How Doctors Choose a Specialty

People sometimes assume that every doctor feels a calling or has a special
skill for one area of medicine or another. But the truth is very
different for most doctors.

Old operating theater in London
Wikimedia Commons (Mike Peel, CC BY-SA 4.0)

When students begin medical school they don’t actually know what medicine entails. Maybe they’ve followed physicians around or worked in a lab. But that is completely distinct from being
in a hospital for twelve to fourteen hours a day writing notes, calling
consults, rounding on patients, operating, or delivering babies. And even
when young students do see these things, they
usually watch from afar and don’t fully understand what’s going on. The
hierarchy, the language, and the rapid exchange of information remain a
mystery.

Nevertheless, matriculating medical students still have ideas about what
specialties they want to practice. Walk around an auditorium during an
orientation and most budding physicians will say they’re interested in one
field or another. This is completely understandable; something motivates
people to apply to medical school. I thought seriously about
becoming an emergency-medicine doctor. I had worked as an EMT in New York and loved the excitement of
emergencies, the rush of adrenaline, and the range of patient presentations.
But I didn’t really know what it was like to work in an emergency room for
a twelve-hour shift.

Once medical school starts, things slowly change. As they study the
biological systems and dissect in the anatomy lab, some students realize
that they now feel dispassionate towards what they once loved. Suddenly, the eye
or the heart or the skin is not as interesting as the lungs or the brain or
the intestinal system. Granted, this is all still theoretical — it
is early, and the students have not been inside the hospital yet. But inklings
arise and ideas take hold. I enjoyed many of the educational blocks during
medical school and even had a particular affinity for hematology and

gastroenterology
, while taking a dislike, surprisingly, toward neurology (I am now a
neurology resident).

It is during the

third year of medical school
when professional ambitions take shape, as students work in the hospital and
clinic. They rotate through general surgery, psychiatry, emergency
medicine, and neurology, among other specialties, getting a quick but deep
sense about how these areas work. They participate in surgeries, clinic
appointments, and

hospital codes
. Decisions about a future specialty often form during these samplings.

But there is often much more to those decisions. I liked nearly everything during third year. I found the
operating room fascinating. You stand at the operating table and
assist the surgery residents and attending as they open up the
patient and take out parts of the intestine or the gallbladder. You
peer into a living human body in real time. You see the problem; you fix or
remove it; and then you sew the patient’s skin back together. Other
specialties are similarly awe-inspiring. On my obstetrics rotation I

delivered babies
. In the emergency room, I participated in

trauma codes
and watched the effects of

treating drug overdoses
. There is so much to marvel at in medicine that each rotation is appealing
in some way. How can a student settle on one specialty?

When faced with this impasse, another deciding factor is often
a teacher or mentor.
After all, the word “doctor” comes from the Latin verb docere, which means “to teach.” The degrees we receive when we graduate from
medical school read M.D., or Medicinae Doctor — “teacher
of medicine.” So when we speak of a

doctor’s purpose
 it is implied in the word that the purpose is not just to heal the sick but to teach the
next generation of doctors, and also one’s patients. Notice this passage from the

Hippocratic Oath
:

I swear by Apollo The Healer…. To hold my teacher in this art equal to my
own parents; to make him partner in my livelihood; when he is in need of
money to share mine with him; to consider his family as my own brothers,
and to teach them this art, if they want to learn it, without fee or
indenture; to impart precept, oral instruction, and all other instruction
to my own sons, the sons of my teacher, and to indentured pupils who have
taken the physician’s oath, but to nobody else.

Image via Flickr

These lines that deal with the doctor-student relationship come before the parts about
the doctor-patient relationship. It is one of the few professions left in this country that
still functions as an apprenticeship (somewhat similar, in a few respects, to being a Ph.D.
student under an adviser). One studies a specific topic very intensely for
an extended period of time with a group of professionals who teach you how
to do what they do. This means that who teaches you matters as much as what you’re
taught.

When I rotated through neurology, the subject area excited me, but I was particularly impressed by everything about
the doctors. They took the time to explain things to students, which in the
busy context of the hospital and clinic isn’t always a priority. They
treated patients with great respect and kindness. They knew an impressive
amount about the subject and beyond. I felt inspired. Though many
other physicians in internal medicine, pediatrics, and elsewhere were
similarly impressive, my experiences were more mixed in those departments.
This at least was my unique experience; colleagues of
mine reached different conclusions.

The physician teachers also affect the culture of each department. For example, emergency medicine doctors are frequently seen as adrenaline
junkies. They love going rock climbing, bungee jumping, racing in triathlons,
and so forth. This is not true across the board, but one likely finds a
higher proportion of people who have those hobbies in emergency medicine. Specialties fit certain personalities or interests. I found that more
neurologists shared my interests — many of them study human consciousness,
autonomy, and free will, which tie into my fascination with the humanities.

The last element that helps medical students choose a specialty is
lifestyle, or how much time one has outside of the hospital. Surgeons
seemingly live at work even when they’ve graduated from residency programs.
Surgeries can be long and tedious; unexpected disasters occur during
operations; patients need emergency surgeries; and many post-operative
patients need close monitoring to make sure there are no complications. Pediatricians, by contrast,
tend to have much more normal lifestyles. They can work in an outpatient clinic
from, say, 8 a.m. to 5 p.m. Any child with an emergency goes to the emergency room, not
to the outpatient clinic, and pediatric patients tend not to have as many
chronic, difficult-to-manage illnesses as adults (like heart disease or high blood
pressure). Pediatricians focus more on preventative measures,
such as well visits and vaccines. As a pediatrician it is much easier to keep up with
family or hobbies outside of medicine. I loved surgery, but I could not see
myself putting in the hours to do it every single day for the rest of my
life. Neurology, on the other hand, like pediatrics, often involves a more
balanced lifestyle.

And this is how we choose: subject material, mentor and teacher experiences,
department personalities, and lifestyle. But the truth is that
many of us who go into medicine could be happy in a number of specialties,
which is an important perspective to have. It means that we love, broadly,
the subject and practice of medicine, and that our curiosity about disease
processes and treatments does not start and stop in one specialized silo or
another, just as most diseases do not stop in one body part or another. It’s what makes medicine such an enthralling and difficult field.

The Costly Complications of Emergency Medical Care

During one Emergency Department (ED) shift, EMTs brought in an older woman to the hospital. She had called emergency medical services (EMS) and explained that she had low blood
sugar, or hypoglycemia. Hypoglycemia can lead to
coma, brain damage, and death as well as other more minor symptoms such as tremors and sweats. But when the EMTs arrived to pick this woman up, her blood sugar levels were normal — there was no emergency at all. In fact, as she admitted once she was in the back of the ambulance, she only called EMS because she had run out of glucose strips, which diabetic patients use to monitor their blood
sugar. A family medicine doctor can easily procure these for a patient, and running out of these strips in no way constitutes a medical emergency. Once this
woman got to the ED, the physicians drew her blood for labs, examined her, and measured her blood sugar again in order to make sure there was no emergency.

In another instance of misused resources, a middle-aged gentleman called an ambulance because, supposedly, he could not walk. However, the patient was able to get himself up from the stretcher and climb onto the ambulance, which his daughter said was normal behavior for him. He received a full workup in the ED with labs and x-rays. Similarly, a mother brought her son into the ED because he needed a full physical before playing sports. The ED physicians spent time speaking to the patient, doing a physical exam and drawing basic labs to look at his blood.

These kinds of situations occur daily — we squander emergency medical resources on non-acute medical conditions. Sadly, emergency physicians and EMTs do not have a choice in the matter, which can be disheartening in a system where resources are precious. And while there are many factors affecting inefficient emergency medical care, we have a law to blame for at least some of the daily inefficiencies — EMTALA (the Emergency Medical Treatment and Labor Act).

*   *   *

Congress passed EMTALA in 1986 with Ronald Reagan’s signature, ensuring, among other things, that patients requesting emergency medical care receive it regardless of their ability to pay. In a 2001 article published in the Baylor University Medical Center Proceedings journal, Dr. Joseph Zibulewsky puts the law in perspective. In 1986 and 1987, case studies from Cook County Hospital in Chicago described how other hospitals transferred patients to Cook County because the patients could not pay for their care, a practice known as “patient dumping.” The studies concluded, as Dr. Zibulewsky writes, that “this practice was done primarily for financial reasons.” In fact, “the reason given for the transfer by the sending institution was lack of insurance in 87% of the cases.” Moreover, the patients who were transferred were twice as likely to die as those who were not transferred. Nor were these isolated events: “This practice was not limited to Chicago but occurred in most large cities with public hospitals. In Dallas, such transfers increased from 70 per month in 1982 to more than 200 per month in 1983.” As a result of widespread patient dumping, EMTALA was signed into law.

