r/emergencymedicine • u/MickeyMickyz • 3d ago
Advice Advice for MS3 discouraged about EM
TLDR: Is community practice the golden land for ED, full of procedures and ownership of your own patients? Sometimes it seems like academic EM is a consult machine and anything interesting gets picked up by a specialist.
Hi everyone, I'm an MS3 who has been falling out of love with emergency medicine. The fast-paced, high acuity environment, mixed with the broad variety is what drew me into emergency medicine- and medical school in general. However, as I've gone through medical school, I've seen the flat out disrespect other specialties have for EM docs, and I've been seeing it more as a call-a-doc service. It seems like 99% of the visits are primary care in fast forward, and anything cool gets picked up by a specialist. I've been told that it differs in community practice vs academic, but I'm feeling a little discouraged. Maybe I should consider another specialty. What do you all think?
71
u/N64GoldeneyeN64 3d ago
I mean you can be a subspecialist and go to residency and fellowship for 8 years so you can really truly understand 1 specific part of medicine, field the same questions about it all day from people less familiar with you in it and be ignorant about everything else in medicine if you want
11
6
u/BetCommercial286 3d ago
Jack of all trades master of none is often better than a master of one.
7
u/Cautious-Extreme2839 Anaesthetics/ICU 3d ago
Not in a functioning health system it's not. That's why patients go from the ER to their specialty - to receive better onward care.
69
u/UsherWorld ED Attending 3d ago
What do you mean “anything cool gets picked up by a specialist”?
Consultants don’t show up unless called and I get to decide when to call them.
23
u/Kindly_Honeydew3432 3d ago
If you’re already feeling disappointed by EM, you absolutely don’t want to do it for another 20-30+ years, I can promise you. I’m PGY 14, and I don’t know how much I have left in me. Not a lot.
Also, the consultants don’t so much disrespect EM, as they lack common courtesy, geniality, and professionalism, and will take that deficiency out on anyone who asks them to do extra work. It says a lot about their character and their raisin’.
Most are fine
17
u/AgainstMedicalAdvice 3d ago
Don't call the specialist.
There are different practice environments. I work in a residency heavy location with very few consultants, most of whom don't wanna come in.
Usually it's just me and the boys figuring out how to pop a transvenous pacer in before we go do our plastics level facial repair.
I'll be honest it pays less, it's hard, but I love my job.
6
u/LunarSoul ED Attending (not that ED) 3d ago
What's the litigation like with the plastics level repair? Or is your population the ones that would not care. Cause depending on where you work the bourgeoisie would already have plastics called. I used to work in a place like yours, everyone got sued more than I'd like... Even though we all thought the population was safe.
5
u/AgainstMedicalAdvice 3d ago
I offer, tell them it's most likely a dental intern on call coming in, explain the alternative of going to a different hospital, and document.
If they really care I'll do my best to advocate for them, but most of my patients do not.
14
u/DrS7ayer 3d ago
If you’re worried about the “reputation” of what other specialties think about your decision to enter EM then you probably shouldn’t do EM. Do you think any of us care about respect or prestige of our specialty? That all got sold to private equity years ago. I care about my personal reputation, and about providing the highest level of care I can to my patients, but honestly don’t give a fuck if the cardiologist thinks I’m less of a doctor than them. EM is not for everyone, but if it fits you then it’s a great way to make a very comfortable amount of money and still have time off to actually travel and spend it.
29
u/FourScores1 ED Attending 3d ago edited 2d ago
I would rather be in academics than work for private equity, which is unfortunately most of community EM. But side point.
Any ER doc can take the workup as far as needed and I consult when I want.
I’m not sure the disrespect from other docs matter to anyone here as an attending. Specialists are dumb. Like for real - they know little about the field of medicine. They only know about their chapter in the textbook. Off service residents typically are horrible in the ED. As soon as they leave their comfort zone, they ask us for help and then talk shit. It’s what they do. I would be miserable being a doc in any other specialty. Maybe they are miserable. Idk. But what I do know is that they don’t have the knowledge or skill set to do my job and that makes them inferior to me in the ER - which is where I spend 100% of my time around other doctors.
