Specialty series: emergency medicine10 min read

Today’s inane image of the day:

One of the advantages of being in a transitional year program is the opportunity to rotate through a variety of specialties and experience them as a resident. Sometimes I wonder if all of us question our specialty choice from time to time – how can we be sure we made the right decision? [I still don’t actually think we can be – but we can make the best of it or make the switch if it becomes unbearable.] Anyway, I am currently in the midst of my emergency medicine rotation and decided to start a medical specialty series with some of my thoughts on what I liked and didn’t like. Warning: this is an exceptionally long entry!

Background

Emergency medicine [EM] is a pretty self-explanatory specialty: they are the first-responder physicians of the hospital and reside primarily in the emergency room. Most patients that enter the hospital will first be evaluated, stabilized, and worked-up by an emergency medicine physician. They are the gateway to admission onto an inpatient floor or ICU.

Residency in EM is typically 3 years [though I’m learning that some specialized programs as well as some of my osteopathic colleagues are in it for 4 years] and involves primarily EM rotations but also a few ICU and specialty months [e.g. OB, trauma, burns, surgical]. Fellowships are typically 1 year in length and include areas such as pediatrics, critical care, disaster medicine, toxicology or sports medicine.

Matching into EM is getting more and more competitive. Many medical students are prioritizing work-life balance and the ability to only work approximately half of the month [most attendings only need to work 13-15 shifts/month to achieve “full time” status] definitely lends itself well to having time for family or other hobbies. Residency training is relatively short and salaries are desirable [some junior attendings work in remote or rural areas for a substantial salary increase in order to pay off loans then later move to settle down]. The 2014 Charting Outcomes in the Match shows that there are 1.2 applicants for each of the 1,786 1st year positions in EM. 1,371 U.S. seniors matched and 106 U.S. seniors did not match. The average USMLE Step 1 score for matched U.S. seniors was 230 and for the USMLE Step 2 it was 243.

What I like about EM

Fast-paced

As an intern, I’m only expected to see around 1 patient an hour in the Category 2 area [at Henry Ford, Category 1 is the most urgent – most of these patients are headed for the ICU or to the OR; Category 3 is more like an urgent care]. Some of the senior residents I’ve worked with pick up 3 patients an hour [when it’s busy – obviously this depends on how full the chart rack is]. In comparison – when I am on 30-hour call for an internal medicine service, I am capped at 7 admissions [I think this is a fair comparison because many Category 2 patients that meet inpatient criteria will go to a general medicine floor, so the acuity of the patients seen is similar]; our EM colleagues definitely see a higher volume of patients each shift. Generally there’s a lag in between seeing the patient and getting results from lab testing or imaging, so there’s time to start the work-up on another patient. As always, there is an attending overseeing all of our plans and ensuring that nothing gets missed. [their lists are even more overwhelming to me!].

I like the fast-paced environment because it makes the shift fly by. The high patient volume also means exposure to a wide range of pathologies.

Procedures

In the Category 1 area, plenty of patients need invasive lines – central lines, arterial lines – as well as advanced airways. Although as a rotating intern at Henry Ford, I do not do any Category 1 shifts, I did have a few while I was a medical student at Beaumont Health. While I was in the higher acuity area, I performed intubations and inserted arterial lines, which are procedures I will soon have to become proficient in [however, in a less chaotic environment!]. There are some minor procedures in the Category 2 area – laceration repairs, incision and drainages. Sometimes patients appear healthier than they really are and are triaged into the Category 2 area but need to be moved into a monitored bed – those are instances where the resident can continue to manage the patient and may have a chance to do procedures as well.

Shift work

There’s no such thing as being “on call” in EM – the emergency room is supplied with physicians and midlevel providers in shifts. As a rotating intern, my shifts are either 7a-5p, 3p-12a or 11p-8a. We are scheduled for 18-21 shifts each month [our EM colleagues get a few extra ones]. If you think about a 30-day month, this means you could have 9-12 full days off… which is a lot if you consider the fact that we are only guaranteed 4 days off on floor months. One big advantage emergency medicine has over many other specialties is that when you’re on, you’re on. When you’re off, no one will page you about a patient. It’s refreshing to be completely free from patient care.

Personalities

I got along with a lot of the emergency medicine residents and attendings when I rotated as a medical student and currently as a resident.When trying to decide whether a specialty is a good fit, it’s usually a good sign when you get along with your colleagues. Many of the residents/staff I’ve encountered have a “get it done” mentality – they are not afraid to do a very thorough physical exam [you can trust the ED to have done a DRE and guaiac card for every GI bleeder] or get their hands dirty with a procedure. They are very versatile and able to think on their feet. I would also describe many in EM as laid back [not when it comes to medical care, but general demeanor], which makes sense when you’ve seen as much as they have in the ED.