EMTALA consists of three basic tenets all of which must be followed regardless of a patient’s insurance or financial status. First, any person who presents
to the hospital for medical care must receive a medical screening examination (MSE) to ensure that there is no emergency medical problem. As the law reads:

if any individual (whether or not eligible for benefits under this subchapter) comes to the
emergency department and a request is made on the individual’s behalf for examination or treatment for a medical condition, the hospital must provide for
an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available
to the emergency department, to determine whether or not an emergency medical condition…exists.

As the examples at the beginning of this post illustrate, no matter what a patient comes in with, an emergency medical condition must be ruled out, so a medical workup must be performed. Additionally, the ED must “provide such medical treatment of the condition as may be necessary to assure, within reasonable medical probability, that no material deterioration of the condition is likely to result from or occur during the transfer of the individual from a facility.” In other words, the patient’s condition must be stabilized before discharge. If the hospital is not equipped to care for a particular medical condition, the hospital must transfer the patient to another hospital capable of providing the needed care.

And all this does not just apply to ED physicians. Any specialist consulted by the ED (in fields like neurology or psychiatry) must see the patient within 30 to 60 minutes of being called. EMTs are also beholden to
this law. As Zibulewsky explains, an “appeals ruling in Hawaii has extended this [EMTALA] to virtually any ambulance, even those run by city or county services.”

Thus, once a patient is in an ambulance, he or she “can be considered to have come to the ED.”

Image via Shutterstock

Hospitals and physicians face stiff consequences for failing to abide by EMTALA. The law applies only to those hospitals and physicians who
participate in Medicare, which nearly all of them do. And if the
hospital violates EMTALA, reimbursements can be taken away. On an individual level, physicians can be responsible for up to $50,000 in civil court if they violate the law. Given how many
hospitals and doctors receive reimbursements from Medicare and how much money hospitals receive from Medicare (hundreds of
billions of dollars), it behooves institutions to follow EMTALA as best they can.

Unfortunately, the law is incredibly problematic for many reasons. In the first place, vagueness abounds: what counts as a medical screening examination? Is it just a physical exam? Is it just a history of the patient’s present illness? Must a CT scan be included? This is completely nebulous. Also, what counts as stabilized? If a person is bleeding to death with a broken leg and a physician stops the bleeding and casts the leg, can the patient be discharged without a follow-up appointment with a physician? If the trauma has left someone severely debilitated and is surviving only on a ventilator, is it now the hospital’s responsibility to find an acute care nursing home and continuous care for this patient? Does the hospital keep the patient in the ICU and eat the cost indefinitely?

Furthermore, the law adds population burden and financial cost to a floundering medical system. A 2008 article by Dr. Damon Dietrich and Dr. Michael Crapanzano concluded that while “EMTALA was intended to provide all patients the right of medical care in the ED regardless of ability to pay, a cost: benefit analysis performed by Duke University…suggests it did just the opposite.” Moreover, “EMTALA actually impedes access for an EMC [emergency medical condition] by overwhelming resource capacity.” Many people who come to the ED actually need emergency medical care, not just glucose strips. And putting time and resources into non-emergency care takes away resources and time from emergency care. Also, because care is “free” in the ED, patients have no qualms about coming in whether their problems are or are not acute. In turn, this leads to overcrowding. Some statistics, though not proven to be a direct consequence of EMTALA, demonstrate the severity of the problem. In 2001, “two out of every three hospitals reported diverting ambulances to other hospitals” due to ED overcrowding. Additionally, “ED visits in 2003 rose to 114 million, up from 97 million in 1997.” This overcrowding with uninsured patients costs the hospitals and its patients tremendous amounts of money. As a result, emergency rooms close, further exacerbating the problem of ED overcrowding. Between 1988 and 1998, 1,128 EDs closed, leading to dramatic increases in patient volumes and waiting times at other EDs.

Then, of course, there is the financial burden. An ambulance ride itself can cost over a thousand dollars. Also, the authors of the Duke study estimated that EMTALA has a net cost on hospitals, government agencies, and social welfare that runs in the billions of dollars. We thus have good reason to think that EMTALA places financial strain on our medical system as well.

But it’s not just patient care and hospital emergency rooms that are negatively affected by this law. According to the American College of Emergency Physicians, ED doctors “on average provide $138,300 of EMTALA-related charity care each year, and one-third of emergency physicians provide more than 30 hours of EMTALA-related care each week.” Unfortunately, ED physicians have no say in the matter — the federal government mandates that they donate their time and money. Some physicians are rightfully upset that they are not receiving compensation for the work that they have no choice but to do.

