Need Honest Opinions

[NewPoster]

I need honest opinions. I have a 260+ Step 1 and honors in all clinical rotations thus far (have done everything except pediatrics and psych). I am interested in EM for the pace/acuity/variety of complaints. I get bored easily and have found that I thrive in a somewhat chaotic, fast-paced environment. I don't like the idea of being a super sub-specialist, I want to be the kind of doctor that can "do it all." I was talking to an EM resident and he said that with my grades/scores, I should go right to a lifestyle specialty like rads or derm, and I shouldn't do EM. He sort of killed my dream for a hot second. Is there any truth to this? Is this a common sentiment?

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[doggydog]

Jesus.

 

[NewPoster]

Jesus.

Just trying to see if this is a common theme among EM residents (wishing they had gone into another field). This seems like the best place to do an informal poll.

 

[KinesiologyNerd]

This isn't going to end well.

 

[RustedFox]

 

[Strider_91]

Well being as no one is giving you a serious answer and I like posting I'll let you know what I think they are going to say just based on me stalking all the stickies and posts in this forum.


The general consensus seems to be that EM is not for everyone and is not really a lifestyle specialty but if you love what you do you can have a great life doing it. Do not go into any specialty because of the "lifestyle." No matter how good the lifestyle you will spend the majority of your life at work and if you hate derm and are miserable doing it you will have a terrible lifestyle. Even worse, everyone telling you it's a lifestyle specialty will probably make You even more miserable because it will not apply to you.

Also according to some on this forum EM is going down the tubes and becoming more bureaucratic by the minute but tbh that seems to be the general direction of medicine in any field but I'll let them tell you about that, they would know better.

Do something you love that will provide you the most fulfillment in life and if you feel that two fields will be equally fulfilling to you, go with the one that provides the better lifestyle for you personally not what the general consensus calls a lifestyle specialty.

I have no experience in EM so take what I'm saying with a grain of salt but I do have life experience and have watched people in my family go through life without passion/ fulfillment and it is a hard thing to see the look in a loved ones eye when they come home from a job they hate.

 

[name?]

I need honest opinions. I have a 260+ Step 1 and honors in all clinical rotations thus far (have done everything except pediatrics and psych). I am interested in EM for the pace/acuity/variety of complaints. I get bored easily and have found that I thrive in a somewhat chaotic, fast-paced environment. I don't like the idea of being a super sub-specialist, I want to be the kind of doctor that can "do it all." I was talking to an EM resident and he said that with my grades/scores, I should go right to a lifestyle specialty like rads or derm, and I shouldn't do EM. He sort of killed my dream for a hot second. Is there any truth to this? Is this a common sentiment?

When I think about spending my career in a dark room looking at pictures, or in a bright room looking at moles, my circadian rhythm sighs wistfully, but my soul cries. Those are great scores. Doesn't mean you should go into one thing vs another. Or, maybe I chose the wrong field and I'd be much happier treating psoriasis. It's possible, just not likely. Do what makes you happy. Smart docs in the ED who like hard work are great to work with and have fun most of the time. Holidays and nights get old, but taking care of people who are sick and dying (even on Christmas) is sort of why I did the whole doctor thing. My $0.02

 

[WilcoWorld]

I need honest opinions. I have a 260+ Step 1 and honors in all clinical rotations thus far (have done everything except pediatrics and psych). I am interested in EM for the pace/acuity/variety of complaints. I get bored easily and have found that I thrive in a somewhat chaotic, fast-paced environment. I don't like the idea of being a super sub-specialist, I want to be the kind of doctor that can "do it all." I was talking to an EM resident and he said that with my grades/scores, I should go right to a lifestyle specialty like rads or derm, and I shouldn't do EM. He sort of killed my dream for a hot second. Is there any truth to this? Is this a common sentiment?

The old phrase that is true about the general practice of medicine is especially true about EM:

If you can see yourself being happy doing anything else then you probably should. If you can't... welcome to the club.

 

[dadaddadaBATMAN]

That's exactly what a fox would say.

To op: you gotta do what you wanna do. But asking this is sort of like asking someone on a first date "Do you think I'm settling too much here? My friends tell me I could do better"

 

[erdoc00]

I had a 265 step1 and graduated #2 in my class. I had done tons of derm research but knew that ER was my calling.

