The end of the year that would not end

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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.

The 8 am to 8am to 5 pm shift

Yes sir – it’s a killer of a shift, yet seemingly a necessity of medical school for some unknown reason. I remember once trying to explain to a patient as to why I had been up 24 hours and how I had only 12 hours left and how this somehow made sense. Part way through I realized that I hadn’t been speaking to a patient at all, but rather debating with a plant that was in the lobby of the hospital. It was sleep deprivation, pure and simple. Why we do this still escapes me – I figure we must have a rather poor union to negotiate 120 hours a week at ~$1 an hour. I suppose at least we get paid something, although at such a low rate it almost adds more insult to injury.

Now it’s not all bad, I mean that there are some nights where you do get to sleep (for a couple of hours) while on call. This results from the fact that hospital work is variable and that call is completely dependent on the patients on the ward. There are those rare occasions when the patients simply fall asleep after they’ve been tucked in for the night and there is nothing exciting for a young doctor to see or do. But then there are also others, like last night for me, that are freaking insane.

Last night, while on call, I got sucked into the drama of the ER. My mistake was to walk by at 9 pm on a Friday – when things were just beginning to heat up. I initially stayed to do a little stitching – a man had come in with a cut to his forehead which needed three stitches (I gave him four). By the time I was done, the first of the traumas were beginning to come in and things were suddenly very busy.

There was a young fellow in a car accident who was thrown through the windshield into a field (no seat-belt). He then picked himself up, dusted off his jeans and walked over to the nearest house to phone the ambulance. Needless to say, he had many a laceration across his back. He may not have cried when he crashed his truck but he sure didn’t like the needle. This made me a little nervous as he was a big guy, who obviously could take a bit of pain. I didn’t want to make him too angry, but at the same time I needed to give him a little morphine to dull the pain and a little lidocaine so I could sew him up. And after debriding his back I got to sew up the many lacerations and it was glorious. It really was. I wish you could have been there to see it. I did vertical mattress, horizontal mattress, simple and continued stitches. Truly it was fantastic! Really – by the time I was done – it was a work of freaking art. Also, by the time I was done, the ER was really jumping.

This time there was a young lady who decided to code (arrest) and another young lady who had been a car accident. Both came in at the same time which suddenly made the little ER a very busy place (remember I am working in a rural hospital and there are few beds with few doctors at anyone time). I helped stabilize the young woman who had had the car accident, and then went over to the patient who had arrested to see if I could help there as well. This too was freaking awesome – kind of like that TV show ER (except it didn’t suck).

Even though I was rather enjoying myself in the ER I had to run and answer a couple of calls on the ward. There was delirious patient and the one who fell on her face on the way to the bathroom. there was the hyperkalemic patient and then another who couldn’t make up their mind whether to stay in normal sinus rhythm or to go tachy. By 4 am my high from the ER had worn off – the wards will do that, i.e. wear you down slowly. By 6 am I was spent … my eyes hurt and it felt like I was moving through water when I walked…

Luckily, this was only a 26 hour shift for me and I was able to head off to bed by about 9 am. I don’t remember walking home or getting into bed – but I must have at some point. I woke several hours later – glasses on my face, scrubs still on and the afternoon sun shining through my open window. Now the countdown until the next on-call shift starts. T minus 4 days … ack!

Ortho Test

Done, done, done. It’s another box that has been checked off of the list – another exam down (4 of 10 this year). It is a good feeling to have it done and out of the way. It was more of a paperwork exercise than a test of what I know – which is frustrating. It is frustrating because I felt  as though I had put more effort into studying for the test, than the instructors had put in writing it. Throughout the exam there were spelling mistakes, poorly worded questions and vague answers. The kicker is that I ran into a friend who had the head of the department (the person who writes and administers the exam) as her preceptor for ortho, and this Dr. admitted to her that each year there are a number of complaints about the spelling and grammar of the questions. So the mistakes have been around for some time and yet, year after year no one has bothered to make a couple of simple corrections!

