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. 


Blogger miss-elaine-ious said...

If you don't mind working on your own there are plenty of periphery hospitals looking for coverage. Most are using staffing services like MedEmerg, but would rather have docs that stay. It really depends on your comfort level of working on your own so soon after you're done your residency.

In some periphery hospitals the ED docs do the admitting (and admission orders) and the internist or covering family doc takes over from there.

I'm also an Ontario girl, so I speak as a local. I love the description of Center of the Universe.. they really think they are. :D Good luck with the job hunt!

11:49 PM

Blogger DrShroom said...

It's pretty much like that on this side of the pond... sorry

6:55 AM

Anonymous surrealmeds said...

Have you considered the tomato capital of Ontario? From what I've seen, there's much less problem with specialists and moving complicated cases down the road is easier. Not to mention the centre of the universe is rarely even mentioned.

11:21 AM

Blogger Jess said...

I work at a certain SW Ont "Centre of the Universe", but probably not the one you're talking about. I also work at a smaller peripheral centre (think halfway between my CoftheU and a certain border crossing). We use Health Force Ontario regularly and would love, love, love to have you around. Think about it -smaller city, barely any ER holds longer than 3 hours, and fairly simple admitting procedure. Plus, us nurses kick ass!

8:53 PM

Blogger Couz said...

Jess, if you're referring to SCGH, it's actually on my list. And a good friend of mine is an ER doc there (a guy, recent grad, hired last year).

If you're not talking about SCGH or the NHS, you're going to have to e-mail me and tell me where you are.

9:23 AM

Blogger Resident Anesthesiologist Guy (RAG) said...

Feeling your pain - if only for this month - but consulting sucks ass.

10:35 AM

Anonymous Anonymous said...

I've come to the conclusion that each job comes with it's own problems. It all depends on whether a particular set of problems are ones you can handle, or not. The grass isn't always greener.

That being said, I'd love to have you closer to me!


1:34 PM

Blogger Dr. Anon. said...

It's the same down- under!
Sorry to say :(

5:18 PM

Anonymous Anonymous said...

how's the studying going? and one more thing: how do you stay motivated to study?

12:35 PM

Blogger Midwife with a Knife said...

I think the consult problems are just a sign of a deteriorating medical system. I don't really feel like in my specialty, I can really refuse consults, even if it's a stupid one (one that a normal ob should be able to handle), but not everybody feels this kind of responsibility. And really, why take the liability, etc. if you're never really going to get reimbursed adequately? (I don't know if that's the issue on that side of the border, but it is here)

9:15 AM

Anonymous Anonymous said...

I am sorry to delude you, we are Romanian immigrants in Italy, my wife is working in the ER as a student to graduate as an professionally nurse.
There's one local (italian) proverb I would like to share with you:
"Tutto il mondo e paese" meaning that "All world is just like your village"
Yeah, same procedures, nasty personell, careless doctors, bullshit administrators here to.
I can tell that since I do the whole research in englis for my wifes graduation thesis, and have contact with a lot of her experience. Get used to it, and since you won't, couse I feel i know you are something just like my Angela, prepeare to be the best, forgive and forget no one, and when in power open up your own business in the sector, with your own humanitarian rules and rule all others (locally) out of busines by providing excellency.
Forget relocations, it's an illusion.
By the way, my wife's paper is about how to temporarely asign an identity to unidentified persons in emergency room, not to mistrake cures or blood transfers among unidentified entries untill police can track down thei'r reall ID and relatives, wich might as whell take days.
If you can find me any good material related to this, please send it to me (or the link) at:
I accept help from anybody else, thanks for bearing with us.

Emil Pop.

12:04 PM

Blogger Liana said...

Ugh. Maybe come to Alberta? We have a pretty good referral system (you call and tell them what you need, then they call you back when they get the specialist on the line). And I have to say that 99% of the specialists I consult are very friendly, helpful and polite. I very rarely get the run-around, maybe because the referral system does the running around?

Or maybe I am just lucky...

12:18 AM

Blogger Patrick P. said...

I'm an ER doc in Texas and this is bringing back memories! Every hospital where I've worked has had it's quirks with coverage, medical staff issues, etc. If it's anything like Texas, there is more demand for ED docs than supply so moving to different hospitals is fairly easy. The more you work, the more you will understand what you really need in a practice.

If you don't mind, I'd like to ask a question. I'm putting together a video of several suturing techniques. Would you have used a video (either viewed online or from a DVD) during med school, residency or after residency? Thanks for the input.

3:38 PM

Anonymous Jes from said...

5 years after EM Board cert and a dozen hospitals later it is pretty much the same everywhere. But there are brilliant moments in the craziest hospitals at the most unexpected times. The Italian guy really got it right. Get to the top then set the standards by being an example of excellence. If there is one thing I have always tried to do it is make sure I am only in hospitals where I feel supported by the people I work with closely. the job is stressful enough without adding layers of unneeded duhrama!

9:14 PM

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