SS2 : What is Emergency Medicine? A Community EM Doc’s Story

ss2

Session 02

In this episode, Ryan talks with Dr. Freess, a community-based Emergency Medicine physician who shares with us why he likes Emergency Medicine and how you can become a competitive applicant. He also talks about the benefits of being an EM doctor and why he would still have chosen to become an Emergency Medicine doctor if he ever had to do it all again.

Here are the highlights of the conversation with Dr. Freess:

His path to Emergency Medicine:

Initially wanting Pediatrics and realizing after shadowing that he wanted Emergency Medicine

Why he chose Emergency Medicine:

  • Fast-paced atmosphere
  • Down-to-earth people
  • Variety (everyday being completely different)
  • Meeting people and learning about them

Can introverts be good EM physicians?

Yes, a little different but you can create a bond with the patient probably in a different way.

Working in a community hospital vs. academic hospital:

  • There is a teaching aspect in the academic setting but there are more patients, more processes, residents, etc.
  • In a community setting, you can fine tune things and it allows you to have more time to patients.
  • Find what’s best for you.

A typical day for Dr. Reess:

  • Flexibility in shifts:
    • Morning shifts begin at 7am
    • Afternoon shifts start at 5 pm
    • Overnight shifts start at 10 or 11 pm
  • Sign into the computer and see who to see next
  • There is no predictable day
  • As you move up the leadership ladder, you get to pick better shifts.

What is it to be a shift worker?

  • There are set time periods where you’re scheduled to be there.
  • There is not call for the most part once you’re off the clock.

Does shifting have negative effects on health?

  • There are health detriments when you change your shift around a lot but there are ways that you can work around it so it works best for you.
  • There are ways to avoid burnout.
  • There are ways to diversify your career especially when you get older and it gets tougher to switch shifts (ex. part time, administration, free clinic, etc.)

Traits that lead to being a good EM doctor:

  • Flexibility
  • Making quick connection with patients
  • Being okay with not having long term connection with patients

How to be a competitive applicant for EM:

  • Well-rounded in medical training and medical interest
  • Accepting to change
  • Up for a challenge
  • Someone with different life experiences since it goes along with being able to make connections with people

Main drivers for competitive matching in EM?

  • Desire for shift work and working less hours than other specialties
  • Having good work-life balance

What residency was like for Dr. Reess:

  • Strong work-life balance and family-oriented
  • Residency is a little half of your typical day since you need to do rotations in every specialty to get a sense of how they operate and get the basic knowledge

What he wished he knew going into EM:

  • Majority of your day is dealing with “not exciting” things
  • 95% of your patients are the routine stuff and 5% of your patients are the exciting stuff

What he wished primary care providers knew about EM:

EM doctors are there to stabilize emergencies.

What he wished hospitalists knew about EM doctors:

What resources EM doctors have

Unique opportunities outside of clinical care for EM physicians:

  • Hospital administrators
  • Chief Information Officers / Chief Medical Officer
  • Pharmaceuticals
  • Consulting
  • Community Medical Board

What he likes most about being an EM physician:

  • His everyday job and great work-life balance
  • “Stop and go” lifestyle

What he likes least about being an EM doctor:

  • Shift work in nights and weekends
  • Inconvenient times and unpredictable schedule

The future of Emergency Medicine:

  • More observation medicine
  • More community help
  • Generalized health system where they become the “brokers” of healthcare and the center of medical care

Some pieces of advice for those interested in EM:

Try it out and try in different settings. Find diverse rotations and trauma centers. Do a community medicine rotation abroad. Do diverse experiences and understand what EM is outside of the major trauma center.

Links and Other Resources:

www.mededmedia.com

Transcript

Introduction

Dr. Ryan Gray: The Specialty Stories Podcast is part of the Med Ed Media network at www.MedEdMedia.com.
This is the Specialty Stories Podcast, session number 2.
Whether you’re a premed or a medical student, you’ve answered the calling to become a physician. Soon you’ll have to start deciding what type of medicine you will want to practice. This podcast will tell you the stories of specialists from every field to give you the information you need to make sure you make the most informed decision possible when it comes to choosing your specialty.
Welcome back to the Specialty Stories Podcast, session number 2. We are a whole two weeks in. Last week’s episode if you haven’t listened to it yet, go check it out in your favorite podcast app, all about dermatopathology. Something I’d never really even thought of, dermatopathology. I’m excited to learn a lot more about all these amazing specialties there are and hear from physicians that are doing these specialties, that are practicing this every day, and find out why they’re doing it, and what you the premed and medical student can be thinking about as you are deciding where to go.
This week we’re going to dive in and talk all about community emergency medicine.