I still love doing my third jail clearance of the night and having the cops restrain a belligerent obese intoxicated male who's spitting on the staff... I mean that's a life saved as much as anyone else. A chronic alcoholic blowing a .310 without any report or evidence of trauma is certainly something that requires years of specialized training in caring for acute emergencies.

same goes for the mentally ill homeless guy who's on his third visit for the week. I worked many years to develop the skills necessary to deliver him our finest boxlunch ham and cheese sandwich.

how about the PTA super parents with their honor roll kindergartner who has a fever of 100.1 (he usually runs low so anything above 99 is a feber in him) and isn't getting better since this morning. I'm sure glad I was at the top of my class in med school and paying attention during residency... could you imagine what wouldve happened to that poor child if I didn't prescribe those antibiotics!

Don't let the haters rain on your parade OP. If you have the chance to follow your heart, I say go for it.

there isn't a day (or night shift) (or evening shift) (or holiday shift) that goes by that I'm not grateful for the chance to be solving all of societies medical and social problems. I especially laugh at those poor unfulfilled suckers in their derm offices working 30 hours a week...

 

[erdoc00]

Oh I almost forgot... I loved psych too but didn't want to just limit myself to that full time...

I can't tell you how grateful I am to be involved with the multitude of personality disorders that overwhelm the ER on any given shift. I find Cluster B borderlines the most fulfilling personally!

 

[Psai]

Oh I almost forgot... I loved psych too but didn't want to just limit myself to that full time...

I can't tell you how grateful I am to be involved with the multitude of personality disorders that overwhelm the ER on any given shift. I find Cluster B borderlines the most fulfilling personally!

Oh god, I had one the other day and needed help but she used her splitting powers to get the rest of the staff against me. That was really annoying and I will never call for help again except from other physicians

 

[Strider_91]

I had a 265 step1 and graduated #2 in my class. I had done tons of derm research but knew that ER was my calling.

I still love doing my third jail clearance of the night and having the cops restrain a belligerent obese intoxicated male who's spitting on the staff... I mean that's a life saved as much as anyone else. A chronic alcoholic blowing a .310 without any report or evidence of trauma is certainly something that requires years of specialized training in caring for acute emergencies.

same goes for the mentally ill homeless guy who's on his third visit for the week. I worked many years to develop the skills necessary to deliver him our finest boxlunch ham and cheese sandwich.

how about the PTA super parents with their honor roll kindergartner who has a fever of 100.1 (he usually runs low so anything above 99 is a feber in him) and isn't getting better since this morning. I'm sure glad I was at the top of my class in med school and paying attention during residency... could you imagine what wouldve happened to that poor child if I didn't prescribe those antibiotics!

Don't let the haters rain on your parade OP. If you have the chance to follow your heart, I say go for it.

there isn't a day (or night shift) (or evening shift) (or holiday shift) that goes by that I'm not grateful for the chance to be solving all of societies medical and social problems. I especially laugh at those poor unfulfilled suckers in their derm offices working 30 hours a week...

So would you choose EM again? Do you hate your job?

 

[da8s0859q]

So would you choose EM again? Do you hate your job?

 

[RelicLTD]

I hope this doesn't devolve - I think the more polarizing sarcastic and idealistic responses we get, the better this thread will be... Where's birdstrike!?

 

[alpinism]

I hope this doesn't devolve - I think the more polarizing sarcastic and idealistic responses we get, the better this thread will be... Where's birdstrike!?

Too late.

Speaking of dermatology...


An actual patient I had not too long ago:

Chief complaint of leg pain in a 10 year old male

Me: tell me about this pain in your legs

Mom: the skin behind his knees is really dry and itchy

Me: what type of medical problems does he have?

Mom: oh he has eczema

Me: okay what does he use for the eczema?

Mom: hydrocortisone cream

Me: have you been using it?

Mom: we ran out last week.

Me: why didn't you get more?

Mom: well I’ve been too busy

Me: okay have you tried regular lotion then?

Mom: yes but it gets dry again after a few hours

Me: have you tried putting lotion on every few hours then?

Mom: well no I’ve been too busy

Me: have you tried having him put the lotion?

Mom: yes but he likes it better when I put on the lotion

Me: umm okay well have you tried benadryl for the itchiness?

Mom: we ran out of that too last week

Me: sigh ill give you some hydrocortisone and benadryl for now but you need to see your PCP and buy some from target or walmart.

