A career in emergency medicineBMJ 2011; 343 doi: https://doi.org/10.1136/bmj.d5151 (Published 20 August 2011) Cite this as: BMJ 2011;343:d5151
- Bilal Salman, core trainee year 1, emergency medicine, West Midlands, UK,
- Emma Jenkinson, core trainee year 2, emergency medicine, West Midlands, UK,
- Kasyap Jamalapuram, specialty trainee year 5, emergency medicine, West Midlands, UK,
- Caroline Leech, consultant in emergency medicine and pre-hospital medicine, University Hospital Coventry, Coventry, UK
“Emergency medicine—isn’t that just triage?” Bilal Salman and colleagues disagree
Emergency doctors are sometimes regarded by other specialties as jacks of all trades and masters of none. In reality, emergency medicine requires you to maintain an extremely broad range of clinical skills and knowledge. As emergency doctors we regularly encounter the best (and worst) that medicine has to offer, so training in the specialty has to enable us to deal with just about anything.
Advantages and disadvantages of a career in emergency medicine
An exciting, varied, challenging job
Exposure to all specialties, requiring a broad knowledge and skill set
Practical, hands-on specialty, requiring quick thinking and action
Flexibility suits trainees who don’t work full time—good for doctors with families
Number of consultants is predicted to grow, so career prospects are good
Teamwork within the department, with other specialties, and with other healthcare professionals and the emergency services
Excellent opportunities for covering events, working abroad, and other roles outside hospital
Shift work can make it difficult to maintain a good social life and healthy work-life balance (and it is likely that consultants will soon be required to provide 24 hour cover on site)
Challenging patient population
Often working under pressure, owing to the nature and volume of patients and time constraints
Occasional hostility from patients (and colleagues)
Rotas are not always well covered, and departments often rely on locums
It can be difficult to follow up patients and to get appropriate feedback
To maintain a fast pace and enthusiasm
To be involved in team working and leading
To have a breadth of knowledge
To be flexible in terms of working hours
To have communication skills
To have manual dexterity
To function well under pressure
Emergency medicine (previously known as “casualty” and then “accident and emergency (A&E)”) became a recognised specialty only in 1972. Before then, emergency departments were led by orthopaedics and dealt primarily with injuries. Most of the workload today is medical, but the department is the first point of call for emergencies in all specialties and deals with a vast spectrum of illness, from life threatening emergencies to minor ailments and social problems. We believe that some of the most important developments in emergency medicine over the past decade have been the introduction of a structured career pathway, curriculum, and examinations. The six year training pathway for emergency medicine begins at the end of the foundation programme (fig⇓).
Entry to specialty training in emergency medicine is from the acute care common stem (ACCS) programme, a generic programme shared with acute medicine and anaesthetics. The first two years consist of six months of emergency medicine, six months of acute medicine, and a year of anaesthetics and intensive care medicine. The third year is specialty specific and includes six months of paediatric emergency medicine. Progression to higher training (at specialty training year 4) is through a national application process. Specialty training years 4-6 involve placements of 12 months in departments of various sizes and patient demographics. It is also possible to subspecialise or to dual accredit in an area such as paediatric emergency medicine, intensive care medicine, acute medicine, sports medicine, or pre-hospital care. It is worth thinking about this early on and tailoring your training and CV accordingly.
A day in the life of a senior house officer in emergency medicine (Emma Jenkinson)
6 pm—I am starting a late shift and arrive to find the department full. I start in the paediatric area and see a mix of unwell children and minor injuries.
10 pm—I move to minors [minor cases] and, again, see a mix of minor injuries, aches, and pains. These patients are generally satisfying, as you can sort them out yourself and send them home. I do get frustrated with the regular response to my question, “Did you take any painkillers for your headache?”—“Oh no, doctor, I don’t like taking painkillers.” I see one patient who has cut his hand while drunk. This requires suturing and is a simple wound, but the suturing takes nearly an hour because the patient is unable to keep still.
