March 2023

In this VETgirl online veterinary continuing education blog, Dr. Justine Lee, DACVECC, DABT talks about why you shouldn’t go into ER right after your graduate from veterinary school … spoiler alert … keep reading before you make a snap judgment!

By Dr. Justine Lee, DACVECC, DABT
Director of Medicine / CEO, VETgirl

Why you shouldn’t go into ER after you graduate veterinary school

OK, full disclosure, this is going to be a very controversial blog.

Right now, there’s both a big need and a big movement for new grads to straight from veterinary school to the veterinary ER. Emergency rooms need emergency doctors to handle the ever increasing caseloads and everyone knows the higher salaries look pretty darn attractive to new grads with ballooning student loan debts.

And I hate to break it to you, but all ER positions are not created equally…and for this reason I personally don’t recommend going into ER right after you graduate veterinary school (without serious thought). Why?

Well, bluntly, many ER clinics are not truly equipped to mentor and support a new graduate – and you’re not good enough to handle the ER life…

Yet.

You’ll get there one day. I promise it’ll take a few more years, if you stay in it full-time and continue to embrace your learning opportunities every day.

But right now, you should NOT go into ER immediately after veterinary school.

Please, hear me out.

A few weeks ago, I wrote about whether you should do a veterinary internship or not. From July – October of my small animal internship, the learning curve was STEEP. Bluntly, it was really steep. You don’t know how much you don’t know when you graduate. During the first few weeks and months of my internship, I was tachycardiac being the only emergency doctor in all of greater Boston (Tufts was 30 minutes away, and there were less specialty clinics and ER veterinary clinics 25 years ago!). By October, I was the master of all. Nothing could walk through that ER door in the busy city of Boston that I couldn’t handle. By January of my internship year, I was on top of my game. (I was also super burnt out, but could see the light at the end of the tunnel by March). After rocking a massive caseload with support from fellow internmates, residents, and veterinary specialists, that 1-year internship advanced training single handedly made me the clinician that I am today.

In one short year, my internship gave me 5+ years of caseload and learning experience. It gave me the confidence to be able to treat anything that walked through the door. I quickly became a master of venipuncture, cystocentesis, taping body cavities, unblocking, taking radiographs with limited staff, restraining pets by myself while simultaneously hitting a vein, and developing ninja-fast reflexes (for real. They still talk about my muzzling skills, along with inappropriate work attire there). It improved my client communication. It improved my ability to work up cases efficiently and quickly, while clearing the “list” of 20-30 cases waiting to be seen (Damn you, Sundays and full moons and holidays!). It taught me how to learn from my mistakes and bounce back. It taught me how to work with drugs or protocols that I had never used before. It taught me how to learn from way-more-experienced veterinary technicians. It taught me that you can’t always practice the ivory tower way, and that street medicine can work. It taught me to work with financial limitations and treat blocked cats with on a shoestring budget, and parvo cases with orally dextrose and SQ fluids in hospital. It helped me master procedures (e.g., spays, neuters, bite wounds, urethral obstructions, gastric lavage, thoracocentesis, abdominocentesis, etc.). It grew my knowledge base. It taught me to grow wings and fly. It FORCED me to fly.

Angell internship Justine Lee

Justine Lee as a baby intern veterinarian at Angell in 1997

Likewise, as Angell is associated with the MSPCA, I had a ton of surgery and tissue handling. I had to spay and neuter all the shelter animals on surgery rotation before I could scrub in on anything, and I was able to master the 16-minute dog spay (which is good for an intern, not that I’m racing or timing myself or anything).

Most importantly, it truly gave me the confidence to do it all.

But, I was surrounded by over 30 veterinary specialists and a few HUNDRED years of experience in our amazing veterinary ER and ICU nurses.

Here’s my general rule.

You remember Captain (Pilot) Sully, who landed his plane on the Hudson River in New York City after a bird strike? It was a combination of fast thinking, some luck, but importantly thousands of hours of training in the flight simulator which allowed captain Sully to save 155 lives.

Heroic Pilot Chesley “Sully” Sullenberger and the saved US Airways Flight 1549

As an emergency veterinarian, you must be that. You must have the hundreds of hours of training – both didactic and hands on – and confidence within an environment where you are best supported to succeed.

Don’t get me wrong – there are several strong ER training programs that are out there to specifically train new graduates to obtain a didactic component to their position along with the clinical component that will definitely going be helpful. These concentrated training courses provided by board-certified specialists can help train you, along with wet labs to help you place chest tubes and tap chests.

But,  keep in mind, you also have to have the ability to do the following (HARD THINGS) in the veterinary ER simultaneously while seeing cases, talking to owners, and documenting your medical records:

• Efficiently run and CONTROL the room / ER / ICU
• Have strong communication skills to direct staff more – or less – experienced with you
• Communicate to pet owners in a clear, structured, efficiently short but THROUGH and empathetic way
• Efficiently order treatments appropriately and cost-effectively while minimizing tech inefficiencies and patient handling/stress
• Continuously triage patients while multiple people are demanding your time simultaneously
• Know hospital protocols and estimates and create and navigate through them efficiently
• Simultaneously charge for things appropriately prior to that patient being discharged
• Effectively know doses and order pharmacy meds quickly and appropriately while utilizing appropriate antimicrobial stewardship, cost-effective pharmacological management, and be aware of drug interactions
• Have high emotional and financial intelligence to accept guidance when you are wrong
• Manage client expectations and staff expectations effectively
• Navigate complicated medical records while documenting and maintaining appropriate medical records
• Answer CSR / front desk staff queries and provide rapid medical assistance on callbacks, triages and follow up on another doctor’s previously seen cases
• Teach technical staff if they don’t have the experience or technical ability to get that Doppler or place that IV catheter or that urinary catheter
• Efficiently manage your Pyxis or Cubex while you oversee your drug calculations and your technicians drug calculations
• Communicating with pet owners while they are visiting in between ER cases while also maintaining the professional level within the ER/ICU
• Help verify complex medical math on CRIs with conversion of mmol/l vs. mEq to ensure patient safety

Justine_Lee_veterinary_ER

Rocking it with some amazing veterinary technicians at Animal Emergency & Referral Center

Not only that, but my concern about new vet school graduates going straight into the veterinary ER? Unfortunately, you don’t know how to manage anything LONG-TERM!

Until you’ve actually managed a chronic diabetic patient and had to tweak its insulin, you don’t know how to manage it.

Until you’ve had to adjust your methimazole dose to deal with the renal insufficiency being unmasked to readjusting the dose because the cat now has severe pruritus or increased liver enzymes, you don’t know how to manage it.

Until you’ve had to manage a degloving wound for a pet owner EVERY. OTHER. DAY for weeks at time, you can’t see how it heals.

Until you’ve had to manage a dog with IMHA and adjust and tweak all the meds and adverse effects from the meds for the next 4-6 months, you don’t know how to manage it.

Until you’ve had to manage that chronic atopy case, you don’t know how to long term manage it.

Until you’ve had to manage that subclinical bacteruria and chronic UTI, you don’t know how to manage it.

So, why is this important?

Because it gives you the framework and grounding of routine veterinary medicine, while working with pet owners for follow up… because that’s where the human-animal and veterinary-pet-owner bond develops!

Don’t get me wrong. I want more veterinarians in the ER field. It’s my passion. It’s my mojo. It’s an amazing, fulfilling, challenging, but rewarding job. And personally, GP isn’t for me (so much long term follow up but more gifts and cards and lovin’ in return!). But I’ve done it and felt comfortable with it and learned how to.

I truly want you to love ER medicine. But what I don’t want?

To see ER medicine chew you up and burn you out. To see ER medicine deflate you before you even had a chance to “get good.”

To see you load that seizing dog on barbiturates but never check a blood glucose.

To see you rupture that urethra and beat yourself up.

To see you kill or mismanage cases in the process, simply because appropriate mentorship, training, and experience is not available to support you, a new graduate.

You have the rest of your life to do ER and mix things up. Learn the basics and principles first in a more calm, structured manner with mentorship and support.

Get more hours in the case simulator like Captain Sully before you pilot that ER jumbo jet… because there is good mentorship or intensive ER training or internships out there to support you.

Because you know what? It’s hard.

Photo source:
Chesley Sullenberger source: https://commons.wikimedia.org/wiki/File:Chesley_Sullenberger_(49536521753).jpg
US Airways Flight 1549 author: Greg Li (https://www.flickr.com/photos/22608787@N00)
Chesley Sullenberger author: Gage Skidmore (https://www.flickr.com/people/22007612@N05)

  1. Another Angell alum! Great post, I agree 100 %! My first week solo was July 4th weekend and my first case was a cat with a esophageal foreign body (turned out to be a toy mouse) followed by a cat that went to anaphylaxis after a rabies vaccination–the referring vet was so concerned he drove the cat to the hospital himself (!) and that cat spent three months hospitalized but slowly improved.

    You are spot-on about the ER practices that have maybe one doctor, one tech, and an assistant to manage the phone. These practices have no interest in training the next generation of vets, rather, it’s all about the bottom line where to remain well into the black is achieved by controlling labor costs and inventory. Avoid like the plague! You’ll definitely learn from it but in the wrong manner. Look closely for the programs with LONGEVITY.

  2. Great article, Dr. Lee! It’s always nice to connect with you!
    Even through your wisdom and experience!
    Rose

  3. After graduating veterinary school, I did a rotating internship at a very busy private practice in the Northeast. It taught me a lot about medicine, myself and the profession in general. Afterwards, I spent one of the busiest years of my life in general practice. My mornings were packed with surgery and afternoons with appointments every 15 minutes. I spent the next 18 years as an Emergency veterinarian on the floor seeing cases and making the flexibility of schedule work for my life as a busy mom. I loved taking my kids to the zoo in the mornings and then getting to act like a hero on the swing shifts do ” all the things” surgery and all. One of the things I am most proud of is looking back at what could have been better and helping to design a program that never leaves new doctors alone. They always have another doctor with them on every shift for their first 6 months out of practice. It allows for them to receive casual feedback from associate doctors every shift and includes much more structured written weekly feedback on “approach to a case” and then formal monthly feedback as SMART goals for growth and development from their medical director. I am grateful that new doctors have this as an option and wish it was an option for me when I was starting. I am also grateful that my company allows for continued mentorship and growth in a variety of ways. I think this is a really personal decision and would advise that there are a lot of options to choose from. Being curious and asking lots of questions is always a great plan when deciding which path is best for you.

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