What I Do

(With a hat-tip to the Happy Hospitalist.Nothing new or profound here so my regular readers may, if they desire, ignores this article completely or read on and forgive the basic level of information presented. -PB)

A young reader writes, “Dear Dr. Bear, I am a senior in high school and am thinking about being a doctor. What does your job involve?”

I am a resident physician, meaning that I have graduated medical school and am now doing my specialty training, in my case in a specialty known as “Emergency Medicine.” Some people do not know that Emergency Medicine is a specialty but as you will see, its practice does involve some specialized training as well as an approach to medical care that is somewhat unique. I am a little more than halfway through what will turn out to be a four-year period of post-medical school training. Emergency Medicine training is typically three years but I did an intern year in Family Medicine after which, screaming in fright, I made the switch to Emergency Medicine. (I did not get “credit” for that year in my new residency program.)

No matter what specialty you pursue, you will have to do an intern year which will consist of exposure to all of the major medical specialties. You may perceive this to be of little value if you are, for example, going to do dermatology but since Emergency Medicine is a generalist field, every little thing we learn is useful and can be applied somehow. In other words, I have never been delivering a baby on an obstetrics rotation and said, “Man, this is bogus. I’ll never have to deliver a baby in my real job.”

Medical school itself lasts four years and in all but a few cases needs to be preceded by a four year (or however long it takes you) course of study at an accredited college that leads to a Bachelor’s degree. I have a Bachelor’s of Science in Civil Engineering and, unlike most physicians, did not go directly from college to medical school but instead worked as a Structural Engineer (the cool branch of Civil Engineering) for many years. This made me what is called a non-traditional student but if you’re sure you want to be a doctor there is no need to interrupt your journey and you may as well take your lumps when you are young. The process of applying to medical school and positioning yourself for acceptance is well described on the Student Doctor Network and to them I refer you to find all the information you could ever need. Take advantage of it because even ten years ago, when I was applying, this kind of thing either didn’t exist or was a spare sketch of the resource it has become. I think we now have the first generation of people who take the internet completely for granted.

So I am what is known as a Resident, a physician but one who practices under the supervision of other physicians who have finished residency and are fully-trained in their specialty. These doctors are known as “Attendings” or “Attending Physicians.” We are called residents because once, long ago, if you desired additional training past medical school (which was at one time not common or even felt necessary to practice) you lived in the hospital while you trained. While the hours are long in residency, we no longer live in the hospital but the name has stuck. Residents are also called “House Staff” at many hospitals, again with the implication that they belong to the “house.”

Just for your information, you can be a licensed physician and still be a resident. In other words, I occasionally have patients who insist on seeing a “real doctor,” not a resident. Leaving aside the debate as to whether you are a “real doctor” on the day you graduate medical school (you are), licensing in most states only requires that you complete an intern year and have passed all three steps of the United States Medical Licensing Exam. From a legal point of view, there is a basic level of knowledge and skill that every doctor should possess and this is the minimum for legal independent medical practice doing anything which you feel comfortable doing, can get insured to do unless you want to work without liability insurance, can convince hospitals to give you privileges to do, and can convince patients that you know how to do. Practically, however, you need to specialize and get additional training unless your ambition in life is to work at a low-level Urgent Care. I don’t have to tell you that medicine is very complex with a rapidly expanding body of knowledge that one person wouldn’t be able to assimilate in a hundred lifetimes. Specialization is a de facto necessity.

I generally work 14 twelve-hour shifts in every 28-day block. I either work the 9 AM to 9 PM shift or the 9 PM to 9 AM shift, with seven consecutive days on one or the other. Next year I will work seven to seven instead of nine to nine which allows for some overlap between the third year and the second year residents. The most we ever work is three shifts in a row with at least two days off afterwards. Our schedule is set up so we work Friday, Saturday, and Sunday for two weekends in every block but get the other two off. It sounds like a pretty reasonable schedule and it is. We are allowed to trade shifts so if, for example, you need a bigger block of days off you can swap with another resident provided that you don’t violate the work-hour rules for Emergency Medicine.