Midnight—An ambulance alert arrives in resus [resuscitation]: a man with an ST elevation myocardial infarction, who is transferred rapidly to the cath lab [catheterisation laboratory] thanks to rapid assessment and liaison with cardiology.
12 30—I move to majors for the remainder of the shift: patients are piling up, and there are no beds. My patients include a woman with bleeding in early pregnancy, an elderly woman from a nursing home with urinary sepsis, and a man with neck pain after a road traffic collision.
2 am—It’s the end of the shift. There is no need to set my alarm clock, as I am on a late again tomorrow, so I can enjoy a lie in.
There are two examinations to complete: the College of Emergency Medicine membership (MCEM) and fellowship (FCEM) examinations. The College of Emergency Medicine was established in 2008. The MCEM exam is in three parts: part A is multiple choice questions, part B is short answer questions, and part C is an objective structured clinical examination. This must be completed before higher training can be entered. One author (EJ) who recently completed the MCEM exam found it to be “very reflective of the workload and skills required for emergency medicine.”
Senior trainees sit the FCEM exam, which is mandatory for obtaining the certificate of completion of training to become a consultant. The FCEM comprises five separate parts: a clinical short answer question; a clinical objective structured clinical exam; a management viva; a critical appraisal short answer question; and a clinical topic review viva (candidates will already have handed in a project for the college to review before the exam). The FCEM exam covers a wide range of topics that fairly assess each trainee’s experience and knowledge in the workplace, and it helps develop skills and knowledge that will be needed for work as a consultant.
Emergency medicine is becoming increasingly popular, and entry is competitive. We advise medical students and foundation trainees to plan early and maximise their exposure to the specialty, particularly during attachments, special study modules, and electives.
A day in the life of a consultant in emergency medicine (Caroline Leech)
5 pm—I start my on-call shift: the department is full, and there are “breaches” [patients who have been in the department for more than four hours], owing to a lack of beds. I check the SIFT [senior intervention following triage] tray in majors and make sure that all appropriate investigations have been ordered for patients waiting to be seen. I do a walk around of the department and review some of the cases seen by the emergency department doctors.
6 pm—I supervise a registrar giving propofol sedation to reduce a dislocated shoulder and fill out an online DOPS [direct observation of procedural skills] assessment.
7 pm—The wait is building up in minors, so I identify the “quickies” and take a nurse with me to do treatments: we see nine patients in an hour.
8 pm—An alert arrives: a 53 year old man with bradycardia and hypotension and no response to atropine. The electrocardiogram shows an unusual broad complex tachycardia without P waves. His venous blood gas reveals hyperkalaemia, so we start treatment and involve the medics. A nurse shows me an electrocardiogram for another patient, who has an anterior STEMI [ST elevation myocardial infarction] so we move him to resus and put out a STEMI alert.
9 pm—I am asked to review a 1 year old child where concerns have been raised about non-accidental injury.
9 30 pm—Called to observation ward to see a depressed patient wanting to discharge herself: I manage to persuade her to stay voluntarily and ask the emergency department junior to request an urgent mental health assessment.
10 pm—The alert phone rings to forewarn of three patients from a road traffic collision: we initiate the trauma alert and massive transfusion protocol before their arrival and allocate staff roles. I am the team leader. As well as running the trauma alert I have to speak to the police and the patients’ families.
12 30 am—The department is under control, so I let the registrar and senior nurse know that I am leaving and am on call until 8 am. There are no phone calls during the night.
Choosing foundation jobs
Plan your foundation jobs carefully. Although it is tempting to choose acute medicine or anaesthetics, you will gain further experience in these during core training, so opt for other specialties, such as paediatrics, surgery, obstetrics and gynaecology, orthopaedics, or general practice, depending where your interests (or weaknesses) lie. Aim to complete your life support courses (advanced life support, advanced paediatric life support, advanced trauma life support) as early as possible, and try to achieve “instructor potential” for useful CV points and experience. Identify a mentor early on who can guide you in making career decisions and provide you with some insight into current training and developments.
Competing interests: None declared.