Tales from the Emergency Room and Beyond...

2011-06-06T22:08:00.002-04:00

Testing, Testing, 1,2,3...

I'm not even sure how to do this anymore. And I doubt anyone is still listening. But apparently, Blogger will let blogs lie dormant for 2 years + without shutting them down. Huh. Who knew?

The danger in that is that inevitably, after practicing emergency medicine for 2.5 years, things will eventually wear you down enough that they will come boiling to the surface in a tsunami of resentment, irritation and rage at... well, everyone. At patients, at their families, at other doctors, at various support staff, at administration, at politicians... no one is safe.

And then, even if you thought you'd never blog again, you find yourself longing for an outlet... something that isn't satisfied by the soundbites generated by a Twitter account.

I may be back. Unless I can talk myself out of it.

2009-01-30T20:35:00.002-05:00

Miss Me?

It's been a busy time since I last posted. I finished residency. For good. I worked full-time at a walk-in clinic, which made me realize several things:

1. I can deal with uncertainty
2. Walk-in clinic medicine is not bad medicine by definition. It is what you make it.
3. When you have no idea what is going on, have the person come back in a couple of days. If the problem hasn't resolved, it will likely have declared itself.
4. You really do prescribe the same 5 meds over and over.
5. Improving your flow at a WIC will carry over into other areas.

Most importantly, it made me realize that I would NOT want to do WIC medicine for the rest of my career.

Thankfully, I packed up my family and we headed down to our new town. And I started my new job. For the first time ever... I am THE doc. Staff. The buck stops here. The end of the line. Holy... crap.

After much time had gone by and I had no urge to update here, I wondered if it was time to hang up my blogging shoes. It's been a good 3 years. But I don't know that I have much more to say.

Then again, maybe I do.

I'll continue to ponder this one for the next little while. Thanks for your patience, for those of you still checking in here.

2008-11-26T21:15:00.002-05:00

You Can't Make This Stuff Up

A gem from my job-search tour...

Here's the scene. I'm touring a beautiful office of the Family Health Team attached to the hospital of a mid-sized community. The physician recruiter, a retired surgeon, is chatting with my husband while I listen politely to the head of the Health Team. At one point, the recruiter says to my husband:

"All but one of the family doctors here are women. In fact, most of the physicians in this community are women. It's okay though... male physicians don't work hard anymore either."

Love it. My husband didn't share this gem with me until we were in the car on our way out of town. I couldn't help but laugh at how ridiculous it was.

Needless to say, this community is no longer on my list.

2008-11-23T15:57:00.002-05:00

The Home Stretch

I am 10 shifts away from the end of residency. Finally, I feel like things are coming together. Well, on some shifts I do. Other shifts, like today, make me feel like I'm an incompetent idiot. No difficult patients, no mismanagement, no problems... but a combination of little things that manage to crush any bud of confidence that might have been taking seed in my rookie brain.

Here's a hint at how my shift went. First I started off seeing a teen with MSK pain. He had injured himself, kept playing sports, and didn't understand why it still hurt 2 months later. Gah. I re-x-rayed him to make sure that his injury hadn't displaced, and sent him out with a referral to the sports medicine clinic. Then I moved on to a traumatic finger amputation. It required a pretty extensive repair of several fingers and took me over an hour once the x-rays were done and the blocks put in (to knock out the feeling to the affected fingers). In the meantime I was working up a possibly biliary colic and an elderly gentleman with syncope. I followed that up with a therapeutic paracentesis, a suicidal teen and a pair of lower GI bleeds. I wrote admit orders (yes, we still do that at our hospital) consulted specialists and arranged admissions. And I did it all with nearly no help. I ran each case by my preceptor before discharge/consultation/admission, but otherwise barely saw him over the course of my shift.

In spite of this, my end-of-shift evaluation was mediocre at best. Among the comments:

When I was presenting my biliary colic case to him, I accidentally said 'cholecystitis' when I meant 'cholelithiasis'. So apparently, that means that I need to review my diagnosis and management of gall bladder disorders. Regardless of the fact that based on everything else I said I clearly just misspoke and didn't actually think that a woman with a relatively benign abdomen, no fever, no white count, normal abdo bloodwork and no ultrasound findings more compelling than sludge in the gall bladder actually had cholecystitis. But apparently that one brain fart means I'm an idiot.
When I asked his opinion on anesthesia for my patient with the mangled hand I asked him if he thought I should do individual finger blocks or simply block the whole hand. On my evaluation he wrote that he thinks that I need to evaluate my anatomy of the hand if I think that a hand block is necessary for finger repairs. For the record, if anyone ever asks me if I want three separate finger blocks or a hand block, I'll take the hand block. But apparently, that question also attests to my incompetence.
In a 14-year-old with melena stool, I neglected to ask the patient about binge drinking. And when the surgeon asked me about his alcohol intake, my response was "he's only 14!". When I asked him, he did indeed binge drink every weekend. So I looked bad. And naive. Oops.
At the end of it all when I felt like I'd spent the entire shift being run off my ass, I realized that I had only seen about 1.5 patients per hour. My goal is currently 2-3. Sigh.

It really doesn't take much to knock the wind out of my sails. No matter how the shift went, I can't shake the feeling of incompetence. I feel like a complete impostor, and feel like if people only knew how little I actually knew I'd have my medical license pulled. Even when the shift goes beautifully, I have an irrational paranoia that the staff in my department all know that I had initially expressed interest in staying there after completing residency and was ignored. Like they're taking about me during departmental meetings and laughing that I actually thought I was good enough to work there. See? I told you I was losing my mind.

Not passing the exam really didn't help. It's not like I can justify things by saying to myself "well, the college thinks I'm competent enough in emergency medicine to practice independently"... clearly, they don't. And now I really regret writing the exam when I did. I would have been in a much better place mentally if I had just deferred until I was finished residency. I don't feel like I've gained anything by sitting it once already, and right now it's serving as confirmation of my deepest fears of inadequacy.

This just sucks.

2008-11-12T19:56:00.002-05:00

Time to Fess Up.

I didn't pass. There, I said it. It's official.

I'm okay with it. I know that it was a long shot. It was still a hit to the pride (hell, I think the last time I failed ANY exam I was about 19 years old) but I'm over it. And now I actually feel much better. I'm back to studying, but the stuff I WANT to know... not the stuff I think will be on some stupid exam.

Hopefully, it won't affect my employability. Most people just assume that since I'm not finished residency until December, that I haven't written it yet. I don't correct them.

So where do things stand now? I am 15 emerg shifts away from the end of residency. And in that amount of time, I also have to complete a research project (a study of consultant response times to pages from the ED and how the delay affects ED flow) and complete enough scans to become an independent practitioner of ED Echo.

Oh, and at the same time I'm still working at the clinic, looking for a job and trying to be a mom. Gah.

We're talking to four different communities right now, and visiting three of them next week. I'll keep you posted.

2008-10-15T17:23:00.002-04:00

Bitter Barn: Population, Me.

I am SO done with this residency shit.

I am tired of having no control over my life.

I am tired of working my ass off for crappy pay.

I am tired of being the lowest rung on the ladder, and people thinking that they can shit on me as a result of that.

I am tired of having to listen politely while staff doctors bash each other incessantly.

I am tired of constantly being made to feel as though I know NOTHING, even if what I am currently not knowing is not something that I have ever come across before and will never use in my specialty of choice.

I am tired of the feeling that there are not enough hours in the day to do everything I want to do as well as I want to do it.

I am tired of every second of my day being taken up by SOMETHING, leaving me no time at all to do nothing. I miss doing nothing.

I'm tired of people expecting me to show up to things that waste my time, just because I'm told to. Sitting through the same academic half days that I sat through during my maternity leave is NOT helpful, nor is sitting through ICU rounds when the topic is the utility and outcomes of various strategies of hemodialysis.

I'm tired of living in a place where I don't have any friends to just sit with and vent over a glass of wine. Not that I'd be able to find the time to do so, but anyway...

I'm tired of feeling like the staff in the emerg all think I'm incompetent. Part of that might be paranoia, but when you listen to people bitch about their peers for long enough you start to wonder what's being said about YOU behind your back.

I'm just tired.

2008-09-30T19:07:00.002-04:00

So What Else am I Doing?

Now that I finally have time to talk about things OTHER than my emergency medicine board exams...

I got a new job. I actually started it in late August. Since my hospitalist gig wasn't really working out (I didn't like the one hour drive, I didn't like the fact that half the time my orders didn't get carried out, I didn't really like the 'hospitalist' role in general) when they started pushing me to commit to a more consistent schedule I took the opportunity to bail out.

Then, something better fell into my lap. I was working with one of the emerg docs in August when she mentioned something about a 'shift at the clinic'. I asked her if she did walk-in clinic work in addition to the emerg, and she confessed that she did. I say confessed simply because around these parts (and in most parts, I guess) walk-in clinic doctors don't have the best reputation. At best, they're solely motivated by money and cranking through patients as quickly as possible. At worst they're seen as antibiotic dispensers, willing to give patients whatever the hell will get them out of the office in the least amount of time. But this was an emerg doc that I admired, and here she was admitted that she also worked at a walk-in. Huh. Interesting.

I told her that I had looked into working for one past-time at the beginning of my residency and didn't know how to get into it. She told me that the clinic she was working at was always looking for docs to provide more coverage. She paged the doc who ran the clinic... and boom. By the end of the week I worked my first shift as 'one of those walk-in clinic doctors".

And I liked it.

Why?

Well, I can't deny that the amount of money that I can make in one short 5 hour shift is awesome. My $200K line of credit for medical school liked that part. But there were two things that I liked even more...

The first was the fact that I didn't answer to anyone. I didn't have to justify my decisions to a preceptor, and no one had the option of seeing the 'real' doctor instead. I finally felt full accountability and full responsibility... and I loved it.

The second was the fact that I felt appreciated. I never thought that was all that important to me, but it made a big difference. I understand that emerg is a pretty thankless job. You're seeing people at their worst, they're sick, their family members are worried and stressed, they're often angry at being made to wait for hours on end... I get that. But there were a few times... after seeing a woman in early pregnancy after a stillbirth, counselling a guy with first-episode HSV infection, reassuring a new mom that she wasn't doing anything wrong... simple things, really. But the patients were just so thankful to me afterwards. Maybe they expected the typical 'McMedicine' that walk-in clinics are famous for and were surprised that I took the time to sit and listen. But I was actually surprised by how much a simple 'thank you' meant to me. It made me feel a little narcissistic, but it was a stark contrast to the emergency department.

So I have a new part-time job. Emerg resident by day, walk-in clinic doctor by night. And mom at all other moments of the day. No wonder I'm exhausted.

2008-09-27T17:46:00.006-04:00

The Aftermath...

The exam is done. Thanks to a confidentiality agreement signed before we sat down to write, I can't tell you anything but the vaguest of accounts. So here it is:

First of all, to any of you writing an exam in a city where you do not live... as tempting as it may seem at the time, do not attempt to do ANYTHING with that weekend other than write the exam. I made the colossal mistake of inviting Mr. Couz to bring the Bean to COTU for the weekend. That way, I figured, the day that I was doing my written, Mr. Couz and Bean could hang out with family, and the next day after my oral we could enjoy the city. Big mistake. Huge.

Mr. Couz got sick. Bean does NOT travel well, and screamed the better part of both nights. Seeing as how Mr. Couz could barely get out of bed, that left me to tend to screaming baby. So no chance for any last minute review, no chance for clarification of concepts, no 'one more chapter'... hell, there was barely even any sleep. So I did both parts of my exam in a semi-comatose state, with a head cold to boot. I croaked my way through my oral, and blew my nose through my written.

If I fail, I wish I could blame the circumstances. But I can't. I know I wasn't prepared enough.

The oral was actually surprisingly straightforward. Which makes me think that I missed a few 'tricks'. The written, on the other hand, was incredibly vague.

A 60 year old man presents to your emergency department with some mild fatigue X 1 week, malaise and one episode of diarrhea. What is your ONE most likely diagnosis?

Are you freaking kidding me?

What 5 questions (list ONLY 5) will help you to narrow your differential?

Gah. Totally not representative of reality, and a lot of the "guess what I'm thinking" game.

I find out, for better or for worse, at the end of October. I have yet to decide if I'll confess if I fail. Although it's fairly anonymous here (more or less), it's still a huge hit to the pride. Plus, since my program didn't want me to write early in the first place, it will suck to have a big "I told you so" hanging over my head.

But now on to other things. I feel like my life has been on hold for so long I don't know what to do with myself. Although I know I won't suddenly feel like I have tons of free time (having a baby sure took care of that) I can't wait to get some aspect of my life back.

2008-08-30T19:07:00.002-04:00

And The Doubts, They Keep a' Comin

Emerg is a fickle place. One day a shift can have you feeling like you're on top of the world. You feel competent, efficient... hell, even the patients themselves are happy with the care you're providing. But just around the corner is another shift waiting to make you feel like you've been punched in the gut. Yesterday I had one of those shifts. The gut kind.