Dr. Dan Frees: My name is Dan Frees, I’m in emergency medicine.

Dr. Ryan Gray: When did you know you wanted to be an emergency medicine physician?

Going into Emergency Medicine

Dr. Dan Frees: I guess relatively early on compared to most medical students, and it was actually before medical school. I was in a what would kind of be called a combined program in college where we got early acceptance into medical school, though there’s no shortening of the period, it was still an eight year college and medical school. And part of that program was your junior and senior year of college you actually did what would be considered med school rotations, like third year, fourth year rotations. As an undergrad you obviously didn’t have any responsibility but it was kind of I would say trumped up shadowing where you actually had a role, you kind of were there for a month or two months, people got to know you. I mean you had very basic roles as opposed to purely shadowing, and I thought I wanted to be a pediatrician, my mind was open but that’s kind of one of the things I was interested in, but the pediatrics rotation was always very popular and the seniors got it. So as a third year, a junior, I had to pick something to do and emergency medicine sounded good, so I picked that one. Honestly probably a couple hours into the first shift I was like, ‘What was I thinking? This is what I want to do.’ I just loved the fast paced atmosphere, kind of all the people, everyone kind of seemed like me was down to earth. So obviously I went into medical school with my mind open trying to see if anything could knock emergency medicine off the pedestal. But honestly from that first day of shadowing if you will, it’s kind of what I wanted to do.

Dr. Ryan Gray: What do you think led to that decision? You mentioned fast-paced and down to earth people, but what do you think- what pulled you and continually reaffirmed this decision for you?

Dr. Dan Frees: I mean a lot of emergency medicine physicians say they’re kind of ADHD, like they kind of want to be in a lot of directions at once, and that fits well with emergency medicine. I don’t know that’s technically my personality but I do like a lot of variety, I like kind of not knowing what’s going to come in next, what’s going to happen next. I love every day being completely different as opposed to a job where you kind of go to office hours, you know you have these appointments at these times, and these are the people you’re going to see, you kind of know what they’re going to say and what you’re going to say. Every day is totally different in the emergency department, so I hate to say it’s a little bit of an adventure every day you show up but I kind of like that aspect of it. As well as I’m kind of the person that- not to say I own the room because I don’t, but I like meeting a lot of people, I like talking to people, I like kind of conversing with people I don’t know, and learning about people which goes along well with emergency medicine. Actually probably an inherent part of that specialty.

Dr. Ryan Gray: Would you say that you’re an extrovert?

Dr. Dan Frees: Yeah I think so.

Dr. Ryan Gray: Do you think introverts can be good emergency medicine physicians?

Dr. Dan Frees: Yes they can. It’s a little different, and actually one of my partners I can think of, I would definitely say he’s an introvert, but he sort of creates a bond with a patient in a different way. I’m a little more of the energetic like ‘nice to meet you, let’s quickly get to know each other and let’s find out what’s going on with you,’ almost with a little bit of energy. Whereas he’s very calm, collected, almost what you kind of picture- I know if this is for millennials they’re not going to know what we’re talking about, but Marcus Welby, kind of very buttoned up doctor approach, you can trust me, let me help you, and I think he has a lot more of that personality and that can work in emergency medicine. Maybe you’re not going to be quite as fast or as energetic but it can definitely work, you can make it work to your advantage.

Dr. Ryan Gray: What type of setting are you in? Are you in a community hospital? Are you in an academic hospital?

Dr. Dan Frees: I’m in a community hospital though in the northeast as you probably may know from being in Boston recently, what we define as a- actually what I would call is a mid-size community hospital, but by northeast definitions that’s very different than national definitions. Nationally a mid-sized emergency department is probably 20,000 to 40,000 visits, mine is about 60,000 whereas just in the northeast we have generally bigger hospitals. But I’ve also worked- the residency I graduated from, UConn, I’ve worked at their main site intermittently over the last couple of years as per diem doing a couple shifts a month and then switched over to actually one of their other- what’s considered their community sites though it’s still an academic center, and worked a couple shifts there. Though actually over the last couple years- or actually sorry, it was the last couple months I’m actually kind of focused back to where I am right now just a pure large community hospital.

Community Hospital Versus Academic Hospital

Dr. Ryan Gray: What factored into that decision for you of working in a community hospital versus an academic hospital and having the residents around you?

