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After the Match

After the Match

Managing the Paradox

Cook, Thomas MD

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doi: 10.1097/01.EEM.0000466620.85746.07


    Emergency medicine is a paradox to be managed, not a problem to be solved, and the excitement of starting residency can bog down in the quagmire of tough shifts with demanding patients. Is this all there is? Is this the rest of my life?

    I have conversations each year with residents ruminating on these questions. Despite matriculating some of the brightest and most upbeat people into our program, they still become frustrated with the never-ending flow of patients. EDs never shut down. The patients never stop coming.

    My message to residents is to relax. You are feeling what every other EM resident has experienced. My challenge to them is to take what you are given and make it into what you want. Two choices for a career were available when I was a resident. The most traveled path was to join a group and work shifts. The other was to seek an academic job working with a residency, typically at reduced pay and relatively low academic standing.

    But emergency medicine emerged to be powerfully attractive to the best medical school graduates, and the opportunities exploded. EM graduates have become integral to a wide range of health care niches including critical care, disaster preparedness, EMS, global health, hospital administration, hyperbaric medicine, information technology, media relations, medical student education, palliative medicine, pediatrics, public health, politics, simulation medicine, sports medicine, toxicology, ultrasound, and the list goes on.

    No other specialty comes close to this diversity. You think urologists are doing this? After all of that training, they have relatively few choices. All day it's, “Drop your pants, and let's see what's going on.” Imagine doing that for 30 years.

    The critical aspect of finding future happiness, however, is to consider what you really like and what you can tolerate. If you grit your teeth at low back pain and substance abuse, but find really sick patients exciting and interesting, understand you have alternatives. Intensive care fellowships are now open to EM grads. Understand this is a purely clinical career. There is a lot of patient contact that is highly intense, and that is what you will likely do all of the time. The ability to diversify your work might be very limited.

    What if you do not like this? What if your interest is some clinical contact but also the opportunity to be involved in nonclinical work? Perhaps EMS or disaster management would be better for you. These are purely administrative jobs. Emergency physicians do not ride along on ambulances; they manage the people who do.

    Do you want to understand how the business of medicine works? Many grads just want to punch out shifts, pay off loans, make money, and have fun. But some want to understand how the money flows from the patient interaction to bank accounts. Most physicians just groan about the implications of the Affordable Care Act. Understand that change always creates opportunity. Emergency physicians are uniquely suited to become leaders in health care management. No other clinician even comes close to understanding the interplay between EMS, mental health services, disaster management, police, trauma, the uninsured, critical care, pathology, radiology, the media, and all the clinical services available in a given health care system.

    You will be presented with enticements (money) as you progress toward graduation to live a life that may serve someone else's dream more than yours. To pursue additional education and delay the gratification of immediate access to a high salary is often the rate-limiting step between a compromise and what you really want. Always remember your career is a long-distance race, not a sprint. Think more about where you want to be when you are 50, not 30.

    (Read Part 1 of this series, “Buyer's Remorse” at

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