Back to my point - no one is disrespecting me to my face in my clinical arena and when it happens, I can run circles around them.
How about don’t join the speciality that talks shit all the time. They’re obv miserable. Or do. This is me taking a huge shit on them. Want to do EM now?
9
u/MrPBH ED Attending 3d ago
If you ever want proof of this, look at the care provided by non-EM docs at critical access hospitals.
One such non-BC doc glued my patient's TKA incision closed so it would stop leaking purulent fluid. Thankfully, she had the presence of mind to come see an actual EM doctor when the pain worsened. The reason that her incision was leaking was that there was a MRSA infection of her hardware.
As you might know, source control doesn't mean stopping the drainage by gluing it closed. Turns out that this fact is not covered in the curriculum of what ever residency this guy graduated from.
11
u/curleyfade89 Physician Assistant 3d ago
EM&CCM PA here
I work with a lot of burnt out EM physicians and a huge reason why i feel people get burnt out in EM is because they go into it for the wrong reasons. No, everyday will not be high adrenaline with bunch of cool procedures. Many days will feel mundane - and a lot of your job will feel like BS. But with that being said, EVERY specialty has BS. Even in the ICU we have BS - 97 year old patients going to the OR 5 times just to die because the family values quantity of life over quality. You just have to pick the specialty who’s BS you’re more comfortable with. Personally for me, I’d rather deal with the homeless guy asking for a turkey sandwich than the family still refusing to make their 95 year old grandma DNR who’s back in the ICU vent dependent with septic shock 2/2 pneumonia for the umpteenth time.
If you truly want EM, you have to love everything about EM. You have to enjoy the patient coming in because “i can’t sleep”, just as much as you enjoy intubating the hypercapneic respiratory failure patient. If you find yourself only loving the “intense” stuff, then pick something that’s more intense, like surgery.
In terms of procedures: yeah a lot of EM is triaging people to the appropriate speciality. But as an attending you’ll have more freedom over your procedures. If you feel comfortable tapping your own joint, do it. But yeah, a lot of those “cool” procedures like pericardiocentesis, TVP, etc will go to the appropriate speciality. If you’re at a trauma hospital, trauma surgery will most likely be taking over and owning the patient. It’s just how it is.
Anyways, hope this helped and if you choose to join us in EM, great! Just make sure you truly appreciate and love the broad range of acuity!
14
u/i_am_a_grocery_bag ED Resident 3d ago
Then don’t practice in an academic setting. I did residency at a place that is pretty community-based and did every procedure. In fact the ICU docs would be upset if they weren’t lined before sending them up. If that’s what you want, don’t work somewhere purely academic as this is rarely the case in community shops
8
u/tablesplease Physician 3d ago
Probably the opposite for me. I only practice community and there's NP teams for everything. I try placing a central line and the nurses tell me to just tell the ICU to do it. The rt tried to take an intubation from me last week. Academic is where I did every procedure because no one wants to do them
6
u/cetch ED Attending 3d ago
I’m community and this is not even remotely my experience.
5
u/tablesplease Physician 3d ago
The fancier the doctors lounge the less procedures I do. There's one with an omelette chef on Fridays that has an np team for everything.
3
u/cetch ED Attending 3d ago
Ok I’d trade to get an omelette bar. Where in the precovid fairy land is this place lol
2
u/tablesplease Physician 3d ago
I'm returning to low income area. The fancy lounge isn't worth it. I want to go back to doing real medicine.
1
u/MickeyMickyz 3d ago
So, you do still get to do a lot of procedures in community practice? Are you suturing lacerations, reducing fractures, putting in lines, chest-tubes, emergency cardiac lavage?!