And here is the funny thing... it wasn't even the shift itself. I saw a reasonable number of people (which is of note as I am currently working on my 'flow'... ED talk for how many patients I can see in a shift) and none of them were terribly difficult. I was over on the low-acuity side of the emerg, so there were lots of foreign bodies in eyes, MSK stuff, lacerations, cellulitis... like I said, nothing too interesting.

But because the shift was actually a little slow (I can say 'quiet' now that the shift is over, right?) the staff that I was on with decided to go over some practice oral exams with me. Now this is usually a good thing... I need all the help I can get. The first practice oral he lead me through was a trauma... I talked through it until I had an airway secured, multiple chest tubes in place, had done an EDE (ultrasound) to rule out pericardial tamponade... the staff kept asking "but what would you DO at this point" clearly looking for a specific answer. What was he looking for? An ED thoracotomy. One where I should have known to cross clamp the aorta, no less.

Are you freaking kidding me? Not only have I never seen one done, in ATLS they actually refused to teach it to us on the poor anesthetized pigs as we should apparently never be doing them. So then he had me completely panicked because (a) it would not likely occur to me to SLICE OPEN SOMEONE'S CHEST in the middle of the ED, and (b) I couldn't tell him what 4 freaking pieces of equipment I would need to do this procedure.

The next scenario didn't get any better. It was a difficult airway-- 350 lb guy with a goatee, fat under his chin that touched his chest (so a surgical airway would also be a nightmare), can't see cords on direct visualization, can't effectively bag and can't fit an LMA. I was still so flustered that I completely blanked on the dose of etomidate that I'd need for RSI. In the end, I was supposed to figure out that the guy aspirated his dental plate and it got hooked on his epiglottis. Sigh. Needless to say, that one didn't go well either.

And that's when the real panic set in. In discussing how I could possibly blank on the dose of etomidate needed for RSI, the staff learned that I had actually only done one RSI on my own. Yup. Three month of emerg and only one RSI. Which lead to a long discussion about what else I haven't done...

The conclusion was that I'm lacking in exposure. No kidding. I've always suspected that I have a white cloud hanging over my head... I live in a one-emerg town, and whenever I hear on the morning news that someone was stabbed/hit by a train/drove into a rock cut I regret not being at work the night before. I've done as much emerg as the next guy (well, with the exception of the two months that will unfortunately happen AFTER my exam) but I just haven't seen the really bad stuff. The staff in question went on to tell me about his last night shift, which included a case of blastomycosis pnemonia, two mixed OD's requiring RSI, and a penetrating trauma to the chest (which, incidentally, was the inspiration for the thoracotomy scenario as they actually did one... and no, the patient didn't survive).

Really? I don't know what I can do to fix this. In the past month I've worked 3 out of 4 weekends (including a long weekend) in the hopes of seeing some good stuff. I've offered to take on double the number of night shifts in my next emerg rotation, but that still doesn't guarantee anything exciting will happen. I'm not sure if I've somehow failed over the past year or if the program has somehow failed ME. But the reality is that even after 10 out of 13 rotations completed, I don't feel at all ready to do this on my own. The thought of giving up emerg to go back to nice, safe family medicine has occurred to me with increasing frequency over the past few days.

Is it wrong to wish for a sudden influx of really, really sick people? There are just so many things I haven't done yet that I really don't want to do for the first time when I'm on my own.

2008-08-26T20:28:00.003-04:00

I Have So Much To Say...

Really, I do.

I want to talk about my hunt for a full-time emerg position for the end of my residency.

I want to talk about my new part-time job.

I want to talk about balancing medicine with being a mom, and the effect that one has on the other.

I want to talk about the culture of abuse in medicine and why we shouldn't ignore it anymore.

I want to talk about some of the political bullshit that has been going on around our emerg department.

I want to talk about how going through medical training has changed me as a person... for better and for worse.

I want to talk about some of the crazy cases I've seen (with details changed to protect privacy, of course).

I want to talk about family medicine, and whether or not I'll continue to do it.

There is SO MUCH I want to talk about.

But instead, I am studying. Right now I have 16 days until my emergency medicine board exams. I have come to terms with the fact that I might not pass them. I feel like the other examinees are miles ahead of me. Besides having actually finished the residency program (I still have 3 months to go), they all have 2 months as staff emerg docs under their belts. I am no where near where they are right now, and I feel it. I'm trying not to panic, knowing that the only real consequence to failing this exam is the hit that I'll take to my pride. That, and the $2500 I'll have to shell out to write it again next year. But I'll still be employable. Even in full-time emerg.

In the meantime, though, I've put my life on hold. I haven't even started to apply for full-time jobs. We haven't even looked into where we'd like to live. My baby weight is still firmly attached to my midsection. I haven't worked out since before getting pregnant. I can count the number of times I've gone for a run since giving birth on my fingers. I haven't read anything but my review books and Tintinalli for months. I've lost touch with long-distance friends and still have managed to live in this town for over a year without any semblance of personal life beyond my husband and my kid. I haven't cooked in so long I forget where our pots are kept. I haven't blogged in ages.

But for better or for worse, in 19 days it will all be over.

Thank God.

2008-08-10T09:51:00.002-04:00

This Sucks

The summer olympics have started and I am exactly a month away from the biggest exam of my life.

Cruel and unusual, I tell ya. Can I get an expansion chip for my PVR?

2008-07-26T23:06:00.003-04:00

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.

2008-07-13T20:43:00.003-04:00

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.

2008-07-07T19:53:00.002-04:00

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.

2008-07-02T20:36:00.002-04:00

First Day in Emerg

And I am thoroughly humbled.

More when I have time.

2008-06-20T19:53:00.002-04:00

The Exam

Just in case you were wondering, I've decided that I'm going to sit for my board exams in September. I've already paid the fees, and I *do* still have 2 months and 21 days left to study.

I decided that I would wait and see how I felt after the practice exams that my department was nice enough to organize for us this week. I didn't have high hopes, as I've done all of two months of emergency medicine in the past year and the last time I was in the emerg here was 11 months ago. That's a long time to be out of the swing of things.

Well... I wish I could say that I aced the practice exams and that my confidence is back. But no. In fact, I failed two of the four orals. In one of them, I practically killed a patient.

So why am I still thinking of writing the exam? Well for starters, I did really well on the written. And my strength is usually the oral. I'm good at thinking on my feet, less good at retaining minutiae that I don't use every day. So if I already have a pretty good base of knowledge for the written, that helps a lot. As for the oral... well, I sucked. I won't sugar-coat it. But one that I passed I managed to get through with very little knowledge simply by thinking my way through it, and the two that I didn't pass were for incredibly STUPID mistakes on my part. Things that when I'm actually confronted with the situation, I always think to do.

If you're curious, I forgot to ask about Viagra use before giving a cardiac patient nitro, and had to watch helplessly as his pressure bottomed out in spite of fluid bolus after fluid bolus. Finally I conceded defeat after starting him on two different pressors and crystalloids. Gah. The other case I failed because I didn't examine the scrotum of a young boy with RLQ pain and vomiting. I ruled out appendix and missed a testicular torsion. Again, stupid mistake that I would never make in real life. Grr.

Basically it all went down in a way that made me realize that once I'm back in the emerg and getting back in the EM frame of mind, it will all be second nature. I *can* do this.

Hearing that PGY-3 EM candidates have over a 90% pass rate made me feel better as well. Heh.

One more week until I'm back in emerg. It's been forever. I can't wait!

2008-06-17T20:15:00.002-04:00

Adventures in Sitemeter

Every now and then I like to browse through the Sitemeter link at the bottom of my blog to see how people have stumbled across me. Today I'm laughing my ass off at some of the Google searches that have lead people to Tales From the Emergency Room and Beyond.

My favorite? "Unrecognizable penis"

My husband's favorite? "Married to a doctor sucks"

Love it.

2008-06-14T11:47:00.002-04:00

Introducing...

I've added a cool new blog to my blogroll called Mothers in Medicine. I poked around their site and found I could identify with an awful lot of what they're going through over there. I still find it hard to wrap my head around the fact that I'm somebody's 'mother'. Odd. But I am, so I might as well get used to the idea before the Bean actually starts calling me that.

2008-06-13T16:42:00.002-04:00

My Own Personal Hell

Remember my earlier post about being WAY too emotionally involved where children are concerned these days?

Have I ever mentioned how much teeth skeeve me out?

So guess which emerg resident, currently rotating through anesthesia, got stuck in the pediatric dental room THREE TIMES already in the past two weeks?

Gack. I get goosebumps just thinking about it.

2008-06-11T20:06:00.003-04:00

Crap. Crap, Crap, Crap.

There are now exactly 3 months left until the emergency medicine board exam. I sent in my registration and payment ($2300!!!) a few weeks ago.

And now I am panicking.

This is not an easy exam. Right now, I haven't actually been in the emerg since last fall. And I've only done 8 weeks of emerg in my PGY-3 year. I will have completed only another 8 weeks by the time the exam rolls around.

I've been actively studying since March. I didn't get nearly as much studying done as I'd hoped during mat leave (no big surprise), and it's been going VERY slowly since then. I have covered 1/6th of the material I need to. And there are things I'm definitely going to need to review more than once.

My life consists of this: I wake up. I go to work. I come home from work. I play with the kidlet for a couple of hours until his bedtime. I put kidlet to bed. I study until I go to bed. I sleep (getting up with Bean overnight) and repeat the whole thing the next day. There is literally NO time for anything else. I don't watch TV. I don't read. I can't even go for a run without thinking that I'm wasting valuable study time. I am wondering if this life is actually sustainable for the next 3 months.

Downside to not writing it this year? I'm not sure. I'd still be able to work without it. I'd have to check with the chief of staff here if they'd be willing to hire me without it, but I don't think it will be a problem. It would mean having it hang over my head another year. Mr. Couz thinks that it will be harder to write once I'm out of the study zone and in the real world, but I can't imagine it would be anything but easier once I've been out working for awhile on top of studying the theoretical side. I can't really think of any other drawbacks.

Downside to writing it this year? Having to push myself to the max to prepare for the next 3 months. Having to come up with the money to write it. The very real possibility of failing it on my first go-around, which will leave me in the same position as not writing it at all only $2300 poorer, and significantly humiliated.

Gah. I need to talk to my program director.

2008-06-10T19:54:00.001-04:00

Gah.

I've now been back at work for 6 weeks, and there are two arguments I NEVER want to have again as long as I live:

1. That all emerg docs are not inferior clinicians who just triage people and refer everything without doing any actual medical management

2. That having my baby delivered by a midwife was NOT a stupid, irresponsible decision

Seriously, people. Just let it go.

2008-06-02T19:50:00.002-04:00

Hmm. Didn't See THIS One Coming.

One of my strengths in emergency medicine is my ability to have empathy without getting emotionally involved. I'm not made of stone or anything, but I have never had the breakdowns that my friends and colleagues have. I don't fault them for it... if anything, watching their totally normal reactions to horrible situations (stillborn babies, terminally ill children, victims of abuse, etc.) has made me wonder if I'm the one who is defective in some way. I've been involved in many a traumatic situation, but when the staff involved are offered the chance to debrief and get counseling I've never felt the need. My husband is a wonderful ear for my complaints and shoulder for support, and I've never needed to look further. One of my first shifts here involved a code on a perfectly healthy toddler. She died. I appreciated how tragic it was, but it didn't affect me deeper than that in spite of the fact that I was pregnant and hormonal at the time.

Then I had the Bean.

It was like flipping a switch. My ability to stay impartial and unaffected has been completely lost. Having to reduce a trampoline-induced displaced fracture on a child nearly had me in tears of sympathy my first week back at work. Hearing another person's account of a case of child abuse that had presented to emerg made me so nauseous I thought I was going to throw up in the middle of an academic session. Today, just putting a 1 year old (who looked strikingly like my own kidlet) under anesthetic for a minor surgery had me choked up-- the child's confusion and tears, his agitation when he woke up in recovery, the anguish and helplessness on his mother's face as she rocked him before giving him up to the anesthesiologist-- I just couldn't stop thinking of my own son and how hard it would be to watch him be taken away by strangers and waking up confused and in pain afterwards.

I wonder if this happens to men.

2008-05-30T17:30:00.003-04:00

Seriously?

So since I have to disappear for 15 minutes midway through my workday, it's pretty much common knowledge at work that I'm breastfeeding. Hell, it's not like I'm doing it with a preschooler... my kid isn't even 6 months old yet. But possibly because my kid looks older (95th percentile in both weight and length, for God's sake!) I still get the occasional raised eyebrow. But no one says anything at work. It's not like I'm taking a lunch break (God forbid!) or something equally decadent. I'm hooking myself up to a machine to be milked like livestock.

Coming back from a recent pumping 'break' (thank God no one was using the urodynamic testing room!) the surgeon I was working with wasted no time in getting back to pimping me. Keep in mind this is the same man who tested my medical knowledge with such meaningful questions as 'how many times did my hand touch the suture needle?' and ' which hand do I use to hold the scissors?'.

