Welcome to our next installment in So You Want to Be. In this series, we highlight a specific specialty within medicine, such as emergency medicine, and help you decide if it’s a good fit for you. A lot of you asked for emergency medicine in our poll, so that’s what we’re covering here. If you’d like to see what being an EM doctor looks like, check out my personal YouTube channel, Kevin Jubbal, M.D., where I do a second series in parallel called a Day in the Life. Once the world is back to a more normal baseline, we’ll be doing a Day in the Life of an Emergency Medicine doctor.
What is Emergency Medicine?
Emergency medicine is the specialty concerned with treating patients who are acutely ill with urgent healthcare needs. This can be treating acute conditions like myocardial infarction, or heart attack, or treating exacerbations of chronic health conditions, stabilizing patients involved in trauma, and more.
Because EM doctors treat acute conditions from every field of medicine, they have to know a little bit about everything but don’t dive deep in any one specific domain. Think of them as the jack of all trades, master of none. If you’re having a heart attack and don’t have a cardiologist nearby, seeing an EM doc is the next best thing. As my emergency medicine colleague says, “if you ever have a medical problem, we are the second-best doctor.”
Generally speaking, the job of the EM doctor is to stabilize the patient and then refer to the specialist in the appropriate field. For example, if a patient comes in with multiple fractures after a motorcycle crash, they’ll stabilize the patient’s airway, breathing, and hemodynamics, meaning their blood pressure and circulation. After that, they’ll call the orthopedic surgeons to assess the extremity fractures and the plastic surgeons to address the facial trauma. That’s an actual case from when I was in a plastic surgery residency.
The practice of emergency medicine is largely a function of location — what type of hospital do you work at?
At an academic center, you’ll be at the cutting edge of research, equipped with the latest and greatest in medical technology, therapies, and resources. In terms of salary, you won’t get paid as well as a community or private practice doctor, but you’ll have better benefits and job security. You’ll have protected time to pursue research, and you’ll enjoy paying it forward by mentoring and teaching medical students and residents. If you’re at a Level I Trauma center, you may expect to see more complex cases compared to other settings.
As a community emergency medicine doctor, expect to “do everything.” At larger community hospitals, there will be more specialists for support, but at smaller community hospitals in more rural settings, there’s less support and a larger scope of practice. You’ll be treating more patients on your own, but you’ll also be transferring more complicated patients to other facilities that are better equipped.
Lastly, urgent care is unique in that you’re working at a stand-alone facility, generally without a hospital or other specialties for backup. You’ll be handling lower acuity cases, with the option to transfer patients to the emergency department, or ED, depending on how sick they are. This is a less stressful environment and is considered a good option for doctors wanting to ease a bit toward the end of their careers.
How to Become an Emergency Medicine Doctor
For many nonsurgical specialties, you first do 3 years of internal medicine residency, and then subspecialize into gastroenterology or cardiology or infectious disease or another specialty through fellowship. Emergency medicine is different as it has its own residency training.
Emergency medicine residencies are either 3 or 4 years in duration. Some experts in the field say that 4-year training programs are optimal, as it provides better preparation, an opportunity to further develop personal maturity, improve inpatient interactions, and have greater self-confidence. Additionally, it provides more time to explore and develop areas of interest and pursue research interests. On the other hand, 3-year programs have distinct advantages, such as spending 1 less year in training, earning an attending salary 1 year sooner, and most graduates say they are as satisfied with their training and don’t feel they are lacking in preparation.
On average, more academic institutions with research incorporated into the training will have 4-year programs, whereas more community-focused institutions without a research focus will have three-year programs.
Given the highly diverse and varied nature of emergency medicine, it makes sense for the residency curriculum to also be highly diverse and varied. Most of your time will be spent on emergency medicine rotations, but there are also rotations to trauma, orthopedics, ultrasound, critical care, anesthesia, pediatric ICU, obstetrics, and more.
Emergency medicine paved the way in residency admissions with the Standardized Letter of Evaluation or SLOE. Applying to residency is similar to applying to medical school in that you fill out your primary application with your personal statement, but also submit letters of recommendation. The SLOE is a way to standardize the letter of recommendation. Rather than a gushing letter saying how great you are, the letter writer must answer a standardized set of questions, such as the nature of how you know the student, their commitment to EM, how they compare to their peers, and more. This makes it much easier to quantify, standardize, and compare letters of recommendation. This will likely become more commonplace amongst other specialties as Step 1 transitions to Pass/Fail.
The residency interview process is more laid back than most other specialties, which is reflective of the specialty being less formal than most. Rather than grilling you on standardized questions, EM interviews are more about the “Beer Test”, meaning having a casual conversation and deciding whether this is someone you’d enjoy having a couple of beers with after a shift.
The stereotypical EM applicant is the student who loved everything in medical school, who couldn’t sit still, and always needed to be active and doing something. They’re the ones that want to know a little bit about a lot of things, rather than a lot about a few things. Some would even say ADD, easily distracted, and always on the go. These are often the athletic, outdoorsy, and adventurous types who enjoy camping, running, and rock climbing.
Subspecialties within Emergency Medicine
As with other fields in medicine, you can subspecialize with fellowship after completing your residency.
One of the most popular EM fellowships, sports medicine, is concerned with non-operative treatment of musculoskeletal injuries, pre-participation evaluations, and management of acute and chronic medical conditions of athletes. If you want to do operative treatment, you’d want to check out orthopedic surgery with a sports medicine fellowship.
Wilderness medicine is focused on meeting the unique challenges of emergencies in austere environments. This includes tropical and travel medicine, hypothermia, altitude-related illnesses, envenomation, and other animal-related injuries.
