Congratulations! Maybe you matched, maybe you scrambled. Either way, you’re here, and after four years of reading and watching, you are about to finally start doing. Get all those practical skills: Intubate! Drop central lines! Insert chest tubes! Sign verbal orders within 24 hours! Write medicolegally bulletproof notes that also capture all the RVUs necessary to maximize billing.
As you embark on your journey to becoming an EM doc, let me offer you a perspective on what EM means to me. I hope it makes you think about why you are going into EM and what you want out of a career that will span 15 to 30 years after residency. I hope you are honest with yourself about whether you chose this path for reasons that will sustain your career because many people and patients are depending on you having made the right choice.
Bottom line up front: Medicine is hard. Emergency medicine is hard. And it’s supposed to be because you’re dealing with human lives.
I’m speaking as a community EM doc. We are not stockbrokers or hedge fund managers. We didn’t come up with a cool app in our 20s (we were busy not failing organic chemistry). We didn’t trade our personal ethics for politics. We didn’t go to law school because we had nothing better to do after college. At some point in our lives, whether explicitly or implicitly, we decided that we wanted to take care of people. People we are not related to. People we don’t know.
I’m a PGY-18 (I graduated from medical school in 2005 when there were no iPhones, only Razors and Nokias; when Coldplay’s Parachutes was playing in every Starbucks where I was studying; when young Americans were still being killed in Iraq 2 years after Bush had declared victory). I don’t feel old, but I’ve been doing this job for almost two decades. With the military, I had the privilege of going to places where people did terrible things to each other while we tried to put them back together. I did it in Shanghai. I did it in downtowns and uptowns in US cities. Now I’m at a community hospital in California, serving a leadership role in my small independent EM group, serving a community that sees my hospital as their hospital, and having the privilege of hiring new EM docs, seeing who they are, how they perform, what kinds of jobs they are looking for, what they are not.
On social media, I also now have the privilege of seeing what the conversations are surrounding EM.
And I’m a little disappointed. Sometimes sad, sometimes encouraged, but often disappointed.
There are lots of posts on social media about burnout, ungrateful patients, unsustainable volumes. Folks are tired. I am too. And I’m glad to see we are more comfortable talking about these things openly and can support each other. But what I don’t read or hear anymore are collective celebrations of the craziness of the job. When someone posts about having to stay to help at the end of their shift because a mass casualty showed up, I think, hell yes – that’s what we trained for – emergencies. A terrible day for patients can be a great day to be us. Yet I read more responses like not wanting to be at that shop, not wanting to be in that situation, sucks to not getting out on time, etc., than “thank you for what you do” and “I’d be right there with you” and “good for you.” When someone posts about leaving a shift after multiple code 3 medically ill patients tubed, lined, medicated, and admitted, I think, hell yes – that’s what we trained for – emergencies. You leave tired but with the satisfaction of practicing at the top of your license. Yet the responses are again more like how legally risky that is, unfair we are being abandoned by other docs, not enough pay to be doing all of that, etc., than “that sounds like a fantastic challenge” and “I’d love the chance to rise to that occasion” and “what a great experience practicing true emergency medicine.”
While emergency medicine is hard, physically, mentally, emotionally, so is every other field of medicine. The grass is not greener elsewhere. Talk to your colleagues and listen. You’ll realize that all our jobs are hard, and there are more similarities than differences. Don’t be disappointed that we are not special; be comforted that we are not alone.
There’s a Chinese saying that I had heard from my parents earlier on in my career: Doctors make money for other people to spend.
Maybe it’s my immigrant mentality, but doesn’t making a lot of money mean you have to work really hard to earn it? And doesn’t holding a highly respected position in the community year after year, survey after survey, mean that we must hold ourselves to high expectations, despite the in-your-face insults and the Yelp reviews that we seem to feel so much more acutely than all the unspoken/unrecognized wins and saves – things that society takes for granted, things only we who do this work see and appreciate?
Yet, I feel like everywhere I turn, I hear folks talking about “fair” compensation for “sustainable work.” The first time I heard it, I thought… yeah, that sounds right. But the more I read/listened to the details surrounding this thread, the more it sounds like MORE pay for LESS work. I shouldn’t have to work as hard as the docs who have done this for decades, who held on their shoulders the entire community of uninsured, unhoused, unwanted by all other health care settings. And not only that, I should be making more than they do because I have higher loans and a higher cost of living. Can you imagine how much Uber, Lyft, DoorDash, and Grubhub are charging now? And subscriptions to an unlimited data plan for an iPhone 13, Hulu/Netflix/HBO Max, and Amazon Prime are going up every month.