Him: "Here's a question for you... how long is breastfeeding recommended in Scandinavia?"

Me: "Well, the WHO recommends 2 years..."

Him: "I'm not asking about WHO, I'm asking about Scandinavia."

Me: "I have no idea."

Him: "Six weeks, at the most. There are high levels of toxins in women's breastmilk there, so breastfeeding is viewed as unhealthy. Interesting, isn't it?"

Me: "Whatever."

I was not about to justify the fact that I breastfeed my son to this bonehead.

2008-05-24T20:06:00.002-04:00

Creeping Towards the Finish Line...

I'm starting to feel like residency might actually end some day.

To put this in perspective, this realization is probably panic-driven. There are 3 months and 14 days left until my emergency medicine board exams. And yes, I'm counting. And as old as it makes me sound, nothing makes you more aware of the passage of time like watching a child grow up. The Bean is moving forward at a dizzying pace (figuratively speaking-- not crawling yet, thank God!)... he's sitting, reaching, grasping, rolling, and has just cut his first tooth. It's all going so fast.

If I hadn't taken maternity leave, I'd be one 4-week rotation away from the end of my residency training. I'm watching my co-residents go on to bigger and better things-- accepting fellowships, staff positions-- I can't help but feel envious. Two of the residents in my year have accepted staff positions at the hospital where we've been training. So as of July 1st although they won't be allowed to supervise me directly, they'll be my staff.

I can't believe I still have 6 months to go. It feels like forever.

2008-05-06T20:48:00.003-04:00

Things that Will Someday Manage to Kill Off the Human Race*:

10. Band saws, table saws... pretty much any kind of saw that plugs in to the wall. I'll stick to the kind that work on human power, thanks.
9. Throwing gas on a campfire because it's dying out.
8. Backyard trampolines-- because kids don't have enough ways of injuring themselves already?
7. Working on high structures without appropriate safety equipment-- unless you can fly, not a great idea.
6. Inserting large objects into body cavities that I'm fairly certain God intended to make "exit-only"
5. Anything that involves building a ramp
4. Riding bikes without helmets... why make a potentially minor injury a potentially major one?
3. ATV's/Snowmobiles (depending on the season, but the injuries are interchangable)
2. Motorcycles, regardless of helmet use
1. Not wearing seatbelts. Seriously... I can't believe that people still get in a car and don't buckle up immediately. Are they stupid, or just have a wicked death wish?

And yes... every single one of these is based on at LEAST one case I've seen this week. Welcome back to medicine.

* (or, possibly, just the stupid people)

2008-05-02T11:15:00.001-04:00

Back to Work

The time has come. Just a few days shy of the Bean hitting the 5 month mark, I am going back to work. Where did 6 months go? Now I'm starting to regret being off for nearly a month before I gave birth. I guess in hindsight it's easy to forget how brutal those last few weeks were-- working on my feet, sleepless nights spent trying to get comfortable, heartburn that made me vomit, hip pain that made walking near impossible... oh right, THAT is why I went off work at 37 weeks. And it's not like I had any control over the fact that he was nearly two weeks late. But now I'm wishing that I had that extra month with him. The weather is getting nicer, he's getting more and more fun by the day, and I know damn well that keeping up breastfeeding after I head back is going to be more than a little challenging as I came to realize during my ATLS weekend.

Not all of me is dreading it. I'm quite comfortable leaving Bean in the care of his very competent father. We won't have to start thinking about daycare for quite some time. We have a posse of very willing babysitters (my inlaws) living 90 minutes away who are more than happy to fill in when conflicts arise. Since Mr. Couz will still be working part-time when I go back, they are a Godsend.

My first rotation back is ortho/plastics outpatient clinics. Lots of fractures, lots of minor procedures. I'd better bone up on my MSK anatomy this weekend so that I don't look like too much of a tool.

I've missed work. So much of my identity is tied up in my job that I've really started to feel at loose ends as I've emerged from my post-birth haze. I've missed the challenges of the emergency room, and feel myself falling behind my colleagues when it comes to my knowledge. Even more odd is the fact that thanks to the delay of my maternity leave, I won't be finishing my residency until December. The emergency department where I'm training has already committed to hire two of my co-residents. Technically, they'll be my staff after July 1st. Weird. I just feel like my life stopped and everyone else's went on, and now I'm running to catch up.

Even weirder will be trying to explain to the testosterone-y world of orthopedic surgeons that I need to disappear at lunchtime to spend some quality time with a breast pump. Heh. That will be fun.

Time for a gratuitous Bean shot:

2008-04-30T13:58:00.000-04:00

Enough Already!

I have stayed mostly quiet on the topic of the Macleans article that hit newsstands in January. It examined the doctor shortage across Canada, gave tips on how to find a family doctor, and looked in particular at the shortages in rural areas. Sprinkled liberally with anecdotes and horror stories, it was intended to sell magazines. It caught my attention, and the Bean and I took a trip to our local Chapters to peruse the article in question over a Starbucks Soy Chai (the Bean is sensitive to dairy).

It was just another verse of the same song. I've complained about it before. And now other people are complaining about it too. The backlash from the article was heard across the country. Blaming female physicians for the doctor shortage is misguided. Now I know that the plural of anecdote isn't data, but I don't know of ANY female physician throwing it all away to spend more time with her children. But that might be because I don't know many female physicians who are married to male physicians. In the real world, income usually wins out over traditional gender roles. If Mom's income potential is $200K and Dad's income potential is $80K, if one of them is staying home with the kids it sure as hell isn't going to be the one who gave birth to them. Particularly not with med school debt to pay off.

I've said it before and I'll say it again... louder this time, for those of you in the back.

IT'S NOT A WOMAN THING.

Physicians just aren't like that anymore. Gone are the days of the kindly old doc who has a family practice, delivers babies, does shifts in the emerg, cares for his inpatients in the hospital, does house calls, visits the nursing home, and does coroner call on the weekends. You know the type... known to everyone in the community but a stranger to his own family? Men have wised up. That's not a life. No one ever lay on their deathbed and wished they'd spent more time at work. The popularity of 'lifestyle specialties' is a testament to this. For the past few years, there have been spots left over after the match in specialties like general surgery, orthopedic surgery... hell, even neurosurgery hasn't filled in the first round. At the same time, the popularity of anesthesia, radiology and emergency medicine have gone through the roof. It seems that the only surgical specialties that are still uber-competitive to get into are the ones that offer a reasonable lifestyle on top of the hefty paycheque-- like ENT and plastics.

Family doctors as a whole are setting up sustainable practices. That means picking a practice structure (FHT or FHN) that lets you leave work behind at the end of the day. That means less call. That means building a practice that won't leave young physicians burned out in 10 years. That means having a life outside of medicine. Imagine the nerve of these young physicians, trying to have it all! Since more women are entering medicine, it MUST be their fault!

Ask any of the old-school docs nearing retirement. They'll back me up. It's not just women. It's ALL new doctors. We're soft. We didn't train as hard as they did-- we didn't have to live in the hospital, we were allowed to be married. We got days off. We're paid. Our residency is shorter. We are protected by a union that enforces the rules and keeps us from being used as slave labour. We aren't willing to be on call. We protect our leisure time with the ferocity of a rabid dog. We don't want to work more than 60 hours a week. How dare we.

Why complain about it? The evolution of medicine has been positive in many respects. We aren't paternalistic, and medical decisions are now made with the patient calling the shots. We listen. We consider more than just the illness (in family medicine, anyway) but the social context. We have lives outside of medicine, and protect the longevity of our careers by not working to the point of suicide or burnout. We make a decent living, but are more likely to choose a smaller paycheque in order to work fewer hours. And what's the harm to the system? Well, maybe we'll need a few more doctors. We've seen that coming for years. And those doctors will be better people for the choices they've made... none of which can be attributed solely to gender.

2008-04-19T20:09:00.003-04:00

Medical Spouses, Revisited

I was reading with interest the blog postings over at Edwin Leap's place regarding the wives of doctors. It's a topic that is of interest to me, seeing as how I don't really understand how anyone would knowingly choose to marry a doctor. I have sung the praises of my own medical spouse here before. What was more interesting to me was the fact that Dr. Leap didn't know any husbands of physicians to include in his interviews. Interesting. I can only infer from that fact that Dr. Leap is considerably older than I am, since the year that I graduated from medical school over 50% of my graduating class was female. And of that class, everyone who matched to emergency medicine was female.

But I digress. I just figured I'd give Dr. Leap a hand from the other side of the fence. On behalf of my husband, here is what sucks about being married to a doctor (some specific to emergency medicine, some not):

Clerkship and residency. Nothing about this part DOESN'T suck. You watch your spouse work themselves into the ground, miserable and sleep deprived and can only hope to God that things will get better. Sometimes they don't. (see: surgeons)
You marry their debt, too.
The not-so-subtle insinuations that you're a kept man if you're married to a doctor
The assumption that you're rich because your wife is a doctor
Having to socialize with other doctors
It's a job that's hard to leave at the door when they get home
Often unpredictable work hours... just because their shift ends at 8pm, doesn't mean you'll necessarily see them home before 11pm. And you're expected to take that in stride.
Your career often takes a backseat to their career, whether you like it or not.
The possibility of bringing home more than they bargained for-- Norovirus, influenza, hepatitis... all real risks.
The assumption that because she is a doctor, your wife is a pompous know-it-all.
Childbearing delayed for longer than biologically ideal
Holidays rarely being celebrated on the actual day, causing issues with extended family.
You don't have to worry about nurses preying on your spouse (as mentioned by Dr. Leap) since the majority of nurses are still female. Then again...

What doesn't suck about being married to a doctor?

Good income, once the debt is paid off.
Wearing scrubs to work means less laundry
For most specialties, your spouse is employable pretty much anywhere-- nice flexibility.
In the case of emergency medicine, you will have a spouse whom you actually see and can spend time with.
I'm cute. :-)

In all seriousness, I wouldn't have married me. My husband is a glutton for punishment.

2008-04-17T18:53:00.000-04:00

Random Thought for the Day

I was talking on the phone with my cousin today. She just had her second child by repeat c-section. She had her first by c-section as well. So that got me thinking.

As my loyal readers know, I had a c-section back in December with my first (and possibly only... the happy amnesia hormones haven't kicked in yet!) kidlet. My indications for section were listed on the OR report as 'left occiput transverse causing arrested second stage". In English, that means that the Bean's head was turned to the side and wedged behind my left hip. I pushed for 3 hours in a variety of interesting positions, but he just wouldn't turn into a birth-able position. My midwife was wonderful, but after 18 hours of labour to have to have a c-section felt frustrating and disappointing.

And then I thought about everyone else I know who has had a baby in the past year. Doing the math in my head, my rough estimate is that about 90% of my friends who had a first baby this year had a section. And only two of those (out of about 15 or so) were scheduled (one was breech, one had pre-existing medical conditions)... the rest were 'failed' attempts at vaginal delivery. All the reasons seemed legitimate-- fetal distress, not dilating past 6 cms, that kind of thing. But the c-section rates in my circles seem abnormally high. So my first thought would be to wonder what is biasing my sample.

My friends are all relatively young (between 25 and 35) although perhaps a little older than biologically ideal for a first-time mom. They are all professional and well-educated, healthy and fit, and all work full-time. But that's where the similarities end. They have a variety of body types (short to tall, tiny to less tiny), have a variety of careers (pilot, teacher, sales, medicine)... none used reproductive technologies to get pregnant. The time it took them to conceive range from "oops, we're pregnant" to nearly a year. None of them were "too posh to push", and all but one had intended to birth vaginally. Every reason they were given certainly sounded more legitimate than "let's move this along so that I can get home".

Is there something fundamentally wrong with us that so few women are able to birth vaginally these days?

I find this odd.

2008-04-14T10:00:00.000-04:00

The Reality

This week I had to head back to the Centre of the Universe (home of TBFTHITW) to do my ATLS course. That's Advanced Trauma and Life Support for those of you not in medical circles, an intensive two day course designed to prepare doctors for dealing with various trauma situations. It's a great course, and I've been meaning to take it since first year of residency. But it was never in convenient places, never at convenient times, and it cost over $700. So the time was never 'right'. But I need it to work in the emergency room, and I'll be ready to work independently very soon.

No biggie. So load up Mr. Couz and the Bean and head down for a weekend of fun and trauma, right? Except the Bean still screams bloody murder from the moment he's put in the car until the moment we take him out.* The COTU is about a 5-6 hour drive away. A variety of other logistical reasons made it increasingly obvious that bringing the family with me was probably not the smartest thing to do.

So on to plan B. I was to go alone. There was enough expressed breast milk in the freezer to easily last a few days, and I'd bring my pump with me to keep up my supply. A breast pump is not a glamourous thing at the best of times, but we do what we have to. The course coordinator promised that she was sympathetic to my situation and there would be a place for me to pump during the course. And there was. An empty auditorium with windows in the doors that was open for any random people to wander through. Um, thanks.