During our first year we work mostly off-service (not in the Emergency Department) rotating on other specialties such as Trauma Surgery, Internal Medicine, Critical Care, Pediatrics, and Obstetrics to name a few. During second and third year we spend most of our time in the Department with a few months reserved for electives. Some programs mix it up a little more. The advantage of doing all the off-service training early is that by the start of second year, you are done with call forever. “Call” is the practice of spending the night in the hospital, in addition to your regular daytime duties, to take care of your existing patients, admit new patients, and handle emergencies. I did two intern years, approximately 150 nights of call, and got meaningful sleep on so few call nights that I can count them on the fingers of one hand. Considering that you may have call every fourth night for most of intern year and you cannot just go home in the morning afterwards but usually stay until one in the afternoon, you can imagine that intern year can wear you down.

But shift work isn’t too bad. You have to discipline yourself to sleep during the day or else the temptation to carry on as if nothing has happened can lead to a big sleep deficit which manifests as the subjective feeling of always being tired and falling asleep whenever you sit down. But if you can master the art of sleeping during the day you will always be well-rested for your shift, bright-eyed, bushy-tailed, and ready to go.

We also have conferences to attend during the month. Unlike other residencies that may have an hour of didactic training (lectures) every day, because of the nature of our work we throw them all into a once-a-week, five hour block. If you are just getting off of a shift you still have to go. Likewise if you are on a day off. No excuses. On the other hand conference sometimes runs concurrently with a shift and since conference is mandatory, you are excused. It all evens out. We also have a Trauma Conference once a month which is also mandatory as well as an occasional wild-card thing like Animal Lab where we practice procedures (chest tubes, internal pacers, surgical airways, for example) on live, anesthetized pigs or dogs (all of which are euthanize at the end of the lab). I love dogs (I have five of them) so it can be a grim business. On the other hand we rarely get the chance to do a surgical airway on human patients and if one day, the skills you learned on a poor dog help you save somebody’s toddler…well….it will have been worth it. No question about it.

So I mentioned that I am learning the field of Emergency Medicine which, as medical specialties go and despite what you have seen on television, covers a broad range of medical complaints. A “complaint,” by the way, is medical-speak for the problem that brought the patient to the Emergency Department. In Emergency Medicine, we can see patients with complaints that are so idiotic they transcend idiocy and achieve a sort of moronic nirvana (“My ass is sweating”). We also see patients with some of the most serious injuries and medical problems that you can imagine. Like that biker who you saw get hit by a truck when you were twelve who had big chunks of himself smeared across the road. You can bet that if he wasn’t dead at the scene, some Emergency Physician struggled mightily to keep him from dying long enough for the trauma surgeons to save his life.

So it’s a real mixed bag. Some nights you feel like a school nurse treating things that would have kept normal people home and some nights the trauma and serious medical complaints just keep rolling in and the minor complaints stew for hours complaining about the crappy sandwiches and the limited television stations.

The purpose of Emergency Medicine is two-fold. First, our job is to assess and stabilize injured or severely sick patients until they can receive definitive treatment. “Stabilize” means to keep them from dying by reversing or halting the processes that lead to death. Shock, for example, is a common presentation and as it is just brief rest stop on the road to death, a chance for the Grim Reaper to sip his latte and finish his bagel before he gets to you, we treat it aggressively. Now, as hospitals are somewhat crowded and we can not always get even extremely sick patients admitted quickly (and even if we can the admitted patient can wait in the Emergency Department a long time until a bed is available) we often not only stabilize but make the diagnosis and initiate the definitive treatment. Critical care (also known as intensive care) is a big part of our job and while most of us enjoy it, it sucks up huge amounts of time and detracts from our second job which is to see as many patients as possible in the shortest amount of time.

