside of medicine, the price for escaping the daily grind in the ED is almost always 1-2 years of fellowship. The good news is that most fellowships feel a lot more rewarding than residency if it’s being done for the right reason.

 

[miacomet]

I think that you are overlooking posts #33 and 39 where I listed the more common options of CCM, palliative, sports med, etc. Those are the common options for “the average EP” but they require 1-2 years of extra training to become more than average. On the other hand, 17 years ago J.D. Polk was an average EP and one of my attendings when I was a resident. 15 years later spent busting his ass while taking a big pay cut and he is now the Medical Director for NASA. So, I suppose that becoming something more than average is a bit of a process.

This question of “how can I get out of EM or get a high paying side gig” has been discussed in multiple threads. Embedded within these discussions is undertone (not necessarily from you) of accomplishing this with nothing more than a 3 or 4 year EM residency. Here is the brutal truth - that almost never happens. EM residency from most programs makes someone an average EP and earns them the ability of working in an average community ED. That’s it. Anything beyond that is earned from hard work, talent developed before or after residency, and often a financial investment (aka, a pay cut). So, unless someone has developed some great skillset outside of medicine, the price for escaping the daily grind in the ED is almost always 1-2 years of fellowship. The good news is that most fellowships feel a lot more rewarding than residency if it’s being done for the right reason.

Agreed.
Personally, I think 3 years of IM plus three years of pulm/cc would give most more options than EM/Cc.
Four to six years of training is a lot for a palli/sports/occ med. Given these poorly remunerated (and to my mind, boring) options, I think many would be better served by IM with its multitude of more interesting fellowship options. Most EM folk, or at least many, would be more interested in, say, cards than palli or sports.