15
EMERGENCY MEDICINE
Fast-paced and unpredictable, EM is one of the newest specialties in medicine. It has grown to meet the challenge of 100 million emergency room visits per year. As you know, the emergency room is always open and easily accessible. Emergency physicians (EPs) must be prepared for any type of medical problem that arrives at the door, whether by foot, car, ambulance, or helicopter. It is never boring. They take care of a wide cross-section of Americans of all ages and races, rich and poor, insured and uninsured. These specialists like to work fast and think on their feet while serving on the front lines of medicine.
WHAT IS EMERGENCY MEDICINE?
EM involves the immediate care of urgent and life-threatening conditions found in the critically ill and injured. These physicians are really specialists in breadth—their broad-based training encompasses acute problems that span several clinical disciplines. No other specialty can match the astounding variety of patients found within the emergency room. You will see, hear, and smell things that most doctors will not. In just one shift, an EP may care for patients presenting with asthma attacks, atrial fibrillation, gunshot wounds, dislocated shoulders, and even cockroaches stuck in their ears. Every now and then, the EP will discover a zebra, such as a pheochromocytoma (adrenal gland tumor) in a young woman with high blood pressure and headaches.
✓ Likes working with his or her hands.
✓ Is an adventurous, action-oriented leader, and team player.
✓ Can make logical decisions during rapidly changing situations.
✓ Likes variety and the unexpected.
✓ Is capable of juggling multiple tasks at once.
EM became a specialty only about 40 years ago. Until then, most doctors who covered acute, emergent, and traumatic illnesses were actually board certified in other fields, such as internal medicine or surgery. In smaller hospitals, just about anyone (including psychiatrists) could provide coverage in the emergency department (ED) for anything from a minor cut to an inflamed appendix. Some of these doctors left their original specialty to work full-time in EDs and grandfathered their way into becoming EM specialists.
During the 1960s, physicians began to realize that patients would have better clinical outcomes if they received prompt and appropriate care from the moment they entered the hospital. This small group of physicians recognized the need for formal study and training in EM and subsequently founded the American College of Emergency Physicians in 1968. Over the next 5 years, they worked to establish the first residency program at the University of Cincinnati and lobbied Congress to pass the Emergency Medical Services Act. As a result, EM began to expand rapidly, using federal funds to develop prehospital emergency systems and to expand EDs. In 1979, the American Board of Medical Specialties recognized EM as an official clinical specialty.
Today, only physicians who have completed an EM residency are hired in the nation’s emergency rooms. All across the country, EPs provide immediate recognition, evaluation, care, and disposition of a diverse adult and pediatric population. When dealing with acute problems, whether nonurgent or life threatening, their primary role is to stabilize the patient. They evaluate the ABCs (airway, breathing, circulation), take quick histories, perform focused physical examinations, order relevant laboratory and radiology tests, and contact consultants. In the contemporary ED, these specialists must be completely sure that all life-threatening causes of particular symptoms are completely worked up and ruled out. Despite being such a young arm of medical practice, EM has matured into a rigorous clinical specialty. You will receive formal training to handle just about anything that may walk through that door.
A typical shift in the ED is full of variety, drama, and excitement. As you greet the frequent fliers, who often come for both food and medical care, the chart boxes begin filling up with new patients to be seen. First might be a man clutching his stomach due to abdominal pain caused by pancreatitis. The next patient may be a pregnant woman who presents with vaginal bleeding and cramping abdominal pain—possible signs of an ectopic pregnancy. In this case, you take on the role of gynecologist, conducting a pelvic examination to see if the cervix is open or closed. You may even, depending on your training, take on the role of radiologist in such a case, using a handheld ultrasound device to determine if the patient has a viable intrauterine pregnancy. Obviously, the EM physician has to love juggling dozens of different problems, situations, and treatments while teaching and interacting with patients at the same time. At any time, a code blue (cardiac arrest) or trauma could bring this somewhat orderly environment crashing down. You are generally the first doctor to arrive in the resuscitation room, a place where patients in respiratory distress—with dropping oxygen saturation and pink frothy liquid coming out of their mouths—need immediate endotracheal intubation.
The practice of modern EM does not formally include any continuity of patient care. Because EPs work in shifts and only focus on acute medical problems, there is no patient follow-up. (Unless, of course, the patient returns to your emergency room a few days later.) After admitting or discharging a patient, the EP moves on to the next one sitting in the waiting room or being flown in by helicopter. Thus, medical students interested in this specialty should carefully consider whether having their own group of long-term patients is important. Unlike world-renowned experts in other specialties, EPs—and other hospital-based specialists like radiologists and anesthesiologists—are behind-the-scenes doctors who may remain largely anonymous to health care consumers.
