Category Archives: 3rd year

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!

My surgery rotation is done … for now.

My rotation through surgery ended for the semester and I am glad that it is done. I did not enjoy it – I worked hard for little gain. The surgeons I worked with all had first assists, senior doctors, or residents to help with the procedure at hand. This meant that I was relegated to the farmer john pose (where ones hands are held at chest level on their imaginary suspenders). On top of this school policy, I found out later, limits third year students from getting too actively involved. I suppose this comes much to the relief of the patient but from my point of view this made for a very tedious 3 weeks. Standing and watching somebody do surgery all day long is probably one of the most boring things you can do. Couple this with 1:4 call and the biggest challenge becomes trying to catch a nap with no one noticing. I found the experience really frustrating to say the least.

It’s frustrating because I feel at this level of training where a large number of medical students are still undecided there should be some encouragement or enticement for the particular specialty. There are ways to get junior students involved (in my humble opinion) that would not endanger the patient in any way, or even slow down the surgery in any aspect. What I found instead was a speciality that almost discouraged junior students from wanting to join. If someone is interested in surgery at this level it would have to be part of higher calling, in order to give you the strength to put up with all the crap. The sad part is that I don’t really see much of a change in the attitudes post graduation.

From the residents I saw working in surgery, they were working damn hard for a few scraps of OR time. The first two years of the surgery residency program, at least at this school, doesn’t seem to offer much other than scut work. By the third year the residents seem to gain some good hands on experience, and their level of responsibility increases from there. Once the 5 years of residency is done there is the need for a fellowship which adds another 1 or 2 years. This is a long time in a system that is geared more to break you down than build you up. I couldn’t do it. I have neither the intestinal fortitude nor the patience.

In the end I suppose I did get something out of this rotation, by this I mean I can definitely cross surgery of the list of things I want to do with my life. I’m not quite done with surgery yet, as I have another rotation after Christmas, something to look forward to I guess…Meantime, Monday brings a new rotation in Obs/Gyne which promises to be good.

Finally – the wards!

This past week has had a number of firsts for me – first week on the wards, first on call shift, first breaking bad news session and the first vaginal delivery that I have seen. All in all it was a good week, although things really didn’t start that way.

Start of the week – I was eager to make an impression and so planned to head into the surgical ward a little earlier to meet the doctor. In my eagerness I forgot the critical door code for the change rooms. This meant I had to sneak into the change rooms from the back way through the patients entrance much to the nurses chagrin. By the time I had talked my way past the nurses station and found my way into a set of scrubs I was late. This was definitely not the impression I had wanted to make on the first day. To make matters worse I was with the antagonistic anesthesiologist who forgot nothing and bugged me about everything.

Despite the bad start and the insentient teasing from the attending doctor, I have to admit I learned a tonne. By the end of the first day I could start an IV, intubate and extubate patients and by day 3 I was working on my lumbar puncture skills. This was of course all done under the watchful eye of the doctor who would not let me live down any mistakes made and who was quick to jump in if the IV was taking more than 2 pokes (I do honestly feel for the patients here and want to definitely thank those that I came across for their patience).

As I mentioned above this week also had my first on call shift. The on call policy is a little different here than it is in the big city. For one there is one resident and one medical student on for the entire hospital for the night. You can be (and will be) called for anything and everything. There seems to be a lot of leeway with what I am to do so long as I discuss with another doctor or resident … Vitum Medicinus gives probably the best run down of what the first night is like if you’re at all curious read it here.

This week brought 70 hours of work and a learning curve where it honestly felt like I was preparing for an exam every day (with the exception of the academic 1/2 day). It was exhilarating and exhausting at the same time. I think I am finally beginning to realize just how hard this year will be and how much I will enjoy it. Finally – the wards!

3rd year program alternatives

3rd Year looks like hell. My friends walk around like zombies – tired, stressed and with a hunger for brains knowledge that can’t be satisfied. All of my close friends from 3rd year chose to do their year through the traditional larger, tertiary care, teaching hospitals. There is an alternative that I have known about for some time but which I have never really considered. The alternative 3rd year program is offered through a smaller community hospital, located a good 2 hours from the larger city. This has never been a consideration in the past because it would mean that I would have to relocate myself away from family and friends to this smaller center for the next year. Now that third year is once again on the distant horizon I find myself weighing the pros and cons of completing the alternative 3rd year program.

Pros –

  • Smaller group of doctors that students work with
  • More chance of actually getting a meaningful reference to help with CARMs
  • More opportunity for focused learning
  • A much higher instructor to student ratio
  • More personal time to prep for exams?
  • Focus is on family med
    • Could be a good thing because practicing family medicine in a smaller center is actually of interest to me.

Cons

  • Distance from friends and family
    • Still a large concern and would mean additional costs.
  • Focus is primarily on family medicine
    • Could be a bad thing because I still haven’t quite decided that this is what I want to do, and my exposure to family medicine thus far has not all been positive.
  • Limited exposure to medical specialties / rare cases
    • How much do you actually see as a third year student?
    • No exposure to the traditional CTU set-up, as all complex cases are transfered to the larger hospital setting.
    • Less exposure to internal medicine than one would receive at a tertiary care center
  • Exam time prep may be problematic
    • Because of less exposure to different cases / specialties

From what I have seen and what I have heard is that this program is great, that is to say if you’re interested in practicing as a generalist when you’re done (which I think I am). Regardless, I intend to apply and to see if I will at least have the opportunity to participate.