Category Archives: Medical Specialty

The real “ER”

When I think about my childhood and what I imagined I’d be doing when I get older–Dr. Mark Green from the series “ER” comes to mind. I grew up every Thursday night watching the show with my mom. I loved everything about the gritty, fast-paced drama. When some gruesome scene of a thoracotomy came on, my mom, turning away from the screen with a look of horror and disgust, would say, “you really want to do this in life?!” And I would sit there grinning, wide-eyed…and nod my head, yes, I can’t wait.

I’m very much still the same person who turns towards the terrible things in life. Twenty years later, it is in the Emergency Department where I feel most comfortable in the vastness that is medicine. It is unpolished, unapologetic, rough around the edges, a meeting ground of people from all walks of life. It takes a certain personality to want to spend time there. I am privileged and humbled to be there to help.

The heart of emergency medicine is what we call the “undifferentiated patient”–in layman’s terms, a patient with a complaint but no diagnosis–it is up to us–the Emergency Medicine folks to try to figure out what is causing your chest pain, stomach pain or swollen calf. We hone in on your story, symptoms, vital signs and labs to begin to narrow down from the hundreds of possible diagnoses the two or three life-threatening ones. It is our job to make sure you don’t have them and treat if you do.

Every patient is a mystery diagnosis. We don’t know you. Many times we’ve never met you or have the luxury of previous notes from your regular physicians. Yet we get to figure out what is wrong with you. Our job has been described as the most exciting 60 minutes of every speciality. And it is true. We get to see almost every diagnosis in medicine.  

Unlike the TV shows, our job is not always full-throttle, chest tubes flying, ribs cracking, shocking people (we don’t even use those paddles any more). It is some combination of charting, bedside procedures, discussions with patients, discussions with consultants and juggling a million and one tasks at once. I will say, twelve hours in the ED can fly by in a blink.

As I finish up my second month rotating in the speciality, here are the most exciting, the most typical and the most unusual things I’ve come across:

  • The normal stuff-Charting: No TV show ever shows just how much time we spend documenting. It would bore most viewers to death if they had to sit through our clicking. But that is a huge part of what we do. We pick up patients when they turn “red” on our screen (that is, the patient is finally in a bed after waiting for a very long time for that bed to become available) and after our 10 minute conversation and physical exam, we spend often double that time making sure we meticulously document our encounter. In today’s age of complicated medical coding systems and reimbursement it is just part of the job.
  • The normal stuff-Placing orders, waiting for results: After we meet you, our investigation begins. Even before we set foot in your room we begin critically thinking about the potential causes of your complaint and what path we’ll need to go down. Emergency medicine is very chief complaint driven. That is, whatever symptom is bringing you here must have a cause and in our department we love ruling things in and out-specifically the scary stuff. We geek out on pre-test probabilities, most likely scenarios, typical presentations and making sure we never ever miss anything that can kill you. That is our job in a nutshell. We place orders to relieve your symptoms and investigate the cause. Often this means juggling multiple patients and checking back on our results, re-accessing, going down a different path based on what we find. TV shows never show just how calculated our job is. Emergency Medicine doesn’t exactly have the best reputation of being the “thinking” speciality, but I beg to differ that we actually ponder and digest just as much if not more than the internal medicine folks–for us things are just done at a faster pace. Things can change in an instant and we are constantly on guard, re-prioritizing, changing course and staying on top of the very dynamic place we call the ED.
  • The exciting stuff: Yes, Emergency Departments get the sickest patients. We have to move quickly when things are going terribly wrong. We get to put in airways when you are about to stop breathing; chest tubes when you collapsed your lung or have a pleural cavity filled with blood; we place central lines when your blood pressure is low and your body is in septic shock; we even put needles into the sac around your heart when there is blood constricting it from beating; we stich up foreheads after bar fights and reduce shoulders that have popped out of their socket. We pretty much get to do lots and lots of amazing, adrenaline inducing procedures. But those are the sorts of things that break up your shift, most of the time we are just seeing patients, thinking about them and charting.
  • The abnormal but normal to us stuff: We get to see some of the oddest things that can happen to a person. Some visits are heartbreaking. Some are humorous. Some are really annoying. Others catch you off guard. We see the best and worst of humanity. You absolutely never know what is about to walk through the door and that makes our job so unique.

The past two months have been the best. I love all the mundane, the exciting, the normal and the difficult parts of my future career. Each of my rotations has been very different, building on my skill set and continuing to add to it. I’m so excited about the career path I have chosen and very proud to call myself a future ED physician. I have one more EM rotation ahead of me and then the process of applying for residency!