Mom: ugh can't you do anything else for him??


Yes my friends this is Emergency Medicine in the year 2016.

 

[Psai]

Too late.

Speaking of dermatology...


An actual patient I had not too long ago:

Chief complaint of leg pain in a 10 year old male

Me: tell me about this pain in your legs

Mom: the skin behind his knees is really dry and itchy

Me: what type of medical problems does he have?

Mom: oh he has eczema

Me: okay what does he use for the eczema?

Mom: hydrocortisone cream

Me: have you been using it?

Mom: we ran out last week.

Me: why didn't you get more?

Mom: well I’ve been too busy

Me: okay have you tried regular lotion then?

Mom: yes but it gets dry again after a few hours

Me: have you tried putting lotion on every few hours then?

Mom: well no I’ve been too busy

Me: have you tried having him put the lotion?

Mom: yes but he likes it better when I put on the lotion

Me: umm okay well have you tried benadryl for the itchiness?

Mom: we ran out of that too last week

Me: sigh ill give you some hydrocortisone and benadryl for now but you need to see your PCP and buy some from target or walmart.

Mom: ugh can't you do anything else for him??


Yes my friends this is Emergency Medicine in the year 2016.

"I have medically evaluated your son and determined that you are not having an emergency. You are now free to leave the premises."

or "You think you're busy? See the 10 patients I have waiting for me who are having actual emergencies? Yeah. Bye."

Discharge.

2 minute visit, 3 minute documentation. Next.

 

[hebel]

I need honest opinions. I have a 260+ Step 1 and honors in all clinical rotations thus far (have done everything except pediatrics and psych). I am interested in EM for the pace/acuity/variety of complaints. I get bored easily and have found that I thrive in a somewhat chaotic, fast-paced environment. I don't like the idea of being a super sub-specialist, I want to be the kind of doctor that can "do it all." I was talking to an EM resident and he said that with my grades/scores, I should go right to a lifestyle specialty like rads or derm, and I shouldn't do EM. He sort of killed my dream for a hot second. Is there any truth to this? Is this a common sentiment?

Have you had any experience in the ED yet? If not, I would try to get some exposure because after experiencing it you may not have a dilemma anymore. EM sounded great to me on paper, and that was my plan. However, 2 EM rotations later I was already sick of it and switched to another specialty choice.

My thoughts are if you end up loving a specialty... congratulation, you're a lucky person and you should do that. If you don't love anything, make a list of what you liked (or atleast don't hate) and then pick the one with the best lifestyle/salary/job security combo for you.

 

[evilbooyaa]

Too late.

Speaking of dermatology...


An actual patient I had not too long ago:

Chief complaint of leg pain in a 10 year old male

Me: tell me about this pain in your legs

Mom: the skin behind his knees is really dry and itchy

Me: what type of medical problems does he have?

Mom: oh he has eczema

Me: okay what does he use for the eczema?

Mom: hydrocortisone cream

Me: have you been using it?

Mom: we ran out last week.

Me: why didn't you get more?

Mom: well I’ve been too busy

Me: okay have you tried regular lotion then?

Mom: yes but it gets dry again after a few hours

Me: have you tried putting lotion on every few hours then?

Mom: well no I’ve been too busy

Me: have you tried having him put the lotion?

Mom: yes but he likes it better when I put on the lotion

Me: umm okay well have you tried benadryl for the itchiness?

Mom: we ran out of that too last week

Me: sigh ill give you some hydrocortisone and benadryl for now but you need to see your PCP and buy some from target or walmart.

Mom: ugh can't you do anything else for him??


Yes my friends this is Emergency Medicine in the year 2016.

To bolded - clearly not too busy to come to the emergency department instead of just getting the medications that help with the condition.

 

[RustedFox]

"I have medically evaluated your son and determined that you are not having an emergency. You are now free to leave the premises."

or "You think you're busy? See the 10 patients I have waiting for me who are having actual emergencies? Yeah. Bye."

Discharge.

2 minute visit, 3 minute documentation. Next.

You're a ressie, so that flies for now.
Out here in community land, not so much.

 

[BAM!]

I say do ortho instead. unless you're a weakling.

 

[BAM!]

Here's why I did Emergency Medicine. This applies to all the other snowboarder, surfer, sky diver, bucking bronco riding, rockclimbing thrill seekers out there.

