5 things I wish I knew before I went into emergency medicine

What I wish I knew before I went into Emergency Medicine

Let me start by saying I love emergency medicine. The chaos, the critical thinking, and the ability to bring calm into any emergency is truly gratifying. But there are also challenges in the thrill and the fun of emergency medicine. Here are a few things I wish I knew before selecting the emergency room as my office.

You aren’t the final expert on anything.

I think most people come into the medical field thinking that they are going to become master diagnosticians. The world will be graced with our medical prowess and intellect as we continually diagnose and treat the most obscure of maladies with expert precision. All will thank us for our astute clinical skills and we will be the smartest person in any room.

After you have typed ‘’abdominal pain, unspecified’’ into the diagnosis for the twentieth time in a week, this belief begins to evaporate.

We are the experts in sniffing out badness. When the patient minimizes a complaint and you latch on and diagnose the subtle myocardial infarction that the patient thought was indigestion, that’s a win and you deserve to pat yourself on the back for that victory. But even with us arriving at the answer, cardiology will come and definitively manage the problem.

We are not definitive care for most conditions (maybe a nursemaid’s elbow?) but we are the gatekeepers of definitive care and our ability to find the one patient that is trying to die in focused care or quickly activate the STEMI response is where we shine. Our calm under pressure and ability to shove a patient’s history and physical through the wood chipper of medical decision-making and somehow come up with a differential diagnosis is our bread and butter.

Remember that you aren’t the definitive expert on anything, but your expertise is critical to patient care.

Efficiency is prioritized over quality in our healthcare system

Our healthcare system is overloaded. In my local area, patients are often waiting a minimum of 3 months to see a new primary care provider. This will result in many problems coming to the emergency department that would have been prevented (and ultimately still need to be managed) in the primary care setting. The COVID pandemic exacerbated already existing healthcare supply issues and the pressure relief valve of the healthcare system is the emergency department.

Your doc can’t see you for 6 weeks? Go to the ER and have someone evaluate you.

Your medicine ran out? Go to the ER and get a bridge.

Can’t get a CT scan for 2 months? Go to the ER and they can do it today!

You called the office and happened to mention your chest hurt 2 weeks ago? GO TO THE ER!

As issues with the outpatient setting continue, our volumes will likely continue to swell with more and more problems that do not truly belong in the ER. With more volume and supply concerns, comes the need to do more with less.

Your ability to see as MANY patients as possible without a severe quality issue is prioritized against seeing as many patients as possible with HIGH quality. If you perform well, you will be pushed to see more faster and the churn will continue. Without going into the ethics or the pros and cons of our healthcare system, understand that this is the reality in which we work.

Remember that our mission is to care for patients, not generate as many RVUs as possible.

You are a PA in a doctor’s world

The healthcare system is changing, reimbursements are being cut, hospitals are operating on smaller margins, and a PA costs a whole lot less than a physician and functions (from an administrator’s eyes) much like a physician in the emergency department. I am not a doctor (#notadoctor) and continually reinforce to people that physicians are critical to the effective function of our healthcare system. But the days of every patient being physically seen and completely managed by a physician are long gone. PAs will continually supplement the docforce (can I submit that word to be formally accepted as real?). I often wonder if soon you will see one physician in an emergency department overseeing several APCs (Advanced Practice Clinicians) with very little direct patient care performed by them.

However, remember that the chief expert in medicine has historically been a physician, and the likely minimum of 7 years of medical training they went through better prepared them for medicine than your likely 2 ½ years of post-grad training. All that aside, that gap starts to close the longer we practice, a PA working in a specialty for 5 years likely has seen a lot that resident or a new grad physician hasn’t seen. And this is where the beauty of collaboration begins to really show. Have I diagnosed a severe problem when my physician said don’t worry about something? Yes. Has my collaborating physician stopped me from missing something? Yes. Less likely are these situations due to someone’s ineptitude and more likely each of those patients benefitted from extra eyeballs and minds examining their presentation.

Maybe medical school was too long, or too expensive. Maybe you thought becoming a physician seemed less desirable than becoming a PA. Or maybe your PA you saw growing up was awesome and your doc was not. Whatever reason you chose to pursue PA; ultimately, the physician is the expert in your specialty, and you will always be working with them to care for patients.

It's not as fun when you get older (but still is pretty fun)

I started in emergency medicine when I was 18, volunteering with the rescue squad. I loved the late nights, the adrenaline, the action. I worked 72 hours one week and 12 the next and didn’t care if sometimes had to work a Saturday or be at work over dinner time. Fast forward to the age of 30 with a family, and suddenly working from 2pm to midnight is not as fun as it once was. The kids will be awake at 7 am regardless of whether you got stuck for an extra hour trying to get your trauma patient accepted somewhere in the state.

Don’t get me wrong, emergency medicine is still my favorite area in medicine and likely always will be. But many things that seemed appealing about it in younger years may become challenges later. Finding rhythms and ways to work with friends and family and make sure you still have SOME routines and regularity in your life are key to longevity.

You will miss something

If you work in medicine long enough, you will miss something. You’ll minimize a complaint only for the patient to come back 24 hours later critically ill. You’ll forget to order a test, your patient will say something as you are thinking of the last thing they said, or your patient won’t mention the only critical piece of information to their visit. Another good reason for PA-physician collaboration is the benefit of 2 people checking information, meds, orders, labs, results. Examine every patient’s information like you could be missing something and if things aren’t adding up, then take a step back and re-evaluate your initial decision-making and biases.

Admitting your lack of perfection also allows us to be more graceful to our fellow co-workers. I found a stroke missed by a colleague a few days before due to the subtlety of the presentation, I also had the benefit of a patient coming back because they didn’t feel better. It is impossible to be perfect in medicine and every human makes mistakes. Do not throw your colleague under the bus unless you also wish to have tire marks inflicted on your face when you inevitably fail.

You will miss something. Take steps to minimize your chances for error and also consult your colleagues if something is not adding up.

Summary

Ultimately emergency medicine is the most exciting and most fun speciality, but it is not for everyone. We need clinicians working in primary care, gastroenterology, addiction medicine, and the list goes on. Every practice has its pros and cons and consideration of your work-life balance and quality of life and work is critical to longevity and success in our professional careers.

What are some things you wish you knew before emergency medicine? Is there anything else you think should be told to grads considering EM?