For a practicing Emergency Physician, this means seeing at least four patients an hour to be considered a guy who pulls his weight. It may not sound difficult but while many complaints are minor, some are not and almost every patient we see is completely new, a Rossetta stone who needs to be deciphered. In fact, it is not unusual to get a “drop off,” a severely demented (senile) patient from a nursing home who hasn’t spoken a word since the Clinton Adminstration and for whom you have only a sketchy medical history (if that) and a chief complaint of “altered mental status.” If you’re lucky you can elucidate a reasonable list of her many, many medical problems from the medication list (if it was sent with the patient) but sometimes you have nothing to go on at all. Sorting it out takes time.

On arriving at the beginning of my shift, I pick up a computer tablet, scan the list of patients waiting to be seen, and select the next one on the list. I do this for the next twelve hours, consulting with my attending to some level depending on the seriousness of the complaint. I am now carrying the trauma pager so when a trauma comes in I drop what I am doing (if it is not an emergency) and run the trauma with trauma surgery and the attending who usually just stands back until his resident scews something up (which happens a lot, it’s training you understand). Occasionally critical patients, those with potentially life-threatening problems, come in and I again drop everything to take care of them. All of this is done in cooperation with the nurses who do most of the actual patient care, the Unit Coordinators who keep the administrative life-blood flowing, and a team of allied health professionals which includes Physician Assistants, Respiratory Therapists, Phlebotomists, Radiology techs, and the like.

One of the biggest parts of our job is coordinating care which involves, among other things, arranging consults, calling on-call physicians to admit patients, talking to the medical examiner after a death, calling patient’s primary care physicians, and a myriad other tasks that keep us on the phone longer than any other specialty.

If you like multi-tasking you will like Emergency Medicine.

13 thoughts on “What I Do

  1. “No matter what specialty you pursue, you will have to do an intern year which will consist of exposure to all of the major medical specialties.”

    Almost. Anatomic/clinical pathology is the one specialty that does not require an internship.

  2. Panda,
    How helpful did you find your 3rd and 4th year (med school) rotations in deciding your specialty? Obviously, your ‘misspent’ intern year is an indication of a decision that wasn’t right for you, but was that a consequence of not experiencing ‘enough’ of family medicine to know that you didn’t like it?
    Also, as an up and coming medical student, is it unreasonable for me to choose a school based on how well it will prepare me as a doctor? Basically, should I look at medical school as a very important part of my instruction, or just a stepping stone leading to the ‘real’ learning during intern and residency years?



    (Rotations helped me “rule out” (decide against) certain specialties.  While it would probably be pretty cool, for example, to be a surgeon, two months of surgery as a third year medical student beat any desire I had to be one out of me with a vengeance.  Same with OB-Gyn which, while actually a very interesting specialty has a lifestyle in residency (as observed from a medical student’s point of view, that would have been intolerable.

    Go where you are accepted and if you can choose between more than one acceptance, decide based on some combination of location and price.  All American medical schools are of roughly the same quality.  Some are better than others but the differences are not worth getting excited about and you can match into any specialty from any medical school at any program.   As you say, look at medical school as a stepping stone.  Study hard, do well, pay attention, and you will learn all you need to know. -PB)

  3. “Also, as an up and coming medical student, is it unreasonable for me to choose a school based on how well it will prepare me as a doctor?”

    What criteria would you use to judge that quality? Even with detailed correspondence with multiple students at multiple schools, this would be hard to determine. Further, due to many schools having multiple hospital affiliations, the situation is complicated further (school A could have surgery affiliations at 3 hospitals, but only 1 offers a good rotation.)
    A good bit of how good clinical rotations are depends on who you have on your team (residents, attendings, etc.)

  4. “Also, as an up and coming medical student, is it unreasonable for me to choose a school based on how well it will prepare me as a doctor?”

