In residency, we always talked about “real life,” as if we were learning emergency medicine on this academic island surround by a sea of other types of practice. We said things like, “only at _______ would you see something like ______.”
After 3 years of residency and 1 year of fellowship, it turns out that you still see generally the same type of things in the community and you still often deal with the same degree of complexity. As emergency department acuity rises nationally, it’s rare to see the isolated “classic” presentation of an illness in an otherwise healthy patient.
The most notable difference from working in a community department compared to a larger academic center is the “Surge.” At larger (often academic) centers, we frequently take it as a given that patients will have to wait. They wait for all the built-in inefficiencies that come with training the next generation of attendings--consults, second opinions, thorough workups, residents away for lecture, etc.
To a certain extent, there’s some built-in comfort with the wait that develops in these types of environments, in the sense that the waiting room is just a number that only occasionally dwindles down to zero in the early hours of the morning.
In contrast, most graduates will take a job in the community, where patients are often brought directly back to the room--bypassing the waiting room entirely. Additionally, we’re now entering an era where salary is tied to things like length of stay, patient satisfaction, and left without being seen metrics.
One area that isn’t well taught at most residencies is how to deal with a surge of patients registering in triage for a single coverage shop. Seeing 1.5-2 patients per hour seems doable until you realize that 14 of those people just happened to present within 45 minutes of each other during a shift. This kind of surge is a predictably unpredictable part of the job.
This brings up the question of how can an emergency physician digest this and still give quality care?
Everyone practices somewhat differently, but my anecdotal solutions have been the following: