Career Paths in EM:

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Career Paths in EM

• What a Varied World We Work In
• H. Gene Hern, Jr., MD, MS
• Residency Director
• ACMC - Highland Hospital
• Assistant Clinical Professor of Medicine
• University of California, San Francisco

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• The 60 year old man with chest pain.
• Who do you call?
• Family Physician
• Internist
• Cardiologist
• Emergency Physician

3

• A 22 year old snowboarder with a broken wrist and
  left flank pain after a fall?
• Who do you call?
• Family Physician
• Internist
• Orthopedist
• Emergency Physician

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• 4 year old with a fever and lethargy at 1 AM.
• Who do you see?
• Pediatrician
• ID specialist
• Neurologist
• Emergency Physician

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What is EM all about??

• Stabilization
• Initial Diagnosis
• Initial Disposition
• Team Work
• Variety

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Variety - The Good Part

• You NEVER know what is coming through the door
  next

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Variety - The Bad Part

• You NEVER know what is coming through the door
  next

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History

• First Programs 1970s Subspecialty Boards
  (Tox Peds) 1992 142 ACGME Approved
  Residencies o 21 R 1-4 format o 13 R 2-4
  format o 108 R 1-3 format o 11 5 year
  combined EM-IM o 3 5 year combined EM- Peds
• o 3 6 year EM-IM-Critical Care
• o 1 5 year combined EM-FP

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Specialty (Expertise) Areas

• Resuscitation (Trauma/Medical, all ages) EMS
  (out of hospital care systems
  oversight) Disaster/Mass Gathering (planning
  for the worst) Environmental (e.g. hypothermia,
  lightning) Acute pain management (2/3rds of ED
  pts. have pain)
• ????? Wound management (10 of patients)

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Specialty (Expertise) Areas

• Medical toxicology (ABMS subspecialty) Domes
  tic violence and abuse
• Injury prevention/control (research
  advocacy) Observation medicine (beyond the
  initial hours) Hyperbaric medicine (ABMS
  subspecialty) Hospice and Palliative care (ABMS
  subspecialty)
• Critical Care

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Pros of a career in EM

• ??Variety All ages, all types of problems
• Knowing WHAT to do in an Emergency (Is there
  a doctor ?)
• Work on a health care team
• Little overhead (stethoscope, brain (PDA))
• No pagers, Office headaches
• Flexibility (hours, locations, etc.)
• Sherlock Holmes first contact with the
  patient as problem solver/detective

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Cons of a career in EM

• ????? Shift Work (physiologic socially). This
  is both our greatest advantage, and our curse.
• Some nights/weekends/holidays forever
• Work in the Fishbowl. The care we provide will
  always be retrospectively critiqued by others
• Social Police BEWARE if you believe that
  patients deserve illnesses based upon
  choices
• Lack of specialty recognition (disappearing)
• Turf wars (only academic settings)
• Hospital Overcrowding and Safety Net of Society

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Technical Skills of the EM Physician

• Airway Control Laceration repair I D
  abscesses Chest tube/ Open thoracotomy Central
  line/ Intraosseous /Arterial line Splint
  application FB Removal (skin, eye and
  orifices) Joint reduction/ Arthrocentesis Slit
  Lamp Regional nerve blocks Procedural
  sedation Bedside ultrasonography

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Intellectual Skills of an EM Physician

• Radiograph interpretation
• (decisions on YOUR readings) EKG/ Rhythm
  strip interpretation
• (decisions on YOUR readings) Resuscitation
  management
• (infant or elderly, medical or
  trauma) Concurrent info management with therapy
  Multiple simultaneous patient mgmt
• Differential diagnosis generation
• Prehospital medical direction

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Intellectual Skills of an EM Physician

• Phone interaction skills
• (consultants, families, nursing homes,
  EMS) Orchestrating health care resources
• ( ED as nerve center) Communication
  skills
• (bedside, fam. room, team leader/member) D
  ecision makers
• (a problem that you must treat)

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Intellectual Skills of an EM Physician

• Sick versus not sick
• What tests are needed
• What to order and when
• Admit versus Observation versus Home
• Floor versus ICU
• Treat now and with what
• Problem solvers

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What Makes a Good EM Physician?

• Able to think on your feet Multiple
  simultaneous task management Procedurally
  adept Organized and time efficient Nonjudgment
  al Thick skinned (No Thanks here) Stress
  junkie Enjoy prob. solving immediate
  gratification

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Unique Approach of EM Physicians

• Focused history PE (directed to the true
  problem) Pessimists (ROWCS Rule out worse case
  scenario). We have a single shot with the
  patient. Disposition critical
• When and wherehome, next day follow-up,
  observation unit, ward, telemetry or ICU.

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Practice Environments

• University hospital County
  hospital Teaching community hospital Community
  hospital Toxicology (consult
  inpatient) EMS (out of hospital
  care) Ambulatory care centers Observation
  units Cruise ship/travel
• Relief work/international

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EM Fellowships - ACGME Accredited

• Pediatric Emergency Medicine Medical
  Toxicology Sports Medicine Undersea
  Hyperbaric Medicine Hospice and Palliative
  Care

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EM Fellowships - other

• Non- ACGME accredited o EMS o Critical
  Care o Research Clinical, Bench, Health
  Systems o Clinical Teaching/ Education o ED
  Administration o International
  medicine o Ultrasonography o Geriatrics o Simul
  ation

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EM Research

• Where are most acute trials getting their
  patients?
• EM Research goes EVERYWHERE
• Stroke and Neuro Protection
• Resuscitation
• Acute Cardiac Syndromes
• Head Injury and Trauma
• Pain Management
• Infectious Disease

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Combined Training Opportunities

• EM-IM
• Hospitalist, academic, split
  time EM-Pediatrics
• Peds ED director/ academic/ hospitalist/
  split EM-IM-CCM
• Academic

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Non-Traditional Opportunities

• Deans office NHTSA CDC-P Industry
• - Pharmaceutical
• - Venture Capital
• - Bioengineering

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Resources

• Medical Student Section of SAEM Home
  pageMultiple articles ranging from career
  selection , planning your 4th year and
  interviewinghttp//www.saem.org
• SAEM Residency CatalogThe most comprehensive
  and current resource for objective information
  and comparisons of EM residencies.http//www.saem
  .org American Academy of Emergency
  MedicineRules of the Road for Medical Students,
  a 400 page comprehensive text. Free download to
  members (student membership is free)http//www.aa
  emres.org/rules_road.shtml Emergency Medicine
  Residents AssociationMost material is available
  only to members.http//www.emra.org

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Thanks!!!

• Drs. Chisholm and Katz
• The Residents and Faculty at Highland for
  inspiring me every day