Perhaps an analogy will help: Imagine you're surfing. You see a set wave. it lines up perfectly. It's a little bigger than you're comfortable with but you decide to go for it anyway. You make a steep drop and power down the line as fast as you can. Your eyes are focused on the lip which slowly starts to curl over you. You're 100% focused on not falling for fear of getting obliterated by the power of the ocean. You slide out of the tube and over to safety. It makes you feel alive! You want to talk with your pals about it. You have never felt so awake in your life.

There are moments like this in the Emergency Department which make you feel alive, awake, and completely focused. They are sometimes brandished in incredible emotions, both good and bad.

...but like anything. running codes gets old. placing people on life support loses its sex appeal. I'd rather call a surgeon to put a chest tube in than do it myself. I've been there enough times that now it's work. At some point, the romance of the Emergency Department will no longer make you feel as alive as it once did. And it may happen sooner than you think.

I'm sure you can have similar experiences in other fields, in different ways. And yes, EM still has moments of greatness. It's actually a pretty good career choice. But unless you know you'll be happy pulling nights, weekends, and holidays at 50 years old, I say choose something more cush.

 

[mega_colon]

As someone who watched personable derm applicants with 270 steps go unmatched last year, don't discount the competition you will have there.

Going 260+ is no guarantee you won't be scrambling prelim in the end.

 

[Psai]

As someone who watched personable derm applicants with 270 steps go unmatched last year, don't discount the competition you will have there.

Going 260+ is no guarantee you won't be scrambling prelim in the end.

Saw this too. Even happens from top schools.

 

[NWwildcat2013]

I need honest opinions. I have a 260+ Step 1 and honors in all clinical rotations thus far (have done everything except pediatrics and psych). I am interested in EM for the pace/acuity/variety of complaints. I get bored easily and have found that I thrive in a somewhat chaotic, fast-paced environment. I don't like the idea of being a super sub-specialist, I want to be the kind of doctor that can "do it all." I was talking to an EM resident and he said that with my grades/scores, I should go right to a lifestyle specialty like rads or derm, and I shouldn't do EM. He sort of killed my dream for a hot second. Is there any truth to this? Is this a common sentiment?

Dont listen to these people. They are just projecting what they wish they could do (well informed or not) onto your situation. I have similar scores and whenever I express an interest in neuro to classmates they scrunch their face and say something about not ever fixing anything and wasting my score and then something about skin or bones being better.

 

[erdoc00]

Dont listen to these people. They are just projecting what they wish they could do (well informed or not) onto your situation. I have similar scores and whenever I express an interest in neuro to classmates they scrunch their face and say something about not ever fixing anything and wasting my score and then something about skin or bones being better.

Yes, all these people "projecting" with years of actual experience as an attending and having already completed residency.

Theres a reason certain specialities have better overall satisfaction when doctors are surveyed. While certainly every individual is different, I think these general trends exist for a reason. But disregard experienced feedback in favor of feeling like you know better; that's surely a more informed position than an attending's "projection."

 

[NWwildcat2013]

.

 

[Danbo1957]

Here's why I did Emergency Medicine.

...but like anything. running codes gets old. placing people on life support loses its sex appeal.

man, that was funny. (wipes eyes with a sniffle)

 

[alexalex]

Dear god people. You got nice scores, great. Whya re you sharing them with residents? I don't know, but what I do know is that you should choose whatever you WANT TO DO FOR THE REST OF YOUR LIFE. If I had woken up a year ago to a 210 or 260 I would still be doing the same damn thing, and everyone should. clearly you will need a backup if in lower end and aiming high, and you will have an easier road for something less competitive, but your life and your likes are still more important than a number or someone else's opinion. If you are unsure about a specialty that is one thing, but being worried that you are "wasting a score" is ridiculous. Grow up and find yourself something you are passionate about so that you don't waste your life and talent.

 

[RustedFox]

Dear god people. You got nice scores, great. Whya re you sharing them with residents? I don't know, but what I do know is that you should choose whatever you WANT TO DO FOR THE REST OF YOUR LIFE. If I had woken up a year ago to a 210 or 260 I would still be doing the same damn thing, and everyone should. clearly you will need a backup if in lower end and aiming high, and you will have an easier road for something less competitive, but your life and your likes are still more important than a number or someone else's opinion. If you are unsure about a specialty that is one thing, but being worried that you are "wasting a score" is ridiculous. Grow up and find yourself something you are passionate about so that you don't waste your life and talent.

I don't always quote posts. But when I do, I quote for truth.

 

[RustedFox]

Dear god people. You got nice scores, great. Whya re you sharing them with residents? I don't know, but what I do know is that you should choose whatever you WANT TO DO FOR THE REST OF YOUR LIFE. If I had woken up a year ago to a 210 or 260 I would still be doing the same damn thing, and everyone should. clearly you will need a backup if in lower end and aiming high, and you will have an easier road for something less competitive, but your life and your likes are still more important than a number or someone else's opinion. If you are unsure about a specialty that is one thing, but being worried that you are "wasting a score" is ridiculous. Grow up and find yourself something you are passionate about so that you don't waste your life and talent.

This is... the most interesting medical student.... in the world.

 

[FootballFoot]

Yes, all these people "projecting" with years of actual experience as an attending and having already completed residency.

Theres a reason certain specialities have better overall satisfaction when doctors are surveyed. While certainly every individual is different, I think these general trends exist for a reason. But disregard experienced feedback in favor of feeling like you know better; that's surely a more informed position than an attending's "projection."

EM is #3 on satisfaction I think.


I made a mistake. It was actually #5, but that's still pretty high imo.

 

[Tenk]

Do whatever you want to do for the next 20-30 years and don't look back.

 

[PlutoBoy]

I need honest opinions. I have a 260+ Step 1 and honors in all clinical rotations thus far (have done everything except pediatrics and psych). I am interested in EM for the pace/acuity/variety of complaints. I get bored easily and have found that I thrive in a somewhat chaotic, fast-paced environment. I don't like the idea of being a super sub-specialist, I want to be the kind of doctor that can "do it all." I was talking to an EM resident and he said that with my grades/scores, I should go right to a lifestyle specialty like rads or derm, and I shouldn't do EM. He sort of killed my dream for a hot second. Is there any truth to this? Is this a common sentiment?

Do derm and don't look back!

 

[fahimaz7]

I need honest opinions. I have a 260+ Step 1 and honors in all clinical rotations thus far (have done everything except pediatrics and psych). I am interested in EM for the pace/acuity/variety of complaints. I get bored easily and have found that I thrive in a somewhat chaotic, fast-paced environment. I don't like the idea of being a super sub-specialist, I want to be the kind of doctor that can "do it all." I was talking to an EM resident and he said that with my grades/scores, I should go right to a lifestyle specialty like rads or derm, and I shouldn't do EM. He sort of killed my dream for a hot second. Is there any truth to this? Is this a common sentiment?

3.95/260/270/260
I am happy in EM. Wouldn't have changed a thing. Do what makes you happy and not what others think will make you happy.

 

[RustedFox]

Earlier in the thread (not quoting the whole thing) it was mentioned how "He normally runs 97.6 so 99.8 is a fever for him" is a common chorus amongst ppl.

I hate this nonsense so much. So much. There are many things that piss me off, but this one in particular just squeezes on my nutsac.

My community education outreach can only go so far, and then there are those granola-munching, yin-yang as$holes that just won't listen.

Its that 2% that ruin it for the whole lot of parents out there. Discharged. Discharged. Discharged. I used to be generally willing to listen and instruct and establish rapport, and all that nonsense.

Not anymore.

No.

Eff you.


Discharged.


Maybe thru negative reinforcement, they will learn that "this is not what the ER is for".

I want to see a :15 second news soundbyte on EVERY DAY TV, saying "that's not what the ER is for".

"Does your child look good, but hasn't pooped today? That's not what the ER is for."
"Does your child have a fever, but it went down with Tylenol and then came back 6 hours later? That's not what the ER is for."

[ fill in the rest for me, homeboys - you get the idea ]

(.....)

I hate to say it, but I think this sourness might really be a product of my environment, now that I think of it.

I worked with dChristismi at her shop for a year or so. I would work with her again in a heartbeat. THAT gal has critical care chops like I don't have anymore. Period. I was not so cold and callous when I worked there. I regularly went "down to the lake out back" after a shift and just thanked the universe, or God/Yahweh/Adonai/Whatever that I was still happy and healthy.


RustedFox's soul is exposed and on-trial here on SDN. Exalt me or take me to the woodshed as you see fit.