So there I was, sneaking out of my trauma lectures every 3-4 hours to get intimate with my breast pump while sitting on the floor of the handicapped stall in the women's washroom.

It doesn't get more glamourous than that. We'll see how well this pumping thing works out when I'm back to work in May. He'll only be 5 months, and I'd rather not wean him quite yet.

This Dr. Mom thing is tricky.

*And to those of you who have ever said 'he'll just cry himself to sleep', I wish you were in the car for our entire 8 hour ride to grandma's house. Four 15 minute naps were the only respite from the screaming and crying. We're transitioning him from the infant bucket seat to a rear-facing convertible carseat in the hopes of helping the problem. Cross your fingers for us.

2008-04-13T21:47:00.000-04:00

Running the Recruitment Fair Gauntlet

Recruitment fairs are commonplace in my neck of the woods. Communities are looking for doctors, and are eager to lure new grads to check out what they have to offer. This can range anywhere from free housing to locum physicians to incentive grants and pens with the community's name embossed on them. Woo-hoo.

Last week, we had a local one. It was restricted to communities from the north, so not as broad a scope as the annual "Physician Recruitment Fair" that tours the academic centres in southern Ontario every fall. As I am still unsure of what my future holds, I decided to attend. And since he gets as much say in it as I do, Mr. Couz came along. And we brought The Bean, which was our excuse to make a speedy getaway if needed.

I was quickly reminded why I hate these things. Picture a long hallway, flanked on both sides by booths plastered with posters staffed by eager recruiters reaching out at unwitting candidates as they pass by. Sometimes they are joined by physicians from the town in question, or various local politicians or hospital CEO's. Often they have tables covered with pens, corkscrews, canvas bags and other various pieces of junk emblazoned with the community's name.

According to Mr. Couz, I am far too polite at these things. I was really only interested in two particular communities... towns that were large enough to have an emergency department that had dedicated emergentologists (as an aside, I'm not sure if that's a word... in Quebec, however, I'd be an 'urgentologue') rather than family doctors who staffed the emerg. Plus Mr. Couz and I have a longstanding agreement about how far away from our families we're willing to be. Our view is that if we're going to be far enough that air travel is required to see them, we might as well move to Victoria where the cherry blossoms bloom and the weather is perfect all year round.

In spite of the fact that we went to the event with the intention of just speaking with those two communities about their return-of-service agreements and whether or not they're hiring this year, I managed to get waylaid by nearly every small community in attendance. And I always feel compelled to politely hear them out, even if I have no intention of moving my family to whatever godforsaken place they're selling.

I don't know why these things make me so damned uncomfortable. I feel bad for the communities trying so desperately to recruit doctors. It's one of those things that makes me feel guilty for not practicing family medicine. But I know I'm not what they're wanting.

2008-03-30T13:57:00.002-04:00

It's Not You, It's Me

I miss blogging. I've been thinking of it a lot lately. In fact, I have three half-finished posts saved on my MacBook. At the rate I'm going they're never going to get finished and posted. Serves me right for being so long-winded.

Truth is, mat leave is busy. Damn busy. I'm trying to balance baby, dogs, household and studying for my emergency medicine board exams in September. Even with Mr. Couz home more often than not (nice having a husband that works part-time for this reason) every spare minute is accounted for. And I can't imagine it getting any better once I'm back to work.

So I'm trying to do everything now. Spend time with the kid, learn ALL of emergency medicine, reclaim pre-baby waistline... I'm starting to feel like I've bitten off more than I can chew.

More soon, I hope. I miss my blog.

2008-03-06T15:08:00.003-05:00

I Am a Bad Person

It's Match Day! Why do I, as a third year emergency medicine resident, care? After all, we matched our incoming class of PGY-3 EM residents back in November. We're a rural centre which rarely fills all of our family medicine spots. I have very little contact with first year family medicine residents, and will only be a resident myself until the end of November. So basically, this day doesn't really have any impact on my life. Except, possibly, to bring back the PTSD flashbacks of my own Match Day 3 years ago.

Because someone who once did something very nasty to me is graduating from medical school this year. Word on the street is that she's not in a great position to match to her chosen specialty. If there is such thing as karma, she is currently drowning her sorrows somewhere as we speak.

I am a bad person. ;-)

2008-02-22T15:58:00.007-05:00

Adventures of a Hospitalist

Before I went on maternity leave, I was moonlighting (I moonlit?) at a community hospital. It's about an hour from the centre where I'm doing my emergency medicine training, and they had originally approached me about doing shifts in the emergency room. Just before I finished my family medicine training they arranged for me to work a buddy shift with the head of their emergency department (who also happens to be the head of the ED where I'm doing my residency) to test the waters. This community is clearly recruiting hard-core. I jumped at the opportunity. Like most community ED's, 99% of the stuff I saw during that 24 hour shift was routine. Belly pain, URTI's, broken bones, lacerations... nothing that made my heart race.

It was the other 1% that made me reconsider. Without delving into details that might compromise confidentiality, a pediatric trauma came in. A pre-teen with a traumatic head injury who was awake and alert but confused and combative. He didn't end up intubated, but was eventually transferred by air to the closest centre with a pediatric neurosurgeon (none of the adult neurosurgeons were comfortable taking the case). It scared the crap out of me, and still would if I faced the same patient today.

So I decided not to moonlight in the ED while I was completing my residency training. Certainly not before I had completed my PALS and ATLS (both of which I'm scheduled to take over the next couple of months). The decision was not made lightly-- they were offering me $3K a shift (and now have upped the ante to $4K a shift). Money I could REALLY use right now. It's hard to say no.

But the hospitalist position was a perfect compromise. The hospital was desperate for coverage, and were hoping to lure me into signing with them when my training was done. The deal was sweet-- a spot on their Family Health Team, shifts in the ED, inpatient care (in the GP-run hospital), and some work in the nursing home attached to the hospital-- all of this for $500K a year. So doing the hospitalist gig occasionally would let me get familiar with the hospital and it's staff, and help me decide if I should commit to them or not.

Instead, I learned a lesson... nurses can make or break an entire hospital.

Working in academic centres has been a mixed blessing when it comes to relationships with nurses. They are used to working with residents (and therefore having an MD in house all the time) and therefore may end up calling the resident for relatively minor issues simply because they're there and available. There are some truly phenomenal nurses that I've worked with that have probably forgotten more medicine than I know. And although I came across the odd bad apple, it seemed that in an academic environment the damage a lazy or incompetent nurse could do was mitigated by the fact that they often worked with other (better) nurses who could advise them and pick up the slack. I've complained about the occasional nurse in this blog before, but raved about good nurses far more than I've complained about them. And now I realize that I've been spoiled.

Among the issues I've seen/experienced in my time at this hospital:

Orders for tests being disregarded. Seriously. If I ordered a test, it's because I think it's needed. If you disagree, tell me. Or the doctor on call. But to simply not carry out the order? You have to be kidding me.
Along the same lines-- if I am requesting accurate ins and outs on a patient with heart failure, DO THEM. Simply writing 'to bathroom' on the fluid output sheet isn't enough. I'm not asking you to cath them, just ask them to pee in the freaking hat.
Please don't come to me in a panic because your patient doesn't have breath sounds on the right. Not when it is CLEARLY documented in both the admission notes and progress notes that the patient had a right lobectomy 5 years ago and NEVER has breath sounds on the right. You only have 2-3 patients in your care and none of them are particularly acute... take a second to flip through your patient's chart.
If there are three nurses gathered at the nursing station gossiping and a patient's family member asks if he can have a glass of water, don't sigh loudly, roll your eyes and act like breaking up the gossip party is the biggest imposition in the world.
You know I'm only here to round. You know that every time I come in, the first thing I do is ask the nurses if there are any urgent issues with their patients. Please be ready to answer the question. I know you've been on for three hours by the time I come in.

Some of these are minor complaints, I know. Except for the 'disregarding orders' thing. But the bottom line is the fact that these nurses just don't seem to care. Maybe I'm being naive, but I can't imagine someone with a job as important as a nurse simply going to work and going through the motions. And not even all the motions, as they seem to pick and choose the duties that they deem necessary and do the bare minimum in order to keep their jobs. The nurse manager says that she's so inundated with complaints against the nurses (from both doctors and patients) that dealing with them has become the primary focus of her job. She is planning to quit.

The experience made me realize that no amount of money in the world will make me work in this environment. And it's no wonder they've had so many problems keeping physicians. And it made me that much more hesitant to take any emerg shifts there-- not when I feel like I can't trust the nurses.

Memo to hospital administration-- there's more to physician recruitment and retention than throwing money at the problem. Who'da thunk it.

2008-02-21T21:37:00.002-05:00

Looking Ahead

Already I'm stressing in advance about my return to work. I'm going back earlier than I'd like, but that's influenced by two factors. One is money-- we need it. We don't have it. Mr. Couz doesn't make enough to keep our household afloat (thanks to my med school debt) on his own, and my union only tops up our unemployment to 70% for the first 5 months or so.

God, I hear myself whining about this and have to laugh. I know in the US, only 6 weeks of maternity leave is protected and I also know that a LOT of people don't get any top-up at all. But I live in a world where literally everyone I know who has had a baby has taken the full year as protected by law. And many of them think I'm nuts for going back early. But there's more.

The CCFP-EM exam (my last licensing exam for emergency medicine) is in early September. I must be finished my program within 3 months of this exam in order to be eligible to write it this year. I can do that if I go back after 6 months of maternity leave. Which, since I went off when I was 38 weeks pregnant and The Bean was nearly 2 weeks late, means I'll be going back when he's just 5 months old. It feels too soon.

But my program has been wonderful. Remember how they handled the trauma rotation from hell last summer? Well, they've stepped up to the plate once again. Not only have they decided that my second month of 'community ER' doesn't actually need to be done out of town, but they've made me a schedule as family-friendly as possible. So what do I have left?

1. Ortho/plastics: Sounds horrific, but it's a clinic-only rotation with normal people hours. And no call. I might even get a lunch break.

2. Anesthesia: I'll be working 7:30am until 3-4pm. With lots of down time. And no call. In the same hospital as my town's NICU, which will be helpful if I'm still pumping at that time. Gah. The things that guys don't have to worry about.

3. ER

4. ER

5. Elective: I'm planning a sports medicine elective here in town. Again, sweet hours. No call. If it doesn't work out, I'll just do an extra month of ER.

6. ICU Sudbury: The only less-than-ideal part. Heavy call, long hours. I'm saving a week of vacation for this one. So hopefully missing what will essentially amount to 3 weeks of my son's life won't hurt either of us too much.

7. ER

8. ER

Sigh. I'm already stressing about how on earth I'm going to handle balancing parenthood and residency. Not to mention studying. I haven't managed to fit that into mat leave very well so far, and it's only going to get worse. I think I'm going to have to learn to survive on very little sleep.

I loved EM Physicians recent post about balance-- you can read it yourself here. It reminds me that if I push through this last 6 months I will eventually have enough control over my life to create my own balance. And a big part of why I chose emergency medicine was in order to have the freedom to live the parts of my life that have nothing to do with medicine.

Like my family.

2008-02-20T12:43:00.004-05:00

Yet Another Identity Crisis

I've been at a bit of an impasse lately regarding the future of this blog. As you all know, I'm currently on maternity leave. Those of you who read this blog regularly are also aware that I vowed not to let this blog turn into a 'mommy' blog. The problem is, when you've spent three months at home, two of them with a baby, and haven't done anything relating to medicine in that time, it's more than a little difficult to find something to talk about that ISN'T mommy related.

The Bean is doing great. He's quite the little porker (tipping the scales at nearly 15 lbs at his 2 month well-baby visit) and is smiling, cooing, and has recently discovered that his hands are the tastiest things ever. He sleeps well at night (usually) and hates napping during the day. And much to my relief, I am very much in love with my little man.

It took about a month for the hormones to stabilize and for me to start to feel halfway human again. My hemoglobin came back up to 107 in spite of my intolerance to supplements-- my prenatals did the job just fine without making me sick. The only lasting effects of my pregnancy is a dull ache in my left hip and being more out of shape than I've ever been in my life. I'm very much looking forward to spring when getting outside with the Bean and the furkids isn't quite so complicated a process.

I started going back to my academic half days when the baby was 4 weeks old. Mr. Couz um... 'lovingly encouraged' me (read: booted me out of the house because I was driving him nuts) to head back. I've been going in an attempt to clear the cobwebs from my head. The emergency medicine exam is looming, and I'm not getting any smarter. Gah. So in the meantime, if I'm not a doctor right now, what am I?

So here I am, getting my feet wet and blogging again. Much as I'm venturing slowly back into the world of medicine. This should be interesting.

In the meantime, here's a gratuitous Bean shot:

2007-12-29T22:06:00.000-05:00

Given Up on Me Yet?