Working in an ED does not necessarily mean that all patient interactions are curtailed by shift work and acute care. Although EPs do not develop longstanding ties with their patients, they often establish a strong relationship with the community in which they practice. Plenty of patients, especially uninsured indigent persons looking for warmth, food, a place to sleep, and regular medical care, visit the emergency room often and form bonds with its staff. “Do I get to have a primary care–type relationship with all patients? Of course not, but I do get to know my community and many of the people in it,” commented an EM specialist at an inner-city hospital. “This is ‘their’ hospital and for many of them I, or one of my colleagues, actually end up taking the role of the family doc. It’s hard to do in a busy ED, but building good rapport and relating with some of our most challenging patients is one of the more rewarding aspects of emergency medicine.”
GENERALIST OR SPECIALIST?
Despite their specialized focus, EPs are, in a way, true generalists. Although some may categorize these physicians as “jack of all trades, master of none,” EPs do have their own area of expertise: knowing the most important (i.e., acute or life threatening) presentations of problems across the entire medical spectrum. They must be as comfortable with a gynecologic emergency as with a pediatric trauma patient. In a single work shift, an EP can deliver a baby, stabilize an accident victim, evaluate a possible case of appendicitis, manage a traumatic airway, treat an asthma attack, and diagnose congestive heart failure. No other specialty of medicine, not even EM’s closest cousin—family practice—matches the breadth of acute problems that these physicians must be prepared for. Because EM physicians really get to do it all, students who enter this specialty like the fact that they will be real doctors. You will know what to do if someone has a heart attack on an airplane or when a child gets hurt at the playground.
Although the spectrum of disease varies depending on practice location and community, EPs are trained to handle anything, including patients, usually indigent or uninsured, who use the emergency room as their primary care clinic. This is why some describe the ED as “the world’s largest family practice clinic.” As an EP, you will not necessarily see true emergencies all the time. In fact, about half of your patients will present with problems that are more appropriate for a primary care doctor—the common cold, musculoskeletal pains, rashes, and other nonurgent complaints. It is kind of like being a family doctor but without the long-term continuity, practice of preventive medicine, and clinic setting. Your goal, instead, is to treat the acute problem at hand and then direct patients to the next appropriate step for their medical follow-up.
EMERGENCY MEDICINE REQUIRES MANY SKILLS
For most patients who seek urgent medical care, the EP is usually the first doctor on the case. This initial evaluation is both a privilege and a challenge. Patients do not arrive in the emergency room with their medical chart or old records. They may answer your questions poorly. As such, EPs often have to piece the clinical history together from fragments provided by unresponsive sick patients, family members, emergency medical technicians (EMTs), police officers, and other sources. Being the first person to ask the appropriate questions in a limited amount of time can be frustrating. You must act like a sleuth. You must have the confidence to make fast medical decisions based on limited, incomplete information. For an EM doctor, nothing is more satisfying than taking a few bits and pieces of history (and abnormal physical findings), ordering some laboratory tests, and coming up with a working diagnosis and treatment plan.
While one case is being stabilized, many more are waiting patiently (and often impatiently) for evaluation, treatment, discharge, or admission. The EP constantly juggles many tasks at once, whether acquiring data, making decisions, or performing procedures. Patients, laboratory results, nurses, chest x-rays, family members, and other physicians all vie simultaneously for your immediate attention. Because you are doing so many things at once, emergency care sometimes requires knee-jerk action, after which additional thinking is necessary. In a short amount of time, you coordinate a wide range of treatment plans, from readjusting an asthma patient’s medications to suturing wounds of another patient who also just received a chest tube. With recent advances in medicine, more and more patients are coming to the emergency room with complex problems, such as unusual drug interactions, or complications from procedures that did not exist before, like organ transplants. Now, EM specialists find themselves with even more responsibilities to manage at once.
With many stressful events occurring at the same time, the ability of an EP to triage patients becomes even more important. Based on the French word trier, meaning “to sort,” triage involves allocating treatment to patients based on a priority system that assigns resources to where they are most needed. As patient advocates, these doctors must recognize the difference between the truly sick and those with less urgent problems. After all, “some patients are not as sick as they think, and others are not as well as they wish.”1 This is where triaging comes in. Without it, many people desperately in need of medical care might not receive it while their physician’s attention is focused elsewhere. All EPs learn to master this skill. After sorting patients correctly when many arrive at once, emergency doctors take care of them all the way through discharge or admission.