Dr. Dan Frees: I like the teaching aspect and the variety aspect of the teaching and being with residents, kind of I like learners. I’ve always even through college, like I loved kind of- I hate to say mentoring high school students, but that kind of programs where you were interacting with people a little bit- with one step below you. But I’ve always enjoyed that, I love teaching. More than anything else in academics, what I really like is just the atmosphere. Kind of searching for knowledge atmosphere whereas even the attendings that have been out thirty years are a little more of in a ‘I want to learn something new’ mindset. ‘Let me learn from you even though you’re younger than me’ mindset than in community. On the flipside things are always a little crazy in academics. There’s obviously a lot more patients, it’s often a little busier, the processes with a lot of residents can be a little tough, whereas the community you can really fine tune a lot of that stuff and it’s a lot better flow, sometimes you feel like you can take more time with patients, so I like both aspects of it. But one thing I would add is everyone- I actually do some residency interviewing for the program that I help with, and it’s one of those- everyone says they want to go into academics because it’s kind of that’s what you’re supposed to say, but I don’t know that that’s true. You figure 80% of people are not going to go into anything academics, they’re going to go into pure community. So I don’t think it’s bad to kind of evaluate yourself and say like, ‘I think I would like to work in community medicine, and I’d likely be good at that.’ I think you have to find what’s best for you. For me it’s kind of a split, but for the med students out there, I know some med students have talked to me and said they kind of feel bad not saying they want to be a residency director, or not saying they want to go into academics. I don’t think you have to feel bad about that. You have to kind of find what role is best for you.

Dr. Ryan Gray: Describe a typical day for you.

A Day in the Life of an Emergency Physician

Dr. Dan Frees: Well in emergency medicine there’s no definition as to when it starts. I have shifts that start as early as 7:00 AM, I have afternoon shifts that start at 3:00 or 5:00, and I have overnight shifts that start at 10:00 or 11:00. And so depending on the day, it would depend what shift I have. I kind of get ready, put my scrubs on, show up at work, and sign into the computer, see who’s next to see, and go from there. Sometimes it’s busy, sometimes it’s not, sometimes you’ll jump in to see a real sick patient, sometimes you’re seeing a lot of what would be considered Urgent Care patients, and then what I do when my shift ends, I clean things up and kind of take care of all my patients as quickly as I can to get home. Sometimes that means staying a little extra, sometimes you’re out right on time, but I think by my description you can kind of tell what I way saying before is there isn’t really a predictable day, which is something I like.

Dr. Ryan Gray: You mentioned having different shift times, and working different shifts. Is there a point in your career where you can work the same shift every day, or whatever days of the week you’re working?

Dr. Dan Frees: Well to answer your question a little bit, I don’t know that it’s a point in your career. Through our people that have managed that, it’s actually something that we tell our residents to somewhat avoid when they’re looking for a job, is there are some places where it’s kind of, ‘well this person just works day shifts Monday, Tuesday, Wednesday because they’ve been there 25 years and it’s hard for them.’ Not even it’s hard for them but like they’ve earned their prime shifts. Which is probably not something you want your group to have everyone have their niche shift and other people get stuck with everything else. But that is an option, especially if you move up in leadership you can kind of pick your shifts a little bit better, especially a lot of directors or nurses and directors might not work overnights just because they have meetings the next day. So that’s one way to control it. But I will say what is very common in groups, and actually is very helpful for the group, is some people will often trade some stability in their shifts for not as desirable shifts. So for example, I know my groups in the past we’ve had people that worked Friday, Saturday, Sunday, Monday every week, so they worked all weekends. It doesn’t mean they can’t have a weekend off if they want to take vacation, but they trade kind of having that predictable schedule and having a nice three day period off every week for that- doing the weekends. You could be a night doctor. Most groups are so willing to having a night doctor that they will say, ‘Just pick your days, pick whatever days you want to work as long as you work enough days, if you’ll do dedicated nights.’ That’s one way to control- kind of control the irregularity of shifts. So there’s ways to do it. Most people don’t because one of the benefits of emergency medicine is we don’t work quite as many hours as what would be considered typical for doctors. So we do have some flexibility, as much as our shifts are moving around a lot, we do have some flexibility in when we work in terms of days and times.

Shift Work

Dr. Ryan Gray: Describe that shift work schedule to someone who’s listening that may not understand what that means as an emergency medicine physician to be a shift worker.