And yet, I support the idea of EMTALA. It would be callous to kick patients in need of emergency care to the curb simply because they can’t pay. As Avik Roy, health care policy expert and Opinion Editor at Forbes, has written in National Affairs, “There are some instances in which we should obviously consider more than economics: Certainly no wealthy nation should allow a destitute woman who has been hit by a car to die in the street. Likewise, in a pressing emergency, catastrophic care should be provided to those who need it, and the costs can be sorted out later.” Absolutely.

However, this law, a classic example of unintended consequences, is not the way to assure that care. It increases the cost, time, and population burden on the ED and also mandates that physicians give up their time and money to treat patients whether or not those patients need emergency medical care. And this is not just a partisan fight: political and healthcare activists of all stripes find this law deleterious and inadequate and have called for its repeal. But repeal of EMTALA seems distant as we try to sort out the effects of the Affordable Care Act. Nevertheless, if we cannot repeal it, we must improve upon it and rectify its effects as best we can to ameliorate patient care in the emergency room.

Image via Shutterstock

Incidentally, the problems arising from this law also illustrate an important point about medicine and politics. Politics is not some drama playing out on a distant stage and leaving most of us unaffected; it affects physicians and patients — so at some point all of us — every day in very practical, tangible ways. Whether EDs or hospitals face overcrowding, closures, or mandated care, all roads lead through the workings of politics, a topic which we can’t ignore if we want to understand medical practice. As John Adams famously wrote in a letter to Abigail Adams, “I must study Politicks and War that my sons may have liberty to study Painting and Poetry Mathematicks and Philosophy.” Adams’s point, though meant for his generation, holds true for all of us. We must familiarize ourselves with politics and ideas — these affect every interest and every profession as all are confined and freed by law. Medicine is no exception.

Opioid Overdose in the Emergency Department

Image via Shutterstock

I had just finished introducing myself to the resident when the EMTs wheeled in a patient on a stretcher. The patient’s face was completely pale and expressionless and his eyes were closed; his hair looked disheveled and unwashed. He wore tattered jeans, a soiled white t-shirt with holes, and white sneakers with untied shoelaces. His age, according to the EMTs, was 34, but he looked as if he were 50, with a sagging face and prominent wrinkles that no 34-year-old should have.

Other than this, we knew nothing about him. An anonymous person had called 911 and reported that this gentleman was “not awake.” This is not uncommon, as many folks who get into gunfights or use drugs do not want to be caught by police, and associate the medical profession with the law. As further contribution to our complete ignorance, the unconscious patient could not tell us what had happened.

Moreover, he was apneic, which means his breathing rate was dangerously slow. Without adequate oxygen intake, his heart and brain
would perish. As I wrote about in my post on running a trauma code, one of the most important aspects of a patient’s care in the ED is the airway — physicians ensure that the system that takes in oxygen works. With diminished breathing, this patient needed oxygen. Thus, the ED resident rushed to set up tools for intubation: sticking a tube down the patient’s throat to provide a space for oxygen entry.

When a patient like this comes into the ED — unconscious with no clear history — the ED physicians give the patient a few basic drugs that can save his life. These therapies target the most common causes of AMS (altered mental status) or total lack of consciousness. One therapy is glucose or sugar administration. Hypoglycemia (low blood sugar) can affect a person’s mental status. The brain primarily uses glucose for its processes; without glucose, it starves, leading to unconsciousness. One of the other therapies is naloxone, also known as narcan. Naloxone is an opioid antagonist, a term that describes its inhibitory actions at opioid receptors in the nervous system. Opioid agonists include drugs like morphine and heroin that cause sedation and respiratory depression. Naloxone acts quickly to reverse these effects in patients who overdose on opioids.

A fellow student and I watched as the attending physician injected a dose of naloxone into the patient’s IV. The patient shot up in bed, trembling, sweating, and breathing rapidly, his eyes wide open. That’s the catch with the agonist and antagonist relationship: because their effects oppose each other, their manifestations also oppose each other. While opioids sedate, naloxone stimulates. The patient screamed at the nurses and physicians and threatened them. He hurled expletives at the healthcare staff and swung his arms at the nurses while demanding to leave the hospital, as spittle flew from his mouth.

