Type A? Quick-thinking? Adrenaline junkie? Emergency medicine awaits you
John F. Dery, DO (right), is an associate medical director for Michigan’s Life Net Helicopter EMS. (Photo courtesy of Dr. Dery)
This is the fifth in a series of articles profiling medical specialties. The first article focused on anesthesiology, the second on physical medicine and rehabilitation, the third on osteopathic manipulative medicine and the fourth on dermatology.
Quintessential Type A personalities, emergency physicians thrive on the fast pace and variety of their field. “What other job could I have where I get paid to shove big needles in people’s backs and put a piece of plastic between their vocal cords? I love my job,” says John F. Dery, DO, who practices emergency medicine at two hospitals in Lansing, Mich.
“In emergency medicine, you see all types of patients with all types of complaints,” says Terrence M. Mulligan, DO, MPH, an assistant professor of emergency medicine at the University of Maryland School of Medicine in Baltimore. “You have to be ready to take care of anyone and anything anytime.”
Established as a distinct specialty in the United States in the 1970s, emergency medicine is one of the youngest medical disciplines. Yet it has developed into the second largest specialty in the osteopathic medical profession, with 45 AOA-approved residencies and nearly 1,000 positions. The AOA has also approved 11 combined programs in emergency medicine and internal medicine and four in emergency medicine and family medicine.
Ranging from moderately to highly competitive, almost all AOA-approved emergency medicine residency programs fill each year. In addition, DOs make up 9% of the more than 5,300 trainees in the 159 emergency medicine residencies accredited by the Accreditation Council for Graduate Medical Education (ACGME).
Emergency medicine pays in the middle to upper-middle range for medical specialties, with annual earnings based mainly on the number of shifts a physician wants to work per month, says Mark A. Mitchell, DO, the president-elect of the American College of Osteopathic Emergency Physicians (ACOEP). On average, emergency physicians make about 25% more than primary care physicians.
Emergency physicians just out of residency average from $280,000 to $310,000 per year, notes Otto F. Sabando, DO, the director of the AOA-approved emergency medicine residency at St. Joseph’s Regional Medical Center in Paterson, N.J. “The closer you come to a megacity, the less the pay,” he says. “You’ll find higher salaries in Texas, Iowa, North Dakota and other areas that don’t have emergency medicine training programs because of the need to attract board-certified emergency physicians from other parts of the country.”
DO helps develop emergency systems abroad
Contending that relief organizations can sometimes foster dependency and undercut local practitioners, Dr. Mulligan aims to “teach countries to fish” instead. Engaging in international development, he helps foreign countries start or implement emergency medical systems or components of such systems.
Lacking emergency medicine training programs, many developed countries have emergency rooms that are staffed by physicians trained in other specialties. Dr. Mulligan spent more than four years in one such country, the Netherlands, running an emergency department and establishing and directing a model emergency medicine residency program. “The Netherlands is a country with great primary care, cardiology and oncology. But their emergency system is about 20 years behind where we are,” says the immediate past chairman of the American College of Emergency Physicians’ international emergency medicine section.
“It has taken the United States 40 years to build our emergency system to level it is at now,” he says, noting that only a handful of countries have such developed systems. “About 30 to 40 countries are in the middle of building their systems, and the rest have no emergency systems or are just trying to get them started.”
Today, Dr. Mulligan advises a wide range of countries on everything from systems development to the purchase of ambulances. He serves on the governing boards of the International Federation for Emergency Medicine and the African Federation for Emergency Medicine, as well as the steering committee of the American Association of Colleges of Osteopathic Medicine’s International Collaborative. He is also the executive editor of Emergency Physicians International magazine and an associate editor for the African Journal of Emergency Medicine.
Dr. Mulligan encourages osteopathic medical students who are interested in emergency medicine to serve international rotations. He has helped numerous med students find such opportunities and can be reached by emailing firstname.lastname@example.org.
One peculiarity of the field is that newly trained emergency physicians typically start at the top of the pay scale but make less money when they’re older, as decreasing stamina forces them to cut back on shifts, Dr. Sabando observes. The relatively high starting pay appeals to those who have to pay back student loans.
“Emergency medicine doesn’t require any start-up money,” adds AOA Trustee John W. Becher, DO, who recently retired after 40 years as an emergency physician in New Jersey and Pennsylvania. “If you are already in debt for $200,000, that’s a big attraction.”
Although emergency physicians typically work 10- or 12-hour shifts, often overnight and on weekends, the specialty offers time for activities outside of medicine. “When you work, you work. But when you’re off, you’re off,” says Dr. Mitchell, the president of the Emergency Medicine Division of Schumacher Group, which staffs and manages hospital emergency departments across the country. “You don’t have to wear a pager and be on call.”
Dr. Mitchell notes that some emergency physicians work 20 shifts a month, while others work just five or six shifts, depending on their personal needs. Many women are entering emergency medicine because of this flexibility, he says.
But more than the pay and potential time off, the intensity and excitement of the work is what attracts individuals to emergency medicine.
