I experienced the same dilemma as well. I went so far as to get letters of rec from both specialties and did rotations in both.

I did a SICU sub-I as well as a home EM rotation and an away EM rotation early 4th year to decide.

I loved the OR, the critically ill patients, and the fast pace of general surgery. I hated the hours and was nervous about the potential lifestyle sacrifice as I have a wife and toddler.

I enjoyed the fast pace of EM as well, the procedures, and the variety. I also liked having limited hours, but I despised shift-work.

During my 2nd EM away I realized that EM felt more like a job and that I was "grinding" my way through each week. It felt more like a job. Reading about EM algorithms and illnesses felt like a chore. I found that reading about general surgery was interesting to me. General surgery felt like a grind many days too, but for me the OR time and getting to witness a patient improve on the floor every day as a result of our team's hard work made it feel very fulfilling.

I also realized that for most of the patients that I considered "exciting" in the ED, the general surgery resident on the trauma service was the one who ultimately was running the show, not the ER doc. I knew I didn't want to be just managing airway while someone else had all the fun.

I didn't get along with the personalities in the ED like I got along with the personalities on the surgery service. They felt like "my people".

Lifestyle is whatever you make it after residency. You can be your own boss as a surgeon, not so much in EM. I spoke with one physician who is a family friend who quit surgery residency to pursue EM due to family issues. He was filled with regrets.

I felt as though I would die a little inside if the OR was not part of my life.

My wife got sick of hearing me talk about it and told me to f*ing apply to surgery already.

Matching to general surgery in a month, couldn't be happier.