EMRA and CORD Student Advising Guide

Ch. 1 - Choosing Emergency Medicine

Emergency physicians have the privilege of taking care of patients and their families during the most vulnerable moments of their lives, simultaneously being a resuscitationist, detective, team captain, coach, and metaphorical bartender. The breadth of skills and knowledge required to bring order to the chaos of the emergency department on a daily basis is what sets us apart, and also dictates which types of medical students will be successful and fulfilled by choosing emergency medicine.

A Brief History of Emergency Medicine

In order to understand the practice of emergency medicine today — and the 240 EM residency programs approved by the ACGME by 2018 — it helps to understand how we have evolved as a specialty. Post-World War II, America experienced a tremendous period of prosperity including a quadrupling in the number of automobiles, 41 thousand miles of new highways, and the development of suburbs. This new mobility, coupled with increasing specialization in medicine, separated many patients from the family physicians that traditionally cared for them. In 1955, emergency “rooms” (which have since grown into “emergency departments”) were staffed by physicians from a wide variety of specialties who were not necessarily equipped with the specialized training required to treat the breadth of patients. The ED was labeled “the weakest link in the chain of hospital care.” The care provided to soldiers injured on the jungle battlefields of the Vietnam War was superior to the care received by many civilians in the United States.

In 1966, the National Academy of Sciences published “Accidental Death and Disability: The Neglected Disease of Modern Society,” which highlighted accidental injuries as the leading cause of death during the first half of one’s life, an epidemic problem with significant economic and human costs.¹ That same year, the National Traffic and Motor Vehicle Safety and Highway Safety Acts created mechanisms for the federal government to create new safety standards for automobiles, as well as the development of national standards for the implementation and advancement of pre-hospital EMS systems.

Then in 1968, John Wiegenstein, MD, and a small group of physicians practicing in EDs came together to form the American College of Emergency Physicians. Membership was limited to those who “voluntarily devote a significant portion of their medical practice to emergency medicine and surgery.” Their goal was to organize the innovative trailblazers who were creating an entirely new way of delivering acute, unscheduled care across the country, determining the best ways to run and maintain viable emergency departments.¹

In 1970, Bruce Janiak became the first emergency medicine resident at the University of Cincinnati, and by 1975, there were 31 EM residency programs. These pioneering residents took a chance pursuing training in emergency medicine, a specialty which was not yet officially recognized. In 1979, the American Board of Emergency Medicine achieved primary board status by the American Board of Medical Specialties, and EM officially became the 23rd medical specialty.

In 1986, the Emergency Medical Treatment and Labor Act became law. Prior to EMTALA, “patient dumping” was common in some communities, whereby poor, often critically ill patients were shifted from private to public hospitals, many times to the patient’s detriment. EMTALA requires all hospitals that accept Medicare to provide screening and treatment for emergency medical conditions, regardless of insurance status. And emergency physicians are happy to do this. As the safety net of our health care system, we provide more uncompensated care than any other medical specialty.

Over the past several decades, the number of patients visiting EDs has continued to steadily rise, while the number of inpatient beds has continued to shrink, leading to problems with ED crowding. The proportion of patients seen for trauma has declined thanks to injury prevention efforts, while the average age and complexity of patients seeking care for medical illnesses has increased. There is also an increasing number of patients seeking psychiatric care in the ED.^2-4 As increasing emphasis is placed upon the delivery of value-based care, EDs will continue to play a crucial role as diagnostic and care coordination centers where decisions about which patients require costly inpatient hospitalizations are made, which is especially important given that a growing, large majority of hospital admissions originate from the ED.⁵

What Makes Emergency Medicine Special?