The reason, as the attending ED physician explained to the patient, that they kept him in the hospital is that naloxone has a very short life in the body’s system and wears off in about an hour. But some opioids can be long-acting; ergo, this patient could become dangerously sedated again once the naloxone wore off. And he could not, given his mental status, make individual decisions for himself. The patient continued to thrash around until a police officer from another part of the ED came over. Not surprisingly, the patient calmed down.

Watching this elicits mixed emotions. What if this person did become more violent? Would I actually need, physically, to defend myself from this drugged individual — a man who clearly has little sense of what is and is not reckless and harmful? And then there’s sympathy; how unfortunate that such a young person could fall into a life of drugs. Further, what will his fate be? Will he ever give up using drugs? I also could not help but find it humorous that as soon as the police officer came into the room, the patient calmed down. The law and its enforcers have a potent effect, indeed. Lastly, this was an incredible physiologic feat of saving someone’s life using a drug with an antagonistic molecular construction — another wonder of modern medicine to put on the list of scientific achievements.

We may soon witness scenes like this in a more public sphere. The wonder that is naloxone is currently being distributed to police officers in big cities to use on people overdosing on opioids, according to The New York Times. The same thing is happening in New Jersey, too. Government agencies are responding to a rapid increase in the use of opioids: “Gov. Andrew M. Cuomo committed state money to get naloxone into the hands of emergency medical workers across New York, saying the heroin epidemic in the state was worse than that seen in the 1970s, and the problem is growing.” Of course, this is not going to rid us of addiction, but it will certainly save lives. And as the New York City Health Commissioner noted of naloxone, “It’s really quite miraculous. Anyone who’s ever reversed an overdose will never forget it. People wake up.”

How the ED (Emergency Department) Works

Ambulance image via Shutterstock

The Emergency Department is one of the most active and exciting parts of the hospital because it is the hospital’s sieve. The ED physician determines
whether an injury or complaint is life-threatening or not and then treats or admits the patient to the hospital if necessary. Someone usually comes in by
ambulance or private vehicle with a general complaint — referred to as the chief complaint — such as “stomach pain,” “chest pain,” “leg pain,” or “shortness
of breath.”

But occasionally, the first assessment of this chief complaint begins outside of the emergency room. Paramedics or emergency medical technicians who bring
the patient in by ambulance identify someone clearly in need of medical attention. Outside of the hospital they take the patient’s blood pressure, heart
rate, breathing rate, and temperature (collectively known as vital signs). These measurements indicate the seriousness of the situation. For example, if a
patient looks pale and sweaty, and his blood pressure is 80/40 (extremely low), this indicates the need for emergency treatment. However, if a patient calls
for an ambulance but has normal vital signs and looks healthy, then he can wait a bit longer for medical care, and the ambulance does not rush to the
hospital.

When the patient arrives in the emergency room, he will see a similar setup at many different institutions (I can testify to this because of my days spent
as an emergency medical technician in New York City, where I saw the emergency rooms of many hospitals). The doctors and nurses sit at an open station with
computers in the center of the circular or semi-circular room. The patient beds stand on the outer edges of the circle in small slots separated from each
other by curtains and, in some cases, by an actual wall. Usually, a patient is hooked up to a machine that continually takes vital signs and projects them
onto a screen facing the doctors and nurses.

Once the nurses bring a new patient back to a bed, the resident physician assigned to that bed asks one of the medical students to go see the patient. We
have ten minutes to interview the patient about the chief complaint and do a focused physical exam, which means we only ask about and examine bodily
systems that relate to the chief complaint. If a patient has chest pain, we do not ask about or examine the foot.

Difficulties abound with this assignment. First, some patients come to the ED and want to have all their problems taken care of, which is impossible to do
in a short period of time. Additionally, the ED is only meant to handle emergencies. Someone who has a broken leg, for example, may also want to talk about
a muscle sprain in his shoulder — but a sprain is far less concerning and does not need immediate attention. Second, some patients want to have a long
conversation with a medical student or physician. They may feel lonely at home, or have a difficult social situation, or just want to chat. And while we
must listen to the patient, these conversations may be irrelevant to the chief complaint. Moreover, other patients with life-threatening problems arrive
regularly and need an ED doctor more urgently. Finally, some patients come seeking pain medications because of an addiction, or some may malinger (faking an illness for some type of secondary gain, like getting out of school
or criminal prosecution).

Dealing with these kinds of patients is integral to the art of medicine in the ED. The methods we were taught in first and second year
about how to manage disease and what questions to ask tend to dissolve when dealing with human beings who have different motivations for coming in to the
ED. We need to understand those motivations and, occasionally, quickly work around them in order to address a patient’s life-threatening
illness.