While triaging and examining patients, EPs apply lots of technical procedures in their diagnosis and treatment plans. Yes, these doctors really do get to perform much of that wild and crazy stuff seen on television. Remember, EM is a specialty in which urgently treating the very sick involves manipulations and hands-on procedures. You will insert nasogastric tubes, reduce joints, defibrillate hearts, suture lacerations, incise and drain abscesses, intubate with endotracheal tubes, and deliver babies. Like playing with needles? Every day, there are always opportunities to place intravenous, central, and occasionally intraosseous lines. Even more complicated procedures like cricothyrotomies (inserting a needle through cartilage of the neck to create an airway) and thoracotomies (cracking the chest) are also possible. For medical students who like to work with their hands and think surgery is the only answer, take a closer look at this specialty. EM is a quicker route to being a broad-based doctor who also gets to play with scalpels, needles, and thread.
TREATING TRAUMA PATIENTS
The dramatic, cool procedures that attract medical students to the field of EM are often performed on trauma patients—people with knife and gunshot wounds, or those who have been critically injured in motor vehicle accidents, drownings, construction accidents, natural disasters, and more. They are quickly transported to trauma centers and met by eager, capable EM physicians waiting to perform miracles. The idea of saving lives every day excites many medical students and is the strong appeal of this specialty.
A multidisciplinary problem, trauma always involves an entire team of doctors, namely EPs, trauma surgeons, and anesthesiologists. As an EP, do not expect to be the sole individual doing all the work. Typically, the trauma surgeon calls the shots during the resuscitation. After all, the appropriate management of internal injuries due to trauma falls within the realm of surgery. It is important for EPs to recognize the boundaries of their special knowledge and skills. You must learn to appreciate the presence of and guidance by the surgery team with whom you share space.
Furthermore, these divisions will depend a lot on the EP’s practice environment. Working at a large university-affiliated trauma center is very different from working at a small community hospital ED. Some EPs are literally the only doctor in the hospital, and although one would not expect trauma patients to be taken to such a place by ambulance, the “walk-in” trauma—someone with a gunshot wound dumped at the hospital door by friends, or someone who gets to the ED on their own without activating the emergency medical services (EMS) system—is a reality. Such situations clearly require a lot more out of the EP since other vital staff (surgeons and anesthesiologists) may be several minutes away from the hospital.
In saving patients with traumatic injuries, the specific role of the EP depends on the type of trauma and the hospital. First and foremost, all EPs secure the patient’s airway, which can often be surprisingly difficult. For those who thrive on adrenaline-inducing challenges, intubating trauma patients may involve suctioning blood, teeth, or even brain matter out of the way while keeping the patient immobile in a C-collar. Doing this while listening to the falling tones of the oxygen saturation monitor, indicating that the patient’s blood oxygen level is reaching dangerously low levels, is not for the faint of heart!
Before the surgery team arrives, the emergency doctor continues the rest of the trauma assessment: evaluating the patient’s breathing, circulation, disability, and exposing them. While stabilizing the patient, these roles can be quite fluid, depending on the patient’s next outcome. To assess the need for surgery, one might use ultrasound imaging to locate free fluid in the belly of a patient with blunt trauma. A quick ultrasound that locates fluid around the heart or air in the chest cavity (pneumothorax) can lead to a life-saving procedure before the x-ray technician even gets to the trauma bay. EPs often place central lines and chest tubes. Once again, however, their most important role is to stabilize the patient until definitive treatment (surgery) arrives. As such, future EPs who want to go at it alone, or who become easily annoyed by orders from surgeons, may find their role in caring for trauma patients much more limited than they anticipated.
OCCUPATIONAL HAZARDS IN THE EMERGENCY DEPARTMENT
For the next 20 to 30 years, your workplace will be a chaotic, messy, and tense environment. For some, the confines of the emergency room seem like a more dangerous work environment than the clinic, operating room, or ward. You will often be performing invasive procedures under time pressure, with blood splattering everywhere. Patients may not necessarily divulge any possible pathogens they may be carrying. And, all sorts of nasty bugs and critters make the ED their very special home. Here, brave EPs are at an increased risk for exposure to everything from multidrug-resistant tuberculosis to hepatitis B and C, from HIV to potential biological warfare agents. The ED is, after all, one of the top locations where medical students have been exposed to accidental needlesticks.2
Although there is the potential of being exposed to an infectious agent, most modern EDs take all sorts of steps to minimize the risk. As a result of universal precautions, the rates of infection of the most concerning viruses (hepatitis B and C, HIV) are extremely low.3 Regardless, emergency doctors realize that hazards exist every day on the job, including stray radiation from portable x-ray machines and the stress of shift work. They are willing to accept these challenges to practice in a challenging, dynamic, and fun environment.
