The world of medicine is like a bubble. A lot of people THINK they know what goes on there, but unless you're down in the trenches it's unlikely you do. So here is my semi-anonymous blog, here to tell you what really goes on in the life of a medical resident.

Saturday, July 26, 2008

I Just Really Need to Know...

So my job search continues. I am considering various communities both in Ontario and out. And as I spend more time in our local ED, I am considering those options even more carefully. In fact, even if I *am* offered a staff position upon completion of my training (4 months and 2 days to go!) I'm not sure I'd stay. Don't get me wrong... it would be nice not to have to move (again), and I can't even imagine the logistics of listing and selling a house with a baby and two large dogs. And Mr. Couz would keep his job, where he is rapidly accumulating seniority. And we wouldn't have to get accustomed to yet another community. And I am already familiar with how this hospital (and ED) works. And therein lies part of the problem.

As is the case in many hospitals across Canada, life isn't perfect here. We are a tertiary care centre... the trauma centre for the region, and the biggest hospital for an enormous catchment area. If it can't be handled by us, it goes to the Centre of the Universe. But we do have pretty much every specialty represented here, so really there isn't much that can't be managed by our hospital. In theory, anyway.

In reality we have MAJOR coverage issues. And this is a fact that is actually pretty well hidden from patients for the most part. On any given day (particularly during the summer months) we have sporadic coverage (at best) in plastics, ENT, maxillofacial surgery, neurology, infectious diseases, vascular surgery, and ophthalmology. This is understandably a problem, and has resulted in enormous waste of resources-- relatively minor problems being airlifted to other centres simply due to lack of coverage at worst, or at best a waste of significant amounts of the ER doc's time on the phone trying to convince someone... anyone... to see these patients. 

A recent case of acute angle closure glaucoma took 2 hours to arrange disposition... Criti-call first put us in touch with Ivory Tower Hospital (ironically, in the town the patient was actually from) who refused us because "your town is not in our area". Then we were sent to Not-so-Far Hospital, where the ophtho on call didn't have a YAG laser (required for definitive management). He suggested having the local police track down one of our town's local eye guys and bringing them in by force. Um, yeah. That will go over well. So in the end? Centre of the Universe took her. So 2 hours of wasted ED time during single coverage when the staff doc was stuck on the phone, begging various centres to manage this patient before he went permanently blind. PLUS the airlift transfer on top of that. 

But that's not even the worst of it. Even the various specialists on call are refusing consults. Few of them actually answer pages in a timely fashion. Those who do feel compelled to argue every attempt at getting them to see or admit patients. I understand not wanting to come in at all hours, but we're admitting the patient to your service, writing the holding orders and arranging all initial tests and treatments, and all you have to do is see them in the morning. What the hell is the problem? Surgery refuses to admit unless they have a documented surgical problem... makes sense, but if the diagnostic test that will confirm the existence of said problem isn't available until morning why take up an ED bed and resources in the meantime?

Another recent episode involved a patient who came in with a tendon laceration. It wasn't in the hand (and there was no plastics coverage anyway) so we called the ortho on call. It was causing significant problems with function (sorry for the vague-ness, but there's only so much I can change and still have the situation make sense) and was far too complicated for us to attempt repair in the ED. Ortho's response-- is the bone broken underneath? No? We don't do that, then. 

I would have accepted that had the orthopod not called back in 15 minutes saying that his next OR was cancelled so we could send the guy up for immediate intra-operative repair. Hm. But 15 minutes ago you "didn't do that"? Or just "didn't do that" unless there was nothing better to do?

Even the hospitalists have taken to arguing admissions. Admitting the guy for observation and serial troponins after an episode of cardiac-sounding chest pain in a low-risk patient? Call cardiology. But cardiology won't admit him unless he has ECG changes or a positive trop. So call hospitalist. See where this is going?

It's unbelievably frustrating. But I'm still at the (apparently) incredibly naive rookie stage where I think patient care should be everyone's ultimate goal. 

Tell me that it's not like this everywhere. Because THIS is the part of emergency medicine that I can imagine causing burnout in 5 years. 

Sunday, July 13, 2008

Baby Wars

It's funny the different reactions to a resident having a baby during residency. It's only coming up now, since I've been back in the emerg for the first time since mat leave. When people see me again for the first time in nearly a year, they often stop to welcome me back and ask about the baby.

I know they're just being polite. I don't whip out pictures or anything. Well, unless they ask specifically. Heh.

Now I'm about to make a bunch of huge generalizations here, so bear with me.

Men, for the most part, almost don't see having a baby as a big deal. Many of them have kids, and it didn't really shake the foundations of their lives or anything. They enjoy their kids, but are glad to be at work. An example of this is the one staff whom I worked a day with in anesthesia. Our OR was being shut down early due to some kind of humidity control problem. It looked like we'd be done by 11am or so. Nice. So my staff suggested I take off. 

