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.

Sunday, July 01, 2007

Knowing Our Limits

So I am now the proud holder of a professional practice license. This means I'm allowed to practice medicine independently "in the areas of medicine in which Dr. Couz is educated and experienced". Or at least that's what it says on my license. My specialty of record is family medicine.

Since I still have a poorly-paid day job (emergency medicine resident), exercising my shiny new license will be confined to evenings and weekends. Moonlighting, as it's called in medical circles, means working extra shifts in addition to residency. In provinces that aren't Ontario (most of them, anyway) residents are granted limited licensure after second year, after which they are free to moonlight to make extra money. In Ontario, the only way to moonlight while still in residency is to do it like I did-- complete a residency in family medicine first, then do further training in a more specialized area.

Here's where things get sticky. Although I feel perfectly comfortable working at this point in a walk-in clinic or family doctor's office (short-term locums are a great way to make some serious cash during a week of vacation), I don't feel comfortable in the emergency room on my own. Seems obvious, considering I'm choosing to do an extra year of training in it. But since rural emergency rooms around these parts are fairly desperate for doctors, and since I have family members and inlaws in key positions at said hospital, and since I do have a considerable amount of debt to pay off... well, I can safely say that I'm feeling the pressure to start working from more than one source.

It's hard to say no. A 24 hour shift in a local 'rural' emergency room will mean $3000 in my pocket (or on my line of credit, more appropriately ). I can legally do so any time after July 1st. But ethically, I'm still hesitant.

I have already done one shift at the hospital in question, as a resident with an attending as back-up. A safety net, so to speak. And really... over that 24 hour shift, I was able to handle 98% of what came through the door. And with the exception of one case of a child with a traumatic closed head injury, I could have managed just fine on my own. But it's that nagging 'what if' that keeps me from committing to shifts.

There is actually a lot about practicing community emerg that is still unfamiliar-- no CT available, at any time. The x-ray techs go home at 5pm and need to be called in if there is an emergency. Ditto to the lab techs. I've never been in a position of having to decide if a patient needs bloodwork or imaging enough to call in the tech, or if it can safely wait until morning. It's a whole new ball game.

It actually scares me a little that freshly-minted family doctors are even allowed to do emerg shifts. I can only think of one friend of mine doing so whom I actually believe is up to the challenge-- but he started his residency in ortho, did ATLS and trauma rotations before switching programs, and was lucky enough to have a primary family medicine preceptor (the one you spend the bulk of your time with) who did a considerable amount of emerg shifts in a community ED. Although I appreciate the amount of obstetric experience I got through him, I can't help but wish I got a little more emerg. As it stands, in two years of family medicine residency all I got was two lousy months in the emergency room. My elective time was taken up by transfer credits from when I was a FRCP Emergency Medicine resident-- a month of anesthesia, a month of emergency psychiatry and two months of general surgery. All helpful and pertinent to EM, but actually EM experience probably would have been more helpful.

All that to say that even though I CAN run out and start doing shifts in local community ED's, I don't actually think I should be. I'd feel more comfortable working in a student health centre, or in some kind of walk-in clinic. The money is tempting, as is the experience, but if something came in that I couldn't handle and the patient suffered from my lack of experience I'd never be able to put it behind me. Not that I believe that I'll be able to handle anything that walks through the door with ease after my PGY-3 EM training is done, but I'll certainly be in a better position than I am now.

I'm scheduled to do ATLS this month, and my trauma rotation in August. Hopefully, I'll feel more confident afterwards.


Blogger Xavier Emmanuelle said...

Good for you for sticking with your principles. It really shows good character that you're giving up the opportunity to pay off a significant amount of debt (which I'm sure is causing stress) in favor of what you feel is ethically responsible.

2:15 PM

Blogger Dr. J. said...

Another option is to make a deal with the hospital that wants you to cover their emerg. That deal being that they provide a second physician who is available by phone and to come in if needed to help you out.
If they want you to work there they will probably arrange it for you.
That's what I did when I was first in Iqaluit since I hadn't worked emerg for a while at that point and it was really helpful even just to know back up was available.
Food for thought...

10:42 PM

Blogger john said...

Dr J has a better idea than I do but..
If I was in the back of the beyond with a medical emergency, I'd be happy to have a vet work on me.