EM is hard for its own unique reasons, and it provides its own unique rewards. So it needs its own unique type of doctors.
So why did you choose emergency medicine? Because you liked codes and resuscitations and procedures? Because of the lifestyle that it was billed to provide? “Work hard and play hard.” Work 14 shifts a month, and have 16 days off for surfing, skiing, rock climbing, mountain biking, backpacking. Because it was competitive? Apparently, EM has become so popular that it is on par with ophthalmology for its selectivity (when did “EROAD” become a thing?). Did that challenge draw you because you wanted to keep overachieving?
Instead of asking if EM is a good fit for you, I challenge you to ask if you are a good fit for EM.
We all know good EM docs have to be comfortable with a lack of structure, willing to make decisions with incomplete information, be “a jack of all trades but a master of none,” etc. But I would argue, more importantly, EM needs its doctors to have an unwavering internal drive to do the right thing when no one is looking. Because no one is.
Where we work, no one wants to look. No one wants to be in the ER. Not patients, not hospitalists, not consultants. We see patients (and consultants) dragged kicking and screaming, patients who are half or fully dead a hallway away from patients who are pissed they had to wait hours to be told they are OK, like that was bad news. Our biggest admirers will never be other doctors we call or patients we treat. They are more often our biggest critics. Our fellow EM docs, nurses, and techs, the first responders that bring us patients, are the only people who regularly bear witness to our actions. They are surly, stolid, and more prone to sharing butt jokes than compliments.
EM asks its doctors to have a strong stomach and a weak nose. The ED is where a community’s physical and emotional wounds, smells and secretions, sounds and furies swirl together at all hours of day and night. EM asks its doctors to accept unequivocally that what we do is, and should be, hard, and believe deeply and personally that, even in the absence of gratitude from our physician peers or external validations/recognitions from public media or gift baskets from grateful patients, what we do matters.
And the reward? It is a front-row seat to the most unadulterated version of life. We are invited to see, intervene, and participate in some of the most terrible, beautiful, and memorable moments in people’s lives. We get to touch every part of the human body – skin, fat, muscle, nerves, vessels, tendons, ligaments, bones. We get to see every aspect of the human mind – fear, paranoia, shame, sadness, joy, bravery, love. It’s all laid out in front of us on shift. Parts of it come home with us. Some of it breaks us a little, some a lot. Some of it makes us feel on top of the world for a while. Whether we want to or not, most of it brings us closer to the human experience than most jobs can ever hope to do.
So, are you a good fit for EM?
From all the chatter, a lot of people have reasons why many spots went unfilled this year and whether that was a good or bad thing. Because of a job report from ACEP? Because patients stopped checking in after COVID-19 showed up, so groups weren’t hiring? Because more pop-up EM residencies … popped up? And people couldn’t tell the difference between an old-school program with a tradition of excellence (where residents fed from a firehose come out ready to take on anything) from one with a shiny new hospital with cool tech/gear fueled by a healthy insured payer mix (where graduates who signed up for the “EM lifestyle” never waded through sick patients and now suddenly are dealing with a LOT of sick patients coming back en masse)?
Community hospitals like mine that ask their doctors to work hard because there’s hard work to be done are having a hard time right now. Are they losing doctors to regional or national groups who can offer better paychecks (because of strategically placed hospitals capturing more insured patients) or easier work (because of a healthier patient population they serve)? Are they losing doctors to nonclinical careers because those doctors who picked EM over dermatology or anesthesiology weren’t ready to put their heads down to do the type of work that comes with the specialty?
I know there are important, very justified reasons why good doctors are leaving EM. Metrics suck. Non-physicians running hospitals and dictating how to treat patients suck. Insurance companies playing payment denial games and lobbying on state and federal levels to lower reimbursement suck. Outside consulting firms telling us to do our job better with fewer staff suck. But right now, in my own personal recruitment experience this year, and in the social media bubble I’m swimming in, it feels like EM docs have shifted priorities from finding joy in the hard work of treating sick human beings, from wanting to use all our skills to our utmost, to instead looking for the easiest work for the best pay.
So I ask again – are you a good fit for EM? Why did you choose this job? Is it enough to carry you through the next 3 to 4 years of residency into the next 15 to 30 years of practice? If not, what needs to change? The sooner you figure this out, the sooner one of two good things will happen. Either you will find more contentment and peace in your EM career, or you will be wasting less time for yourself, the rest of us who are already in this, and the patients who will continue to come through the ED doors.
Yang Wang is an emergency physician.