• Undifferentiated patients — EDs have become the diagnostic centers for a growing majority of patients in today’s health care system. Emergency physicians often are the first to assess a patient, and a broad differential diagnosis must be considered to ensure that the patient’s symptoms are translated into an appropriate diagnosis.
• Sick or not sick? — From the doorway of a patient’s room, emergency physicians must be able to quickly answer this question. We must always first consider the worst possible diagnoses for any given chief complaint, while also considering what is most probable or uncommon and therefore likely to be missed. This differential is continually reweighted as test results return and responses to treatment occur. This does not always lead to a clear diagnosis, but patients are risk-stratified and the risk arising from dangerous diagnoses is diminished through this approach. While it may feel unsatisfying to discharge a patient with an unclear diagnosis (such as “abdominal pain of unclear cause”), sometimes the most dangerous thing that a patient can have is a label of an uncertain diagnosis (such as “GERD” for unclear epigastric pain), since labels provided in the ED can strongly influence the care received after admission and the follow-up plan.
• Quick rapport — Emergency physicians must rapidly establish trust with patients and families they have never met during times of vulnerability and uncertainty. It’s been said that “people don’t care how much you know, until they know how much you care.” This is not the time for complex physiologic discussions; it is the time to connect, show empathy, and help others feel at ease. You are the calm in the storm.
• Critical decision-making — The acuity of the ED requires you to make management decisions based on your clinical assessments, often without the benefit of complete information or diagnostic testing. A tolerance for chaos and uncertainty will serve you well. An emergency physician will make 10,000 implicit and explicit decisions in a shift; 10 of these will be wrong.6
• Multitasking — This may be better described as “distracted decisionmaking” because emergency physicians need to rapidly shift their focus between patients among a variety of distractions — all without letting the quality of decision-making be affected.
• Teamwork — Relationships within the ED and throughout the institution are hugely important. Your character is the cornerstone of your ability to be the leader of a team. Your colleagues need to know they can count on you. Get comfortable trusting your instincts and your team. The successful EM physician is able to appear in control and unflustered (even when panicking on the inside). They are able to calmly lead a resuscitation, listen to the input of the entire team, and prioritize the many necessary tasks and interventions.
• Procedures — Emergency physicians must be experts at resuscitation and airway management, plus be skilled in a variety of other procedures ranging from basics like suturing and vascular access to lifesaving procedures like pericardiocentesis and thoracotomy. Some you will do every day and others you will need to perform just once or twice in your career.
• Safety net — No patient is too poor, too non-compliant, too old, too young, or too pregnant to be seen in an ED. The ED is never closed, and you are never too busy, too tired, or too distracted to care for the patient in front of you. You take pride in the ability to care for those who cannot care for themselves and value the privilege to help people on their worst day.
• Episodic care — For the most part, emergency physicians do not have the continuity of care common to many other specialties. You form very short but important patient relationships. The successful emergency physician gains fulfillment from even brief encounters.
• Ever-changing — Every day is different and unpredictable. You will be repeatedly challenged with new situations. Just as each day changes, EM is a specialty that continues to change. You grow and gain new skills, perform research to support our decisions and care, and keep current with reading, skill acquisition, and practice.

Work Life Balance

ED shifts are a sprint, not a marathon. You will be at the hospital for a fixed amount of time, working very hard — and then you will go home to spend time doing the other things you love. Shifts in EM vary in length depending upon where you work, with 8- to 12-hour shifts being the most common. Some lower volume EDs have shifts as long as 24 hours.

Emergency physicians work days, nights, weekends, and holidays; do not expect a 9–5, Monday–Friday schedule. In contrast, emergency physicians are not “on call” like many other specialists, though you may be asked to cover a shift for a colleague in the event of illness or asked to come in during a disaster scenario.

Given the predictable, scheduled nature of their clinical shifts, emergency physicians have a great deal of flexibility in planning their schedules around important life events. Not having a practice where you are responsible for the ongoing care of a panel of patients provides excellent career portability. 

Unique Challenges in Emergency Medicine

While EM is an overall fulfilling choice of specialty, it does come with its own set of emotional, mental, and physical challenges. These stresses come from the pressure to quickly evaluate, treat, counsel, and disposition patients while also being held accountable for meeting quality metrics and improving patient satisfaction in a chaotic environment that can be made even worse when dealing with long wait times, patients suffering in pain, alarms ringing, and constant distractions. Emergency physicians must also deal with the physical effects of shift work as their waking hours may frequently not follow a normal circadian rhythm.

In the ED you will make lifesaving decisions that may not always result in a good outcome; you will bear witness to terrible trauma and illnesses in both children and adults. You will also have an upfront view into many tragic aspects of society that the majority of the population only hears about on the news, including gun violence, child abuse, drug overdoses, elder neglect, suicide attempts, intimate partner violence and sexual assault, as well as the short and longterm consequences of poverty, homelessness, and substance use disorders. Debriefing after emotionally demanding interactions, reflecting upon events, and having a strong support system all help emergency physicians remain resilient.

Burnout in EM

Although burnout is a serious risk in any medical specialty, a work environment with high demand and little control is most likely to lead to burnout. Maslach and Leiter define burnout as erosion within 3 critical areas: engagement, emotions, and fit. Erosion of engagement involves decreased energy and enthusiasm for medical practice.⁴ Emotional erosion is defined as the transition to cynicism and bitterness. Finally, erosion of fit involves feelings of discomfort, and a sense of isolation. EM is the specialty with the highest prevalence of burnout.⁷ In a national study comparing rates of burnout among different specialties, EM clinicians experienced professional burnout more than 3 times that of the average physician, with 65% reporting symptoms of burnout.⁷

It is imperative that EM clinicians learn how to recognize burnout in themselves and others, and seek help. Fortunately, physician wellness and resiliency have become important priorities for residencies, emergency departments, and EM specialty organizations. Circadian schedules that match our natural forward rotation can reduce fatigue. Global systems changes can address increasing patient volumes. Personal measures that can be taken to prevent and ameliorate burnout include exercise, a healthy diet, strong social supports, self-reflection, and mindfulness. It is also important for workplaces to offer the means of dealing with burnout symptoms. Employee assistance programs play an important role by allowing physicians to self-report and get help, without their problems becoming public knowledge. Possessing varied interests, both personally and professionally, has been found to be protective against burnout.⁷ Some potential ideas are: engage in research projects, write, and join committees and other service organizations. Work to cultivate hobbies, travel, and a maximize life outside the hospital.