The emergency room is also a place where everyone wants something from you immediately, and 9 out of 10 are angry with you. ED patients, who can be unruly, impatient, difficult, rude, or outright violent, are another of EM’s occupational hazards. All hospital EDs are required to care for every patient who comes through the doors, regardless of their ability to pay and how hostile and belligerent they are. Furthermore, as our population ages, health care coverage decreases, and ED visits increase, future EM doctors are bound to encounter more patients, sicker patients, and, most certainly, angrier patients. Hospital EDs certainly feel the greatest crunch due to a health care system that is stretched very thin. Rising medical care costs and the lack of universal health care have left millions of Americans uninsured. With the shortage of health care professionals, fewer hospital beds are available, which leaves upset patients in emergency rooms waiting sometimes for days until a bed opens up.
The end result? Many patients hate the emergency room and often greet their EP with hostility and impatience. They are unhappy that it took 6 hours before their lacerated finger was sutured. They become agitated when you refuse to prescribe antibiotics for their viral-induced cough or narcotic painkillers for their sore backs. There will always be aggressive drunks and argumentative prisoners who will all want something from you, fast. Sometimes, the anger and hostility of unruly patients turns to violence. ED physicians, nurses, and prehospital providers attempting to care for intoxicated or emotionally disturbed patients can often become victims of assault. During a 9-month period in one ED, members of the staff were kicked, grabbed, pushed, punched, or spat upon nearly 20 times.4 Future EM physicians should be aware of the threat of violent and dangerous encounters.
In a busy ED, pleasing all of the patients waiting for medical care is usually impossible. Thus, you must be very thick skinned while juggling the needs of these patients with the more pressing needs of trauma victims and other critically ill persons. Using woefully inadequate resources, you will become adept at pushing the flow of patients through the ED into hospital beds, back home, back to prison, back on the streets, or wherever they most appropriately need to go.
LIFESTYLE CONSIDERATIONS: WORKING IN SHIFTS
Today, the trends in specialty selection among medical students have shifted toward lifestyle specialties—ones with controllable hours and the possibility of a better social and family life. EM is at the top of this list. EPs typically show up at the hospital and work for 8 to 12 hours in a given shift. There is no such thing as being on call, and they never need to carry a beeper outside of the hospital. Once your shift is over, the noise, stress, and demands of the patients waiting in the ED are all left behind as you head out to the golf course, the rock-climbing gym, or the beach. Because of the predictable hours, EPs have the flexibility to plan family and relaxation time without having to worry about getting their patients covered. Unlike other physicians who are called at home, the illnesses and disasters that befall patients everywhere cannot tear you away from your picnic, night at the theater, or errands on a weekday morning.
• Emergency medicine |
$355,280 |
Source: American Medical Group Association.
However, the rotating shift schedule also has many drawbacks. The ED is open 24 hours a day, 365 days a year. Whether just out of residency or approaching retirement age, all EPs find themselves working nights, weekends, and holidays. If you cannot imagine practicing medicine on Christmas Day, Saturday night, or other inconvenient times, especially with a family at home, then you should perhaps consider another specialty. You may dislike having a weekday off when friends and family are working or at school. Moreover, shifts sometimes last longer than anticipated. EM doctors cannot simply walk away from a patient who presents with a possible heart attack 5 minutes before the scheduled end of the shift. They also must arrive a little early and stay a little later to help sign out patients, dictate charts, and tie up other loose ends from the previous shift.
Shift work quickly disrupts your circadian rhythms and normal sleeping and eating patterns, because the shifts typically alternate. In a given week, you may find yourself rotating through several blocks of tiring night shifts interspersed with day shifts or long weekend hours. Furthermore, your responsibilities do not always end after completing an overnight shift. Academic conferences, meetings, family duties, and errands often require your time during the day and prevent you from immediately going to sleep. As a result, EM doctors are always recuperating from their alternating shifts. This life of permanent jetlag can make a 40-hour work week feel more like 80 hours’ worth. Furthermore, constantly upsetting and resyncing your body’s internal clock can have adverse effects on your health. Studies have shown that rotating shift work contributes to higher rates of drug and alcohol abuse, hypertension, heart attacks, divorce rates, work-related accidents, and more.5,6
Basically, shift work is both a blessing and a curse. Most hospitals at least attempt to schedule shifts in a block format, rather than frequently alternating, for at least 1 week at time. Ostensibly, this format would allow your body and mind to readjust to a normal circadian rhythm again. By working the same type of shift for a large block of time, emergency doctors could better adapt their bodies and improve their cognitive performance. Despite the inevitable toll on the body and mind, nearly all EPs love being able to sign out patients and go home completely free of patient and medical responsibility. There is ample time to spend with your family, to spend weekends at the beach, and so on.
