(The following article is directed primarily at those contemplating matching into Emergency Medicine. Those of you who are not may read it but I make no apologies for targeting a particular group of readers. Emergency Medicine has become a very popular specialty lately so I’m sure there is some interest out there. Most of my patients, by the way, even those who know how physicians are trained, don’t know that Emergency Medicine is a specialty. The more chatty ones often ask me what specialty I am going into. Even many of my relatives, and they should know better because I do talk to them now and then, think that Emergency Medicine is something doctors do when they can’t decide on a specialty or if they aren’t smart enough to do anything else.
I am at a small, community program as opposed to a major urban trauma center so our patient mix leans more towards the medical and not surgical/trauma. Not to say that we don’t see some trauma but it’s usually blunt trauma and not penetrating. In other words, I’m just giving you my own perspective. I shouldn’t have to issue any caveats but invariably I’m going to get a ton of irate emails insisting that they do things differently at their program.-PB)
Emergency Medicine is a specialty of speed. Everything needs to be done not only quickly but with an economy of effort that separates the important things about the patient from those that are interesting but not particularly relevant. Victory is declared when the patient has a quick disposition; either treated and sent home, transfered, or admitted to the hospital. Ultimate victory occurs when the patient actually leaves the department. Take for example the typical suicidal patient who has made a lame, self-centered gesture at self-termination. In medical school you are conditioned to explore this kind patient in incredible detail. Consequently, as a new resident your first instinct is to get a detailed psychiatric history, delving deeply into the mileu of the patient’s life to assess his motivations. In reality however, your meaningful discussion with the patient is useless and is only going to delay his final disposition. You know he is going to be involuntarily committed and the sooner he can get somewhere, anywhere, where he can be evaluated by a skilled psychiatrist the better. It’s the psychiatrist’s job to do this kind of thing and he can run circles around you and your rudimentary knowledge of his field. Not only that but as the patient flaps his gums and you pretend to be interested you are falling way, way behind on the eight or nine patients you are working up.
The relevant questions then become, “Did you try to kill yourself, how many pills and of what type did you take, and what do I have to do and what tests need to be ordered to quickly medically clear you for a transfer to an appropriate mental health facility?” The patient usually wants to spill his guts (and if he doesn’t the parents or the loved ones are happy to oblige) but while it is important to be polite, we don’t have the time to hear how you were mistreated as a child. All I want to know is your acetaminophen level and whether it is rising or falling. Not toxic and decreasing? Nice meeting you. I hope you like mushy food and communal televsion. It’s been real. Buh bye.
The idea is to get a disposition. Since we don’t treat long-term psychiatric problems in our Emergency Departement, there is no point in wasting effort. It’s best just to get them out of the department. On the other hand we do treat a variety of medical complaints and on these you need to use the traditonal physician skills of history, physical exam, assessment, and plan. But relatively quickly. It’s a little more complicated than just differentiating lethal from non-lethal complaints but you need to ellicit a chief complaint and tailor your history and physical exam to expose it. Obviously the history should be the longest component of your encounter but even there you can get carried away. I once found myself sitting at a the computer sifting through a patient’s records trying to determine the dates of his seven heart caths at which point I realized that I was eating up time, I wasn’t a medicine resident, and maybe all I really needed was the date of his last heart cath and an old EKG or two to see if anything had changed.
“History of Coronary artery disease with seven stents, last on 2/5/06” is perfectly servicable for the purposes of emergency medicine. If we need more detail we can always get it. You cannot do a six-page medicine-style History and Physical on every patient, even the really sick ones. The typical EM physician works on around four patients per hour so you see how this would be prohibitively costly in time. It is true that some patients present with relatively minor complaints but there is a certain baseline level of paperwork involved with every patient independent of the acuity level.
So you need to be quick and that is one of the skills our attendings try to develop in us. This does not mean, however, that you cut corners. You just need to learn what corners to avoid. Being able to juggle a lot of things at one time is also an essential skill. Every resident in every specialty has to do this to a certain extent but what other residents consider a hectic day is just another routine shift for us. That’s the beauty and the curse of Emergency Medicine. The hours are good. Fantastic for residents even by regular job standards. Now that I am working full-time in the department I rarely go over fifty hours a week and some weeks I barely go over forty. The tradeoff is that we work very hard when we are working. There is seldom time to sit down and there is also no such thing as a break. As long as there are charts in the rack (new patients to be seen, I mean) you have work to do. There are always charts in the rack. There’s a crisis out there or didn’t you get the memo?
Emergency medicine isn’t the hardest job in America, not by a long shot, but I think we have one of the few jobs in the developed world where you can get to the end of a twelve-hour day and realize that you haven’t sat down, had anything to drink, or urinated since before you came on. I know that surgery and medicine residents put in more hours and I have nothing but respect for them but being at the hospital is not the same thing as actually working. In fact, many of the residents in the time-intensive specialties spend a good deal of their time sitting around bitching about how tough they have it which is something that Emergency Medicine residents never have time to do. We’re too busy. We complain of course, but not about staying at the hospital for no reason after our work is done. There is always a reason for us to be there when we are at work; they call it the waiting room. We come to work expecting to work.
But we do get to go home. At first I didn’t believe it was possible but now I am begining to accept the fact that nobody expects us to hang around after out shift is over. Sure, we have to tie up loose ends and ensure that our more complicated patients have a disposition but nobody ever says, “Hey, why don’t you stick around an extra four or five hours in case we get busy.”
My point? If you believe that you’d like Emergency Medicine because you don’t have to work hard you are going to be disappointed. If you like to work hard but also like to have regular hours and a predictable schedule with some time off to think about other things, you are going to be very happy as an Emergency Medicine resident. But thinking of Emergency Medicine as a “lifesyle” residency as is common among medical students contemplating specialty choices would be a mistake. It’s only a lifestyle specialty if you like that kind of lifestyle.
(Next: A Typical Shift For a Typical Resident)