Unhappy in EM, what should I switch to?

[EthylMethylMan]

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[DrMetal]

I'm really unhappy in EM. I struggle with managing undifferentiated crashing patients, as well as dealing with large patient volumes. Obviously this is really bad, and what's worse is that I really don't think I'm ever going to be proficient with either of these skills. I'm seriously looking into switching, but I'm struggling to think of what specialty I could pursue that would not force me to play into these weaknesses. Psych? PM&R? Many thanks for any help.

OB/Gyn . . . .go for the glory.

 

[Crayola227]

Makes no sense. Preggos crash all the time. Way scarier with 2 patients and one is a fragile fetus... and also the most sued over creature on God's green Earth. Ob/gyn training if nothing else is the training of a surgeon. Surgeon who have to operate on crashes. Pregnant crashes. I would not tell someone to go from EM to ob/gyn for the reasons stated.

 

[smq123]

I'm really unhappy in EM. I struggle with managing undifferentiated crashing patients, as well as dealing with large patient volumes. Obviously this is really bad, and what's worse is that I really don't think I'm ever going to be proficient with either of these skills. I'm seriously looking into switching, but I'm struggling to think of what specialty I could pursue that would not force me to play into these weaknesses. Psych? PM&R? Many thanks for any help.

It hard to tell you what specialty to look into because you only mention your weaknesses. That’s not helpful; the list of “specialties with minimal exposure to crashing patients” can range from derm to path to rad onc. What are your strengths? What are the parts of medicine that you enjoy?

 

[smq123]

Makes no sense. Preggos crash all the time. Way scarier with 2 patients and one is a fragile fetus... and also the most sued over creature on God's green Earth. Ob/gyn training if nothing else is the training of a surgeon. Surgeon who have to operate on crashes. Pregnant crashes. I would not tell someone to go from EM to ob/gyn for the reasons stated.

I agree with you, but I will point out that at least in OB the list of possible reasons why a patient is crashing is usually way shorter than it is in the ED. Usually.

 

[DrMetal]

Makes no sense. Preggos crash all the time. Way scarier with 2 patients and one is a fragile fetus... and also the most sued over creature on God's green Earth. Ob/gyn training if nothing else is the training of a surgeon. Surgeon who have to operate on crashes. Pregnant crashes. I would not tell someone to go from EM to ob/gyn for the reasons stated.

Was kidding, does nobody here have a sense of humor?

Asking what specialty to go into (or switch into) is like asking what kind of music to listen to. To which I would answer hard rock/metal, b/c I grew up on Van Halen/Metallica. That's my personality bent.

Not knowing one's personality and what their real interests are, that's difficult advice to give.

OP: what year are you in your training? What do you like about EM, what made you go into it in the first place?

 

[DrMetal]

specialty where I can see patients that aren't so unpredictable,

There's no such thing, they're all nuts. If you like procedures and crit care, stick with EM, and apply for CC later. And every specialty has 'volume'.

Tough it out, stay where you are.

 

[rokshana]

Thanks for the feedback. I'm a PGY-2. I went into EM because I enjoy procedures and thought critical care would be fun. I still think I might enjoy CCM in the ICU setting where things are a bit more predictable. At this point I mainly want a specialty where I can see patients that aren't so unpredictable, and where volumes are lower. I'd preferably still want to do procedures, too.

Urgent care?
Or go work at a VA in their LSUs

 

[moto_za]

Psych

 

[RangerBob]

Psych and PM&R are both great specialties (and the two I was torn between), but many who enjoy EM can’t stand either because they’re so “slow.” So it’s possible they could be a good fit for you if you just don’t like the pace of EM. With outpatient psych you’re devoting you’re time to just one person at a time. Progress will be slow, but could be very fulfilling.

I‘m in inpatient PM&R. Having two patients going dramatically south at once is very rare. So for the most part things are predictable. I love it, but it’s not for everyone, just as psych and EM aren’t for everyone. The best way to find out is to try to do some rotations if you can, and if not, talk in person with some specialists in the fields you’re considering.

As others said, we all have volume. Unless you work at the VA. VA ED docs have a great life FYI...

 

[Southpaw]

Thanks for the feedback. I'm a PGY-2. I went into EM because I enjoy procedures and thought critical care would be fun. I still think I might enjoy CCM in the ICU setting where things are a bit more predictable. At this point I mainly want a specialty where I can see patients that aren't so unpredictable, and where volumes are lower. I'd preferably still want to do procedures, too.

Do you like being in the hospital or prefer a clinic setting? FYI you're early in PGY2 so it's likely things will improve for you. A CC fellowship seems like a good option for you if you're willing to see EM through.

 

[chocomorsel]

Makes no sense. Preggos crash all the time. Way scarier with 2 patients and one is a fragile fetus... and also the most sued over creature on God's green Earth. Ob/gyn training if nothing else is the training of a surgeon. Surgeon who have to operate on crashes. Pregnant crashes. I would not tell someone to go from EM to ob/gyn for the reasons stated.

It was a joke I thought.

 

[grt398]

Thanks for the feedback. I'm a PGY-2. I went into EM because I enjoy procedures and thought critical care would be fun. I still think I might enjoy CCM in the ICU setting where things are a bit more predictable. At this point I mainly want a specialty where I can see patients that aren't so unpredictable, and where volumes are lower. I'd preferably still want to do procedures, too.