Hey, dChristisimi... if there's a shift that needs to be filled up there, call me - homegirl.

 

[gutonc]

Man...RF is hammered.

 

[Psai]

Earlier in the thread (not quoting the whole thing) it was mentioned how "He normally runs 97.6 so 99.8 is a fever for him" is a common chorus amongst ppl.

I hate this nonsense so much. So much. There are many things that piss me off, but this one in particular just squeezes on my nutsac.

My community education outreach can only go so far, and then there are those granola-munching, yin-yang as$holes that just won't listen.

Its that 2% that ruin it for the whole lot of parents out there. Discharged. Discharged. Discharged. I used to be generally willing to listen and instruct and establish rapport, and all that nonsense.

Not anymore.

No.

Eff you.


Discharged.


Maybe thru negative reinforcement, they will learn that "this is not what the ER is for".

I want to see a :15 second news soundbyte on EVERY DAY TV, saying "that's not what the ER is for".

"Does your child look good, but hasn't pooped today? That's not what the ER is for."
"Does your child have a fever, but it went down with Tylenol and then came back 6 hours later? That's not what the ER is for."

[ fill in the rest for me, homeboys - you get the idea ]

(.....)

I hate to say it, but I think this sourness might really be a product of my environment, now that I think of it.

I worked with dChristismi at her shop for a year or so. I would work with her again in a heartbeat. THAT gal has critical care chops like I don't have anymore. Period. I was not so cold and callous when I worked there. I regularly went "down to the lake out back" after a shift and just thanked the universe, or God/Yahweh/Adonai/Whatever that I was still happy and healthy.


RustedFox's soul is exposed and on-trial here on SDN. Exalt me or take me to the woodshed as you see fit.

Hey, dChristisimi... if there's a shift that needs to be filled up there, call me - homegirl.

10/10 awesome attending, highly recommend a+++++ would work with again

 

[e30ftw]

Earlier in the thread (not quoting the whole thing) it was mentioned how "He normally runs 97.6 so 99.8 is a fever for him" is a common chorus amongst ppl.

I hate this nonsense so much. So much.

omg yes...

two pts from my last shift that may or may not be hypothetical (ages changed for hipaa)

6 y/o m presents as call-in from allergist for "anaphylaxis". Mom states pt has been complaining of intermittent abd pain at school dx by school RN as allergic rxn causing him to be sent home from school multiple times over past 6 mo. Saw allergist today, had approx 50 billion allergy tests, all were negative, child then went w/ parents, ate a hamburger or something, c/o abd pain, vomited once, parents called allergist, who said, "you may be having anaphylaxis go to ER for a serum tryptase level."

child looks totally fine, normal vs, no urticaria, only hx was n/v x 1 etc. I told parents, no way is this anaphylaxis, I don't think he needs the blood draw (tryptase is a crap test anyway) parents say, "oh please call his allergist and do what she wants." I call allergist, say basically "This child is not having anaphylaxis, do you still want this test?" to which she replies, "yes". Child stuck for the hundredth time that day, screaming, etc etc. I go back PO challenge the kid, parents seem mildly annoyed by my insistence that this is not anaphylaxis and mild suggestion that maybe it's because he's a kid and kids throw up, throw me a "what do you know you're just an ER doctor" glance, discharged.

Second case from same shift:

~8 y/o f pw several bug bites to her forehead, cheeks, and right arm. Noticed at school today after recess. Mom took kid to peds urgent care where kid told pediatrician there that "my tongue feels tingly" causing pediatrician to diagnose her bug bites (present for about 8 hrs at this point) as anaphylaxis, gave her EPI/benadryl, and sent her to the ED for 4 hrs obs.. No urticaria, just bug bites x 8 hrs and a normal exam with a "tingly tongue". status post epi.

I love EM for the most part but this **** drives me crazy.