For those die-hard blog fans who are still checking in regularly, I figured I owed you an update. Actually, life has been a blur since the Bean made his appearance. Keeping my blog updated has been pretty much the last thing on my mind. But my uncle (and loyal blog reader) reminded me that I owed it to the people who have stuck around not to drop off the face of the earth.

So since I have been quite vocal about birth, my fears, my pregnancy and obstetrics in general... here is my birth story. In typical Couz fashion, told with unvarnished honesty. Don't expect eloquence, or even coherence, as no amount of post-call in the world compares to the exhaustion of a new mom.

Here's how I remember it. At 41 weeks and 4 days we arrived at the hospital for my scheduled induction at 8am. There is some debate over elective induction before 42 weeks, but because the due date that I gave my midwives was the latest of all of the due dates I had been given that spanned a 2 week range I was very confident that if anything I was actually further along than estimated. And after being unable to walk for the past few weeks of pregnancy due to hip pain, I was more than ready. When we arrived at L&D I was checked by the OB on call (I had chosen my induction date based largely on the call schedule of an obstetrician that I particularly respected) and was 3 cm dilated. I had been contracting irregularly for the past 3 days, so the OB decided to break my waters and see if that would move things along. I agreed. Easy-peasy-- waters broken, clear, baby doing great, and I was already 80% effaced. The nurse assigned to me predicts that I will give birth before the end of her shift.

So the contractions got stronger, and I walked in the halls as best I could. I had tested GBS positive a few weeks prior, so I had the company of an IV pole as well as my husband. It was actually handy for leaning on during contractions. They never settled into a regular pattern though, and by noon I was experiencing some hard-core back labour. So they decided to start the Oxytocin drip, and labour got stronger and more intense. I kept forgetting to breathe through contractions because I was just so focused on getting through them. It was frustrating because none of the coping mechanisms that we'd gone over with the midwife were really helping, and every contraction felt like my lower back and pelvic bones were being ripped apart.

By 6pm or so I requested an epidural. 6 hours of augmented back labour was more than enough for me. The anesthesiologist arrived surprisingly quickly, which was a blessing since the first attempt at the epidural didn't work. Apparently I have a very superficial epidural space which confused the anesthetist. Thankfully he suspected it wasn't in the right place and stuck around for 30 minutes until it became clear that it wasn't working and re-did it. I barely felt it at all, either try. By that point I would have gotten a hundred epidurals for the back labour to stop. It eventually did, and I was in a much better mood. Or at least I was in a better mood until I dilated to 8 cm or so and threw up all over my husband more than once as I went through transition. Gah.

The pressure was crazy. Even with the epidural taking the 'sharp' aspect of the pain away, every contraction felt like a giant softball was being wedged against my left hip. I NEVER want to think about that hip now that my pregnancy is over. It was by far the worst part of the whole thing. So now I'm fully dilated, pushing, and coping okay but still having a rough go of it in spite of the epidural. And my stomach was still trying to turn itself inside out every few minutes. Good times.

By 2am my midwife re-consulted the OB (who had passed my care back to the midwife after my induction was deemed to be progressing appropriately) because I had been pushing hard-core for over 3 hours with little progress to show for it. The Bean seemed to be sitting somewhat transverse (again, that damn head against my left hip) and had no interest in coming past my pubic bone. Not even rocking back and forth. At this point, the Bean was still way too high to consider any other strategy (meaning vacuum or forceps assistance).

At this point things got a little blurry. The OB came in and assessed me, and strongly recommended a c-section. And ironically... I freaked right the f*ck out. For all of my talk about opting for a scheduled elective c-section, I've never had surgery before and the idea scared the hell out of me. Apparently the first thing I said was "I can't have a section... my house has too many stairs!"

I did agree, though. The OB on call was a very conservative one with a low c-section rate, so if she thought that it was indicated I was not about to argue. Thankfully, the Bean had tolerated all of the labour and pushing very well. So since the goal of the whole thing was 'healthy Bean, healthy Couz', off to the section room we went.

The first thing I told the anesthesiologist when we got to the OR was that I thought I was going to throw up again. He said that there wasn't much he could give me that was still safe in pregnancy (since I was going to be pregnant for another 10-15 minutes or so) and that the one thing he could give me would likely make me feel drugged. I don't even remember what it was. But obviously I also realized that throwing up during abdominal surgery wasn't really an option. Unfortunately, I had a really strong reaction to that med and don't really remember much but hazy bits and pieces until sometime the next morning. Which really sucks, because I missed my own son's birth. But Mr. Couz was there the whole time, and was a total rock. I love that man.

Such was the way that The Bean came into the world. Weighing in at 8 lbs, 4 oz with APGAR's of 8 and 9. Just needed a little oxygen at birth to get going, and was fine after that. It was a little surprising that he was so big, considering that both my family and Mr. Couz's families tended to make small babies and everyone was expecting a wee thing. Guess he dropped so early he had everyone fooled.

Recovery has been a lot more difficult that I expected. The pain was manageable, but I bled so much during surgery that my post-op hemoglobin was only 70. Plus, it took quite a bit of time for my milk to come in which cause the Bean to be pretty jaundiced (although he didn't require phototherapy, thankfully) and to lose over 10% of his birth weight by the time we were discharged on post-op day 4. And of course, I grossly underestimated how much time I'd be in hospital-- I expected to stay between 4-12 hours post-partum, depending on whether or not I got an epidural. Instead I came in on a Saturday morning and didn't leave until Tuesday night. And for all my talk about elective sections it never seriously occurred to me that I'd need one. I felt frustrated by the way it went down-- after 18 hours of labour the fact that I needed a section anyway felt like a failure. I still haven't figured out how I feel about all of it. But I am very disappointed with the fact that the only bits and pieces of The Bean's birth that I can recall feel like I'm trying to look through a heavy fog. I hate feeling drugged. This was my first experience on the other side of the health care system, and that was interesting. There will definitely be further reflection on that in the future.

So in the three weeks or so since giving birth I've been focused on recovering (more difficult when you can't tolerate oral iron) and getting to know my little Bean. He's beautiful, but don't take my word for it...

2007-11-30T19:59:00.000-05:00

Happy Due Date to Me

Well, today marks the last of the 3 due dates given to me at various points along my pregnancy. I've now been off work for 2 weeks. I'm bored stiff. I don't wish I were still working, because I can't manage to be on my feet for more than an hour without serious pain. I don't fit any clothing anymore other than my stretchy Lulu Still Pants (my only regret is that I only have one pair!). I'm bored, and uncomfortable, and pretty much the size of a small planet. I think I have my own gravitational pull.

So this is the belly. And velcro-dog's butt. Until the big day, I'm spending my time surfing the internet on the couch (using what is left of my lap to precariously balance my laptop). And wishing death on the next person who tells me to "enjoy my free time" (difficult to do when all of your favorite activities are physical ones and walking from the couch to the bathroom is exhausting) and "they're easier to take care of on the inside". Gah.

The Bean has been served his eviction notice. So for those of you asking.... yup. Still pregnant.

Wish me luck

2007-11-28T14:16:00.000-05:00

Did I Make the Right Decision?

I've been second-guessing myself a lot lately.

This time it's in regards to work. I love emergency medicine. Don't get me wrong. And I don't regret leaving the FRCP program-- I really had no intention of doing research, administration, or academia in general. Gah. I am SO through with academia. But I have to admit that after getting my independent practice license in family medicine, I have definitely been doubting my decision to do an extra year.

Some of it is envy. I hear what my fellow family residents are doing-- hospitalist, clinics, family practice. They have all settled into real job where they seem to have control over their work environments and are getting on with their lives. Suddenly, spending my days in a university student health clinic writing sick notes and doing STD testing actually looks appealing. I'm not sure what aspect of it is suddenly looking good to me... realistically, it might just be the possibility of making an actual secure salary and starting to pay off the debt. Money has been a major stress since residency started, and is only getting worse as I face maternity leave. The idea of getting on top of our finances rather than just making ends meet is incredibly appealing.

But it's more than that. Family medicine was... comfortable. Familiar. Safe. I rarely felt like I was in over my head. If I did, I would refer. I would show up to the office in the morning after rounding on my patients at the community hospital across the street, make myself a cup of green tea, eyeball the lab results that had come in that morning, see a few patients-- there was usually the odd curveball thrown at you during the course of the day. Someone sick enough to warrant being squeezed in between patients, someone who was sick enough to send over the the ER across the street (with a quick phone call to the ER doc with the head's up, and another to the charge nurse with some orders to get testing started at triage)... just enough to make the day interesting.

There was always one or two of what a former preceptor referred to as 'heartsink patients'... the ones whose names you see on your schedule for the day and sigh reflexively. The ones who always come in with numerous complaints, none of which are serious and none of which you can ever fix to their satisfaction. And there are always the no-shows, the people who book for an assessment of an ingrown toenail and just happen to confess a 4 year history of bulimia as an aside, the people who show up for their appointments with two family members and expect everyone to be seen in the one appointment slot... it's certainly not smooth sailing all the time. And there were definitely days that bored me to tears.

But the emerg is different. And although I love it, I can't imagine ever feeling as comfortable in the ER as I am in the office. In emergency medicine we're always taught to look for the 'what if?' that could be hiding in the patient's presentation. Sound like typical GERD? Sure, until the otherwise healthy 34-year-old woman goes into v-fib arrest. Looks like a medical clearance brought in by police? Ah, only until the 20-year-old man seizes secondary to the 6 grams of cocaine he swallowed trying to evade police. Abdominal pain with LFT's typical of acute obstructive choledocholithiasis? Only until the incidental finding of dissecting AAA on the CT. All of these cases actually happened, and have made me view every patient as a potential ticking time bomb. In fact, the more I learn about emergency medicine the more I'm convinced I will never know enough to be a good emerg doc. I know I'm not even halfway though the program, but the docs I've worked with just seem to know SO MUCH. Everything I learn just seems to highlight how much I don't know yet.

When I look at the big picture, I still want to do emergency medicine. I love shift work, the pay is better, I don't have to worry about the overhead and 'running a business' aspect of family medicine, I like working with people who are actually sick and not just spending my days holding hands and practicing preventive medicine... I'm not sure where the sudden uncertainty is coming from.

Must be hormonal.

2007-11-06T20:51:00.000-05:00

I Wish

No, no baby yet. I am pretty much term and only 2 ER shifts and a trauma conference away from maternity leave. And although I initially couldn't imagine taking any time before I actually went into labour, right now I'm more than happy to spend my last two weeks of pregnancy on the couch with my feet up.

Pregnancy has not been easy. Pregnancy in a job like mine has been downright brutal. I don't know how people do this.

There will be more soon, promise. Thanks for checking in.

I am currently rushing to complete a presentation for my academic half day tomorrow. I don't know which was the dumber move on behalf of my program-- scheduling me on an out-of-town rotation right before mat leave (I've been commuting 90 minutes to work from 34 weeks pregnant until 38 weeks... nice) or managing to schedule me to present at half day the LAST half day I'm attending before mat leave. Even preparing this damn presentation is challenging... for one thing, I can no longer work comfortably at my desk and my laptop no longer fits on my lap. Gah.

Off to learn more about anaphylaxis and angioedema. Watch this space next week for catching up on the past month or so. And maybe a photo of the planet that is now my midsection. Good times.

2007-10-10T14:53:00.000-04:00

Eleventh Hour Panic

So as much as I’ve tried to deny what comes next, my pregnancy is quickly nearing an end. I am well into the third trimester—my hands are constantly puffy, I don’t remember what my feet look like, putting on socks leaves me panting for breath, and I have only 17 more days of work until my maternity leave starts.

I haven’t been a good pregnant woman. I haven’t eaten as well as I should. My well-balanced, healthy diet went out the window in the first trimester with nausea and food aversions, and I haven’t managed to regain control over it. I rarely remember to take my prenatal vitamins. My exercise routine now consists of walking for an hour 2-3 times a week. I haven’t been swimming, which I intended to do. The prenatal yoga that I managed a few times on out-of-town rotations is a distant memory. Mr. Couz and I haven’t attended any prenatal classes, or even toured the labour and delivery floor of the hospital where I’ll be giving birth. I don’t think I’ve managed to do anything to prepare myself for what lies ahead.

Even my prenatal care has been sporadic. My midwife is very nice, and because I’ve been out of town so often I’ve only attended 3 appointments since my care was transferred to her when I was 20 weeks pregnant. I declined my gestational diabetes test, as my weight gain has been appropriate and I have no family history of diabetes (gestational or otherwise) so I figured it was unnecessary. I enquired about the banking of cord blood vs. delayed cord clamping at my last appointment only to learn that I was far too far along for cord blood banking to be an option. So delayed cord clamping it is.

And now I’m starting to second guess everything I’ve done so far.

Initially when I opted for midwifery care I was very confident in my decision. In the town where I left the midwives had a great relationship with the obstetricians—they were well trained and respected, and the hospital where they delivered was very progressive and baby-friendly. This meant immediate skin-to-skin contact after delivery (unless resuscitation was indicated), no episiotomies, birthing tubs available, lovely birthing rooms that looked less like hospitals and more like living rooms, followed all breastfeeding friendly guidelines (so no well-intended nurse would pressure you to supplement baby with formula because your milk hadn’t come in by post-partum day #2—gah!)… Generally a place where I’d be comfortable to deliver.