Dr. Dan Frees: Well it’s the greatest thing in the world. I guess maybe the greatest thing in the world would be to have shift work where you work the same shift every day, which is what most of the world does, and arguably I think what probably should happen in emergency medicine, but there’s obviously some barriers to it. It’s hard to get people to work every shift at a less desirable shift. In terms of the shift work comparing it to other specialties if you will, it’s much like probably people who’ve grown up doing- working through high school and college, where you were scheduled from this time to that time working at a store, working at an office, stuff like that. And just knowing when you’re showing up, and when you’re scheduled to leave, in emergency medicine it’s so unpredictable that there isn’t usually a hard stop at the end of your shift. Though there are some groups that do do that, simply when your time is over you sign out any patients you have and the next person just accepts it. Most emergency groups it’s kind of a balance. You sign out patients that are going to be there well after your shift, but for the most part you might stick around a little extra, even half an hour, an hour after your shift to get everything organized and take care of your patients that you’ve been taking care of during your shift. But it’s a little different mentality than say someone in internal medicine that might show up and be there for 24 hours, 36 hours, or have office hours and then have to go to the hospital afterwards, or have office hours and they go to the hospital during lunch, then they’re back in office hours. We have very set time periods when we’re scheduled to be there, and the benefit is you’re off the other time. There’s no call for the most part, you’re not going to work, seeing your patients during the day, and then getting calls at night from your patients. You literally go in and when you’re on the clock, you’re on the clock, and when you’re off the clock you go home and other than administrative stuff you’re not getting calls from patients or anything like that, you’re off the clock.

Dr. Ryan Gray: Is there any discussion among emergency medicine physicians about shift work, and the negative effects that it has on health, and stress, and everything else that comes with it?

Dr. Dan Frees: Oh there’s definitely a lot of discussion actually over the last two years. One of the highlighted points of the American College of Emergency Physicians is working on physician wellness. That’s a strong piece of it. There’s obviously studies out there which many people have heard of that say if you work third shift or the overnight it cuts off- I’m making this up, but cuts off five years off your life or something like that. You’re more likely to be unhappy and all these other things. And those are studies not necessarily done in medicine, they’re done more in working for Ford Motor Company making cars in the middle of the night, or working at the electric company overnight. It’s not specific to medicine, I’ve not seen any studies that say specifically in medicine like here’s the effects of working shift work. But overall there probably are health detriments of switching your shift around a lot, and there’s definitely ways that you can work around it, definitely ways that you can set your schedule up that work best for you. They may not work best for other people, and as I said within emergency medicine there is a lot of discussion of kind of ways to avoid burnout, ways to kind of diversify your career near the end of your career. If you feel like when you’re hitting the forties and fifties, that maybe it’s getting a little tougher to switch shifts physiologically. Maybe you go part time in emergency medicine two thirds time, and you have something else on the side. Maybe you go into administration a little bit, maybe you work at a free clinic another time. One of the benefits of emergency medicine is it’s very flexible. There are a lot of things outside medicine you can do, there are a lot of medical activities you can do that you’re very qualified for as an emergency physician that don’t always involve pure clinical work.

Best Traits to be in Emergency Medicine

Dr. Ryan Gray: What traits do you think lead to being a good emergency medicine physician?

Dr. Dan Frees: Definitely flexibility. I hate to say being empathetic because I think that applies to all medicine, but someone who can make a quick relationship with a patient or another individual. I think probably the person that kind of makes friends easily, someone who kind of sees the best in everyone as opposed to kind of finding their one or two friends and sticking with them. But it’s something you have to be very flexible, you have to like unpredictability or be okay with unpredictability, but someone that’s sort of outgoing and can make a quick connection with patients, and also someone that’s okay with not having long term connections with patients. Medical students get a little trouble when they like emergency medicine but then they realize they might want some long term relationships with patients, and unfortunately I have long term relationships with a lot of my patients, but not in the way you would like. But it is a different mentality of kind of a quick hit, get to know someone quick, create a bond with them, trust in them and they trust in you, and then you move on from there, and you do it again.

Dr. Ryan Gray: What makes a competitive applicant for emergency medicine?

Competitiveness of Emergency Medicine
Dr. Dan Frees: I don’t know there’s answer to that. I think unlike some other specialties where there might be some specific answers to that, I think it’s someone who is well-rounded in their medical training and their medical interests as opposed to maybe someone going into orthopedics or going into- I mean cardiology is not something you go into out of medical school, but where it’s kind of you almost want to see someone dedicated to that, they’ve done six orthopedic rotations and all that. I think we’re fine with people having lots of different experiences, and I think that benefits residents and attendings in emergency medicine. Probably sounds semantic to say like someone who’s done well on their tests, and someone who’s studied hard, and someone who’s a good student overall. That’s no different than any other specialty. But someone who’s accepting of change, someone who’s kind of up for a challenge if you will, someone who’s had a lot of different experiences in life is always a benefit because it goes along with being able to make connections with a diverse swath of society.

Dr. Ryan Gray: Is matching competitive for emergency medicine?

Dr. Dan Frees: It has become, yeah. I think when I went through I think there would usually be maybe four to eight spots left in the country after the match. And over the last few years, I think the last two or three years there’s been no spots, or maybe one or two spots. It’s become quite competitive.

Dr. Ryan Gray: What do you think is driving that?