The second reason why I left feeling a little frustrated from the exam actually has nothing to do with the exam itself, but rather with the logistics of the program I’m in. The way that this year is structured has resulted in none of my exams being in sync with my rotations. So, for example, last week I was on Obstetrics where I was immersed in deliveries, C-sections, prenatal and post-natal care but I was studying for orthopedics – which is a completely different focus. I found myself trying to sneak in clinical orthopedic exams into the pregnancy assessment.

“Yes Mrs Smith – your cervix is dilated at 2 cm and you are having regular contractions. Now would you mind if I assessed the ligaments in your knee?”

or

“Yes – that delivery went fine. The baby is healthy, there is no tear that needs to be repaired but I thought there might be some strain in your elbow from that last push so I better take a look at it…”

Next up is my Internal Medicine exam, which comes in the middle of my …. Psychiatry rotation.

Back at it –

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I think I’m in love with scutmonkey – go check it out if you haven’t already. The above cartoon is once again borrowed from her site – you just can’t find a better representation out on the net …

So for the past two weeks I have been working in the ER and loving it. It’s high in volume and learning content. I have found that my clinical skills have really improved over as I learned to master the quick, but thorough focused physical exam. My compliment to insult ratio by patients was 2:1 which is excellent (hey you can’t please everyone).  Best of all – there were a tonne of good stories – which is also excellent given that I have had a bout of writers block lately!

Geriatrics

I have not been particularly interested in pursuing medicine that deals with the elderly. I have (to be honest) not had any good exposure to such medicine while in school. The lectures that I have attended have tried to emphasize the  and promote the positives, but the clinical aspect is usually based out of some kind of institution where the elderly are senile, demented and generally worse for wear. This is, almost the complete opposite of the image that we get in the lectures.  It’s not pretty, in fact it’s down right frightening at times … Regardless of how I feel, more emphasis should be put on the elderly in medical school given that in North America this is a population which is increasing. Creativity is needed in the presentation…such as can be found in the incredible photo-essay “Days With My Father” by Phillip Toldelano.  The photo-essay is sad and yet humorous, it makes one see into the elder Mr. Toldelano’s past, and the life he lead, as compared to the life he leads now. Phillip Toldelano has accomplished what the medical school lecturers failed to do, which is to make the face of aging look human.

All hail MEDPEDIA

No longer will I refer to Wikipedia for all my medical information. Instead I will use MEDPEDIA. All hail MEDPEDIA! If only I had had such a resource for all those useless PBL sessions…

The delivery boy …

12-stereotypes-panel-10[The cartoon, medical stereotypes #10, is from the underwear drawer, one of the best medical blogs out there – so go check it out]

I am sorry for the lack of posts lately. Sometime between my last post and this one, it got really busy. For the past few weeks I have been splitting my time between gynecology, which involves a lot of office consultation and OR time, and obstetrics, which involves many hours on the maternity ward. Needless to say it has been one of the busiest rotations I have suffered through yet.

What have I learned?

Well, first and foremost is that kids are really inconsiderate. Babies will decide to come into the world at any time day or night. In fact, it seems as though most would wait until I decided to grab a bite to eat, a moment to pee, or to go to sleep for the night. I have a new respect for the bleary eyed obstetrician, or family doctor that does this for a living. Never have I functioned on so few hours sleep.

The second thing that I have learned is that the maternity nurses are incredibly protective. At times, seeing a patient as a medical student was as much about getting past the nurse as it was about seeing and assessing the pregnancy. For those first time mothers let me reassure you that you are in good hands. I learned many lessons in sucking up, and it took many, many home baked treats before I wormed my way into the hearts and was being paged on a regular basis to help with assessments / deliveries. Unfortunately, this happened at the end of my two week in the section, so by the time they started paging me I was already on a new rotation. I hope the good will lasts until the next time I’m in the section, sometime in the new year.

The third thing I learned, was that obstetrics is incredibly rewarding when things are going well and incredibly hard when things go bad. I have never before been so physically and emotionally drained following a rotation. All in all, I left feeling thankful that I am in medicine, and looking forward to when I return to the maternity ward.