In my new town, I’m not so certain. I’ve heard a few cautionary tales about making sure the midwife doesn’t wait too long to consult obstetrics in the case of complications, the relationship between the midwives and the obstetricians isn’t quite as friendly, and the birthing practices seem right out of the 1950’s. And I’m getting nervous.

My midwife is aware of our preferences. We’ve gone over every aspect of the delivery and immediate post-partum period and she is aware of my wishes pertaining to every step along the way. She even seemed okay with the fact that I’d prefer a c-section over an operative vaginal delivery (get those forceps away from me!). I think that between her and my husband they’ll be advocating for me if I’m not able to. But still I’m starting to wonder if I’ve done the right thing.

Should I have just gone with an obstetrician? There is one in town who seems to be universally loved by other physicians and patients alike. Of course, I still wouldn’t have been able to guarantee that I’d go into labour while she was on call. As ashamed as I am to admit it I’d still prefer a scheduled c-section over the unpredictability of a vaginal birth, but I am also well aware that no obstetrician in town would agree to that. And since the Bean has been vertex (head down) for weeks already, it looks like my semi-subconscious wishes that he would be breech have gone unheeded. So it looks like I’m doing this the old school way.

What about a family doctor? The one that was recommended so highly by a number of people refuses to accept my family into her practice, even as a professional courtesy. Her practice is closed, and she isn’t accepting new patients regardless of who they are. So much for the perks of being a physician. Having her deliver my baby would have been a back door into her practice, and it would have secured my family a primary care provider.

I don’t know why I’m starting to question all of this now when I’ve been perfectly comfortable with my choice since the beginning. As with all of my other neuroses lately, I’m going to assume it’s hormonal.

2007-10-08T21:30:00.000-04:00

I'm Just a Rolling Stone...

One thing that has been particularly difficult about my medical training in general is the fact that it's never been in just one place. In the 10 years it's been since leaving the city where I grew up, I've moved 5 times. And that's just from city to city. If you include the number of times I've moved locally in that count, it goes up to 7. That's a lot of time spent leaving places, packing, unpacking, and getting to know new cities and surroundings. It's exhausting to think about.

But that's not all. Even my time in one place is divided up into different rotations. During medical school I did electives in four provinces and two continents. It was a great experience at the time. I spent my family medicine rotation in a B&B in a small town, constantly feeling like a guest in a stranger's house confined to a large bedroom. I spent a plastic surgery rotation in a city three provinces away from home again confined to a short-term rental bedroom in someone's house. My first emergency medicine rotation was probably the most bizarre in terms of accommodation-- I was renting a bedroom from the friend of the woman who owned the aforementioned B&B, who also ran a hair salon out of her home. I particularly loved the fact that although she was well aware that I was working shift work, she played talk radio at incredibly high volumes while eating breakfast in the morning-- in the kitchen just off my bedroom. My last elective in emergency medicine, shortly after moving in with the guy who later became Mr. Couz, was prematurely aborted. Three provinces in the other direction and again confined to a small bedroom in a stranger's house in a city where I didn't know a soul, I was so miserable I stacked my shifts in such a way that I was able to catch a flight a full 4 days sooner than initially scheduled.

The end result of all of that moving around is that I am currently feeling a sense of unease. I am currently in my (hopefully) last month of 'away' rotation. I understand the need for it-- there are very few pediatric hospitals in my province (or any Canadian province, for that matter-- we just don't have the population density for it) so in order to get a solid base in pediatric emergency medicine I need to work in one that ONLY sees kids. But lately I've been feeling very homeless.

It's a strange feeling. I feel homesick. But I'm not sure what city I feel homesick for. It changes depending on the day, and sometimes it’s for more than one place at a time.

I miss the town where I grew up in spite of the fact that the only people still living there from my past are my mother and my sister. I miss the neighbourhoods, the shopping, great restaurants… and as I get older I particularly appreciate how nice it would be to live in the same area code as my immediate family. I miss them, and would often give anything to be close enough to enjoy a Sunday dinner the family—and in my somewhat rag-tag family that can include anyone from my mom and sister to my stepdad, my uncle, my cousin and anyone else who happens to come by. I know that I’ll never move back there, however, as the health care system in that province is remarkably similar to third world countries and my husband doesn’t speak enough of the language to be employable as a paramedic.

I miss the town where I did my graduate work—many of my friends seemed to have ended up there, and although the traffic sucks most of the week and the housing has gotten pretty pricey I’d still move back there in a heartbeat. I loved the different neighbourhoods, the transit system (probably the best one I’ve experienced in Canada), the history, nearby greenspaces and rivers, the mix of languages used in everyday business, great restaurants… this is the city where I spent the past month doing pediatric emergency medicine, and I loved the fact that I had enough friends and family there to keep me busy and social on my days off. I reconnected with a lot of people and it made me nostalgic for the city itself.

I miss the town where I went to medical school. More than any other city I’ve lived in, I can see myself moving back there some day. Unfortunately, I don’t think it’s likely considering my past with the emergency department there (see Match Day posts for further explanation if necessary). My husband thinks that I’m just nostalgic for medical school, and he might have a point. Much of the allure of the town came from the people and the strong social networks we had there. I couldn’t leave the house without bumping into someone I knew (both a blessing and a curse) and I loved the fact that half of my building was filled with friends and schoolmates. My apartment had a beautiful view of the lake, my best friend was a 5 minute walk away, and if I needed company all I had to do was cross the hall. My gym, my running routes, the park on the corner… it was my neighbourhood, and it was home for four years. I loved it. Now nearly all of the friends and classmates in question have moved on, but I still have a few good friends kicking around.

More recently I even find myself feeling nostalgic for the town I most recently left behind. Longtime readers of this blog will appreciate the irony, as I hated that city the first time I lived there and was dreading moving back for residency. But the two years I spent there were in a great neighbourhood right near some great wooded trails. We adopted Velcro dog there, got married there, I completed residency there, Mr. Couz retrained as a paramedic there, and we generally settled for two years. Although I bemoaned the distance we were from family (both mine and his) and the fact that most of my friends were residents as well and therefore unavailable for most social activities, I still find myself missing it. And beyond the fact that there was some decent shopping in the area, I’m not even sure what I’m missing.

I guess in each case the common thread is the familiarity. Each town was a place where I lived, worked and played for at least two years. By the time we moved from one place, we had established a routine. We knew where to find decent Indian food that delivered, knew where the off-leash dog parks were, knew a couple of good places to hike nearby, knew where to take out-of-town guests for breakfast… everything essential for making a new place home. And now I’m living in another new city—closer to in-laws but 7 hours of driving away from my family. We’ve been here nearly 4 months already but much of that time I’ve been doing various out-of-town rotations and haven’t had the chance to really get to know the town. My program is very small, and as a result I haven’t met many other residents. The ones I have met are out of town as much as I am, and don’t seem all that interested in getting together more than the required one time a week that we converge for academic half day.

But this is home. We actually own a home here, a first for us. Granted, the upstairs is mostly unfurnished, the backyard desperately needs to be fenced in, and the basement is filled with boxes but it’s ours. Mr. Couz and the dogs are here, which for me goes a good way to making me feel happy. And I know, realistically, that the only way it will start to feel like home is when I make an effort to make it so. But in the meantime, it doesn’t mean I can’t feel a little nostalgic for all of the people and places that I seem to be leaving in my wake.

2007-10-07T18:08:00.001-04:00

Good News and Bad News

So I've been mentioned in a list of the Top 100 Health and Wellness Blogs on a nursing education website.

I'm flattered. Really. But I'm not sure how I feel about being referred to this way:

A Canadian nurse who works in an emergency room provides her insights into her job. This blog reads more like a novel, so make yourself comfortable and enjoy the trauma!

I'm used to being mistaken for a nurse (at work, anyway, where every female in scrubs MUST be a nurse, of course... sigh) but the fact that the person compiling this list mistook me for one makes me think that he/she (I'm not hypocritical enough to assume that the author is a woman just because it's a nursing blog) didn't actually read my blog. Or didn't read much of it. So that leaves me wondering just how much of an honour it is to be included...

2007-10-06T17:25:00.000-04:00

I'm Back.

I'm not sure why it's taken me 2 months to post anything of note. Work has been going okay. I've just completed a month of pediatric emergency medicine out of town, and am now nearing the end of my first half of ICU (my 2-month rotation has been split up into 1 month blocks). I am far enough in pregnancy that I am no longer doing call or night shifts, which kind of makes medicine seem like a normal job-- only at this stage it's all I can do to drag myself through straight days anyway. I haven't done much but work and sleep, and I feel like I'm the size of a house. Running for codes is laughable at this point, as the maximum I can handle is two flights of stairs at a time and even that is slow going.

I've had a few posts on the burner... I haven't been in much of a rush to post them as they seem awfully mopey and whiny. I know that much of it is the hormones talking, but I just didn't see the point in sharing my funk with the public.

So be prepared-- the next few posts (which I will post over the next few days or so) aren't clever or funny. Mostly just random musings and whining. I'm hoping that this too, shall pass and I'll be back to my old self soon. Thanks for the patience.

2007-09-04T15:33:00.000-04:00

Move Along, Nothing to See Here...

I can't believe how long it's been since I've posted.

After leaving the situation in the Centre of the Universe, my program just squeezed me back onto the emerg schedule for the remaining 2 weeks of the month. What I'm doing about trauma is still up in the air, but it looks like I'll be able to make up the week I missed (it was technically just one week since I originally had a week of vacation planned for the end of that block) by just doing horizontal trauma call. That basically means I'll carry the trauma pager when I have days off on other rotations. I am more than happy with that arrangement.

Emerg went fine... I'm getting a little more daring, and learning to behave less like a resident and more like a staff member with backup. There are still plenty of procedures that I'm not comfortable with (I'm on the verge of doing an LP on anyone with a headache!) but it's coming along. I'm a lot more hesitant about posting amusing cases and stories from the ER after some trouble that fellow bloggers have recently found themselves in, so I didn't have much to write about for those two weeks.

Next thing I knew I was on my way to another academic centre to do some peds ER. Thankfully not the COTU and thankfully, it's back in the emergency room. About a thousand times better an experience than the month before. And hopefully, my last far-away rotation ever. I still have two months of 'community' ER to do, but so far I'm scheduled to do one month just an hour away from home (practically commutable, if I choose to do so) and I'm hoping to do the same for my second month after the baby comes. It still sucks being in a generic resident apartment without my husband and my furkids, but I'm managing a lot better than I was before. It doesn't hurt that this is a city I've lived in before, and still have some friends and family kicking around. The feeling of familiarity helps the loneliness. What can I say? I'm a complete suck for my husband.

Being a pregnant resident still has its challenges. Working on my feet at this stage (28 weeks already) is tough-- my feet get really swollen, my back gets sore, and by the end of my shift I get cramps that make me catch my breath. All perfectly normal, so I'm not worried or anything, but it makes life difficult. Not to mention the wardrobe challenges of working in one of the only emergency rooms in Canada where the doctors don't wear scrubs. Thankfully, an absolutely wonderful person whom I barely know came to my rescue with a giant duffel bag of loaner mat clothes. It was like Christmas. Now if only I could find a pair of work-appropriate shoes that I can squish my Shrek-feet into...

I promise to find something to talk about soon. Thanks to those of you who checked up on me, wondering if I was dead.

2007-08-09T19:35:00.000-04:00

Epilogue

So it's over. I talked to my replacement program director (my program director took very unfortunately-timed vacation this week) after half day yesterday, and they have decided to pull me from the rotation, citing 'medical reasons'. So I'm now home. And happy. And rested. And the annoying cramping I'd been experiencing for the past few days that I attributed to being on my feet for too long has completely stopped. And my feet look like human feet, not Shrek feet. And I even have an appetite again. Life is good.

As for trauma, I'll be making up the time with extra trauma call here. Which is fine with me. Hell, I'll carry the trauma pager for the rest of the freaking year if it means never having to go back to the Centre of the Universe. Which I haven been assured I won't. :-)

Best of all, the trauma rotation from hell is now being reviewed. It seems that after the replacement program director got my e-mail he started asking around, starting with the two new staff hires in the ED who finished our training program last year. It seems my experience was anything but unique. And one emerg doc expressed surprise that I'd even attempt to do it 6 months pregnant. Um... yeah. Clearly I had NO idea what I was getting myself into.

Then, however, I had to tell the people at the COTU that I was leaving. In the first stroke of phenomenal luck that I've had since this awful rotation started, Mr. Old-School-Gruff-Intimidating-Trauma-Surgeon who is usually the postgrad education guy is on vacation this week. So instead, I had to deal with the guy who just happened to be the sweetest, friendliest and most approachable of the 6 trauma surgeons on the service. I had only met him once, but he actually took the time to learn my name (a stark contrast from the other staff trauma surgeons). His exact words to me?