After we see and examine the patient, we tell the resident what we think the diagnosis is and what lab tests or imaging we want to get. The resident then
sees the patient briefly and tells the attending physician his or her plan for the patient. The attending finalizes the plan for the patient and the
resident executes it. All this might be clearer with an example from my own experience.

During one of my shifts, a patient presented to the ED with severe back pain. He could not sit still, and cried out every few seconds. He squirmed on the
stretcher, moving his legs up and down, tearing sheets off the bed and clenching his hands to his chest while grimacing. Watching someone in pain is
extremely difficult and can even cause the observer to feel pain. And
there is no question that I felt incredibly sympathetic for this man — so much so that I didn’t want to disturb him by asking him questions and examining
him.

This is another difficulty in the field of medicine. We need to perform certain exam maneuvers or tests even though they cause the patient pain and
frustration. But it can be so difficult to bring oneself, especially in the student role, to swallow that difficulty and foist the necessary exam onto
the patient. How could I bear to push on and examine this man’s back when I knew this would cause immense discomfort? With difficulty, I continued the
interview and briefly palpated the spot on his back that hurt.

Once I finished the interview, I thought about a differential diagnosis. A differential diagnosis is a list of possible diagnoses for the patient given the
signs and symptoms the patient is presenting with, usually listed from the most likely to least likely. This gentleman with left lower back pain, for
instance, had a differential diagnosis list as follows:

1. Kidney stones

2. Herniated disc

3. Pulled muscle

4. Kidney infection (pyelonephritis)

5. Spinal abscess

6. Appendicitis

This list may not be complete, but it gives a sense of the kind of approach a physician takes to a medical issue. And as the physician questions the patient, the list changes. A doctor might ask if this particular patient had his appendix removed. If the answer is yes, then appendicitis comes off the list. A
practitioner uses interview questions and physical exam maneuvers to narrow the list down to one or two very likely diagnoses.

As for labs or imaging tests, these are only done to rule out or in diagnoses after narrowing down the list of possibilities with an interview and physical
exam. This man most likely had a kidney stone, as his presentation of severe back pain with an inability to sit still is a classic demonstration of this
pathology. Therefore, a urinalysis (examination of the urine) or CT scan (an imaging study to look for the stone) was integral to the diagnosis.

After deciding on this, I presented the patient to the resident. Across the field of medicine, medical students, residents, and attending physicians
present patients to each other in a standard format with an ordered listing of information. This information includes the age of the patient, history of
the chief complaint, relevant past medical history, physical exam findings, and a plan for the patient’s care. This gives all medical professionals a
concise, relevant, and standardized summary of the situation. In this case, for example, I might present the patient to the resident by saying this:

“Mr. B is a 44 year old caucasian male with a relevant past medical history of previous kidney stones, here today with a chief complaint of severe back
pain. The pain began five hours ago while showering with no apparent preceding incident. The pain is only better when the patient brings his knees up to
his stomach but otherwise remains severe. The pain is sharp and unilateral on the left side and does not radiate anywhere. The patient took ibuprofen
earlier, but that has not helped. He reports no blood in the urine, no difficulty urinating and no change in bowel movements. On physical exam, the patient
is extremely tender to palpation on his left flank but the exam is otherwise normal. My differential diagnosis includes kidney stones, pyelonephritis,
herniated disc, pulled muscle, spinal abscess, and appendicitis. I’d like to get a urinalysis and CT scan of the kidneys, ureters, and bladder, and give the
patient morphine for pain.”

That’s not a perfect presentation (and at the time mine was far less comprehensive), but it is the kind of formatted presentation that doctors look for
when they see a patient who has severe back pain.

If the ED attending physician is unsure of what is going on or how to treat the problem, the resident usually calls a consult. If the patient is bipolar,
for example, the ED resident calls a psychiatrist to see the patient in the ED and possibly admit the patient to the psychiatric ward in the hospital. If
the patient presents with a stroke, the resident calls a neurologist, who treats and admits the patient to the stroke service. While emergency medicine
physicians are excellent at figuring out what might be going on and whether it is serious, and while they are meant to know a little bit about everything, they
don’t know as much about specific problems as a specialist in that field. Therefore, it is not the ED physician’s job to treat everything neurological,
psychiatric, or cardiac in nature. It is the ED physician’s job to determine who needs to see which specialist physician, and to treat those urgent problems
that they can treat.