How to work in emergency medicine
Dr Monica Lalanda, staff grade in emergency medicine, asks if you’ve got what it takes to succeed in this thriving specialty
What is emergency medicine?
Working in an emergency department means you are at the centre of the emergency pathway and the gatekeeper of the hospital
Emergency medicine is a young, challenging, dynamic and exciting specialty that is constantly evolving. Curiously it is one of the few that has changed its name several times to adjust to the nature of the work, from casualty to accident and emergency medicine, and now to its current name - emergency medicine.
Emergency physicians (EPs) are responsible for assessing, resuscitating and stabilising patients with serious illnesses and injuries before they hand them over to the appropriate specialists at the hospital for definitive management. They are also responsible for assessing, treating and discharging patients who attend with less serious but urgent conditions; who are then sent back to the care of their GP.
In recent years the role of EPs has expanded, allowing them to manage certain pathologies for longer periods, based on adjacent wards often called Clinical Decision Units or Observation Wards. These extend beyond the shop floor, with all its usual activity and adrenaline, to a ward-style environment, where patients stay for up to 48 hours under the sole care of the emergency physicians.
This allows further investigation, treatment and support of patients with a temporary condition, such as chest pain, head injury, an asthma attack or an overdose.
Most departments also have separate facilities to deal with children, which have specialised staff to assist the EPs, such as registered children’s nurses, nursery nurses and play specialists.
Working in an emergency department (ED) means you are at the centre of the emergency pathway and the gatekeeper of the hospital. The specialty has developed a through curriculum and had a number of specific examinations one has to pass to work in it.
Training
Training begins with the obligatory foundation years. It is ideal to get a post in EM, but they are very popular and therefore difficult to get. If a candidate does not get one, they will have to show commitment to the specialty by completing a taster week in an ED, becoming an advanced life support provider (ALS) or getting a relevant audit done. Having an interest in EM is not enough; you will have to demonstrate it!
Once a specialty training programme has been secured, the first two years (CT1 and CT2), which are part of the acute care common stem, will be taken up with emergency medicine and acute medicine, followed by anaesthetics and intensive care medicine.
To enter the third year of core specialty training (CT3) trainees will have to pass Part A of the membership examination of the College of Emergency Medicine (MCEM). If successful during this year, trainees will need to achieve the competencies required to care for children and patients involved in trauma, by taking appropriate posts.
Once completed, trainees will move on to the last three years of their training or specialty training (ST4, 5 and 6). These are designed to allow trainees to gain additional clinical competences and skills in academic EM, critical appraisal and management. Part B and C of the membership examination are required for entry to ST4.
The training programme culminates in an exit examination, the Fellowship of the College of Emergency Medicine (FCEM).
Working in EM
Working as a junior doctor in emergency medicine is never dull. Juniors have to care for many patients simultaneously, seeing a variety of pathologies and severities, unlike in any other specialty. One moment you might be seeing a child with an unexplained limp and the next you could be leading the resuscitation of a patient in cardiac arrest. It is a constant intellectual, emotional and physical challenge, where you never know what is next; that is why a good general knowledge of all specialties is required.
Other elements of the job include working in the returns clinic, where you can follow up patients with minor trauma, seeing patients in the observation area (or clinical decision unit), supporting nurses and performing research. The work is varied and unpredictable!
The work of an EM consultant is also varied and it involves five different areas of interest. They are responsible for:
- General management – staffing, and facilities within a given budget.
- Liaising with people - specialties, pre-hospital services, health authorities, regional health boards, to develop major incident plans.
- Teaching – this involves the academic development of both junior doctors and emergency nurse practitioners (ENPs).
- Clinical work – supporting junior colleagues, organising the joint efforts of doctors of different seniority and specialty, working as doctors of their own patients and, as team leaders, resuscitating patients and managing trauma teams.
- Research and auditing – which they have responsibility for.
In EM you never feel isolated and there is a strong team vibe
It is also possible to work in EM as a staff grade or an associate specialist. The work can be as exciting and fulfilling as that of a consultant, but the level of managerial responsibility is more limited.
Unlike other areas of the hospital, an ED is open 24/7 providing a consistent level of care. The work pattern is either in full or partial shifts. There is little long-term commitment to your patients, as every work day is independent from the next; this makes EM the ideal specialty if you want to work part-time without disrupting your clinical undertakings, so it is easy to combine both family and work lives.
In EM you never feel isolated and there is a strong team vibe. When away from it, I miss the sense of continuous activity as much as the social side of it.
The future
EM is becoming increasingly consultant-led, so the number of consultants will increase. It is also likely that consultants will be required to work late shifts, weekends and nights soon, to provide supervision and leadership 24/7.
There will also be the growth within the specialty. So far paediatric emergency medicine is the only recognised sub-specialty, but there are also possibilities of integrating a job in EM with intensive care medicine.
The use of allied specialists, like emergency nurse practitioners, will become more commonplace. They will work more independently on cases of minor trauma, allowing EM physicians to concentrate on patients who are more seriously ill.
Academic EM is a very young branch of the specialty, but it is slowly gaining space. There is also the scope for developing an interest in pre-hospital medicine (see "In the spotlight - pre-hospital medicine").
The skills you’ll need…
- Personality – assertive, confident, able to make decisions quickly, under pressure, good sense of humour, friendly, good coordinator, good leader, strong team player, able to deal with tragedy, compassionate.
- Best bits – the challenge of the unpredictable, solving clinical conundrums under pressure, the feeling that you can make an immediate difference and save lives, working in a team (they become like a second family), the limited follow-up responsibilities.
- Worst bits – the frustration of management targets, not finding out if your clinical judgment was right or wrong, handling the “obstructive” colleague who doesn’t value you, dealing with sudden death (particularly in the young), the management of violent, disruptive or intoxicated patients when you are at risk.
- Stress – depends on the day!
- Salary – similar to other hospital specialties, but private work is limited.
- Competition – high, but most definitely worth it!