Dr. Dan Frees: A general trend in the expectations people have for themselves and their career, which lead to a desire for shift work and maybe working a little less hours. I’m not saying work harder or less hard, but working a little less hours than other specialties whereas the old mentality is people were called house officers because they lived at the hospital like it was their house. That mentality is gone I think for the better, and along with that comes a lot of people that want to go into a specialty where they can come home to their kids, and come home to their family, and they can go do their own hobbies on a regular basis, and have time to do that, and have a good work life balance which I think we definitely do in emergency medicine. So I think that’s probably the main driver in the- I’m not saying it’s massively changing, it’s not like we were uncompetitive and now we’re competitive, it’s a slow process of becoming more competitive. But I think that’s the main driver is people looking for the lifestyle that emergency medicine provides.

Emergency Medicine Residency

Dr. Ryan Gray: What is residency like?

Dr. Dan Frees: Oh a lot depends on what residency you go to. I was very happy with where I ended up and that it was a very strong family atmosphere. People had a really good- one of the highlights was a strong work life balance. That’s not always true in every residency, in every specialty, every residency is different. But residency is a little less of what I’ve described as the typical day. You obviously have probably only about half of your time is in the emergency department, I may even be off on that, it may be less than half your time is actually spent as an emergency physician during residency because you need a lot of diverse knowledge and diverse interests- or diverse experiences, sorry. You do a lot of off service rotations, you’re rotating in pretty much every specialty out there just to get- A) you get a sense of how they operate so that you can interact with them over the phone quickly and kind of understand where they’re coming from, and understand what they have to offer, and also get that basic knowledge base that they have. So it is a little different than being a full time emergency physician because you have a lot of diverse rotations, a lot of diverse experiences in all different specialties of medicine.

Dr. Ryan Gray: Expand on the comment that you made about the residency that you went to being very family oriented. How do you determine that when you’re looking at residencies?

Dr. Dan Frees: It’s obviously a little bit difficult, there’s no magic way, but I think the strongest thing is most residencies- I don’t know if they do it in other specialties, I think they do, is usually when you go for an interview they will have the night before (there’s different names for it); the interview starts at 8:00 AM in the morning and the night before at 7:00 you meet at a bar, you meet at a restaurant, you meet at someone’s house and everyone who’s interviewing the next day is welcome to meet a bunch of residents or whoever shows up. I think that’s the key is to go to those. You get to meet some of the residents, and you can really get a sense of what they think of the residency, what their work life balance is like. Those are the questions to ask, not kind of what restaurants are good in the area, is kind of how do you- which is often what people do. But it’s kind of ‘how is your work life balance? Do you find that the residency supports your activities outside of medicine? Do you feel like you have enough time off to maintain a lifestyle, to spend time with your family?’ I think you get a good sense of the residency through those experiences, meeting the residents the night before, more so than you probably do on the residency day because I mean let’s call it as it is, a lot of that’s going to be kind of canned speeches and canned presentations. But also there is some truth to the presentations. When you have an hour long presentation that usually starts the morning on your interview day, ‘Here’s who we are, here’s our residency, here’s the rotations you do.’ If there’s a lot in there about kind of work life balance, a lot in there about kind of how they support their residents, about resident wellness, then that’s probably a program that talks about those things. If you’re sitting there and it’s an hour long of what rotations you do, and the prestigious research that their residency is about, and there’s nothing about wellness, well that might tell you something.

Dr. Ryan Gray: What do you wish you knew going into emergency medicine?

Dr. Dan Frees: I guess I wish- now this is not a negative. As much as everyone will tell you don’t watch the show ER and expect that that’s ER, it really- and I was accepting of this. Don’t get me wrong, I’m not saying it like this blew my mind and I’m disappointed, but there really is no way to convey as strongly the truth that the majority of your day is dealing with not exciting things. It’s dealing with a lot of drug abuse, it’s dealing with psychiatric illness, it’s dealing with coughs and colds is the majority of your day. Those exciting things are only maybe 5% of your patients. Those crazy procedures you see where you’re cracking chests, and putting chest tubes in, and reducing shoulders, that’s maybe 1 in 100 patients. And not to say that’s something I wish I had known, that’s something I kind of knew going in, but it is a slightly different type of medicine than I or other people would envision when they’re probably starting residency.

Dr. Ryan Gray: If you wanted more of that, the gunshot wounds, and the trauma, couldn’t you- as you’re deciding where to work and where to practice choose a city that is known to have a lot of that sort of trauma and work at a hospital that has that sort of trauma?

