Emerg!

[Mac8]

I would like to hear what other's think the pro's and con's of a career in emergency medicine are!

[Kirsteen]

Hi there,

 

I'm currently on an Emerg rotation and find that the pros are as follows:

 

1) Diverse presentation of cases.

2) Minimal paperwork per patient relative to other specialties.

3) Shiftwork: the Emerg physicians I work with now tailor their schedules. They work anywhere between 8-15 shifts per month with each shift being 6-8 hours in length. This can permit a decent lifestyle re: the ability to spend time with kids, etc.

4) Ability to work in locations/practices other than your primary Emerg practice. It's not uncommon for Emerg physicians to work in other clinics/hospitals in addition to their primary post.

 

Cons:

1) Shiftwork can sometimes be a bummer: I just finished a 12am-8am shift and it can often feel as though a truck's hit you. I've also heard that shiftwork can grind some folks down, i.e., cause burnout.

2) Some people do not like the ability not to follow a patient once they have been diagnosed in the Emerg, i.e., if a brain lesion is found, how is the patient managed thereafter, etc.

 

Those are a quick few that come to mind.

 

Cheers,

Kirsteen

[Satsuma]

I am seriously considering emerg (all my 4th year electives are now set-up for emerg...though I haven`t done my adult emerg yet, just 2 weeks of peds).

 

People often say that the shift work can be an issue.

Though I just can`t seem to understand why. It seems so much better than call. Yes, 12-8 is pretty crappy. but 8am til 8am (or even 12 the next day) just seems so much worse...even if you do end up with a couple hours of sleep. I hate call! So at least with a 12-8 shift you'd get the day prior to it off.

 

So can someone please give their insight on this issue?

 

Thanks

[Kirsteen]

Though I just can`t seem to understand why. It seems so much better than call. Yes, 12-8 is pretty crappy. but 8am til 8am (or even 12 the next day) just seems so much worse...even if you do end up with a couple hours of sleep. I hate call! So at least with a 12-8 shift you'd get the day prior to it off.

Hi again,

 

First off, I just wanted to note that since the start of residency, Emerg is the only specialty that I've thought seemed pretty great and, if I were to do CaRMS all over again, would have considered applying for with Rads as opposed to Rads and Gen Surg. Thus, the thoughts below are not to poo-poo Emerg as a career, but simply, are a collection of the realities that I'd recently considered.

 

I agree with you, the 8am-12pm of Internal Medicine can be awful and I'd rather do Emerg shifts, but don't forget that, as staff, an Internal Medicine staff will rarely be in-hospital from 8am-12pm the following day, i.e., the grotesque hours end at residency, while the Emerg shift hours--specifically, the night work--continue as staff.

 

I don't know about other programs, but the Mac Emerg residents are permitted to design their own monthly shift schedules, within reason. (They must include a certain number of weekend shifts, night shifts, etc.) This allows for amazing flexibility and permits lots of days off to do things that you need to do. However, on those days off, quite often your sleeping patterns are a bit messed up. For example, I normally get up when the sun rises, but while on the Emerg rotation there have been days in a row when I couldn't get out of bed until about 3 hours later than my norm (that is, essentially I was functioning on Vancouver time for about a week) because of the night shifts I was working.

 

The other item to consider is vacation. I was speaking to a staff ER guy a couple of weeks ago who noted that they are not given vacation time, per se. Instead, since they are fee for service, they have to trade their shifts in order to free up time for holidays. Now that might differ depending on the model that any given department is using to run their practice, but it's an interesting thought nonetheless.

 

Cheers,

Kirsteen

[Ian Wong]

Shiftwork is a hugely powerful concept that is hard to achieve for most physicians due to continuity of care. It is, however, a very important feature for most other health care professionals. Nurses, OT's, PT's, dieticians, etc, all clock in their hours, and then leave their patients behind when the next shift starts.

 

On the other hand, physicians stay late all the time. Many specialties look down on the idea of shiftwork, feeling that if you are handing off your patients, that you are not committed to patient care. This is most prevalent in the surgical specialties, but really most specialties with any significant inpatient presence are like this.

 

Very few physician specialties lend themselves to shiftwork, with the majority of those being ones where patients are rapidly processed and then dispo'ed to other services. These would include: Radiology, Pathology, Emergency Medicine, and Anesthesiology. The ability to leave the patients (and your pager) behind when you leave the hospital is incredibly powerful in making the above specialities "lifestyle-friendly."

 

Of course, if you are solely looking for lifestyle, you could alternately search for specialties that simply don't have lots of on-call emergencies, like Derm or Rad Onc.

 

Still, shiftwork makes any specialty more lifestyle friendly because you have scheduling and control of your hours at the hospital. Other specialties have realized this, and therefore hospitalists and intensivists are filling a very large niche for physicians who are unwilling or unable to continue to follow inpatients on the floors or critical care units once they are admitted to the hospital. I would not discount shiftwork lightly. I think it's a great option to have available if your chosen specialty supports it.

 

Emerg can be a difficult to handle though as their shifts need to be covered around the clock, with a rotating frequency which seems to be much more common than the other shiftwork specialties mentioned above. My Emerg rotations during med school and PGY-1 year made me feel like I was on permanent jetlag, and it was almost more physiologically disorienting than simply being on q4 call. Still, the total number of hours worked was way less than a standard q4 inpatient medicine or surgery rotation.

 

I could never do EM, but that has a lot more to do with my personality style. I hated the idea of seing tons of primary care issues in order to get some high acuity cases. I didn't enjoy the mentality of trying to zoom through patients trying to figure out if their complaints were "admission-worthy." I hate pelvic and rectal exams...

