The Med Student’s Guide to Emergency Medicine (Part 1)

Jordan Soze here. Today we’re featuring a guest post from a good friend of mine who will be contributing more in the future. Zesty Mordton is a fourth year medical student who recently matched into a top emergency medicine program (congrats again my dude). Furthermore, I’ve known him since high school where we bonded over music (and even saw Radiohead together). Dude is brilliant and one of the nicest guys you’d ever meet. By some struck of luck, he happened to be in the class above me in my medical school where he’s been an invaluable mentor during my journey. Naturally, in the twilight of his medical school career, I asked him if he’d like to contribute some of that sage wisdom to Soze Media and he delivered this absolute gem of a post.

If you’re considering applying to emergency medicine or simply want to know what it’s all about, read this post. Bookmark it. Save it. And read it again. It’s an in depth exploration into choosing emergency medicine as a career and the application process, so I’ve split the post into two parts. In part one, he discusses why he chose emergency medicine, what type of students should consider EM, and gives insight into the specialty. In part two, he gives priceless advice on applying to emergency medicine, including competitiveness, audition rotations, SLOEs, how to impress, and so on. Enjoy! 

Hey, everyone! I’m Zesty Mordton and I’m honored to be the first guest contributor to Soze Media. I went to high school and medical school with Soze, and after talking recently, he asked if I’d write a bit about emergency medicine (EM) for those interested in the field. I recently matched into EM and am excited to share some info about the field. Big thanks to Soze for letting me contribute to this great blog.

Let’s dive in!

Why EM?

The quick of it? I wanted a high-acuity field, no personal patients (clinic, continuity of care, etc.), short residency length (I have a boat load of student loan debt), shift-work with no call, and a specialty that I felt meshed with my personality.

For more detail, I think it’d be best to walk through my decision process.

Most students are told that the first decision they need to make is surgery vs. non-surgery. This is reasonable, but the first step I made is whether I wanted acute or non-acute patients. Now all fields of medicine tend to deal with acutely ill patients at some point. But some deal with sick patients more than others.

After my rotations, I considered the most acute fields to be the following:

EM, general surgery, neurological surgery, OB/GYN, orthopedic surgery, anesthesia, critical care fellowship (via multiple residency routes)

After choosing high-acuity, I next decided if I wanted “my own” patients (i.e. clinic and/or patient follow up) or not. Deciding I did not want continuity of care or “my own” patients, I was left with EM, anesthesia, and some critical care options.

Knowing critical care could be achieved through EM and anesthesia, I narrowed it to those two options. You can grab a critical care fellowships a bunch of different ways. I won’t go into all of the options here, but basically EM and anesthesia were the shortest tracts and I enjoyed their “bread and butter” practice more than any other residency. A critical care attending once told me to choose a field based on the residency, not the fellowship options. I think there is some truth to that, just in case you don’t end up getting that fellowship position.

Okay, so why EM? EM residency is three years, it’s shift work with no call, I’m not constantly working with surgeon and their schedules, there’s great variety in practice, and I was apprehensive about CRNAs and the shift of “bread and butter” anesthesia to a more managerial role. 

Lastly, throughout my rotations, I seemed to mesh well with EM physicians and residents more than any other field (anesthesia was a mighty close second though). More on this in a bit.

On a side note, I want to stress that it was my personal experience that drove all of these decisions. Some students might have completely different rotations and think EM is just exaggerated primary care or that CRNA involvement has been overblown for years now (though I do think it is safe to say general anesthesia is shifting to more of a managerial role). You may also disagree with the specialties I consider high-acuity. Either way, I strongly encourage each student to judge specialties based off their own experience, not the generalized experience of others. Don’t exclude surgery because you hear the lifestyle is bad. Don’t include dermatology because you hear the lifestyle is great. Find out for yourself.

EM negatives

The two biggest negatives I hear from residents and attendings are the lack of respect and the high amount of expectation management.

Being an EM physician, you are the second best at everything in the hospital. Intubation? Not as good as anesthesia. Suturing? Not as good as plastics/surgery. EKG interpretation? Not as good as cardiology. The only acception is probably resuscitation.

This second best status doesn’t give you a whole lot of pull in the hospital. Related to this is the fact that you’re going to be calling consults left and right. Ortho, medicine, surgery, cardiology, OB, etc. They’re all going to be woken up at 2AM by your phone call. Even more, you aren’t going to work up their consults exactly how they want. I don’t say this to try and point out how consult services are picky. I say this because EM physicians might forget things and might not work up patients as well as a cardiologist or OB would. This is because while the pre-eclamptic patient is in room 3, a dilated cardiomyopathy is in room 16, and two motorcycle collisions are in the trauma bays. You have so much going on that you will rule out the serious stuff, consult for the details, and try to keep your head above water. It’s just a lack of understanding for what other specialties deal with, just as EM has for other fields themselves (why did that family medicine doc tell the patient to come to the ED?).