 

[erdoc00]

omg yes...

two pts from my last shift that may or may not be hypothetical (ages changed for hipaa)

6 y/o m presents as call-in from allergist for "anaphylaxis". Mom states pt has been complaining of intermittent abd pain at school dx by school RN as allergic rxn causing him to be sent home from school multiple times over past 6 mo. Saw allergist today, had approx 50 billion allergy tests, all were negative, child then went w/ parents, ate a hamburger or something, c/o abd pain, vomited once, parents called allergist, who said, "you may be having anaphylaxis go to ER for a serum tryptase level."

child looks totally fine, normal vs, no urticaria, only hx was n/v x 1 etc. I told parents, no way is this anaphylaxis, I don't think he needs the blood draw (tryptase is a crap test anyway) parents say, "oh please call his allergist and do what she wants." I call allergist, say basically "This child is not having anaphylaxis, do you still want this test?" to which she replies, "yes". Child stuck for the hundredth time that day, screaming, etc etc. I go back PO challenge the kid, parents seem mildly annoyed by my insistence that this is not anaphylaxis and mild suggestion that maybe it's because he's a kid and kids throw up, throw me a "what do you know you're just an ER doctor" glance, discharged.

Second case from same shift:

~8 y/o f pw several bug bites to her forehead, cheeks, and right arm. Noticed at school today after recess. Mom took kid to peds urgent care where kid told pediatrician there that "my tongue feels tingly" causing pediatrician to diagnose her bug bites (present for about 8 hrs at this point) as anaphylaxis, gave her EPI/benadryl, and sent her to the ED for 4 hrs obs.. No urticaria, just bug bites x 8 hrs and a normal exam with a "tingly tongue". status post epi.

I love EM for the most part but this **** drives me crazy.

Those two are some special practitoners... life savers really!

 

[TooMuchResearch]

You're a ressie, so that flies for now.
Out here in community land, not so much.

I don't do that as a resident either.

 

[BAM!]

"I have medically evaluated your son and determined that you are not having an emergency. You are now free to leave the premises."

or "You think you're busy? See the 10 patients I have waiting for me who are having actual emergencies? Yeah. Bye."

Discharge.

2 minute visit, 3 minute documentation. Next.

I get this.

but do you every feel guilty for charging them $150 then kicking them out? (yeah i know, deductibles, insurance companies, copays...)

how about a, "sorry you have the wrong impression of what this place is," as you tell registration no-charge and kick them out. or bill a level 1.

...OR is balance billing the icing on the cake?!

 

[FootballFoot]

Earlier in the thread (not quoting the whole thing) it was mentioned how "He normally runs 97.6 so 99.8 is a fever for him" is a common chorus amongst ppl.

I hate this nonsense so much. So much. There are many things that piss me off, but this one in particular just squeezes on my nutsac.

My community education outreach can only go so far, and then there are those granola-munching, yin-yang as$holes that just won't listen.

Its that 2% that ruin it for the whole lot of parents out there. Discharged. Discharged. Discharged. I used to be generally willing to listen and instruct and establish rapport, and all that nonsense.

Not anymore.

No.

Eff you.


Discharged.


Maybe thru negative reinforcement, they will learn that "this is not what the ER is for".

I want to see a :15 second news soundbyte on EVERY DAY TV, saying "that's not what the ER is for".

"Does your child look good, but hasn't pooped today? That's not what the ER is for."
"Does your child have a fever, but it went down with Tylenol and then came back 6 hours later? That's not what the ER is for."

[ fill in the rest for me, homeboys - you get the idea ]

(.....)

I hate to say it, but I think this sourness might really be a product of my environment, now that I think of it.

I worked with dChristismi at her shop for a year or so. I would work with her again in a heartbeat. THAT gal has critical care chops like I don't have anymore. Period. I was not so cold and callous when I worked there. I regularly went "down to the lake out back" after a shift and just thanked the universe, or God/Yahweh/Adonai/Whatever that I was still happy and healthy.


RustedFox's soul is exposed and on-trial here on SDN. Exalt me or take me to the woodshed as you see fit.

Hey, dChristisimi... if there's a shift that needs to be filled up there, call me - homegirl.

omg yes...

two pts from my last shift that may or may not be hypothetical (ages changed for hipaa)

6 y/o m presents as call-in from allergist for "anaphylaxis". Mom states pt has been complaining of intermittent abd pain at school dx by school RN as allergic rxn causing him to be sent home from school multiple times over past 6 mo. Saw allergist today, had approx 50 billion allergy tests, all were negative, child then went w/ parents, ate a hamburger or something, c/o abd pain, vomited once, parents called allergist, who said, "you may be having anaphylaxis go to ER for a serum tryptase level."

child looks totally fine, normal vs, no urticaria, only hx was n/v x 1 etc. I told parents, no way is this anaphylaxis, I don't think he needs the blood draw (tryptase is a crap test anyway) parents say, "oh please call his allergist and do what she wants." I call allergist, say basically "This child is not having anaphylaxis, do you still want this test?" to which she replies, "yes". Child stuck for the hundredth time that day, screaming, etc etc. I go back PO challenge the kid, parents seem mildly annoyed by my insistence that this is not anaphylaxis and mild suggestion that maybe it's because he's a kid and kids throw up, throw me a "what do you know you're just an ER doctor" glance, discharged.