Dr. Dan Frees: Definitely. My wife’s also an emergency physician, we met at residency, and she works at a trauma center and gets gunshot wounds and all that stuff every day. I get almost none of it in the community, and that’s sort of a selection so she obviously selects to work at that kind of place. But with that said, even using my wife as an example with the gunshot wounds and the knife and gun club as you want to call it, still 95% of her patients are the routine stuff, the marginalized portions of society that end up in the emergency department, only a very small amount. Maybe call it 5% of her patients are the exciting trauma gunshot wound stuff, and maybe 1% of mine are, but it’s still a very low percentage. So you have to be accepting that really as an emergency physician your job is to take care of sort of the sick, the weak, the people that don’t have somewhere else to go, people with chronic illness more so than is maybe advertised. That’s your job.

What Other Physicians Should Know About Emergency Medicine

Dr. Ryan Gray: What do you wish primary care providers knew about emergency medicine?

Dr. Dan Frees: Oh wow, can we do a whole one hour podcast on that?

Dr. Ryan Gray: Maybe.

Dr. Dan Frees: I think it’s the role of emergency medicine. I think there’s this- and this is not their fault, I think primary care is really sort of been under attack and really undervalued for maybe the last 25 years to the point where there aren’t enough primary care doctors, and their resources are very limited. So they’re almost forced to make some decisions of how you kind of triage out stuff that they- I won’t say can’t handle but just their practice and their volume can’t handle so we end up with a lot of primary care in the emergency department, which is sort of a byproduct of the system, not a knock on primary care doctors. There is a lot of what primary care doctors consider emergencies are not things that we consider emergencies. So it’s a matter of what our role is, what we’re going to- we are there to stabilize emergencies. We do a lot more than that, but that is our goal and what we do. I had someone with high blood pressure, this is what we get on a near daily basis, people get sent in from primary care doctors for a very high blood pressure. We look at it and say, “Okay you have a very high blood pressure today. Go home and follow up with your primary doctor,” and the answer is, “Well they sent me here.” It’s sort of a definition of what is considered an emergency and kind of what resources we have. We don’t have unlimited resources, we get a lot of referrals from primary care that kind of, ‘Oh you need to see a neurologist, go see the emergency department.’ Well if you’re not having a true neurological emergency, you’re not going to meet a neurologist in the emergency department, you’re going to meet an emergency doctor. And we’re very good at neurology in many cases, but if the goal as a primary care doctor is to get your patients hooked into neurology and to orthopedics or something like that, then that may not be what emergency medicine’s role is. So I guess what I would like them to know is kind of what our job is, almost like what I said in residency we rotate out of emergency medicine to understand what they do and what their job is. That’s not to say they don’t rotate with us in residency as well, but just kind of an understanding of what our process is, what resources we have, and what we can provide to their patients.

Dr. Ryan Gray: What about on the flipside, the hospitalist that you’re admitting to? What would you wish they knew about your job?

Dr. Dan Frees: Just a little bit on the system and the hospitalists. I have a very- I am very lucky to have a hospital assistant whereby my admitting hospitalists are sitting ten feet away from me in the emergency department and not hiding away in a closet where I think they’re out there. So they kind of have a sense of how is Dr. Frees’ day going? Like is he very busy? Kind of how can they help me and how can I help them which is very beneficial. So what I would say my hospitalist would like to know is maybe to an extent of kind of there’s a lot of, well the admission criteria are this, and I’m saying well this patient has to stay in the hospital. They can’t go home. Regardless of what your admission criteria are, come meet the patient kind of thing. So there’s a little bit of sentiment between hospitalist and emergency medicine, and kind of what- you can sit upstairs and Monday morning quarterback all my decisions, but being down here is a little different. Fortunately I don’t have that big issue. But overall in emergency medicine, hospitalists and emergency physicians I’d say kind of what we’d like them to know is kind of what resources we have, and kind of the experience of seeing the patients in person is a little different than accepting them up to the floor. But I think we’re actually getting better, it’s sort of been a point for the last maybe five or ten years is really the relationship between hospitalists and emergency physicians. Because actually emergency medicine is only forty years old as a specialty, but hospitalists I think is the only other specialty that’s younger than us. So there’s still a lot of development in the role of hospitalists and how they work with other services. So over the last five years I think emergency medicine and hospitalist services have actually done a lot of beneficial work to get together and be on the same page. So I think in most cases we have a very good relationship.

Dr. Ryan Gray: Are there any other specialties- specific specialties that you work mostly with, or a lot with?