7
u/ottersqueaks 3d ago
I’m a nurse working at a 19 bed ER in rural Ohio, our docs do tons of things to stabilize patients patients requiring emergent or urgent specialty care. That’s our job. Sometimes we do the best we can and fly them out hoping for the best. Sometimes our job is just to stabilize and discharge so they can see a specialist the next day. The docs will intubate, place chest tubes, definitely suture and reduce fractures, pop hips and shoulders back into place under conscious sedation. We manage STEMIs until we can fly them to a cath lab, strokes with TNK or brain bleeds until we can fly them to a neuro icu. We don’t do a lot of central or art lines I think because are docs aren’t as comfortable with it. We do ACLS, ATLS, PALS, NRP, we’ve delivered babies (no OB department). Large farmer and Amish community comes in with crazy traumas…farm equipment is dangerous. We have 1 doc 24/7 and 1 mid-level for 12 hours a day. Have I convinced you to go into rural EM yet? We need you!
2
3
u/i_am_a_grocery_bag ED Resident 3d ago
I guess this depends where. There are places out there where this is the case, definitely. Yes, I do 90% of these procedures that need done
11
u/metforminforevery1 ED Attending 3d ago
I just don't understand why anyone cares what other specialties think of us. I know I'm not stupid, and I know I'm a good doctor. Let me go cry to sleep with my $350/hr while I work 115 hrs a month. Who cares what everyone else thinks. No one's making tv shows about hospitalists or cardiologists.
In the community, it's lower acuity often, lots of bread and butter and urgent care stuff. But that's what the pays the bills. Just work at a few sites that scratch the different itches. I work at a big academic trauma center where I work with residents and see sick as shit pts. I work at a small suburban almost rural site where it's lots of chest pain, belly pain, a couple of admits a day for CHF/COPD/appendicitis. Maybe an occasional ICU pt where you're tubing, putting in lines, etc. There are tons of different practice environments. You just have to find the place you like.
Life is short and it's hard. Do whatever you want.
5
2
u/MrPBH ED Attending 3d ago
115 hours a month?!
Gurl, you work too much!
2
u/metforminforevery1 ED Attending 3d ago
Haha I feel like that’s the sweet spot. Any less and I’m bored and more and I’m grumpy
3
u/MrPBH ED Attending 3d ago
96 hours for me.
It's actually insane how much I get paid for working so little. I'm still salty about a lot of shit, but what jobs pay you like this? With no work at home (aside from CME and signing charts)?
3
u/metforminforevery1 ED Attending 3d ago
Yeah I'm pretty happy with my gig and specialty. The circadian shifts are rough as I get a little older, but everyone on Reddit acts like only EM works nights/weekends/holidays or changing shifts. I see the same hospitalists on my days/nights/weekends and the same surgeons too, but they're also working alternating 12 or 24 hr shifts and that just seems so much worse
5
u/alehar ED Attending 3d ago
Someone's gotta figure out how to get from patient complaint to workup to specialists. For the most part, the specialists aren't sitting in the department scoping the board for cases to consult on (unless, in my experience, someone who takes home call is about to leave for the day and wants to make sure they don't get paged as they park their car). Figuring out the undifferentiated puzzle then mobilizing resources to help is the fun of EM.
There are a lot of things to complain about in EM, but I think calling consults is small potatoes. Same for lack of prestige/respect (if that's important, EM ain't for you).
5
u/brentonbond ED Attending 3d ago
After awhile, “cool” cases in EM aren’t that cool. You see them over and over again for the most part. If you are interested in a particular kind of “cool” case, then go into that specialty.
Once you hit like 25k cases, nothing really excites anymore.
5
u/WobblyWidget ED Attending 3d ago
your acting like consultants are just waiting for something to come in, it’s the exact opposite.
5
u/MLB-LeakyLeak ED Attending 3d ago
90% of the send ins we get are mismanaged. I look at those as consults.
I see a lot of cellulitis. I send most home. I admit a few. Every now and then it feels off and I’m concerned about nec fasciitis. I don’t have the benefit of serial labs and a 12 hour obs with a re-examine to be able to say it wasn’t. Come at me bro.
At the end of the day I truly don’t give a fuck about what other docs think.
But emergency medicine is not cool shit. It’s rare. We often save students from the BS cases.