STRESS, BURNOUT, AND CAREER SATISFACTION
EM has only existed as a specialty for 40 years. Yet, for some time, there have been discussions about the high attrition rates in this specialty. Many medical students contemplating a career in EM worry about the potential burnout factor and career dissatisfaction. In a 2014 survey of specialists, EM physicians had the highest rates of burnout.7 Is this specialty really better for younger physicians rather than middle-aged doctors? Several studies refute this notion.
One study, which measured the degree of burnout among emergency doctors, found that although 60% registered in the moderate to high burnout ranges, the projected attrition rates were comparable to other medical specialties.8 Another study, which measured the actual attrition instead of surveying EM doctors about their future career expectations, concurred with these conclusions.9 These authors found that 15 years after graduating from residency, 86.8% of respondents were still practicing EM, which came to an annual attrition rate of less than 1% per year. They also found that the average percentage of time spent in clinical work decreases from 86% in the first year of practice to 60% by the fifteenth year of practice, while the amount of time spent in administration increases from 5% to 25% over the same time period. Physicians who left the specialty cited shift work as the most important reason, along with emotional stress, family considerations (especially working weekends and holidays), and physical stress. In addition, the difficulties in working with new Electronic Medical Records (EMRs) and perceived loss of practice control related to government or hospital-generated practice guidelines (e.g., sepsis or stroke protocols) have been cited more recently as causes of burnout and career dissatisfaction
Regardless of the actual attrition rate, EM does have inherent stressors in addition to working shifts which over time, could lead to burnout: high patient volume, pressure, time constraints, and intensity. In a given shift, you might find yourself working for 8 or 12 hours straight without taking a break for food or rest. The lack of continuity of care, isolation from other physicians in the ED, abusive patients, and little positive feedback from either patients or consulting physicians, all can exacerbate stress. EPs also experience a great deal of doubt over the pressured decisions they make while managing unfamiliar situations with little information. There is always the potential for every visit to be a missed diagnosis (with associated liability). They worry, for instance, about getting sued for discharging patients who should have been admitted.
A lack of respect from other medical colleagues can also contribute to career dissatisfaction and burnout among EM doctors. Due to the fishbowl nature of an emergency room, these clinicians often feel the pressure of their decisions being observed and criticized by other doctors, especially in hindsight. EPs without thick skins and manageable egos will find themselves burning out quickly. Many times you will not have the skills, specialized knowledge, time, or equipment to properly care for your patients, and you will have to call other extremely busy consultants and specialists (surgeons, private internists, etc.) for assistance evaluating an acute abdomen or clearance for admission to the medical wards. Because the ED is perceived as the source of more work for already overburdened doctors, many consultants may question the urgency of an EP’s request and wrongfully dismiss them as triage nurses who simply decide whether the patient should be admitted or discharged.
As EM has matured into a full-blown specialty, however, issues of fundamental distrust or disrespect from other physicians, though still present, have subsided. Many of the older medicine and surgery attendings, who never really trusted the abilities or judgment of emergency room physicians, are no longer practicing. Today most physicians, whether pediatricians or thoracic surgeons, agree that their colleagues in EM are well trained and appropriately call for help when the patient’s condition warrants it.
PRACTICE OPTIONS: THE REAL WORLD
EPs can work pretty much anywhere. Such a variety of jobs should satisfy just about anyone’s needs. Because of the shift work and lack of fixed office practice, EPs are somewhat nomadic—they frequently change jobs, move across the country, or work part-time in multiple hospitals. Most are based in suburban community hospitals, academic medical centers, inner-city county hospitals, or rural acute care centers. Some work internationally or even on cruise ships. Depending on the location, EPs can be salaried hospital employees, independent contractors, members of a practice group, or staff in a managed care organization. Regardless of the situation, part-time jobs abound in EM. Despite the obvious salary reduction, this possibility allows you to balance work, family, and other interests as you choose.
Urban EM offers constant excitement, high patient volume, trauma, and the always engaging multicultural milieu. Although not every city ED serves as a Level I trauma center, the urban EP deals with a greater variety and abundance of sicker patients than their suburban or rural colleagues. Furthermore, a large city hospital usually means a greater availability of specialists for consultations. On the downside, as previously discussed, are the hazards that come with working in the emergency room of an overcrowded urban hospital (infectious disease, needlesticks, and hostile patients), as well as the possibility of violence.
How about rural practice? Because many people still live in the large rural areas of the country, being the small-town EP is a truly rewarding experience. An isolated, rural setting allows the EP to draw on all their skills without having to consult another specialist. As the only physician for miles around, you are responsible for managing many problems yourself. While knife and gunshot wounds are rare, trauma is still inevitable in these locations. Farming accidents occur at a rate of roughly 10 accidents or injuries a year for every 100 full-time farm workers.10 Because of the lack of tertiary care facilities in these regions, rural emergency room doctors become experts at stabilizing very sick patients and then transporting them elsewhere. The increasing use of telemedicine technology adds an exciting new twist to the practice of rural EM.