"You can go to the library and get some studying done," he suggested. 

"I'll probably just head home to study," I said.

"Even better, you can go to Starbucks and study there. Pretend that you're still at work until the end of the day."

"No, I'll just go home. That way I get a chance to see the baby, and can fit in some studying while he naps."

My staff seemed confused that I actually *wanted* to go home and see my kid. And he has two of his own. Odd.

But the female docs seem to understand. But I've encountered some odd reactions as well. When female doctors find out that I'm recently back from maternity leave, many of them seem shocked.

"Why the hell would you want to have a baby during residency?"

A valid question. It's certainly not the ideal time. And if I could go back in time I probably would have waited a bit longer. Or had the baby during my family medicine residency and NOT my emergency medicine year. And the docs that have this reaction are probably the ones who had difficult pregnancies, and can't imagine combining residency with the various health issues that can accompany an otherwise normal pregnancy.

But the reaction that irritates me the most is the one that implies that I've had it easy over the past year. Apparently, issues like not doing overnight call in my last 8 weeks of pregnancy and starting my leave 2 weeks before my due date imply that I'm somehow 'soft', and lucky to be able to do so. I guess this all goes back to the underlying premise in medical education that trainees today have it much easier than trainees of the past, and therefore end up being inferior physicians. It drives me nuts.

But not as much as hearing about yet another medical superwoman whose water broke while she was in surgery, and she finished the case in active labour. Or about the other female physician who did call the night before she went into labour and was back doing rounds before her baby was 6 weeks old. Seriously? I think they're both nuts. And I'm not that girl. So leave me alone. 

Judge me for being "soft" all you want. My pregnancy was physically difficult, and I found working on my feet for full 8-12 hour shifts in my last few weeks of work extremely challenging. And I was pretty damn proud at the time for sticking it out past the point when I could get any reasonable footwear over the swollen balloons that were masquerading as my feet. And I really don't understand why people would feel compelled to share these stories of female physicians who are apparently all much tougher than I am. 

Gah. Now I'm just angry and defensive.

Monday, July 07, 2008

So I Guess I'm Job Hunting...

I don't even remember the last time I had to look for a job. My husband likes to point out the amusing gap in the "Work Experiences" section of my C.V. that started in 2003 (when I began clerkship) and lasted until I did my stint as a moonlighting hospitalist last year. 

In all fairness, yes, residency is a job. But I put it under "Training" so there still looks like there is a huge gap where I did nothing. 

But now here I am, tweaking my C.V. and making contacts. Sigh. And more than a little uncertain about the future. 

When I first married Mr. Couz and it started to look like life might take us to this particular area, I made contact with the region's physician recruiter. I was hoping to sign a return-of-service agreement with the town, which would repay a portion of my tuition (to a max of $40K) in return for 4 years return of service. Sounded good to me. But I didn't want to work in just any rural/underserviced area, I wanted to work in this town. So I wanted a commitment.

Well, it wasn't going to happen. The recruiter was an expert at giving us the run-around. First she said she didn't want to make a commitment until I decided if I was switching programs or not (back when I was in the FRCP Emerg program). Then she couldn't do it that far ahead. Then she said it depended on if I was going to practice family medicine with emerg or just do emergency medicine. But all the while her stalling was laced with flowery promises and plenty of syrupy sweetness. In fact, she always seemed THRILLED that we were considering settling in the town she represented. But she still wouldn't sign anything. So in the end we took the $40K from the government, which gave us until 6 months after the completion of residency to find a town to sign with.

And then I matched here. I made it clear to the head of the department that we intended to settle in the area, and he was happy to hear it. They always had a spot on the underserviced list, he said, and they'd be happy to have me. We bought a house. We settled in.

We still crossed paths with the recruitment agent a few times. Each time she continued to ask if we were still interested in staying, and promised us the moon. But never committed to anything on paper. We started getting concerned, but the head of emerg assured us that she was just flakey and they were definitely interested in hiring me once my training was completed.

Then I went on my out-of-town rotations. And from there, maternity leave. Out of sight, out of mind. Two of the other residents in my training pool are hired by the emergency department to start on July 1st. 

And now I'm back in the emergency department where I'm hoping to work in just 5 months. They're already making scheduling requests going up to December, when I'd be available for work. I find myself working a shift with the head of the department once again. And again, I mention that I'd like to remain in town and be hired by the department. This time, however, the department head looked like it was the first he'd heard of such a thing. In spite of the fact that we'd discussed it twice in the past year. Nice.

So now he's humming and hawing, and telling me to send him a CV while simultaneously listing off all of the other nearby communities that are looking for emerg docs and encouraging me to check them out. Not exactly the reaction I was hoping for. Sigh.

So I'm job hunting. Great.

It has not been a good week.

Wednesday, July 02, 2008

First Day in Emerg

And I am thoroughly humbled. 

More when I have time.