"Couz, the two most important things in life are your health and your family. Right now, you need to think about those two things. Work will always be there. And work should never come before taking care of yourself. So go home and take care of yourself and your baby. Don't worry about anything else."

How sweet (and totally unexpected) is that?

My senior resident was also pretty unfazed, but now that there is a second junior resident that joined our team this week I'm sure she's just relieved that my leaving will be unlikely to disrupt her OR time. No doubt whomever gets stuck with my last two nights of call will be less than thrilled, but I'll be long gone by that time.

Having dealt with the rigid rules and hierarchy that is medical education, I am actually completely blown away by how accommodating everyone has been. Thank God that medicine can actually be human and sympathetic occasionally.

And as of Monday, I'm back in the emergency room. And feeling like the old Dr. Couz. And that's a good thing. I missed me. :-)

P.S. Thanks again to everyone for all their support over the past couple of weeks. Particularly to my blog readers and friends in the COTU who actually offered such things as air conditioned places to sleep and home-cooked meals delivered to the hospital for me. You guys rock. And an extra thank you goes out to my uncle Andy-- until this week, I didn't realize how closely you followed my blog and my life. Although it's been one helluva rough couple of weeks, I feel very loved.

2007-08-08T16:28:00.000-04:00

Thank Freaking God.

I'm coming home. I love my program.

2007-08-05T20:45:00.000-04:00

Another Damn Update...

In spite of my current predicament, I have been really touched by the outpouring of support. Phone calls from my nearest and dearest (which I've been mostly avoiding since the slightest show of sympathy can make me burst into very un-Couz-like tears), posts to this blog, Facebook messages and e-mails from both long-lost friends (who knew they read my blog) to near-strangers offering me respite from my situation (thanks again, Kate!). It makes a girl in a desperate situation feel very loved.

But the week got no better after my post. In fact, my night of call was beyond brutal. By 11pm that night my feet were so swollen (in spite of my TED's support stockings) that I couldn't get my Nikes back on. I had to unlace them and leave them unlaced. The night was a blur, I never did figure out where my call room was (a moot point, since I didn't get a chance to sit down until about 5:30am) and I STILL didn't see any good trauma. I felt so sick on my post call day (nauseous, swollen and prone to fainting) that I ended up being sent home at a reasonable time (not long after noon-- so only 30 hours or so of nonstop work on my feet). There were literally no high points to my week. I drove myself home on Friday after work, in spite of the long weekend traffic, and was greeted after the long drive by my sister and her significant other who made me eat and rubbed my feet. It was nice.

The next morning (after about 12 hours of sleep interrupted only by disturbing dreams of people crashing on the floor and visions of my pager going off) I wrote a carefully worded letter to my program director. Thankfully, she is a very approachable ER doc who has been through a few pregnancies of her own, and has already been a great mentor for me through this experience. Here is the letter I wrote (some details have been changed, obviously):

Dear Emergency Medicine Program Director:

I'm really sorry to interrupt your long weekend, but I'm having some serious problems with my trauma rotation.

This rotation is not meeting my educational objectives in any way. Having already completed two months of general surgery as a PGY-1, I am honestly not finding this rotation helpful at all. I am the junior resident on the team, and my role does not extend past running the floor. Making this more difficult is that fact that no one at any point has explained to me how the hospital works, what exactly is expected of me or even things as simple as how to access x-rays. In fact, many of my duties are only identified as such the following day when they haven't been done and I am berated by various senior member of 'the team'.

My day starts at 6am, when I am expected to pre-round on the team's patients before the senior resident comes in at 6:30am. At that time, I will be quizzed on lab results, urine output and vital signs. A quick round are preformed before the senior heads to the OR, and I am left to run the floor all day. This leaves me running from one end of the hospital to the other for an average of 12 hours a day without breaks. Even my half day is not necessarily 'protected' time, as the other juniors are very hesitant to relieve me of the duty of covering my team's patients and holding the trauma pager. The policy in this centre is that it is your responsibility to find someone to cover for you and if you are unable because the other juniors are unwilling or unable, you simply don't get to attend half day. On Wednesday I was paged out of half day an average of every 5-10 minutes throughout the afternoon, and heard next to nothing of the teaching. Since this is quite clearly a service-based rotation as a opposed to one that values teaching, the Wednesday afternoon was my only chance to get any formal (or informal) teaching and it was a bust.

The only change from this routine comes when the trauma pager goes off. This happens anywhere from 0-2 times a day (in spite of the fact that this is supposed to be the 'busy' time of year for trauma, ironically). I respond, along with about 10 other people, and fight for room near the patient along with the team from anesthesia, the team from the emergency room and the team from orthopedic surgery. My 'role' in the trauma is restricted to doing the secondary survey (the primary is mostly handled by anesthesia), and waiting around while the patient is scanned to see what team the patient will be admitted under. Although in theory I am supposed to be the one to do the procedures, that has been restricted to inserting foley catheters. Honestly, I felt I was getting much more out of traumas in my home centre, where the ER doc would allow me to run through the entire trauma from start to disposition. In addition, I actually found that I had more opportunities to do procedures in the ED in my home centre than I do on this rotation. This experience has been extremely disappointing, and I find that I'm not actually getting anything out of it.

Ordinarily, I would probably suck up the experience and push through it, just to have it behind me. But in light of my current physical limitations, I am having a really difficult time meeting the physical requirements of this rotation. Between the swelling, the back pain, the GERD-associated vomiting that sneaks up on me at embarrassing moments and the pre-syncopal episodes that happen when I spend too long on my feet, this week has been really rough on me. I'm not sure what to do at this point. I honestly don't think I can physically complete the rest of this rotation, but I am concerned about the repercussion of taking leave. I am willing to explore any number of options-- doing extra TTL call during my ortho-plastics and elective rotations, doing a trauma rotation as an emerg resident (as opposed to a gen surg resident) at this teaching centre or elsewhere... I am open to pretty much anything. I think there are many other ways I can get the exposure the trauma I am looking for, because I'm really not getting it on this rotation.

I would be more than willing to discuss this with you as soon as you can. I am hoping there will be another way I can fulfill my trauma requirement for the program and another way I can spend the rest of this month. You can reach me at home this weekend or by e-mail.

Again, I have to apologize. I am in no way a quitter, and debated a long time about addressing this with you. As I said, my first instinct in this situation would be to suck it up and finish for the sake of having it behind me, but between my somewhat compromised coping skills and my concern about the actual educational experience itself I don't think that simply going through the motions for the sake of completing the rotation is my best option at this point.

Thank you for listening, I look forward to your reply.

Couz

Unfortunately, I am still waiting for that reply. I suspect she may have gone out of town for the long weekend. Since I don't feel right bailing on a rotation without the blessing of my program director, I may end up heading back to the scene of the crime tomorrow in order to report to work at my usual 6:15am on Tuesday morning. Sigh. Just when the foot swelling has gone down...

2007-08-01T15:59:00.000-04:00

Quick Update

I know I promised more uplifting posts, but it's just not going to happen. Not anytime soon, anyway.

After being spoiled by starting my EM year by actually doing a month of emergency medicine (astonishing, I know), I am now in hell. I have been shuttled down to Large Teaching Hospital in major Canadian city also known as the Centre of the Universe (or COTU, semi-affectionately). So in my fragile emotional state (for more illustration of this, see last post) I have been sent to a sterile little apartment far from my home, my husband, my fur-babies and everything familiar to me to be overworked, belittled, abused, demoted and generally made miserable. Why is this happening to me? Because I'm reliving some of the darkest days of my medical education... my days as a junior surgical resident.

This is allegedly my 'Trauma' rotation. Bullshit. If this was a true trauma rotation, I'd be working with the TTL (trauma team leader) running the trauma from start to finish. Instead, I respond with the trauma team to all incoming traumas and traumettes (little traumas, or minor injuries that might require a chest tube or something), do a quick primary and secondary survey and then sit around and pick my ass until the patient has been scanned. Then after all of the injuries have been identified, I define which ones are directly relevant to the general surgery team and report back to the staff. Not too bad, right? Particularly since I get first dibs on some of the more invasive stuff (chest tubes, femoral pokes, art lines, etc.). So why am I miserable?

You'll be sorry you asked. My day starts at the hospital at about 6:15am. I am expected to pre-round on patient results and conditions for all of the team's patients (both trauma and regular general surgery patients) before the senior comes in. To add to the fun, the ward is often locked that early in the morning and I have to buzz the intercom for a good 10 minutes before someone will let me in. Which then makes me behind, and I get yelled at for not knowing everyone's Tmax (maximum temperature, indicating fevers and such) over the past 24 hours. My days last about 12 hours long. That's an average. On my feet. Spent running around from one corner of the hospital to the other, mostly completing scut while my senior is in the OR. I rarely have time to eat, and I don't really have the urge to anyway. I am nauseous most of the time, whether it's from being exhausted or stressed I don't know. Thanks to pregnancy hormones, I am quick to cry-- and considering the number of times a day I'm frustrated or overwhelmed, I have had to choke back humiliating displays of emotion more times than I can count. I save it for the 2-3 hours between the time I get home and the time I go to bed to have a hope in hell of waking with my 5:15am alarm.

Doing this pregnant was the stupidest idea ever. My feet are swollen by 8am, thanks to a combination of being on my feet constantly and the 40 degree heat. My back and abdomen cramp constantly, again probably thanks to the time spent on my feet. I've started having those lovely pre-syncopal episodes again, probably in part due to my ongoing blood pressure issues and part due to the fact that I'm back to minimal food intake.

Pregnant or not, this rotation sucks. I am the whole team... just me and the chief resident, who just stays in the OR. I'm trying to do everything, but no one will tell me what 'everything' is or how I'm supposed to get it done in a hospital system that is completely foreign to me. There is no one to answer my questions, and the only time I find out that I was supposed to have done something is the next day, when I'm being yelled at for not doing it.

And to add to the fun, my 'protected educational half days' (teleconferenced lectures from my home school) are anything BUT protected. Today for half day I had to beg someone to take the trauma pager, and he wouldn't cover my call for the afternoon. So I barely even heard any of today's lecture because I was too busy answering pages every 5-10 minutes. Then I got yelled at by my senior for sending a med student to do a consult-- she was placated when I explained that I had already seen all of the urgent consults and assessed them for the OR, and that this consult was VERY non-emergent and the staff requesting the consult admitted on the phone that the patient wasn't likely a 'surgical candidate'... but still.

I've done this already. I've put in my time as a surgical scut monkey. I'm not here to be anyone's lackey, I'm here to learn to run trauma. And I'm getting very little of it. It would have been MUCH more useful to do this as an EM/Trauma rotation. I'd still see the same stuff, but from a perspective that is pertinent to my role as an emergency physician.

Now any other time in my life I probably would have sucked this up and just counted down the days until I was done. But my coping skills have already been recently taxed to their maximum. I'm doing my call tonight, working a full day tomorrow (going home at noon post-call is not an option here on this service... particularly not when your staff surgeon has booked a clinic with 42 patients on your post-call day), back on Friday, then I'm going home. Home to my husband, my dogs, and my crazy sister who is visiting for the weekend with her significant other. There I will carefully construct a letter to my program director explaining my case, my issues, and how difficult this has been. I will emphasize how little I am getting out of it. I will offer to do extra Trauma call during my easier rotations, or even over my maternity leave. But I want to come home.

I just can't do this anymore.

I'm not even reading this post over. Excuse the disjointedness. I might regret posting this later, but what the hell-- you want an insider's look at medical education, here it is. Often, it sucks. And I am too tired to keep sucking it up right now.

2007-07-21T22:28:00.000-04:00

What, Me Worry?