 

Lots of people talk about needing to have lots of persistence and patience to do EM, along with thick skin, which is probably true seeing as most consultants hate getting paged to the ER and will do or say anything to get out of coming in to see the patient. You will therefore be getting crunched both simultaneously by your patients, as well as the consultants you are trying to enlist for help.

 

Additionally, there's the "fishbowl" mentality where all your decisions will be retrospectively judged by a consultant who will typically know more about that patient's disease process than yourself, and who will also have the benefit of longitudinal followup of the patient. If you blow calls or miss cases with any frequency, that consultant potentially becomes an adversary for any future admissions to that service.

 

Still, the pros to EM are that you get shiftwork, a varied and diverse workload, no overhead, interactions with literally all other physician specialties, and hands-on procedures. You can relocate or switch jobs at any time without the logistical hassles faced by office-based specialties. The lifestyle, hours, and compensation is above average relative to other specialties.

 

Ian

[Mac8]

Thanks for your responses! What is the renumeration like for ER docs? I supposed one big bonus is that there are no overhead costs!

Thanks!

 

Mac

[Kirsteen]

What is the renumeration like for ER docs?

Hi,

 

Remuneration depends largely on the model of practice in which you work (fee for service vs. salary) and if you're fee for service, the volume on your service. Other factors that influence what you take home if you're fee for service are: the number of shifts you work and the time at which you work those shifts. Fee for service Emerg docs are paid more in the fee for service schedule if they see patients later in the day, i.e., there's a premium for seeing patients in the evening (before midnight) and an even higher premium thereafter if you see them overnight.

 

As for absolute pay, I don't think it's unreasonable to see an Emerg doc pulling in $350K if they're working full-time. Again, however that will vary based on some of the above factors.

 

Cheers,

Kirsteen

[meme me]

This thread is full of goodies for potential ER docs.

 

Another perk for I could imagine for ER docs that has already been alluded to (and please expand on this for those of you with experience) would be the flexibility. For instance, I'm interested in doing some international medicine when I become a doc (e.g. medecins sans frontieres) and would think that the ability to pick up and leave for 6 months to a year as an ER physician would be far easier than for a physician with a practice full of patients... not to mention the ability of an emerg doc to do a little bit of everything in the field... I would think ER docs would be perfectly suited for MSF work thanks to the versatility of their skills.

[leviathan]

This thread is full of goodies for potential ER docs.

 

Another perk for I could imagine for ER docs that has already been alluded to (and please expand on this for those of you with experience) would be the flexibility. For instance, I'm interested in doing some international medicine when I become a doc (e.g. medecins sans frontieres) and would think that the ability to pick up and leave for 6 months to a year as an ER physician would be far easier than for a physician with a practice full of patients... not to mention the ability of an emerg doc to do a little bit of everything in the field... I would think ER docs would be perfectly suited for MSF work thanks to the versatility of their skills.

 

They don't really have a need for EPs abroad, from what I've heard. What they do need are family physicians, surgeons, and anaesthesiologists.

[White-Tiger]

They don't really have a need for EPs abroad, from what I've heard. What they do need are family physicians, surgeons, and anaesthesiologists.

 

Well, given there's two routes to EM certification in Canada. A family doc with an extra EM year would still have the MSF option wide open...

[coastalslacker]

but I imagine an ER doc's skills would be ideal for that sort of thing.

 

 

But what if they're someplace remote and there's no one to consult?

 

I jest.

[Ollie]

But what if they're someplace remote and there's no one to consult?

 

I jest.

At least they would have an excuse for doing no workup whatsoever!

[meme me]

They don't really have a need for EPs abroad, from what I've heard. What they do need are family physicians, surgeons, and anaesthesiologists.

Can you explain what it is you heard? Did you read about it? Have a conversation with an MSF doc? ...

[leviathan]

Can you explain what it is you heard? Did you read about it? Have a conversation with an MSF doc? ...

 

Just through conversation with emerg docs in the US. Of course doctors of any specialty are welcome, but emerg isn't really the 'ideal' specialty according to them.

[leviathan]

"Emergency medicine as a specialty is relatively poorly suited for international work.

a) EPs have few special skills that lend themselves to low-resource situations. The practice environment of EPs in the United States involves frequent usage of highly technological imaging and diagnostics. The areas in which EPs are truly "specialists" include resuscitation, airway management, toxicology, and the initial management of trauma are low-yield skills in the international setting.

The difficult to define "resourcefulness" of the average emergency physician is unlikey to translate into special skills abroad.

c) Surgical/gynecological fields are far better suited for episodic international excursions. Primary care fields are better suited to longer term, health promotion activities.

 

The emergency physician overseas has no special role that could not be filled equally well by a family physician, med-peds physician or in the vast majority of cases an internist.

 

An "international emergency" needs a response that is almost completely public health based. Individual physicians in the aftermath of, say, another tsunami would likely contribute more by working with a shovel than with a stethoscope."

 

Couldn't have explained it better than this guy (AmoryBlaine) on SDN.

http://forums.studentdoctor.net/showthread.php?t=514318

[Satsuma]

Well it really all depends on what you want to do internationally.

 

In many countries emergency services are not well developed. If so inclined, there is opportunity to help develop these programs and provide training, for example.

 

There is opportunity for clinical work as well if you want it.

 

But meme me...you still have a long road ahead of you. Who knows how things will change in the next 10 years or so.