First responders

When patients present to the hospital, EM practitioners are the first to develop a broad-based differential diagnosis and begin the workup to determine whether an admission to the hospital is warranted. They are well-versed in resuscitation and initial medical management [which can definitely come in handy if you’re on an airplane and they ask if there’s a doctor on-board]. This level of practical knowledge is not readily available in many other specialties [e.g. radiology], especially in sub-specialties [e.g. endocrinology]. Even on internal medicine – especially on the inpatient side – most patients arrive with labs and initial treatment already in-process.

What I do not like about EM

Odd hours/shifts

My circadian rhythm has been completely disrupted because of the odd hours and constant changes in shift times. I started the month with a 3p-12a shift then had 3 overnight 11p-8a shifts, then switched back to 3p-12a for a few days. The last two weekends, I’ve worked 2 overnight shifts then during the week had 7a-5p shifts sporadically. Although there’s some time to try to adjust between shifts [e.g. when I finish an overnight shift, I generally have ~20ish hours of time to recover and switch my sleep schedule back], trying to sleep during the day is a losing battle making whatever time you’re actually awake, unproductive. My overnight shift days usually went something like this: get off work at 8a-9a, attempt to drive home, crawl into bed by 10a, sleep until 3-4p and wake up with a headache, drag myself to the gym and attempt a half-hearted workout from 5-6p, eat some food from 6-7p, nap from 7-10p then drive to work to start my 11p shift. Maybe some of you are better at the overnight thing than I am.

“Enemy” of the hospital

“Ugh, I can’t believe the ED drew a troponin on this guy!”

“We don’t treat asymptomatic bacteriuria anymore! What was the ED thinking?”

“It’s the ED calling with another ridiculous admission.”

I’ve heard comments about the ED throughout my training that can be summarized by the statement: the ED is your enemy. I’m making generalizations, but most individuals who have spent time in various areas of the hospital have heard snide comments or offhand remarks about how the ED did this or that [implying there was a better way]. Not everyone sees the ED in this way and an overwhelming majority of residents/staff I’ve worked with are very respectful of their colleagues’ choice in management. However, now that I’ve experienced being on the ED end of things, I understand why it can be taxing to be the “enemy” of the hospital. Why can’t we all just be respectful of one another?

Liability

I was once told by an attending that the average ED physician will be named in a lawsuit once every 10 years [I tried to look up a source, but couldn’t find anything useful to link]. Many of us may work as attendings for 4 decades, making the average number of lawsuits in one’s career around 4. While this this anecdotal evidence, there’s no surprise that ER physicians tend to be sued more frequently than, say, an outpatient internist. The job demands that nothing be missed, despite unusual presentations for common ailments. Brainstorming a list with broad differential diagnoses has been one area I struggled with; I’m always taken aback when I present a case of abdominal pain and my attending asks, “did you rule out AAA?” Although it may appear that ER physicians do not spend time with their patients, the reality is that it’s all relative. When a level 1 trauma rolls in through the automatic doors, there are numerous physicians at the bedside for as long as it takes to stabilize the patient. An otherwise healthy young patient presenting with stable vitals and a chief complaint of sore throat just doesn’t warrant the same level of attention. This being said, experienced ER physicians know how to do an appropriately focused physical exam and when to spend an extra moment to ensure they haven’t missed a critical finding. Unfortunately, the combination of short-lived interactions, expectation of infallibility, and less-than-desirable environment [busy urban ERs tend to be loud, have a distinct smell and generally starve their patients] make ER physicians the perfect target for lawsuits.

Burnout

The number of hours I’ve spent physically in the hospital has been markedly less this month. I’ve been averaging ~50-60 hours/week, which is significantly better than the 70-ish hours/week while on a busy inpatient month. However, the time I’m on-shift in the ED requires much more energy, attention, and focus than most inpatient medicine rotations. 90% of the time, it’s busy and there are plenty of patients waiting to be seen. Since we are expected to see ~8 patients/shift, this translates into 8 H&Ps to write each shift. Once you’ve picked up a few patients, there are labs or imaging to follow-up on. If a consultant is required, there are calls to be made. Sometimes patients are sicker than they appear and need to be transferred to Cat 1. Sometimes patients get agitated or rowdy and need pharmacologic treatment to calm them down. There’s always something to do, making most ER shifts extremely busy, often leading to missed meals and dehydration. After working 5-6 back-to-back shifts, you reach a level of exhaustion you never thought was possible. Despite having more time off, I still struggled to make it to the gym regularly because all I wanted to do was sleep. I have a couple of research projects and blog commitments that I’ve put on the back burner this month. Although I’ve gotten used to the flow of things in the ER, the high-pressure, nonstop working has helped me understand why ER physicians lead the pack in physician burnout. There is just one word to describe how I feel now that I’m almost done with this rotation: tired.

Conclusion

I definitely considered emergency medicine as a possible specialty choice. Overall, I think I could have been happy in the field if I practiced in the right setting.

For those of you in the field or planning on going into it, do you think this was an accurate representation of some of the pros/cons? What other aspects of the field did I miss?