Ultrasound is being pushed heavily in the ED for its noninvasive diagnostic strengths. Fellows specializing in ultrasound also get to explore novel and future uses of the technology.
Toxicology focuses on the treatment of drug overdoses and withdrawals, envenomation, chemical exposures, and toxic ingestions.
If you want to work in the pediatric emergency department, you’ll complete a peds fellowship after completing your emergency medicine residency.
Hyperbaric medicine focuses on using hyperbaric chambers and hyperbaric oxygen therapies for certain conditions, and also includes the medical aspects of deep-sea diving.
Emergency Medical Services (EMS)
EMS, often combined with disaster medicine, focuses on pre-hospital care. This translates to ground or air transportation and responding or managing larger disasters.
What You’ll Love About Emergency Medicine
There’s a lot to love about emergency medicine. In terms of lifestyle, some love it, others hate it. On average, EM doctors work around 40 hours per week, which usually translates to 3-4 shifts per week, meaning you have several days off. This is shift work, meaning you clock in and clock out, and don’t take work home with you, which isn’t something you can say about most other specialties in medicine. It’s a double-edged sword though — that also means you’ll be working irregular hours depending on your shifts, whether during the day or at night, so a regular circadian rhythm is hard to come by. Also, it is not uncommon to miss important family and friend events or holidays.
Compensation amongst emergency medicine doctors is highly variable on the region and type of hospital you’re practicing at. We found the highest salary of $395/hour in New Mexico, and the lowest of $130/hour in New York. The average EM doctor makes roughly $350,000 per year. EM is also unique in that sometimes it’s more of an “eat what you kill” compensation structure, meaning the more patients you see and the more hours you work, the higher your compensation.
There’s a great deal of team dynamics at play in emergency medicine, as you’re constantly working with nurses, techs, and doctors of other specialties. There’s a large degree of social interaction at play, not only between healthcare professionals, but you’ll be having a large amount of face time with patients and their families as well. You’ll constantly be on your toes the entire shift, without much downtime or breaks between patients. Some love the fast pace, whereas others wish they could get more than a couple minutes to scarf down a snack.
EM can also be incredibly exciting, with a large amount of uncertainty. You won’t know what types of patients are coming in, or when they’ll be coming in. You have to be ready for anything.
What You Won’t Love About Emergency Medicine
Emergency medicine is not without its drawbacks. Unfortunately, a large number of patients abuse the emergency department which can prove to be a large source of frustration. This is NOT a discussion about why the ED is abused, social issues, political issues, or what changes should be made to curtail this, but rather what you’ll be experiencing as a physician working there.
My EM colleague who helped me in the writing of this post mentioned a patient coming in for dry cracked lips during the COVID-19 epidemic. No, that’s not a joke. You’ll also have undocumented immigrants or uninsured patients using the ED as their source of primary care rather than for urgent medical conditions. Homeless patients may feign medical conditions to secure a roof over their heads and food to eat for a night. Those addicted to narcotics visit the emergency department exhibiting drug-seeking behavior to secure pain killers, which has become an increasingly common issue given the opioid epidemic.
These situations aren’t necessarily the patients’ fault, but as an emergency medicine physician, the emergency department serving as a safety net becomes a source of frustration. Dealing with highly agitated or intoxicated patients also means that EM doctors are at higher risk of physical harm from patients compared to most other specialties.
For these and other reasons, EM doctors experience some of the highest rates of burnout. Some contributing factors include working on the front line, consistent high intensity and stress, unpredictability, increasing time required for charting at the expense of patient interaction, and irregular circadian rhythm. There’s also a fear of litigation looming over your head given the higher rates of malpractice claims compared to the average physician.
You won’t be seeing exciting stuff nonstop either. The bread and butter, meaning the most common things you’ll be seeing day to day, often include chest pain, abdominal pain, and headaches. The standard workup can become monotonous and the treatments are not always definitive.
Lastly, you may get some heat from other specialists, who are quick to forget that EM doctors must go an inch deep but a mile wide, whereas most other specialists go a mile deep and inch wide. You won’t know the nuance of every condition, because your job is simply to handle urgent cases, stabilize, and handoff to the specialists when appropriate. For this reason, some specialists will get frustrated for not managing cases to the same degree of nuance that to them may seem obvious.
Should You Become an Emergency Medicine Doctor?
How can you decide if emergency medicine is a good field for you?
If you thrive in fast-paced, sometimes chaotic, and unpredictable environments, it may be a good fit. You shouldn’t mind working an entire shift and enjoy nonstop action, even if it isn’t always the most exciting action. You may be forced to practice intermittent fasting, more specifically time-restricted feeding, as you won’t have much downtime on your shifts. You’ll work hard when you’re at work, but you’ll get to completely unplug when you’re off. No pager, no following up on patients or taking home calls.
You should enjoy the reward of saving lives, as being one of the few specialties that truly do. You won’t always be thanked though, as patients are in the scariest and stressful moments of their lives.
You also shouldn’t shy away from procedures — you’ll be doing more than most other medical specialties, although obviously not as much as surgeons. These procedures are wide-ranging, including incision and drainage of abscesses, lumbar punctures, paracentesis, thoracentesis, suturing lacerations, reducing fractures, and even thoracotomies and chest tubes.
A large thank you to the multiple emergency medicine physicians at MedSchoolInsiders who provided their input. If you’re interested in pursuing emergency medicine, who better to learn from than the EM doctors themselves. If you need help acing your MCAT, USMLE, or other exams, our tutors can maximize your test-day performance. If you’re applying to medical school or emergency medicine residency, our EM docs can share the ins and outs of what it takes and how to navigate the highly nuanced process most effectively.
Thank you all so much for reading! What specialty do you want me to cover next?