Dr. Dan Frees: Really hospitalists would be the closest one. You’re obviously going to talk to a lot of specialists. It depends where you are, too. If you’re in an academic center you may not actually really interact with any attendings, it may be all residents. And depending on where you are in the community, you may be in a very small hospital where when you want the orthopedist you call the orthopedist. You want the cardiologist, you call the cardiologist. You want the neurosurgeon, you wake up the neurosurgeon in the middle of the night. There’s other hospitals where you’re going through a lot of physician assistants. But I’d say it’s pretty broad after hospitalist. I talk to pretty much to every type of doctor on occasion about their patients, about patients I need consultation on, so it’s not a matter of specific specialty that I get to know or work with closely, it’s kind of understanding how to have a positive relationship with all specialties which can be different, and understanding what different specialists want based on their specialty. You can’t quite give the same type of presentation to every type of doctor or every type of specialist.

Unique Opportunities in Emergency Medicine

Dr. Ryan Gray: You mentioned it a little bit before about some unique opportunities as emergency physicians outside of clinical care. Can you talk about some of those opportunities?

Dr. Dan Frees: Sure there’s- sort of because we are the broad ranging doctors if you will, and kind of we call ourselves the hub of the medical system or the medical home, we kind of get to know all the doctors in the hospital because we’re talking to them, kind of everyone sends their patients to us, and we’re right there, we’re out in the open, you know where we are, we’re not in an office in the community somewhere. We’re valued for that when it comes to leadership within a hospital, within health systems, within pharmaceutical systems because when you’re looking for a doctor to do a role that’s not straight clinical, you kind of want someone that understands medicine as much as they understand their specialty, and I think we’re uniquely positioned for that. So when you’re looking for administrators in the hospital, you’re looking to emergency physicians obviously within the department. You’re looking for assistant directors, and directors, and quality directors, and things like that. But even outside the system, I know a lot of people that are CIOs or Chief Information Officers because people love having emergency physicians in that role because we understand how the EMR systems and the commuter systems affect everyone in the hospital. Obviously getting up to CEO, like CMO, again kind of if you’re going to have a doctor in one of those roles it’s going to have someone with a broad range of experiences that kind of knows everyone and can get along with everyone. But even outside that, this is not specific to emergency medicine, you can get involved in pharmaceuticals, you can get involved in consulting, you can get involved in your community working with high school sports teams, kind of everyone loves an emergency physician. I hate to say the example of being on a plane and when they call for a doctor, you don’t really want the psychiatrist or the orthopedist technically to show up, you want the emergency physician. But that analogy kind of holds true in the community as well, when people need someone for the community medical board, when people need sort of a medical advisor to the soccer team, when people need a physician to be on hand for a sports game, they kind of want an emergency physician. So you’re uniquely positioned to do a lot of those things. I work a lot in leadership, I’m very involved in American College of Emergency Physicians, kind of sitting on committees that go over practice management, go over patient satisfaction surveys, that go over how we want to move some legislative issues, about kind of how the laws affect medicine, how laws affect emergency medicine which I find very interesting. I go to Washington once a year and go to a conference there and we meet with actually our representatives and Senators on the hill and talk about some of the issues that are facing us, and current bills that are up that affect us. I find that very interesting, that’s sort of my side item. But there’s any number of ways you can go.

Best and Worst of Emergency Medicine

Dr. Ryan Gray: What do you like the most about being an emergency physician?

Dr. Dan Frees: My every day job, I would have to say. I like having- I like not having call, I like having the schedule of shift work where I can have- totally be dedicated to my family, and be dedicated to everything outside of medicine when I’m not in the hospital, and I like when I’m in the hospital being sort of ‘on.’ I never liked in medical school and residency when I was on services where you were kind of there for twenty hours and you were probably working twelve of them if you will, and the rest of the time you were kind of just hanging out waiting for labs, and then because you knew in three hours you would have to round again so it was just kind of collecting information, where I like in emergency medicine when I’m there I am working. Like I am seeing patients, I’m working hard, and then when it’s time to go I’m going home. It’s not kind of the stop and go kind of lifestyle of maybe an internal medicine doctor, or maybe a cardiologist that’s in the office for a while, and then has a lunch break, and kind of comes back, and then maybe have to make some phone calls after that. I kind of like being on the whole time and then going home.

Dr. Ryan Gray: On the flipside, what do you like least?

Dr. Dan Frees: Maybe the same kind of answer, a little bit of the shift work and nights and weekends. Not to say- that’s something I accept as part of my job, and many sometimes I kind of enjoy that, I actually enjoy a lot of my overnight shifts. But it does take a little toll on you, it takes some time out of your life when you have to take a nap before your shift, and take a nap after your shift when you’re working overnights. I actually don’t mind the weekends that much other than maybe in the summer. I mean in the summer where there’s- it seems every single weekend someone in your friend or family pool has some event that they want you to go to. And most people go to work half of the weekends as an emergency physician, so half your weekends is pretty good for me in the summer when there’s a lot of things going on, it gets a little tough and you’re a little jealous of my physician colleagues that are in different specialties where they’re just off every weekend, then they have that set time with their family. On the flipside I love having a random Tuesday and Wednesday off. Currently I’m sitting at home right now doing this interview, my wife is in the other room with my child, and we actually have the whole day off today, and the whole day off tomorrow together. So Wednesday and Thursday during the day we have completely off together. It’s almost like our weekend. But if I had to pick one thing, I know that’s kind of a weak answer because it’s something I sort of cherish as well. But it is kind of accepting that you’re going to be working nights and weekends, and some inconvenient times, and you don’t have that very, very predictable schedule that some people have.