8:49 AM

Blogger scalpel said...

Experience under pressure is the best education. Bring a couple of good reference books with you, be confident (but not overconfident), and you'll do fine.

None of us were as good when we first got our licenses as we are after a few years of being in the trenches, but good enough is good enough.

A good "second doc" midshift position is great if you can find one, but there is something to be said for flying solo too.

12:31 PM

Blogger MedStudentGod (MSG) said...

From what I've heard (since I was the VP of the Emer med interest group for a couple years) is that here in the states the ACEP disapproves of moonlighting for this exact reason. However, since the people doing it here would be in their 3rd year of an EM residency it seems that they'd be more comfortable with certain situations.

Personally I agree with your decision. A month or two more and who knows?

1:40 PM

Anonymous Anonymous said...

I definitely agree with Dr J and Scalpel. Get out there! In my experience, it's my friends who *did* the R3 in emerg who are now more nervous, don't want to work without a CT & 24 lab in house, etc. Those of us who just took deep breaths and started shifts after our two years are perfectly fine. You learn ten times as much from one shift on your own than ten shifts under someone. As long as you have appropriate backup like Dr J talks about, which I always made sure I did, you'll be fine. And a more confident all-around physician to boot.

I actually discourage the residents in our program from doing the R3 in Emerg, to be honest. I find it decreases, rather than increases, their confidence. Do your ATLS, carry a bag of books with you, make sure the community knows you are new and may need help, and you'll be totally fine. JMHO.

9:57 PM

Blogger Liana said...

I think Dr. J has the right idea. Pick somewhere that one of the community docs will be willing to come help you if you need it. And maybe somewhere close to a big centre so if you need to temporize, at least you won't be doing it for very long.

In my experience as a rural resident so far, I've learned that you can always keep a patient and observe them overnight if you're worried. You can always call neuro in the big city if there's a head trauma and you're not quite sure to do... they'll even talk you through burr holes (wait, am I reassuring you or scaring you?). You can almost always handle the big scary things just by going back to basics and doing your ABCs... essentially just temporizing until someone from big city comes in a helicopter to whisk your patient away.

Congratulations on getting your license :)

2:36 PM

Blogger Midwife with a Knife said...

I agree with anon and scalpel. You'll never feel really confident until you "fly solo" as it were. And face it, the decisions about whether or not to call the lab tech/xray tech in are pretty easy. I'm sure you've learned to tell "sick" from "not sick" by now, and that's all you need to make those decisions.

8:39 PM

Blogger Nikki said...

Congrats, Dr. Couz!

Good for you for realizing your potential limits, although I have to agree with your other commenters that the best way to feel comfortable is probably just to put yourself out there. Good luck with whatever you choose.

8:44 PM

Anonymous Anonymous said...

I disagree with anonymous above. I am a family medicine resident myself.

the reality is that R3 is the MINIMUM for competence in an ER. 2 years of family medicine is not nearly enough training to deal with some of the stuff that potentially may fall into your lap in an ER. Yes 90% a good FM resident can deal with. The other 10% we cannot without further training. I don't know many Family residents who could do an RSI safely in an easy intubation, let alone a difficult intubation. When did you learn in Family medicine the reversal agent for an anticholinergic overdose? Could you put a left sided IJ in on a patient with no BP in a few minutes? What vent setting is appropriate for status asthmaticus and why? Can you use etomidate in Sepsis? What's the dose without looking it up.

I won't belabour the point. I'm an FM resident and I'm not trying to make us look like dorks. My point is that I learned these things by seeking them out, they weren't part of the curriculum. Furthermore knowing these things and actually applying them takes MORE TRAINING UNDER SUPERVISION(ie R3) then what is part of a family medicine program.

11:07 PM

Blogger Jonathan said...

