Emergency Medicine: The Good, the Bad, and the Ugly

Mark Reiter, MD


September 30, 2011

Emergency medicine (EM) is a fast-paced, team-oriented specialty where you can have a tremendous impact on your patients. Emergency physicians are experts on diagnosing and managing the acute, undifferentiated patient.

The landscape of the EM workforce has changed tremendously. Only a few decades ago, most US emergency departments (EDs) were staffed by physicians with no EM training. Many of these early physicians had little interest or expertise in EM.

EM residency training began in the 1970s, and the American Board of Emergency Medicine was recognized in 1979. Dramatic growth in EM residency programs boosted the number of EM specialists now staffing EDs throughout the country; about 70% of emergency physicians are EM trained, according to a 2008 study.[1] In addition, the study shows nearly all (98%) emergency physicians who graduated within the past 5 years are EM trained.

Before you opt for a career in EM, it helps to understand its many advantages, such as the ability to work flexible schedules and see a variety of cases, as well as its challenges. Here are some pros and cons you might consider.


Feeling like a "real" doctor. Emergency physicians are trained to handle virtually any emergency. Although many patients require additional care (for example, surgery), the emergency physician has the tools needed to begin the management of any acute medical condition or injury. You will manage sick patients every day and have a major impact on their lives. You will have the opportunity to perform many procedures, both routine and life-saving.

Making the diagnosis. EDs have become the diagnostic centers for the healthcare system. Patients come to the ED to find out what is wrong, and we can often make a diagnosis during the ED visit that could take weeks or longer in an outpatient setting.

Variety. Emergency physicians see a tremendous variety of patients, including babies and elderly patients, the critically ill and the worried well, pregnant patients, psychiatric patients, and people from every walk of life. Emergency physicians manage patients with all types of medical and surgical illnesses and injuries. Within a few hours of a shift, you may reduce a shoulder dislocation, manage a cardiac arrest, evaluate a suicidal teenager, place a chest tube for a tension pneumothorax, manage a multiple trauma moving vehicle collision, and evaluate a 3-year-old and a 90-year-old for abdominal pain.

Flexible schedule. Emergency physicians typically work 8-12 hours at a time, at all hours. Due to the intense nature of EM, emergency physicians work between 1500 and 2000 hours per year. Most EM practices do not have on-call time. This allows emergency physicians to have time off, often during the weekdays, to pursue outside interests. Many emergency physicians work part-time or take extended vacations, and it is not uncommon for an emergency physician to devote time to other professional pursuits such as administration, leadership, research, education, or entrepreneurship.

Chance to build teamwork and relationships. Emergency physicians work closely with emergency nurses and ancillary staff, other emergency physicians, the medical staff, and many other members of the healthcare team. A successful ED has excellent interpersonal staff relationships and works well as a team.

Compensation. A greater proportion of emergency physicians (65%) -- compared with 53% of physicians overall -- feel they are fairly compensated.[2] Emergency physicians typically work more intensely for fewer total hours compared with other physicians and enjoy above-average compensation per hour.


Stress level. Emergency physicians work very hard, often managing many critical patients at one time. Some patients will die in front of you. You will see patients who are victims of child abuse, rape, or other terrible situations. Litigation stress is common: emergency physicians are the fifth most likely to be sued compared with other specialists.[3] It is widely speculated that emergency physicians have high rates of "burnout" and shorter effective careers than other physicians. However, according to the 2008 AMA Physician Masterfile, the emergency physician attrition rate (including death) is only 1.7% per year, lower than the 2%-3% average of other specialties.[4,5]

Difficult patients. Emergency physicians handle more "difficult" patients than most other specialties. Our patients and their families are typically under strain from their acute medical conditions. Sometimes they will treat the emergency physician, who they typically have never met before, inappropriately. Many of our patients are intoxicated or have serious psychiatric problems. Some of our patients are homeless, prisoners, or have been released from every medical practice in town due to inappropriate behavior. Violent, out-of-control patients often threaten and sometimes even assault members of the healthcare team. As the "safety net," the ED sees everyone who comes through the door, no matter how they have treated us in the past.

Difficult physicians. Unfortunately, emergency physicians are sometimes mistreated by their physician colleagues. EM is a 24/7 operation, and many of our patients require hospital admission or consultation. We deal with uninsured or underinsured patients, some of whom have complicated medical or social situations. In response, emergency physicians are sometimes treated poorly by their physician colleagues, who may be upset about being contacted during off-hours to help manage a patient that they might not otherwise take into their practice.

Practice settings. Less than 33% of emergency physicians work in private groups. The majority of emergency physicians either work directly for the hospital as an employee or work for a national or regional practice management/staffing company. Emergency physicians in these practice settings may have less autonomy, earn less compensation, and have fewer practice rights (because of lack of due process or restrictive covenants).

Crowding. ED patient volumes continue to rise each year. The National Hospital Ambulatory Medical Care Survey estimates that ED visits have grown from 94.9 million in 1997 to 123.8 million in 2008.[6,7] This 30% increase is about double what we might expect from population growth. Instead, EDs are becoming more crowded as a result of an aging population, higher acuity, more regulation, and more available advanced testing. In addition, hospital inpatient capacity continues to decrease, which ups the number of inpatients in the ED. In many EDs, patients wait a long time and are seen in hallway stretchers during peak times.

Inconvenient schedules. Although many emergency physicians enjoy flexible schedules, they do tend to work many evening and night shifts, as the ED is a 24/7 operation with highest volumes in the evening. Many emergency physicians, especially as they get older, find it difficult to work late hours and often frequently change shift times. In addition, the ED must be staffed on weekends and holidays, so we often miss family and social activities due to work responsibilities.

Lack of continuity in patient care. Although this is a common concern among medical students considering EM, few practicing emergency physicians consider this to be a significant drawback. The emergency physician can always follow up on a patient on their own, and our sickest patients tend to make many return visits to the ED.


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