A smaller number of EPs choose careers in academic medicine. Teaching hospitals provide the greatest resources and access to a wide range of expert specialists. Clinically, academic EPs work fewer shifts than those in private practice. Instead, they receive protected time for teaching new residents (at times even paramedics and firefighters), attending academic conferences, and conducting research. EM physicians are immersed in a broad variety of basic science and clinical topics, from the molecular mechanisms of cardiopulmonary resuscitation to the clinical outcomes of novel treatments for asthma. In academics, you stay on the forefront of advances in this field.
EPs who want to take a break from the grind of a busy ED can also opt for working at an urgent care clinic. Although traditionally staffed by family practice or general internal medicine providers, EPs will find their training and experience more than sufficient to manage the types of cases seen in urgent care facilities. The lower acuity of cases can be a refreshing change to EPs looking to change pace or wind down their careers. In addition, some tech-savvy EPs are starting to participate in (or develop their own) telemedicine services that can use modern technology such as smart phone apps to see, diagnose, and treat patients remotely.
Clearly, EM allows you to have a great deal of control over your practice and working life. You can be mobile, choose your own hours, and not be bound to the business of setting up your own practice. For new graduates of residency programs, the job market remains wide open. Despite the closure of hundreds of EDs over the last decade due to cutbacks by health care systems, there still remains a shortage of EPs. Although the number of ED visits nationwide is increasing, the number of departments is decreasing, thus placing great stress on those that remain open. Under most of the scenarios tested, a significant deficit of board-certified EM specialists will remain for at least several decades.11 Of the 32,000 EPs practicing in the United States, only little more than half (16,600) are certified by the American Board of Emergency Medicine (ABEM). As a result, EDs are now only hiring board-certified or board-eligible physicians who are trained specifically in EM.
FELLOWSHIPS AND SUBSPECIALTY TRAINING
Critical Care Medicine
Given that training in EM involves a lot of experience in caring for the critically ill, it was only a matter of time before EM specialists would want to add critical care as a formal subspecialty. Critical care subspecialization in EM has a bit of a “choose your own adventure” quality to it, since there are currently three different pathways to obtain certification. One can obtain certification through the anesthesiology pathway (comanaged by ABEM and the American Board of Anesthesiology), the internal medicine pathway (comanaged by ABEM and the American Board of Internal Medicine), and the surgical pathway (comanaged by ABEM and the American Board of Surgery). Each pathway involves a 2-year fellowship in critical care (with the addition of a surgical prelim year for those choosing the surgical critical care pathway). Clearly the choice of pathway will depend on the work environment a student envisions for themselves—residents who see themselves working in the SICU of a busy trauma center may opt for the surgical pathway, for example. CCM-trained EPs will feel right at home working in the ICU or the ED, and while some will stick with one type of job, others can use the additional training to help broaden their career choices.
Medical Toxicology
A generation ago, a little green sticker called “Mr. Yuck” helped to prevent countless poisoning accidents. In 2000, over two million toxic ingestions or exposures, including 920 fatalities, were reported to poison control centers nationwide. Specialists in medical toxicology know all about the nasty substances that both kids and adults manage to get inside themselves, either accidentally or purposely. These poisons include medications, illicit drugs, chemicals, household toxins, industrial pollutants, hazardous materials, and environmental waste. In light of the growing awareness of biological and chemical terrorism, medical toxicologists provide an essential service. They apply their underlying knowledge of EM with sophisticated expertise in pharmacology. Many times, the treatment for one type of poison could exacerbate the situation if the wrong chemical exposure was diagnosed. The ABEM offers a board certification examination following this 1-year fellowship. If the idea of working in a city or regional poison control center sounds appealing, then you should consider this cool career choice!
Emergency Medical Services
Were you one of those kids who chased fire engines on your tricycle? Many medical students have worked as paramedics and EMTs before becoming physicians. Specialists with fellowship training in EMS study the logistical, organizational, and medical aspects of delivering quality care to sick individuals outside the hospital. These services include paramedic training, new prehospital treatments, disaster preparation, community organization, and more. EPs with fellowship training in EMS typically serve as medical directors of city- or county-wide emergency medical systems.
• Number of positions available: 2047
• 1845 US seniors and 860 independent applicants ranked at least one EM program
• 99.7% of all positions were filled in the initial Match
• The successful applicants: 78.4% US seniors, 5.2% foreign-trained physicians, and 13.8% osteopathic graduates
• Mean USMLE Step I score: 233
• Unmatched rate for US seniors applying only to EM: 7.3%
Source: National Resident Matching Program.