I completed FP residency about a year ago, and went straight to a solo private practice that includes coverage of a rural ER 1/3 of each month. I intially had trepidation manning the ER alone, but several key factors kept me in good stead.
First, when in doubt I utilized the telephone. The community has 3 other doctors with >10 years experience, and all of these docs were receptive to a phone call if I had a question about anything. I even called my old residency director with questions on a laboring patient, he was happy to help. Second, innernet access is available even in rural settings--diagnostic and management advice is a google search away for almost any condition. Third, the ER nursing staff often can help with logistics and even medical concerns. Fourth, especially in a rural setting with limited resources, if there is any doubt about how to manage a patient, transfer them to a tertiary care center with specialists/respirators/ICU/surgeons etc. It does take a certain ability to make quick desicions, and you should be comfortable running a code (ATLS should help with that). I think someone who has completed family practice residency, and has an interest in ER medicine should be able to handle a rural ER. I don't think its as much an ethical issue as allowing yourself to utilize your resources, not being afraid to call someone if the need arises. If you are going to be in an ER residency program, you will certainly have other residents or preceptors that you could call as well. One issue to beware of is need for down time. Doing residency and moonlighting can create fatigue and burnout can sneak up on you. After a year, I still have some anxiety when I get called for a trauma or a code--maybe this never leaves . . . but I step up and do my best, and the majority of the time I really enjoy the work.

11:54 AM

Blogger Liana said...

anonymous 11:07, you bring up a lot of good points, but I think we have to acknowledge that the reality is there are 6,000 docs in Canada doing emerg medicine and only 1,000 of those are emerg certified. Most certified ER docs work in big cities, but 50% of emerg care is dished out in a rural setting. I think it would be ideal if all ERs had at least one certified emerg doc but what do we do in the meantime... shut down all the rural ERs that don't have a emerg certified physician?

I don't think it's so much a matter of memorizing all the things you listed as knowing where to find the information quickly (although the things you mentioned have actually been covered in my curriculum). I also think it's key to support rural docs who cover the emerg by providing them initial training as well as opportunities to refresh skills that don't get used very often (you mentioned lines and RSI as examples).

By the way, a lot of rural hospitals don't have ventilators, and in Alberta at least most rural hospitals don't stock etomidate (I'd probably avoid it in sepsis because of the adrenal suppression, but it seems that the ICU docs are okay with it as long as you let them know when you do the transfer so that they can check a serum cortisol/CST and give some hydrocortisone in the meantime).

7:33 PM

Blogger The MSILF said...

Man, I'm the same way now before internship. I did lots of family med electives and stuff, but now am regretting that I probably will never go back and do the heavier more serious patient specialties.

But good to know that's what moonlighting pays.

And they do have a point about learning mostly on your own.

Did you not have to have ATLS at any point? We are all doing it now, as the very last thing we do before we graduate, and you are required to renew all the time. That's interesting.

And remember, FPs are nice, so the local ones probably wouldn't mind backing you up by phone.

Although the action in ATLS and the points made by anonymous are making me reconsider FP - I was thinking FP + emergency too.

Good post.

8:08 AM

Anonymous Ram (anonymous #2) said...

Good points made by all expecially Liana. Manpower is a big issue and the reality is if every ER had to have CCfP EM or FRCP people half of them would close.

Yes you can't know everything and will have to look stuff up. No doubt. I totally agree

My point is you can't pull out your book and start learning stuff while a patient is crashing. You just have to know it. So YES it is about memorizing these things. and no it's not just about ABC's. People say that all the time and it's much more complicated. the C itself has a big differential and can be a diagnostic dilema as you know.

In terms of procedural skills, any dummy can push the drugs for intubation, but can you trouble shoot your own problems. The extra training is for reptition and to perfect the motor skill you are trying to learn. More importantly, it is to learn how to deal with complications of your own actions.

I don't really believe in learning about critical stuff on the fly. Yes there will be syndrome's that you've never heard of. However, I'm not talking about that. A simple example is Dialysis patients, they get life threatening complications that are only specific to them and have completely different physiology. You need to encouter a lot to these patients to be familiar with what can go wrong. You need to know the different types of dialysis, why they are different and what happens at each session. and that can only be learned by seeing a lot of these patients. ie a tertiary care ER or/and a big closed ICU where everyone is dialysed. You don't see enough of this volume during a family residency. Don't even get me started on Trauma.

FPs are smart and are required to know an enormous amount of information. I find it overwhelming the knowledge required to be a good family doctor. I'm overwhelmed daily by this heap of information. However if the issue is being an ER doc. The reality is they don't pay you for the 90% of stuff that is family medicine. They pay you for the 10% of the time where you basically have to be an intensivist. Do an R3.

10:18 AM


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