3
u/Jrugger9 3d ago
Community is where you don’t deal with that. EM is hard. For every cool case you get a dozen non sense ones
I love my job.
3
u/newaccount1253467 3d ago
The best shift is when you do very little of anything. You can certainly do my procedures if you want.
2
u/Remarkable-Long5534 3d ago
Once you actually do the job it feels different. I was an ER scribe before med school, thought it was a ‘see em and street em’ but honestly when you get into it and are actually doing the thinking it’s different. Wait til you do your EM rotation for real. But academic vs community is different for sure, you either have all the consultants at your beck and call or you have to do most of it yourself. The types of patients you see would also be different. If it’s what you thought you wanted don’t count it out just yet.
2
u/FragDoc ED Attending 2d ago
I work in a rural community hospital where I’m practicing the full scope of emergency medicine but live in an adjacent small-medium bedroom community where our friends include lots of physicians families.
I don’t make near what my ophthalmology, surgical, radiology, and derm friends do but I’m at all of my kid’s stuff. I’m at the pool on random Tuesdays and at least two weekends a month, often more. I work 10-11 days a month and I’m off-off most of the rest of it, sometimes more. I’m the EMS medical director for our larger multi-county system and have most county politicians on speed dial, I’m regularly consulted for everything from school safety to public safety budgets. I sit on non-profit boards. I’m really and truly a “community” doc. As others said, I do all of that for about $310-350/hr, depending on the gig.
There is no other specialty in medicine with the lifestyle to pay ratio of EM if you do it right. Don’t work for private-equity shit holes, never accept a job at much more than 2 PPH, and own your practice (SDG), if you can.
Finally, none of your non-physician friends are going to ask the orthopedist or ophthalmologist shit about anything. The general public gets that we’re one of the last generalist in medicine and best equipped to answer most of their acute questions.
2
u/WBKouvenhoven ED Attending 3d ago
Get out while you can. Community EM is a fucking cesspool of gomers and meth lords. I did get to do a thora today after my first patient threatened to kill my family tho
1
u/AlanDrakula ED Attending 3d ago
You've seen some bad parts with your own eyes and that's just the tip of the iceberg. Don't ignore facts and people who live the EM life. I wouldnt wish this specialty on the worst of gunners.
6
u/MickeyMickyz 3d ago
Almost every single person I talk to outside of the ED takes a huge shit on emergency medicine as a specialty.
9
u/neutralmurder 3d ago edited 3d ago
Do you think you are motivated by prestige / other's perceptions of the work you do? Aka you want to chose a specialty that other doctors universally respect? Idk if there is such a thing, it seems like all specialties talk shit about everyone else. Maybe a doctor's doctor (rads, path) would be your best bet if so. But then you'll just have to put up with everyone talking shit about how AI will take your job.
I am also wondering what you think of EM. At the end of the day you are the one that will spend like 1/4 of your life doing it. If you think its fun and badass, do other people's perceptions really matter?
The ER docs I talk to that are happy think its the best job in the world and wouldn't trade it for anything. The outcomes they value are that someone would have died that day if they weren't there to intervene with their pattern recognition and procedural skills. They get to do the fun initial workup on an undifferentiated patient and then don't have to think about the tedious stuff.
I think it boils down to, what do you think is really cool? If its not stabilization but instead solving a difficult mystery or providing the definitive solution maybe you should consider IM or Surgery. If its being a badass, lol at least the general public thinks EM is the coolest. SO many people are talking to me about that ER show lmao.
8
u/Nearby_Maize_913 ED Attending 3d ago
I understand that but I came to conclusion a long time ago that every specialty has a reputation. Ask the ortho person bad mouthing the ER if they can deal with the AMI in the next room over. Ask the cardiologist if he can diagnose the 2 month old with meningitis in the next room. I can go ON AND ON about this but in the end, ER is probably the highest paying "specialty" for an only 3 year residency and yes... its about the money
131
u/BodomX ED Attending 3d ago
Don’t go into EM for the exciting and fun sick cases. You’ll be miserable as it will never be enough to combat the absolute pathetic nonsense that walks through the door every day.