Don't go into CCM if you're looking to get away from unpredictable patients. Maybe pain medicine like Birdstrike?

 

[DeadCactus]

I would consider finishing residency and finding a low volume ED to work in. Then you can reassess how appealing another residency or fellowship is from the perspective of an attending making good money and working 120 hours a month instead of a resident making no money and stressing to learn an entire specialty while working 200 hours a month.

 

[rokshana]

I would consider finishing residency and finding a low volume ED to work in. Then you can reassess how appealing another residency or fellowship is from the perspective of an attending making good money and working 120 hours a month instead of a resident making no money and stressing to learn an entire specialty while working 200 hours a month.

What EM resident works 200 hrs/month?

 

[Apollyon]

What EM resident works 200 hrs/month?

The RRC limits EM residents to 240 hrs/month clinical (72 hrs/week for all activities, such as didactics). There's at least one Detroit program that was doing 20 12s for all three years. It happens.

 

[DeadCactus]

In addition to Apollyon's point, between off-service rotations and the time spent on didactics, charting, and other academic obligations I think 50 hr/week was fairly reasonable estimate. In comparison to being an attending, there is a lot of inefficiency built into to being a resident that makes an 160-180 hour schedule closer to 200 hours that you actually work and which feels like even more because of the additional circadian rhythm challenges.

Either way, the point wasn't the specific hours but rather the idea that most EM residents having second thoughts should see how they actually like the profession as an attending before they spend $500k+ training in another specialty. Medical education corrupts people into jumping to more formal education to solve every problem. How many posts do we see with people asking about doing a residency or a fellowship or getting a JD or an MBA - not because they have a clear goal in mind or an interest in it, but because they hate their job? There is nothing wrong with additional training but it should be goal based not reactionary.

At the end of the day, despite most of the reasons they're giving, their job is to be a resident and they aren't happy in it. There is a good chance that what they hate is being a resident: being overworked, tired, stressed, constantly trying to survive at the edge of their knowledge, and feeling like an imposter. There is a good chance that the answer is not to spend extra time as a resident in a location a computer sent them to. The answer is to finish and see what life is like when you get more sleep, make more money, and are actually practicing medicine you're proficient at in a setting you've chosen because you like the environment, pace, and people.

I'm not saying it's definitely the right answer for everyone or even for the poster but I would argue it is the right answer for most people who matched into an emergency medicine residency in the first place.

 

[DeadCactus]

PGY-1 but I basically feel the same. Some people much further along in their career here have brought up the fact that every specialty can have high volume, but is it all at once? That's another thing I did not quite appreciate as a medical student, and now watching my attendings struggle with 18+ patients at a time, I wonder how they can do this for as long as some of them have. And they are no slouches.

Not to hijack the thread, but this might be relevant to OP as well. I've heard how GME funding can be an issue for those interested in switching specialties, especially coming from a 3 year residency program. Obviously it depends on the program, but is this a significant problem for those reapplying, and can it be addressed in any way?

I'm not in GME leadership or administration but my understanding is that the funding issue is overblown. GME funding that comes from Medicare gets assigned to a resident when they start training and they are assigned a number of years of funding that match their training program's length. If you start training in FM, you get 3 years of funding. If you switch to Gen Surg after intern year, you would only have 2 years of funding left making you 2 years short. If you started in Gen Surg, you would be assigned 5 years of funding and have 4 left if you decided to switch to FM after intern year.

The caveat to this is that Medicare capped funding on residencies a long time ago but as you've probably noticed that residencies are popping up every year. They get funded by other institutional sources that aren't constrained by the Medicare rule and institutions can often find ways to shift money around to accomodate a trainee who is running into issues with Medicare funding.

 

[Subdivisions Rush]

In psychiatry there are quite a few procedures that one can do: ECT, rTMS, Ketamine Injections. Then there is the usual stuff: meds management; suboxone clinic; some still do psychotherapy.

 

[Shufflin]

In psychiatry here. At the end of a day I still make a big difference and have lots of time and energy for life outside of patient care. It's lower volume than EM and psych "crashes" are hardly ever life-threatening. Shadow someone and think about it.

 

[solitarius]

Having finished rotations in EM and IM, I am glad that I am doing neither.

If you're going to do EM, you might as well seriously consider surgery and make more money.

Having just finished IM, I'm not sure which is worse. Initially, I thought IM at least gives you time to figure complex things out... but being primary is... awful.

 

[Apollyon]

If you're going to do EM, you might as well seriously consider surgery and make more money.

I'm EM, and I've always said, if I was told, "do surgery or do nothing", my response would be, "Would you like fries with that?"

 

[Candidate2017]

Sophomore blues. Training comes from volume and non-clear cut, high stakes cases. You aren't learning if you aren't forced to the edge of your envelope. Push through it and you can look forward to senioritis and applying for jobs at community EDs with slower, smaller volume.

 

[chocomorsel]

Having finished rotations in EM and IM, I am glad that I am doing neither.

If you're going to do EM, you might as well seriously consider surgery and make more money.

Having just finished IM, I'm not sure which is worse. Initially, I thought IM at least gives you time to figure complex things out... but being primary is... awful.

Dude, EM makes damn good money per hour for the amount of time they work. Better than General Surgery I am sure.