    The only time your med school REALLY matters at all is if you want to be an academic physician in which case the amount of money/infrastructure your school has to support biomedical research matters. If you meant ‘doctor’ as clinician, then Panda’s advice advice is sound.

  5. Dr Panda – need some advice – I am a third year out of medschool (got two intern years under my belt) and have just started as an emergency medicine registrar (AKA resident) I am enjoying it (though some of it gets a bit hairy) but i am concerned about being slow – I am averaging about 7 patients a shift (expected to see 1 an hour – 10). I realize this is pretty shit, and want to pull my weight – I take the next triage pt to be seen (always – no cherry picking) and seem to end up with elderly patients with poorly differentiated problems- then get bogged down in paperwork/dispo/ – any hints or tips to speed up my performance? All ears down under. Love the blog.

  6. Dr. Panda, I’m on the patient end of this discussion. Do all emergency rooms have residents on their staff? What about the private or community hospitals. If they don’t have a training program, who staffs their emergency rooms?
    Does one have an advantage over the other as far as patient care and good outcome.

    Thanks, I’ve learned so much already from your blog.


    (Counting the osteopathic programs, there are, maybe, only 160 Emergency Medicine residency training programs in the United States so most hospitals do not have Emergency Medicine residents.  There are a thousand of so teaching hospitals however and other residents may do rotations in the Emergency Department.  Most major urban centers have at least one teaching hospital with residents and many have more than one (Los Angeles, New Orleans, New York, etc.)

    But most hospitals do not have residents.  Private and community Emergency Dpeartments are ideally staffed with board certified Emergency Physicians but as there is a shortage, other specialties fill many spots, particulary at smaller, lower acuity departments.  Hospitals with training programs are generally extremely busy places so the residents, once they get the hang of things, enable the department to see huge volumes of patients.  -PB)

  7. What about being able to open a private practice ? I realize that the options are not as plentiful as those from other specialties, but do you see it being possible?

  8. Panda Bear, my personal experiences (mine, my wife and daughter individually at different times with separate emergency traumas over a 5 year time span involving different specialists each time) with EMT’s, transport, the Emergency Room and the Emergency Trauma Surgeons that staff my local Medical Center have been nothing short of perfect, caring, heart warming and highlyt professional.

    I do not exaggerate that our experiences are really the way it ought to be everywhere all the time.

    I don’t think everyone is as lucky all across the fruited plain however I felt a moral obligation to publish my wholly positive ER/Hospital/Medical experiences, attitude and gratitude to the men and women like you who trained so long and hard to take care of us when we require emergency medical care.

    I do so most especially b/c of the well earned criticism I heap upon you personally and general medicine. You and your colleagues are only human after all.

    Emergency Medicine is one area the American medical system shines brighter than anywhere else in the world, imo.

    For that we Americans are all very grateful.

  9. 4 patients per hour? Unless you are seeing nothing but easy “fast track” type patients you are overworked and unsafe in your practice volume. 2-3 patients per hour is the safe limit acceptable for Emergency Medicine with a mix of the critically ill, the moderately ill, the “sweaty ass”, the procedures, the consultations, the psych evals and all the other aspects of our wonderful and bizarre chosen career/job.

  10. … Now if we could only staff every ED with an emergency back-cracker on call, we’d shine with the light of a thousand suns.

    Sorry, couldn’t resist.

  11. As a surgery resident, I say a little prayer of thanks every time I see one of you guys at the head of the bed in the trauma bay, ready to intubate if necessary. The only way I know how to intubate involved a knife.

    Plus you look in the ears. Ew.

    I also love it when you can look at some dude for 30 seconds and say he’s on meth. I almost never see this enough to have the skills to recognize it without a urine test. Kudos on that too!

  12. Any suggestions for a graduating medical student who did not place in an intern program anywhere in the U.S. and still desperately wants to practice medicine. What can he/she do for a year with an M.D. degree while waiting to reapply? Main interest is in emergency medicine and has a background there.

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