“We’re adrenaline junkies,” Dr. Mitchell says. “We like the unknown.”
Dr. Becher loved the unpredictability of emergency medicine most of all. “When you go to work, you never know what is going to present,” he says. “Just when you think you’ve seen everything, something comes in that it is either a different presentation from what you’ve seen before or a seemingly similar presentation that turns out to be something different. It is very challenging.”
In busy emergency rooms, each shift tends to be chock-full of challenges, so it can be hard for physicians to single out especially memorable experiences. “They happen every day in the ER,” Dr. Dery notes.
However, Dr. Dery recalls one standout scenario because it occurred on April 1. “At 2 a.m., an ambulance crew called and said they were bringing in 32 patients, students from Michigan State University [MSU],” he remembers. “And I said, ‘Ha. Ha. Very funny. April Fool’s!’ But they were serious. The students all had nausea and diarrhea and were vomiting. We had to close down two of the dormitories once we determined it was an outbreak of norovirus.” Because more than 50 students ended up needing treatment, Dr. Dery had to divert some of them to the campus clinic for intravenous fluids so that the hospital emergency department wouldn’t be overwhelmed.
“When you work, you work. But when you’re off, you’re off. You don’t have to wear a pager and be on call.”
Last winter, Dr. Dery was working when a patient came to the emergency department complaining of a headache and dizziness and then passed out. “A resident and I suspected it might be carbon monoxide poisoning, so we asked the fire department to check out the site where the patient began to feel sick, a local YMCA. It turns out that a broken generator on the roof was pouring carbon monoxide into the gym. We got it down, started up triage and were able to evacuate the facility. Luckily, we averted a catastrophe.”
Having the right personality for emergency medicine is critical for anyone contemplating a career in this field. “Emergency medicine lends itself to people who are quick-thinking, who are not afraid to make decisions,” says Daniel P. Lombardi, DO, the director of the AOA-approved emergency medicine residency at St. Barnabas Hospital in New York City. “Individuals who like to work through a diagnosis over a few days are not well-suited to this specialty.”
“In emergency medicine, you have to know a little bit about every other specialty,” says Dr. Mulligan. “There is a saying that emergency medicine is a mile wide and a foot deep.”
Skilled emergency physicians rapidly assess patients, conduct tests if indicated to rule out life-threatening conditions, and determine whether patients need to be admitted into the hospital for stabilization or can be discharged. “If you are someone who always has to have all the answers and you don’t feel comfortable not knowing everything, then emergency medicine is probably not a good fit for you,” Dr. Mitchell says. “While internists dig and dig until they find the answer, emergency physicians make decisions based on what patients don’t have as much as on what they do have.”
Emergency physicians need excellent communication skills. “Much like people who speed-date, they have to be able to walk into a room and within less than a minute, establish a relationship with an unknown individual,” Dr. Mitchell says.
Working in emergency departments also demands emotional resilience, as physicians must constantly break bad news and patients often die. Emergency physicians frequently counsel families they’ve just met on end-of-life issues, including hospice care and funeral arrangements.
Emergency physicians must be very motivated and alert, but they also need patience and compassion. It isn’t easy for most physicians to go from treating someone undergoing cardiac arrest to addressing someone with a relatively minor complaint who is frustrated from having to wait a couple of hours for care. Such abrupt transitions are the staple of emergency medicine and require ER doctors to have exceptional interpersonal skills.
Emergency physicians must be adept at caring for people who have nowhere else to turn, such as homeless people with psychiatric problems, alcoholism and drug addictions, Dr. Mitchell points out. Because of a lack of facilities for the indigent and mentally ill, such patients sometimes stay in emergency departments for days until they can be placed in an appropriate community-based treatment setting.
Beyond having empathy, mental agility and a take-charge personality, emergency physicians need to have manual dexterity for suturing and performing cricothyrotomies and many other life-saving procedures that must be done quickly.
Ideally, students who think they might have what it takes to be emergency physicians would gain some exposure to the field prior to medical school. Dr. Dery worked as an emergency medical technician while in college and became friends with DO emergency physicians who became his mentors, wrote him letters of recommendation to osteopathic medical school, and later took him on rotation.
Dr. Sabando prefers residency candidates who have been EMTs or paramedics, served in the military, or had previous careers as nurses or physician assistants. But he also is impressed by those who have done research, taken basic and advanced life support classes, and served on medical missions. “I rarely interview the traditional student—someone who has gone through college and medical school but didn’t do anything additional along the way—and is now applying for residency,” he says. “That’s someone who has gone through the motions but doesn’t really understand what emergency medicine is.”
College students interested in emergency medicine should also consider serving on search and rescue teams, learning Spanish and other languages commonly spoken in specific areas of the United States, and honing their leadership skills in student-run organizations. Premedical students leaning toward osteopathic emergency medicine can look for opportunities to shadow DO emergency physicians and residents and join the undergraduate division of the Student Osteopathic Medical Association (SOMA), known as Pre-SOMA.