What is your response to the people that say, "Just change jobs, cut back your hours, pay someone to do your nights, and all will be well"?
My response is that the everyone is different. EM works for some people. For the people that it doesn't work for, some of the solutions are "change jobs" or "cut back hours" or "pay someone to do your nights". But these are only temporizing measures if you really don't enjoy the work.
I personally have cut back to part-time, around 72 hours a month in order to make it work. The only reason this works is because it's a few enough shifts that I can justify getting beaten up at work by enjoying the fact that I have most of the month off to do whatever else in life I like. So in my situation, EM is actually a better lifestyle fit for me than ortho. But people need to realize it's a huge pay cut and that it's not "Doctor money." With that said, there are few other positions in life that you can work so few days and make a very good living. So for that, I'm quite thankful. The caveat, though, is that I don't have kids I need to pay for and I don't get to live a "doctor's lifestyle" from a wealth perspective.
The bottom line for me is that full-time EM is not for me. I think too much and worry too much. I also like to spend time with patient's and look at each encounter as an intellectual challenge. This mentality doesn't fit in emergency medicine. I've worked enough places to know that while certain aspects can change, overall emergency medicine is very similar regardless of where you practice. The common threads in nearly every ER/ED are:
1.) They are understaffed: For as much as everyone wants to get wait times down and patient satisfaction up, the bottom line is that nobody wants to actually pay for it. Not enough techs, not enough nurses, and not enough doctors. Also, in my personal opinion 1.5 pts/hr is the maximum any doctor should see at a busy ER with moderate-to-high acuity. But again, nobody wants to pay for it and doctors don't want to take a pay cut.
2.) You are the grunt of the hospital: From an administrative standpoint, nobody really cares about what you have to think. All the hospital cares about is that you don't piss people off and keep people out of the waiting room. You can be the biggest ***** to ever graduate from medical school, but as long as you get along with staff and pay lip service to all of your patients, they could not care less how poor the quality of medicine you practice. i.e... as long as you don't affect their bottom line and don't rock the boat, you're a golden child.
3.) The patient are the same everywhere: I used to think that maybe different parts of the country would be different, but the patient's are the same everywhere. East coast, west coast, mid west... liberal, conservative... rich, poor... the ER patients don't ever change. Your average patient is entitled, frustrated, and doesn't really care what you think so long as you just do what they want. Many patient's have personality disorders... many patient's have agendas... and just about everyone has a sense of entitlement of what they "deserve" while in the ER. This used to not be such a big issue when physician's were treated as professionals. But in the current consumer/business-driven EM model, it's a nearly intolerable environment to work in. As hospitals continue to kowtow to every single patient and their complaints, it's gotten to the point where you might as well just hand them a menu and let them order whatever they want.
4.) Just about every physician hates the ER and doctors in it: I remember being told in residency "Once you're out in the community, things will be better. Specialists will want the consults because it means more money for them." Well I can tell you that this is false. In the community, in academics, in the county... one universal truth still exists: People don't want to work more than they already are. Every time you call another doctor, it means more work for them. They all hate the ER. The hospitalists hate the ER, the general surgeons hate the ER, the ophthalmologists hate the ER, the ENTs hate the ER, the orthopedists hate the ER... It starts to really get old when every admission or consult becomes an argumentative debate about "appropriateness" or "need" of the admission or consultation. And because this is an essential part of EM practice, it will never go away.
5.) There isn't time to do anything other than see patients: This may sound like whining, but it starts to really get old when you are at work for 12 hours and the "norm" is that you aren't going to be able to take a break to eat, pee, have a BM, drink water, or any other essential life task. In your average ER, you are busy from shift begin to shift end. I am so envious of any job where people aren't nose-to-the-grindstone for every single second of their work day. Yes we get paid good money, but that's because we have literally zero time to do anything else while at work.
These are my personal feeling and observations of EM. I think the people that are most happy in emergency medicine are people that are able to take the work at face value (cog in the machine of modern medicine), don't mind being involved as a businessperson/waiter of medicine, don't mind kowtowing to patients/consultants/administration, and don't mind being wrong or missing diagnoses. Or they work in a unicorn job that is not representative of actual emergency medicine.
At the risk of being inflammatory, I really feel that if you have intellectual tendencies, try to act in a moral and ethical manner, and a generally desire to provide the most exceptional care possible, emergency medicine burns you out very quickly. You can only work in a broken system and deal with *****s for so long before the infrastructure of your sanity starts to self-destruct.
Sorry for the rant, but hopefully this helps somebody trying to make decisions about specialty...