Dr. Ryan Gray: I’d say it’s safe to assume that if you had to do it all over again you would still choose emergency medicine?

Dr. Dan Frees: I would, no question.

Dr. Ryan Gray: What do you see as the future of emergency medicine?

Future of Emergency Medicine

Dr. Dan Frees: I think something I’d alluded to earlier is we’ve had this slow trend of a lot of things that used to be outpatient coming to the emergency department, a lot of community resource things that end up in the emergency department now. I think we are- as emergency medicine for about fifteen years or so maybe until recently, we’ve kind of tried to put our hand up and stop that if you will, and go, ‘Well we need to educate you on why to come to the emergency department.’ Like sort of this isn’t our role necessarily to do a lot of primary care stuff. But I think almost the cat’s out of the bag now and that’s unfortunately due to a lot of problems with our American healthcare system, that’s where people are ending up, and that’s sort of the role we’re being forced to take on. And over the last couple years, and I think down the road we’re going to actually have to embrace that, and really reach out to that. And in emergency medicine we’ve talked about doing a lot of follow-up care whereas when people have outpatient stuff that they just can’t get follow-up appointments for, maybe we do a little more of that primary care aspect. Maybe we do a little more observation medicine whereas opposed to admitting patients, we’re holding onto them and taking care of their work up, when they can’t necessarily be admitted, and actually becoming more of that community hub. Maybe it is that if you feel sick instead of going to your primary doctor, maybe the standard does become- and I don’t think this is in the next five years, this is maybe in the next ten, fifteen years, a generalized health system where when you don’t feel good you don’t go see your primary doctor, you come to the emergency department even if it’s not what would be considered an emergency and we’re kind of the brokers of healthcare in a way. We’re sort of the hub of healthcare, then sort of everything comes to us and we then kind of get you where you need to be more so than we already do, we already do that to an extent but even kind of embracing it and setting up systems whereby we actually have a process for us being sort of the center of medical care. A lot of people are over- a lot of people in other specialties are overworked and don’t have the ability to provide some of the resources that the community expects of them. That’s not a knock on them, that’s just where the healthcare system has went, and I think we actually are in a decent position to be sort of the brokers of healthcare, and sort of the hub of the medical- of the American healthcare system.

Dr. Ryan Gray: Interesting. Any last words of wisdom for those interested in emergency medicine?

Words of Wisdom to Premeds

Dr. Dan Frees: Try it out and try it in different settings. Try and find rotations that are diverse. I see a lot of people come through, and it’s hard to avoid this, but they’ll rotate- they’ve done two or three emergency medicine rotations, and they’ve done it all at big trauma centers. And I think that’s fine, that’s almost what you get pushed into when you’re in medical school, but try and find some community medicine. Try and find something that’s a little peripheral to emergency medicine. Do an ultrasound rotation, do a community medicine rotation abroad, which is basically emergency medicine in the United States. And do some diverse experiences and kind of understand sort of as I alluded to before what emergency medicine is outside of a major trauma center. I think that’s important.

Final Thoughts

Dr. Ryan Gray: Alright, there you go, session number 2 is in the books, emergency medicine. I hope you learned something today. I know emergency medicine- when I put out a call for requests on what specialties people wanted to hear from, emergency medicine was right up there at the top, because it’s becoming more and more popular, and as we discussed it’s most likely because of the shift schedule, the shift work, and having a little bit more work life balance. You’re working hard, as Dan talked about, but you have the set hours so that’s kind of cool.

Next week we’re going to dive in and talk all about- it’s a surprise. All about another specialty, I’ll give you that hint. So I hope you join us next week. If you haven’t yet subscribed, please subscribe in iTunes, in Google Play Music, on Stitcher, wherever you listen to podcasts. If you’re listening to this through your Chrome browser, or Safari browser, or Internet Explorer, wherever you’re listening if you’re listening on a browser, go find the podcast app for your device and subscribe to this show and all the shows that we do over at www.MedEdMedia.com.

I hope you have a great week, and we’ll see you next week here at the Specialty Stories Podcast.

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