A State of Emergency: Exploring the Specialty of Emergency Medicine

Perhaps no single aspect of medicine is more visible to the public, especially in stories, film, and television, than the emergency department. Scenes of a crowded room, patients on the verge of death needing major interventions, followed by emotional conversations with family members—these are familiar to anyone who has watched even a few hours of American TV. While these scenes do happen, they provide a limited view of the specialty of emergency medicine. If these extreme scenarios are tempered instead by the average person’s other knowledge of the emergency department – personal, experiential knowledge—then the picture becomes more realistic. (Most people have gone to the ER themselves, or with a friend/family member, for a complaint much less acute, e.g., “It’s probably nothing, but I should get it checked out anyway.”) Patients presenting with “nothing,” patients presenting on the brink of death, and everything in between: this is the specialty of emergency medicine.

Emergency medicine is one of the newer medical specialties, despite the existence of emergency rooms and doctors who worked in them long before it was an independent, board-certified specialty. The growth of emergency medicine training programs, the numbers of specialists, and now, the increasing competitiveness of the field for medical students, all reflect cultural shifts in the practice of medicine and public health. Historically, most patients had a family physician who worked in a small community, did house visits, and managed their care while hospitalized, if needed. This is now rare, and many patients don’t have a family doctor at all, let alone one who would manage their care in an acute setting. As such, many patients now seek care primarily in the emergency department; additionally, it has become the most common entry point for hospital admissions.

Emergency medicine physicians are experts at triage: assessment, diagnosis, immediate interventions, and important decision-making. Generally, EM physicians must make decisions quickly: how sick is this patient? Do they need admitted to a hospital or can they go home? Could this disease process be fatal? What can I do to make them stable so one of the above decisions can be made? Because the emergency department involves all levels of severity, EM doctors must be prepared to deal with anything—they may counsel a patient about the results of a pregnancy test, after which they may stabilize a patient with multiple gunshot wounds, after which they may diagnose a common cold.

This structure means that EM doctors must be good at multitasking, fast decision makers, and unafraid to jump in and get to work. It also means being prepared for anything. Shifts can be busy and stressful or relaxed and slow, and it could change in an instant. For this reason, emergency physicians work in shifts, somewhat unique among specialties. This is an appealing aspect of the specialty for many medical students—there is no call and rarely, relative to other specialties, does work follow the physicians home. The tradeoff, of course, is that the emergency room is open 24 hours a day, every single day of the year, so shifts can be days, nights, weekends, holidays. EM doctors work fewer hours than many specialties (a typical schedule might be 16 9-hr shifts per month) but the shifts may be at unpredictable and shifting times.

The American College of Emergency Physicians (ACEP) defines the specialty this way: “the medical specialty devoted to the diagnosis and treatment of unforeseen illness.” Given this definition, it is no wonder that the emergency department is not necessarily filled with “emergencies.” In fact, the word emergency does not even feature in the definition. Instead, it is entirely up to the patient to pursue treatment, and it is the physician’s job to assess and treat them regardless of his or her own feelings about the severity of the problem. The most incredible aspect of the specialty, to me, is this arms-wide-open approach: the emergency department is open and available to any patient, any time. EM doctors must provide unbiased medical care to anyone who walks in, demonstrating true willingness to take care of everyone who shows up asking for help. The emergency department manages the medical care of the poorest and the richest, of those with or without insurance, of the sick and the well, of cops and criminals, and everyone in between.

In my last required rotation of medical school, I was encouraged by how much I’ve learned during this rotation. The opportunity to talk to patients and provide comfort, reassurance, and when possible, relief, remains a great honor. I also really enjoyed the variety provided by the rotation, because of the nature of emergency medicine. Each shift, and each new patient, was a new opportunity to be surprised. Sometimes the patient’s chief complaint would be spot on and send us down one path of diagnosis, and sometimes we would be surprised at what we found. Although I’m not pursuing emergency medicine as my own specialty, I am grateful to have spent four weeks doing it, sharpening my own knowledge on a variety of topics, practicing skills, and providing medical care to people from all walks of life.

This column is coming to a close —next month I will profile several “smaller” (in terms of percentage of matching students) specialties that haven’t yet gotten a look. After that I will share some final thoughts on interviewing the Match, the ranking process, and more. Stay tuned!

Brent Schnipke

Brent Schnipke, MD is a writer based in Dayton, OH. He graduated medical school in 2018 and is psychiatry resident at Wright State University Boonshoft School of Medicine. His professional interests include medical humanities, mental health, and medical education.

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