Why Emergency Medicine Is The Best Specialty

Authored by: Janine G.

I was an average student – decent grades, moderately better than average board scores, was involved with medical student council, and had some non-published research. None of my fellow students who pursued EM failed to match, as far as I’m aware. There’s a strong feeling (at least I found this to be the case) that EM programs are a bit of a leveled playing field – since EM happens everywhere, and we don’t send people to other emergency departments for the most part (true during residency, not so much afterward) you should get an adequate experience anywhere.

Years:

*A quick warning on this: this was my experience during residency. Different residencies are structured differently depending on the year and how much responsibility you have from the start

PGY-1 – Generally a lot of off-service rotations. EM is the most exciting five minutes of every other specialty (except path – sorry my friends!) and so you need to somehow pick all of that up. Some will be in the ED (stroke, acute weakness, MI, that sort of thing) but some you’ll have to rotate away (OB, sometimes ortho, ICU, anesthesia). There’s typically some ultrasound sprinkled in, either longitudinally or in a block.

Responsibility in the ED varies by location, but the most common model I saw while interviewing is that you’d be responsible for any patient brought back to a regular room. MI, stroke, sepsis, doesn’t matter. If they’re sick enough to be put into a resuscitation bay, you help out with that – lines, tubes, etc. but probably the leader for decision making there will be a more senior resident in conjunction with the attending.

PGY-2 – Similar to PGY-1 will be a mix of in the ED and off-service rotations. You’re now more senior, so most programs by this time will have you running medical resuscitation activations, and in my program, this is when we start running traumas as well. You’ll make a trip to additional ICUs or you’ll return to the ones you had been in previously as a senior resident. My program had a PICU month which I found incredibly valuable that not every program has. We also had an elective this year which made a huge difference for my future career – I’ll be pursuing a fellowship that I likely would not have been able to do if I hadn’t rotated second year.

Other than that, the focus this year is on developing confidence and flow. EM sees a lot of sick patients quickly, and you need to be able to cut through a lot of extraneous information to get an appropriate workup and disposition nailed down quickly.

PGY-3 – You’re the boss now. You spend most of your year in the ED with a bit of time to wrap up residency related tasks such as research and possibly another advanced elective. You’re going to have a larger role in teaching medical students, EM juniors, and any off-service rotators. Some attendings will be pretty hands off and let you sink or swim on your own at this point.

PGY-4 – I didn’t do a PGY-4 year as my program is a three year program, but usually it’s a sub-attending type of year where you theoretically have minimal input from your attending, focus on the flow of the entire ED (rather than just your own pod, which is the case for late PGY-2 and PGY-3) and have time to develop an area of focus, almost like a mini-fellowship. Whether a 3 year or 4 year program is better is hotly debated, and I would encourage you to interview at both to find out which works for you.

Typical Day There really is no typical day, unfortunately. Off-service rotations have wildly different structures, and in some you may be night float, typical medicine hours (7-5), typical ICU hours (6-6), on 28 hour call, etc.

In the ED every shift works the same, but they start at widely varying times and the flavor of every shift can be significantly different from the last.

Many residencies do try to ensure circadian rhythm shift changes, and often will incorporate a night float month in the ED to alleviate the shift burden on the folks that aren’t currently on nights.

When you arrive, you typically sign out the previous team and then get to work following up on their patients and seeing new ones. Not much more to it than that.

Reasons to do EM

  • Excitement: we are the most acute part of a bunch of other specialties. You do the initial management for stroke, sepsis, MI, fractures (location dependent), pneumothorax, altered mental status, arrhythmia, etc. If it’s dangerous – it’s your specialty.
  • Comfort: I can’t stress this one enough. There’s very little that I’m uncomfortable with at this point, and the only concrete example I can think of are pregnancy related emergencies, and that’s something I don’t think you should necessarily ever feel comfortable about anyway. Everything else is something we see on a frequent basis, and know how to manage. You will frequently send people home with things that make other people nervous, like asymptomatic hypertension. Pressure is 200/100 with no symptoms? Have a nice day!
  • Procedures: we’re not surgeons. That being said, procedural competency in emergency medicine is among the highest for specialties outside of surgery and IR. Central lines, chest tubes, intubation, cricothyrotomy, laceration repair, LP, arthrocentesis, etc. are all in your scope of practice. It makes for a nice little break from all of the medicine when you can go sew up a laceration, and I still enjoy doing that.
  • Communication/knowledge: You will never be a specialist in anything except for resuscitation of the dying patient, but we learn a lot about every other specialty. We’re one of the few services who can consistently and intelligently post consult questions to other services. What other service is going to call up opthalmology and say, “Hey, I’ve got a 65 year old lady here who I think has uveitis – she has acuity of 20/80 uncorrected, does not wear contact lenses, has IOP of 15 bilaterally, and my slit lamp exam showed both anterior chamber cell and flare.” Trust me, that conversation goes better than, “The eye is red and painful, can you come see it?”
  • You see everything. Along with family medicine, we are the only two specialties who see every possible patient. Young, old, surgical, medical, etc. You will see them all. You will interface with every other specialty in medicine except for pathology.

Downsides to EM

  • Shiftwork sucks. There’s no way around this. We don’t work as many hours as some other specialties, but you will always be tired. This is somewhat mitigated if your program has a good circadian rhythm to it, but even then, it’s hard to go from days to evenings to nights and back twice a month. Gets harder as you get older too. There’s some evidence that you’ll die a bit earlier than you would have otherwise given the shift work.
  • You will not be a specialist in anything other than the management of the acutely, severely ill patient. That’s our area of specialty, and it’s the real deal – we’re good at it. That being said, it’s not what’s typically thought of as a specific area of medicine, and there will always be things that the specialist is going to do better than you (duh). Sometimes they will question why you didn’t know something that seems obvious to them. Just remind yourself that if you were both in an in-flight emergency, you’d be good at that and they wouldn’t.
  • Reputation: because we have to ask for help in a lot of cases, we get looked down on sometimes as “glorified triage nurses.” In some places, lots of specialties like to hate on the ED; we send patients to all of them so it’s easy to do. Remind yourself that if their loved one gets sick, they’re coming to you – not going to their specialty clinic. This is a bit unfortunate as a common comment from folks who rotate with us is “I had no idea the amount of patients you just send home or manage independently” but unfortunately we can’t get everyone to do a month of ED (despite that we all think everyone should, because everyone interfaces with us at some point).
  • The practice of EM is different in different locations. Things you might like, and might handle in the community (like fracture reductions) might just be done by ortho in academic institutions. If you like both teaching residents/med students and doing procedures, that can make things a bit difficult, and you have to weigh your priorities.
  • Patient expectations and interactions can be really trying. You might find yourself in a circumstance where you just called a code on a young person you couldn’t save, and you have to pick yourself back up and go see the patient who is upset they’ve been waiting 45 minutes to have their ankle sprain addressed. People expect you to be able to answer why they’ve been having abdominal pain for the last year, despite a $10,000 workup that hasn’t shown anything. You have to deal with these situations professionally, and sometimes it can be very, very hard to do.

Summary: I love EM. I truly think it’s the best specialty. I both love the diagnostic challenges, and love that if I can’t figure something out I can send it off to someone who spends their life specializing in the area the problem is in. It’s a hard job, but worth it.

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