Hospice and Palliative Medicine
Seeing patients who are terminally ill and dying is part and parcel of the work EPs do. Despite all our great advances in health care many people will reach the end of life with debilitating illness. Training in hospice and palliative medicine (HPM) seeks to develop physicians who are experts at caring for seriously ill and dying patients. It requires a mindset that recognizes that not all illness presenting to the ED can be cured. Rather, treating such patients involves relieving suffering and improving quality of life when a cure is no longer possible. EPs in this field will find themselves working closely with families, allied care providers, and others in an interdisciplinary team setting to help patients retain dignity, manage their symptoms, and find closure at the end of their lives. Fellowships in HPM are 12 months long.
Pediatric Emergency Medicine
Do you like working with kids in an acute setting? All ED physicians receive training in the acute care of infants, children, and teenagers. It is rare, however, to find a doctor who feels completely at ease treating these younger charges. “Can I stabilize a sick kid? Absolutely. But, I am much more comfortable working with adults,” commented a resident at a large urban hospital. “Kids can fool you—sometimes you’ll see a bunch with minor complaints and then out of nowhere one will really surprise you.” With further training in pediatric EM, EM doctors can easily take on any acute pediatric problem—croup, seizures, earaches, child abuse, fevers of unknown origin, asthma attacks, and trauma. Pediatric EM is an exciting and very rewarding branch of medicine. You will typically work in the ED of a major children’s hospital. After completing this 2-year fellowship, the ABEM offers a subspecialty examination for board certification.
Undersea and Hyperbaric Medicine
For physicians who love scuba diving, this is the perfect fellowship. These specialists are experts at the use of hyperbaric oxygen therapy—the delivery of 100% oxygen at pressures greater than atmospheric pressure. With proper training and use, oxygen becomes a form of treatment that enhances the physiologic oxygenation of the blood and tissues. Physicians who complete this fellowship can treat the harmful nitrogen bubbles of decompression sickness (the bends) and other diving accident cases. They also use this special therapy for patients suffering from carbon monoxide poisoning, gas gangrene of soft tissues, nonhealing wounds, bone infections, and tissue damage secondary to burns and radiation. If you have a special interest in diving, physiology, and gas mechanics, this interesting subspecialty provides an opportunity to apply novel approaches in EM to previously intractable treatment problems. Board certification is available.
Sports Medicine
Just like their colleagues in family practice, EM doctors are eligible for primary care–type fellowships in sports medicine. Of course, they do not perform orthopedic surgeries. Instead, these sports medicine specialists evaluate the overall health of athletes in a clinic setting. Through continuous care, they are responsible for enhancing their patients’ general physical health and fitness and treating injury and illness through medical management. Do you enjoy bedside reductions in the ED? Sports EM physicians are experts in the nonoperative management of various orthopedic injuries. They also draw on their knowledge of exercise physiology, nutrition, and rehabilitation to promote a healthy lifestyle for all active individuals. Unlike just about every other career path in EM, the sports EM physician is able to break out of the confines of the hospital to branch out—whether by owning their own clinic or working as a community, collegiate, or professional team physician. The ABEM offers certification examinations after completion of this 1- or 2-year fellowship.
Emergency Ultrasound
A single clinical specialty does not oversee the use of ultrasound. In the emergency room, physicians perform focused ultrasound examinations to seek a “yes/no” answer to a clinical question. At 3:00 AM, you will be responsible for evaluating the patient with excruciating abdominal pain. Is it pancreatitis, appendicitis, or cholecystitis? Emergency ultrasound is brief, interactive, and answers a limited number of discrete questions regarding one or two organ systems. For example, rapid ultrasound imaging can determine the presence of life-threatening ectopic pregnancies, diagnose pericardial tamponade (blood in the sac surrounding the heart), evaluate the abdomen for trauma, internal bleeding, or aneurysms, and even rule out lower-extremity blood clots without sending patients to the vascular laboratory. The modern emergency ultrasonographer is trained to perform at a comparable level to that of a radiologist. Although many dedicated 1-year emergency ultrasound fellowships exist, the subspecialty remains to be formally recognized by ABEM/ABOEM.
Residency in EM requires either 3 or 4 years of postgraduate training. Unlike other specialties, there are actually three types of EM residency programs. The majority (90) are 3-year programs that begin immediately after medical school. Some (14) are full 4-year programs. Another small group (20) require 3 years of EM residency after a separate internship year (transitional, medical surgical). During residency, the length and number of shifts worked per week vary per hospital. Regardless of the type of program, EM residents also complete rotations in general medicine, critical care, anesthesiology, cardiology, and obstetrics–gynecology. The bulk of their training consists of monthly rotations in adult and pediatric EM, trauma, toxicology, EMS, and aeronautical medicine. Many programs require a research project.