 

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Choosing a Specialty

Now that I’ve been accepted to medical school a common question I often get is, “what type of doctor do you want to be?” Great question, the answer to which will very likely change as my knowledge of anatomy, pathology and disease transforms from something abstract and superficial to real knowledge. Choosing a specialty is one of the most important decisions a medical student will have to make. In just three years, we will begin the process of applying to residency programs, at which point you pretty much have to know what field of medicine you want to be involved in.

Hopefully, study of the various body systems in years 1 and 2 of medical school will help illuminate this for most students–piquing an interest in the brain or the kidneys or some other specialty. If that isn’t enough, medical students get plenty of help guiding them in this decision through exposure to various specialties via clinical rotations in years 3 and 4, mentors, specialty interest groups and shadowing opportunities.

I recently learned that the University of California Irvine Medical School administers the Myers-Briggs Personality Test to students during orientation to help match their personality and temperament with the residency best suited for them.

“…the Myers‐Briggs Type Indicator (MBTI) has become the most popular and widely used psychological test in the world. Based on Carl Jung’s theory of personality types, the MBTI was designed to analyze personality in a systematic, scientific manner. Where other questionnaires (type tests) only illustrate type, the MBTI precisely identifies a person’s personality type preferences. The test enables you to learn more about how you perceive and judge others, whether in an occupational or social situation. It identifies your strengths and weaknesses and shows whether you value autonomy or prefer interdependence.”

To learn more about the MBTI or to take the test for yourself, you can visit the following site.

In addition, the Student Doctor Network (SDN) has a free online test you can take that helps to match you with the specialty best suited for you: try it here

When I did the SDN test my top five results were: physical medicine and rehab (what?! no interest there), internal medicine oncology/hematology (right on), family medicine (boring), internal medicine-nephrology (hmm interesting!), emergency medicine.

It will be interesting to look back on this time and see how my interests have changed. To date, I’ve had the most exposure to Emergency Room physicians and so it’s no wonder the ED specialty ranks at the top of my list. In addition, here are where my current specialty interests lie:

1. Emergency Medicine

Why I like it: As an adrenaline junkie and someone who thrives on high pressure, high stress jobs, I really enjoy the fast-moving nature of this specialty. Every day is different. It allows you to see a huge spectrum of disease touching on pretty much every specialty (you don’t have to choose just one!). You get to perform really fun medical detective work- typically you have never met the patient and must form a diagnosis and treatment plan based on sound clinical judgement and skills of interpreting results/clinical presentation. You literally have someone’s life in your hands and can have the instant gratification of seeing that person get better. Shift work. No “on call.” Good work-life balance. Great for women.

What I don’t like about it: This is actually something I do like about it, but my body doesn’t. You are on your feet all day and it’s a physically demanding specialty. Although I personally enjoy this aspect, I am worried that because of my POTS, as much as I want to do it- I won’t be able to. It is currently very difficult for me to stand for 4 or more, let alone 12 hours, without feeling extremely fatigued. My heart is in a constant state of tachycardia and there are some as of yet unexplained physiological things going on that cause me to feel weak, sore and tired after this type of  excursion. I am working with my cardiologist to improve my physical stamina so my hope is that in four years I may not have this problem. I do have to be realistic however and it’s very likely I simply won’t improve much beyond where I am today.

2. Oncology

What I like about it: This is a very intellectually stimulating field which would allow me to have a dual role as a clinician and researcher. An interest in cancer is in my blood- both of my parents are cancer researchers focusing on novel drug development. As strange as it sounds, your patients are actually sick and you are able to help them. Often times in the ER patients come in with complaints but no real illness- some of them are just lonely. The field is constantly advancing and there is opportunity to play a role in that advancement.

What I don’t like about it: Exhausting all medical possibilities yet your patient still dies-often. Seeing patients suffer more because of the medicine you give them. Dealing with death that is slow and predictable.

3. Cardiology

What I like about it: I find the heart really fascinating and I have a keen interest in disease states of the cardiovascular system. Partly because of my own experience, I am drawn to cardiology and particularly further research on POTS and autonomic disorders. Same as for oncology, you get to establish long term relationships with your patient and create a continuum of care. Satisfaction of seeing someone improve by making positive changes in their lives to reduce disease state. You get to do procedures (stents, cath lab) and interesting diagnostic exams (echo-cardiograms, stress tests, etc.).

What I don’t like about it: So many of your patients are old. Nothing against old people, but I like a varied patient population. Seeing improvement in patients often requires real life-style changes from the patient and being frustrated when that doesn’t happen.

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