This lack of respect may turn some people off. There’s a very good chance your clinical acumen and decision making will be called into question by others on a daily basis. This doesn’t bother me, but does bother a considerable amount of people (for better or worse).

The other aspect of this field that might be a turn off is the amount of expectation management. Some patients think the ED is a place to get an antibiotic for their URI, or to be admitted for their sprained ankle, or get opioids for their low back pain. A big part of your job is to listen to the expectation, and then explain how this will differ from your plan. This can lead to a lot of unpleasantness and difficult patient interaction. I think this is common in plenty of other fields, but not quite in the same quantity as EM.

There are plenty of other reported EM cons. High burn-out, shift work with alterations of day and night shifts, working weekends and holidays, mid-level encroachment, no continuity of care, EM doesn’t make money for the hospital, wide misuse of the ED for primary care, etc. But again, I wanted to talk about some of the most common cons I hear from other students and residents.

In the end, none of these cons bothered me too much. I think there is some merit in not only considering what you like the best, but what you hate the least.

What type of students should consider EM?

EM typically attracts students who are calm under pressure, love procedures, and who prefer shift work.

The ED is a hectic place. You are managing multiple patients at any given time and the variety of pathology spans across every medical field. Even more, some of the patients are actively dying.  There is definitely truth in the adage of EM being the most exciting fifteen minutes of every medical specialty. This results in a high-stress environment on a daily basis. EM docs have to be calm and collected under pressure. Some argue you have to love this frantic aspect of EM, want the adrenaline, etc. While it would help, I don’t think that is true. You simply have to be able to handle it.

The two other aspects that interest students are the high volume of procedures and shift work. You’ll see suturing, intubations, central lines, chest tubes, I&Ds, fairly regularly. You will probably even see a thoracotomy or canthotomy. You will also work either eight, ten, or twelve hour shifts. This is appealing to a lot of students as you don’t take call and your schedule is very predicable. When you’re on, you’re on. When you’re off, you’re off.

Besides these three main characteristics, students may like EM for the reasons I mentioned above in ‘Why EM?’. They also might be attracted to the “chill” factor. For some reason, emergency medicine seems to interest laid back, easy-going physicians. No yelling, no malicious pimping, and relaxed conversation. While I’m sure this isn’t true for all hospitals, it seems to be the general consensus with every hospital I’ve been and with other medical students. 

What qualities to look for in programs?

I don’t think this differs from any other residency.

With the strict regulations imposed by ACGME, you will get a solid education in pretty much any residency program. The biggest thing to assess is how well you fit with faculty and residents in a given program.

With that being said, there are three general types of EM programs out there that may pique your interest. They are academic, county, and community.

Academic programs are affiliated with a university and have great research exposure, fellowship opportunities, and teaching opportunities. They are affiliated with huge tertiary referral centers and arguably see the rarest pathology out there. Think Johns Hopkins, Ohio State, etc.

County programs tend to deal with low-income, underserved patient populations. And, from my experience, these programs deal with the sickest patients in EM. They are usually no-frill, efficient facilities that see over 100,000 patients a year and are pros at trauma, psych, and patients who haven’t seen a doctor in decades. Think LAC/USC, Cook County, etc.

Community programs are typically non-leveled or lower-leveled trauma centers that take care of a middle or high-class patient population. They tend to get some sick patients, but not as much as county programs. And they tend to get some research/teaching opportunity, but not as much as academic programs. There are definitely exceptions, but as a rule of thumb, I would put them in the middle of the spectrum between academic and county. The big draw here is that the vast majority of EM physicians will work at community hospitals. So this arguably prepares you best for the type of practice you’ll find yourself in after you complete residency.

Not all programs fit nicely into one of these three categories. Some places are level I trauma, big centers that are community-based. Some programs may be a combination of university and county. But this is still a useful way to generally categorize programs and things you might like about them.

The thing with these three main program types is that the ACGME has stipulations in place so you get exposed to everything. For instance, you have to do a research project in order to graduate. You have to complete so many procedures to graduate (most community hospitals have an agreement with big level I trauma centers, which are typically academic or county, so residents can do a trauma or ICU rotation with them for exposure to high-acuity procedures). Lastly, big academic and county centers have rotations at small community hospitals so you are exposed to that patient population and pace of medicine.

All in all, while the type of program does matter, you will get exposed to most everything no matter what kind of residency you end up attending. Therefore, the support and fit of the program’s personnel is most important to your choice.

Stay tuned for part 2!

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