WHY CONSIDER A CAREER IN EMERGENCY MEDICINE?
Medical students who would thrive on a career in EM typically like the wide spectrum of clinical challenges and the multidisciplinary approach.12 As the only specialty in which doctors are required by law to treat all patients seeking care, whether or not they have insurance, EM can be very challenging. These heroes juggle what seems like a thousand tasks at once, constantly readjusting moment-by-moment plans as events unfold. They also have the challenge of interacting with a dizzyingly varied group of people while caring for their patients, which sometimes involves fighting with the medical staff to make things happen. So, an EP must meet the challenge of being a diplomat and team player. EPs also thrive on the intellectual challenges. They must be astute clinicians with a solid knowledge of nearly every single organ system and ailment. They really are the only contemporary practitioners who are skilled in the truly broadest range of medicine.
EM specialists must have compassion, empathy, and an open ear, because every shift involves many social and emotional issues. In one day, you might have to tell a family that their loved one has died, counsel a battered woman afraid to go home to her violent husband, manage angry patients, perform a sexual assault examination, address homelessness, and communicate with police and other community services. For many patients who come to the ED for care, the EP is the only doctor looking out for their best interests, whether medical, emotional, or social. You will feel especially proud to serve as their advocate to make sure they get more advanced, specialized treatment when needed. Because of the variety of patients (some with emergent problems, others who are not really sick), your treatment plans will be as wide ranging as their complaints. The primary role, however, of the EP is to stabilize patients, treat acute problems, and determine if they need to be admitted for further workup. EPs, in the end, are experts in rapid decision making. Over time, you will be amazed at how quickly and efficiently you can provide medical care to such a diverse group of patients.
ABOUT THE CONTRIBUTOR
Dr. Jeremy Graff completed his residency (and served as chief resident) at the Alameda County Medical Center, Highland Hospital in Oakland, California. After attending college at the University of Chicago, where he majored in psychology, Dr. Graff spent 2 years as a PhD candidate in psychology at Stanford University. Medicine turned out to be his true calling; therefore he returned to the University of Chicago for medical school. Dr. Graff practices as a community emergency medicine physician and ED Medical Director in Auburn, California. He enjoys roaming the state’s many redwood forests, collecting livestock, restoring vintage stereo gear, and cooking gourmet meals. He can be reached by e-mail at freedom1095@yahoo.com.
REFERENCES
1. Kuhn WF. Emergency medicine: A unique opportunity for medical students. Acad Med. 1999;74(7):755–756.
2. Osborn EH, Papadakis MA, Gerberding JL. Occupational exposures to body fluids among medical students: A seven-year longitudinal study. Ann Intern Med. 1999;130:45–51.
3. Henein MN, Lloyd L. HIV, hepatitis B, and hepatitis C in the code one trauma population. Am J Surgery. 1997;63(7):657–659.
4. Foust D, Rhee KJ. The incidence of battery in an urban emergency department. Ann Emerg Med. 1993;22:583–585.
5. Gordon NP, Cleary PD, Parker CE, Czeisler CA. The prevalence and health impact of shift work. Am J Public Health. 1986;76:1225–1228.
6. Steel M, Ma OJ, Watson WA, Thomas HA Jr, Muelleman RL. The occupational risk of motor vehicle collisions for emergency medicine residents. Acad Emerg Med. 1999;6:1050–1053.
7. Shanafelt T, Hasan O, Dyrbye LN, et al. Changes in burnout and satisfaction with work-life balance in physicians and the general US working population between 2011 and 2014. Mayo Clin Proc. 2015;90(12):1600–1613.
8. Goldberg R, Boss RW, Chan L, et al. Burnout and its correlates in emergency physicians: Four years’ experience with a wellness booth. Acad Emerg Med. 1996;3(12):1156–1164.
9. Hall KN, Wakeman MA. Residency-trained emergency physicians: Their demographics, practice evolution, and attrition from emergency medicine. J Emerg Med. 1999;17:7–15.
10. Runyon JL. A review of farm accident data sources and research: Review of data sources. US Department of Agriculture National Safety Database. www.cdc.gov/nasd/docs/d001001-d001100/d001044/d001044.html. Accessed April 15, 2003.
11. Holliman CJ, Wuerz RC, Chapman DM, Hirshberg AJ. Workforce projections for emergency medicine: How many emergency physicians does the United States need? Acad Emerg Med. 1997;4:725–730.
12. Stamoudis C, Collings J. Third year medical students’ perceptions of emergency medicine as a career. Acad Emerg Med. 2000;7(5):545.