In a survey of residents across all specialties, 53.8% of EM trainees reported experiencing at least one symptom of burnout at least weekly compared to an overall prevalence of 45.2%. Despite this, EM residents reported below average rates of regret about their choice to become a physician (11.4%) or pursue their specialty (3.3%), compared with 14.1% and 7.1% across all specialties.⁸

While burnout is a serious issue that EM physicians must be aware of to actively combat and prevent, the practice of EM is incredibly rewarding. We act as a safety net within health care and have the privilege and responsibility of caring for those most vulnerable. We walk away from shifts having made a tangible positive impact on our patients and community. 

Is Emergency Medicine Right for You?

The “love of every single specialty” seems to be a common feeling among those who go into emergency medicine. In addition to comparing your own traits to those of successful emergency physicians, ask yourself the following questions:

• When you walk through the doors of your emergency department, do you get an overwhelming feeling that you belong there?
• Does the thought of a trauma or code where you can save a life give you a surge of adrenaline and excitement?
• When you see a stranger who is injured, do you run to them?
• Do you enjoy the diagnostic inquiry of undifferentiated illness?
• Do you enjoy a wide range of clinical challenges requiring a variety of skills each shift?
• Do you enjoy a fast-paced work environment?

If the answer is yes to these questions, then emergency medicine may be the right fit for you. You will save lives, solve mysteries, ease suffering, and support others on what may be the worst day of their lives — and you will do it in a clearly defined shift, rather than marathon call days. Emergency physicians are also very portable, able to move around the country and world because we are not tied to a patient panel or practice. If chaos, wide variety, fast pace, or death make you feel anxious and disheartened, then EM may not be the best fit for you. If you are considering EM purely for the “lifestyle and flexibility,” keep in mind that while your shifts are scheduled and predictable, they may be predictably in conflict with spending time with your family or your overall wellness. Choose EM because you love the specialty, not because of any assumptions EM will have on your lifestyle. Watch the Emmy-award winning documentary, “24|7|365: The Evolution of Emergency Medicine,” for an inside look at EM. 

A great resource for evaluating yourself if you desire something more structured is the Careers in Medicine website provided by the AAMC. This self-assessment tool helps you to evaluate your interest in specific areas of medical practice, and propose medical specialties that may be best for you based on your responses.

Post-Residency Career Opportunities

The specialty of emergency medicine provides a broad range of career opportunities after residency training. Graduates can work at community hospitals, safety net inner city hospitals, critical access rural hospitals, university-based teaching and research institutions, or some combination of those. For those looking to explore the country and make use of your work-anywhere skills, you can opt for locum tenens.

While we all practice emergency medicine, daily practice can look very different depending on the setting. In a typical community hospital you will be providing most of the care to your patient and likely will not have all the specialties available at academic hospitals. You will perform more of your own procedures and make complex decisions of when a patient needs to be transferred out. You may be working as the only emergency physician among other attendings, nurse practitioners, and physician assistants. When consulting other specialists, you will deal directly with attendings and only rarely with a trainee. This is likely to be a very different relationship than that experienced in a large academic medical center. These hospitals also come with varying trauma center levels, stroke certifications, cardiac, and cancer facilities. This may impact the patient population seen, as well as your availability of resources. Generally, you will spend the majority of your time caring for patients in the ED, though you may spend a small amount of time with other administrative or quality improvement responsibilities. Many residency graduates may find themselves working in freestanding (non-hospital based) emergency departments, where any patient needing further acute care must be transferred to a different facility.

Another career option is as an academic emergency physician at an academic medical center. In this role, part of your time is spent working clinically, teaching and supervising residents and students. Additional time is spent on non-clinical teaching, research, and departmental service. This clinical work can be very different from that of the community provider taking direct care of patients.

You will typically be responsible for more patients while delegating to and supervising your learners. Some health systems offer a hybrid opportunity wherein some shifts are at the academic medical center and others are at an affiliated community hospital.

As EM has matured as a specialty, more and more graduates are choosing to pursue subspecialty fellowship training. Fellowships are almost always affiliated with residency training programs, and most last 1 or 2 years. Fellowships facilitate increased knowledge in an area of EM that can then be developed into a career niche. Many academic departments are looking for fellowship training for new hires. Some EM fellowships are ACGME-accredited and offer subspecialty board certification, while others often have an associated master’s degree. The EMRA Fellowship Guide is a great resource to learn more about fellowship training opportunities. It offers details on opportunities in:

• EM is a dynamic, exhilarating, ever-changing specialty that is best fit for those with strong interpersonal skills, a calm demeanor, and a desire to work as part of a team for brief, poignant encounters.
• Successful EM physicians are kind, hard-working and flexible, with a penchant for controlling chaos and tolerance of the emotional toll our role entails.
• The EM lifestyle allows for flexibility and portability, without being responsible for a panel of patients during off-time. Emergency physicians work hard when they are on duty and can play and plan when they are off.
• It is our privilege to act as a safety net and care for all who present to the ED.