Second case from same shift:

~8 y/o f pw several bug bites to her forehead, cheeks, and right arm. Noticed at school today after recess. Mom took kid to peds urgent care where kid told pediatrician there that "my tongue feels tingly" causing pediatrician to diagnose her bug bites (present for about 8 hrs at this point) as anaphylaxis, gave her EPI/benadryl, and sent her to the ED for 4 hrs obs.. No urticaria, just bug bites x 8 hrs and a normal exam with a "tingly tongue". status post epi.

I love EM for the most part but this **** drives me crazy.

When you go against the patients' desires like that, does that affect you negatively on your Press-Ganey scores? And do you think that poses a risk to your employment stability?

 

[Psai]

I get this.

but do you every feel guilty for charging them $150 then kicking them out? (yeah i know, deductibles, insurance companies, copays...)

how about a, "sorry you have the wrong impression of what this place is," as you tell registration no-charge and kick them out. or bill a level 1.

...OR is balance billing the icing on the cake?!

I mean the word emergency is right on the name of the place. It's not that hard to determine what's an emergency and what's not.

Also I don't get a cent from them so I don't care. I get paid the same whether I see 10 patients or 20 patients a shift.

 

[e30ftw]

When you go against the patients' desires like that, does that affect you negatively on your Press-Ganey scores? And do you think that poses a risk to your employment stability?

No. We do not send Press-Ganey surveys; I have a great medical director and am not at all worried about my job being threatened by attempting to do the right thing for my patients. That said part of the "art" of community medicine is safely treating your patient and making them happy without initiating unnecessary and potentially harmful therapy.

FWIW in both of those cases I "went along" with the parent's desires, or more accurately, I went along with the care plan laid out by the physician who sent the patient in to be evaluated. I just told them my assessment, which happened to be different than their primary care physician's.. in the first case the parents were mildly annoyed (because they wanted something to be wrong with their kid other than just separation anxiety, etc) in the second case the mom was completely understanding and agreed with me, "I don't know why they told us to come over here.." etc. I find in most of these completely bonkers peds cases sent from urgent cares the parents are just as confused as I am as to why the provider they saw couldn't handle the situation..

 

[e30ftw]

I mean the word emergency is right on the name of the place. It's not that hard to determine what's an emergency and what's not.

Also I don't get a cent from them so I don't care. I get paid the same whether I see 10 patients or 20 patients a shift.

Actually Congress and the court has determined that an Emergency Physician/provider (although not always ABEM..) is required to determine what is or is not an emergency.

It can be annoying at times but is excellent job security.

We like to complain about some of the outliers, but it is extremely important to make your patients happy, for many reasons.

 

[alpinism]

Actually Congress and the court has determined that an Emergency Physician/provider (although not always ABEM..) is required to determine what is or is not an emergency.

It can be annoying at times but is excellent job security.

We like to complain about some of the outliers, but it is extremely important to make your patients happy, for many reasons.

Yeah that's not exactly true.

Straight from the CMS website explaining the requirements for a MSE:

"A hospital must formally determine who is qualified to perform the initial medical screening examinations, i.e., qualified medical person. While it is permissible for a hospital to designate a non-physician practitioner as the qualified medical person, the designated non-physician practitioners must be set forth in a document that is approved by the governing body of the hospital. Those health practitioners designated to perform medical screening examinations are to be identified in the hospital by-laws or in the rules and regulations governing the medical staff following governing body approval. It is not acceptable for the hospital to allow the medical director of the emergency department to make what may be informal personnel appointments that could frequently change."

According to the regulation anyone who is a "qualified medical person" can perform a MSE including MDs, PAs, and RNs.

 

[e30ftw]

Which is why in the bolded part of what you quoted I specifically stated physician/provider. Provider is a broad term that includes "practitioners" as stated in your above copy/paste from CMS.

...