I’m 7 days from being completely done my third year of medical school and it feels good. Life is finally beginning to return to normal …For the last 3 weeks I have been doing an elective in Emergency medicine in a small town in rural Ontario and it has been fantastic! My elective has fallen at the end of the semester so I am fortunate enough to be working in the summer months, when the days are long and the weather warm, even after a long shift at the hospital. It’s the time of year when people out in this area of the world flock to their summer cottages on one of the many lakes in the region. It’s perhaps one of the busier times of the year for the Hospital I’m at, which works to my benefit.
The town I’m in started as a small community of 1500 souls in 1812 and today is only slightly larger, with a population of barely 7,000 people. However, it has a much larger catchment area and, depending on where the geographic lines are drawn, this area can encompass close to 250,000 people in total. Luckily, the Hospital is not the only hospital in the region but it is one of the busiest and its ER is recognized as one of the best in this health district.
One of the reasons why I wanted to come out East was to get a sense of what practicing medicine is like in a small rural hospital in one of the largest provinces in Canada. In BC, I was lucky enough to have the opportunity to spend my clinical clerkship at a smaller regional Hospital, where the focus was on community based medicine and the experience was based in a much smaller hospital than it would have been through the traditional program. The experience at the smaller hospital gave be a basis for comparing how community medicine is delivered in BC and I am seeing some stark differences between BC and Ontario despite the fact that I have only been in Ontario for a short time.
I am struck by how regionalized the delivery of medicine is at the Ontario hospital. The lines of delivery and transfer are clearly drawn and there are larger centers which are preferentially used as the next line of care when the patient requires additional services that the smaller hospital does not offer. This is regardless of capacity or availability of expertise at another site. For example, in the case of acute coronary syndrome, a patient that required angiography would be transferred preferentially to a specific center in a bigger city. However, the system is obviously taxed and this is often a strain on those transfer hospitals that are meant to be the next point of contact. What this means is that there is a large amount of time that the doctors in the community spend on negotiating the transfer of patients. This can have a snowball effect – as the primary care doctor suddenly finds themselves investing a lot of time in simple logistics. This does differ somewhat from what I am used to.
In BC when a patient came in that required a bed in a tertiary care center, a call would be placed to the BC bedline and the onus would be then be on BC bedline to find a placement for the patient. This isn’t to say that the system was without problems, or that the doctors that I knew in BC did not have to spend some time negotiating logistics. Overall, I would say that the BC system worked more efficiently in this regard and it begins to make sense how such a small investment in infrastructure, such as BC bedline, can be a huge saving to the doctor and patient. This is but one example that stood out of the many that I have seen. I am beginning to get an understanding of the larger factors concerning health-care on a provincial level and a better understanding of the problems faced by Canada when attempting to deliver medicine to its people. This exceeds my original objectives for coming out East.
Initially the goal for coming to a smaller hospital in Eastern Canada was straight forward; it was simply to gain as much experience in a center with few students. I was hopeful that the ER would be busy enough that I could continue to hone my technical skills for small procedures, my interpersonal skills with patients, the differential diagnosis as well as the management of patients in an acute setting. These are quite in line with my school’s own objectives set by the various specialties. However, it has become clear that there are a number of other factors that affect the quality of a job in medicine, such as the ability to deliver services effectively, and this will no doubt affect future choices made for residency.
When it comes to CaRMs it seems that the first choices to be made are whether to stay in a medical field or choose something that is more in line with a surgical specialty. Depending on the direction the student chooses the choices then have to be narrowed according to the generalist / specialist route that they would want to follow. Up to this point I have based my choices for future practice on the types of mentors I have had, as well as what I perceive the job to entail. If a specialty cannot hold my interest it will not be something that I invest much time in. This has seemed like a decent approach to narrowing the scope of interest and finding a direction to pursue. The problem is that it doesn’t take into consideration some of the practical aspects, and I am getting a sense of some of these factors while on this elective. The bottom line is that I will now have to go back and re-evaluate where I want to live (i.e. near or far from a tertiary center) and what I want to do (i.e. how much patience for negotiations do I really have). As I have said, it is early in my elective experience and I am curious to see how things sort out of the end of the day. I am unsure at this point whether or not I will be discouraged from doing small town medicine from what I see here. What I do know now is that there is a lot more involved in practicing medicine in a small community and it is at times more difficult that I first anticipated.
I have enjoyed my elective experience so far and I have no doubt that because of this choice I will walk away a much better doctor in the long run. The experiences I have here will further strengthen my choices for CaRMs, and make me a better candidate by allowing me to understand the practice of medicine in Canada in broader sense. This will affect my future practice but perhaps not in ways I first expected.