Things that are currently taking up valuable space in my brain:

Money (or more accurately, the lack thereof)
I'm lonely. I don't think I've ever moved anywhere where I literally do not know one person before.
The fact that I've managed to forget large amounts of emergency medicine in the year it's been since I've done any emerg-- I feel like an idiot at least 3 times a shift.
The balance on our VISA card. It has to be paid off before I start mat leave, or it will continue to eat away at me indefinitely.
I'm leaving for a month-long trauma rotation at the end of this week and don't even know where I'm staying (it's supposed to be arranged by my program)
I'm worried that I'm never going to figure out how to get a freaking OHIP billing number, and will never get paid for the hospitalist work I've already done.
The bases that my paramedic husband is working out of are anywhere from 1-2 hours away. I worry about him being on the road, particularly at the end of a night shift.
Due to his commute, my husband is often gone for 14-16 hours for his 12-hour shift. With me out of town, I am very stressed about how we're going to manage with the dogs.
The scrub tops at my new hospital fit funny-- the mediums don't fit over my expanding belly, and I swim in the larges. I always have to try on 5 or 6 of them on before I find the one random medium that is a big bigger. Gah.
I am worried that if I feel isolated now, my maternity leave will be hellish. Having a baby in late November in Canada is the worst timing ever-- my leave will end just as the weather starts improving.
As is always the case, as my anxiety rises, my appetite disappears. I'm having trouble eating (anything but freezies and popcicles anyway) which doesn't help the way I've been feeling. I'm not too worried about The Bean, since I've managed to gain nearly 10 lbs anyway.
I've had a few more pre-syncopal episodes at work. As long as I'm careful to eat every 3-4 hours I'm hanging in, but I live in fear of passing out in the ER.
I'm worrying about the fact that our last appliance is now nearly a month late. I want my freaking dishwasher. I've lived without one for two years, and I'm dying to have properly clean dishes again.
I am concerned that I will never find a good weekend to take ATLS. I can't believe I put it off this long.
I really want a vacation. Like, want one so badly I can taste it. The beach kind. Or the spa kind. Definitely not in the budget.
I am worried that I am going to mess up my job as a hospitalist. I'm not used to working without backup, and not having anyone checking my orders and treatment plans. I could kill people with this kind of responsibility.
Baby stuff costs money. Money we don't have.
I worry that I'm never going to feel 'at home' in our new town, and will be miserable the whole time we're here.
I'm worried that I'm never going to get a central line on the first try.
I worry that the dogs won't take well to the new baby
I'm very worried that I'm going to suddenly become a 'mom' when the baby comes. In the not-good way. In the high-waisted jeans, always smelling like baby vomit, out of shape, unable to talk about anything but my child's bowel movements kind of way.
I am worried that even after a year of emergency medicine, I still won't feel prepared for work in the emergency room.
I also worry about crying at work. I cry a lot. I know it's the pregnancy hormones, because I never cry. I don't even get PMS. But my coping skills are pretty much nonexistant at the moment.
We really need to fence in the yard, but... big surprise... we can't really afford it. But if we don't do it before the ground freezes, I'm faced with bundling up a newborn in the middle of a Canadian winter to walk the damn dogs.
I worry that I made the wrong decision to pursue emergency medicine when I could have joined a nice, safe family practice and started digging myself out of this financial hole.
I'm worried that I'm going to be miserable away from my husband for the next two months (after trauma, I have another out-of-town rotation). I am a horrible suck when it comes to him. The last time we had to do the long-distance thing I was on elective out west during medical school-- I missed him so much I ended up stacking my shifts and coming home early.
I'm worried that I'll never work up the motivation to unpack the rest of the house now that the important stuff is done. Let alone paint the colours we had already picked out.
I'm worried that my PDA will finally figure out that I've been unable to HotSync it for over a year, and will lock me out of my desperately needed Lexi-Drug and 5 Minute Clinical Consult programs.
I am worried that I will hate my post-baby body, and that no amount of diet an exercise will make things right again.
I am now down to my last pair of dress pants that still fit. If I'm going to be moonlighting until mat leave, I'm going to need to find some maternity work clothes-- NOT something I want to spend money on at this point.
I worry that our child will be born with some kind of severe disability and will be dependent on us for life.
I worry that my dogs will somehow escape my watchful eye and unfenced yard and find their way onto a nearby busy street where they will be hit by a car. I didn't say that all of my fears and worries were rational ones.
I can no longer see my own genitals. I worry that my feet won't be far behind.
I worry that my husband will never get on with the EMS in town, and will have to commute to out-of-town bases the whole time we live here.
I realized that next month's trauma rotation isn't an ER-trauma rotation... it's a general surgery rotation. My last general surgery rotation (as those of you who have read this blog since the beginning may remember) nearly killed me. And that was BEFORE I was pregnant. I can't do 10 hour days on my feet anymore, and I certainly can't handle assisting in the OR. I've applied for vacation to shorten the rotation by a week, but if it doesn't get approved I'm thinking of pleading sick leave on the basis of my inability to stay upright for long periods with my ongoing hypotension. And my rapidly developing anxiety disorder.
I am worried that my inlaws, whom I love, will begin to drive me nuts now that we're living relatively nearby.
I'm disappointed that Rebecca is Canada's Next Top Model. I was really rooting for Sinead.

Okay, enough bitching. More uplifting posts to come.

2007-07-12T21:39:00.000-04:00

The Untouchables

I've never been able to figure out exactly what other specialties have against emergency medicine. As a general rule, emergentologists (I love that phrase) are seen as the cowboys of medicine-- they do the medical equivalent of balancing spinning plates on their fingers. Which also means one false move and they all come crashing down. Emerg docs seem to be viewed with a mixture of envy and derision. Generally speaking a few things make emerg docs different from other specialties. For starters, we have lives outside of medicine. We still make good money (not surgeon money, mind you, but why make buckets of money when you don't have time to enjoy it?). We play as hard as we work. When we leave the hospital, we leave the patients behind and don't get paged when problems arise. We have to know about a lot of things, but we don't know most of them beyond their initial stabilization and management (or as one of my preceptors likes to say, we know the first 10 minutes of every disease). We are always being pulled in multiple directions, often by people who are actively trying to die. We have to handle everything from the small benign stuff (like a sore throat, minor lacerations, sprains) to the worst cases (trauma, VSA, sepsis, anaphylaxis) and everything in between.

So emerg docs also end up being the scapegoat for any number of questionable medical encounters. When you're juggling several critically ill patients at a time, sometimes stuff can slip through the cracks. And sometimes, things don't get worked up as thoroughly as they could be before they're referred on. In the ED, the emphasis is on disposition-- in other words, where is the patient going to end up? If they have an acute abdomen, they're probably headed to surgery regardless of the results of their LFT's-- so it doesn't always make sense to wait for them before calling the surgeon. But then the surgeon turns around and bitches to anyone who will listen about how they got a 'bogus consult' for abdo pain that wasn't even worked up.

I think that the biggest problem in situations like this is that although emerg docs rotate through nearly every major specialty through the course of their training, specialists rarely are obligated to spend any significant amount of time in emergency medicine. So it's rare that a specialist can see things from our point of view. The surgeon might just see that they were referred something as a 'query appendicitis' on the basis of right lower quadrant tenderness, rebound tenderness, guarding, anorexia and an elevated white cell count. In spite of the increased use of ultrasound and CT, the reality is that appendicitis is still largely a clinical diagnosis. Take the same case two hours later, when the surgeon (or, more likely, surgery resident) emerges from the OR long enough to lay eyes on the consult. Suddenly, the patient's tenderness has 'magically' migrated a bit higher, there's no rebound tenderness and they're claiming to be hungry. So suddenly my 'classic appy' now looks a lot more questionable, and the surgeon rolls his eyes at the stupid consult that the ED wasted his time with.

I often feel sheepish, because I know that had I gotten the same story and/or clinical exam that the surgeon did I never would have consulted in the first place. But I have no control these things.

On Facebook (my new addition) there is actually a group devoted to "Stupid Consults from Stupid Doctors". Most of the posts to the group are from residents in academic centres complaining about things that have been sent to them from the ED-- consults which, in their eyes, are inappropriate. My response? It's easy to judge from your end of the filter. Maybe those obs/gyn residents feel like they must get referred everyone with pelvic pain or heavy bleeding, but since they don't see the 98% of patients that I send home it's hard to muster up sympathy. Refer pelvic pain? Only with a positive urine preg test. Heavy bleeding? Only with extenuating circumstances, like the woman I saw last week with the hemoglobin of 68 who was still bleeding heavily in spite of treatment with Ovral. I'm no gyne, but I think that warrants intervention.

The other side of the coin is the spread of defensive medicine. From what I understand from fellow emergency medicine bloggers, the problem isn't nearly as bad here as it is in the U.S., but it's starting to seem that way. Take ortho, for example. At the last two academic centres where I've worked, emerg docs do very few reductions of displaced fractures. As someone who wants to learn these procedures, I find this frustrating. Leaving a patient taking up an emerg bed for hours until ortho can organize themselves to come down and reduce the fracture is silly when we could get it done in just a few minutes. But as it was explained to me, "if something goes wrong with the reduction, the emerg doc would have a really hard time defending their choice to do it themselves when the experts (that would be ortho) are readily available for consult". Gah. A big part of the reason I chose to finish off my training with a year in this 'less-academic' centre is the fact that the attitude here isn't that the A-B-C's of primary assessment stand for airway, breathing and consult. Emergency medicine isn't just 'referology'. We actually do the reductions, the procedures, the conscious sedation, the airway management... it's a refreshing change.

Don't get me wrong-- inappropriate consults happen. And they probably happen more often than they should. Emerg docs aren't perfect. But we do the best we can. And until you've spent a few shifts in our shoes, give us the benefit of the doubt.

2007-07-10T21:33:00.000-04:00

I Think I Sold Out...

So I made my decision. After talking to some more established emerg docs who have done shifts in the smallish emerg that is courting me to take shifts there, I have decided that I am in NO WAY ready to do emergency medicine. I appreciate all of the points made by commenters regarding rural medicine-- I agree, sometimes you just have to take a deep breath and jump in. But in my case, I don't think I've done enough emerg through my family medicine residency to make that jump.

But that doesn't change the fact that there is debt to be repaid. And after buying a house, the bank balances are looking awfully sparse. And we're faced with some lean times with an impending maternity leave looming. Gah.

So where does that leave me? Well, I could just keep plugging away at residency, Mr. Couz can pick up extra paramedic shifts, and we can hope for the best (financially speaking). But the bills are piling up. And since the Canadian government is holding nearly $7000 of my hard-earned cash hostage while they process all of the reassessments they've slapped me with over the last few years (I mean really... contesting my medical school tuition claims? The government is the whole REASON I paid $15K in tuition a year, and now they think I'm lying about it? The injustice infuriates me) I don't really have much of a choice. I have to moonlight.

Luckily, this month I'm doing nothing but emergency medicine, which makes for a reasonable (although erratic) schedule. So I examine my options. My new town is ripe with walk-in clinics catering to the 30K-odd "orphaned" patients in our region. Perfect. McMedicine at it's finest-- I can practice what I know (family medicine), not have to drive far to do it, and make some extra money. Problem is, I've only had an independent practice license for a couple of weeks, and I haven't even figured out how to go about getting a billing number. And the idea of figuring out billing right now is a little overwhelming.

But then the same little hospital that had been courting me to work in emerg presented another option-- they are currently desperate for hospitalist coverage. I can come in for as long as I want, as many days a week as I want and they'll pay me $130/hr to see as many inpatients as I can. They don't seem to care if I see everyone or only a few people, they just want to take the pressure off the 'on call' physicians. So I wouldn't be responsible for call at all. The on-call doc would follow-up on any tests I order, and since they send anything more unstable or critical than urosepsis or pneumonia to the centre where I am doing my ER training, the patients are usually straightforward. Hmm. Intriguing option.

So I took it. Forget the fact that I hate inpatient medicine, forget the fact that rounding on inpatients was by far the most boring and tedious part of my family medicine rotations, forget the fact that I have to drive 45 minutes each way to this outlying hospital... starting tomorrow, I am Dr. Couz... hospitalist. This has the potential to be exactly what I'm looking for, or a complete disaster. Only time will tell.

I am a medical whore.

2007-07-01T12:56:00.000-04:00

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.

2007-06-28T16:25:00.000-04:00

Quick Update...

Just so that no one thinks I've dropped off the face of the world, I'm in mid-move. After passing my CCFP exams (yay, me!) and finishing my family medicine residency, I've packed up Mr. Couz, Big Dog, Velcro Dog and The Bean (who, at 18 weeks gestation, is still very portable) and moved to a less "academic" region.

Stay tuned. More adventures of Dr. Couz are coming as I become a full-fledged emergency medicine resident (again) and muddle through various rotations across Canada (the downside of a less "academic" centre is that it's not big enough to support specialized rotations like trauma and peds emerg) while moonlighting my ass off (so much debt to pay off!), as I try to fit my rapidly-expanding waistline into Hazmat suits (makes the scrubs look positively stylish!).

But in the meantime, I'm just trying to get the internet hooked up at our new house. Trying to focus on one battle at a time.

Back soon.

2007-06-21T20:31:00.000-04:00

Learning my Lines

... but not in the musical theater sense.

This month I've been in the ICU. A very intense rotation. I've been dealing with patients sicker than any I've ever seen before. I've seen medicine do things I didn't know were possible. I've seen countless people who were clinically dead brought back to life with electricity and drugs. I've seen people who should be dead kept alive for days, sometimes weeks, using medications, ventilators and a little luck. It's been a long month.

The reason I've chosen to do ICU (as a family medicine resident, it's not a required rotation) is for the procedures. Now I'll be doing another 2 months of it as an emergency medicine resident in the coming year, but I figured another month of it would be more helpful than my other choices (including palliative care, more internal medicine and more geriatrics). There are lots of procedures done on a daily basis in ICU that come in handy in the emergency room. Before this rotation I had superficial experience with most of them, but I figured this would be a good chance to hone my skills.

Not so much. I have had a horrible streak this month. If anything, I think I'm getting worse at the procedures I should be getting great at. Central lines have become the bane of my existence. Before this rotation, the only experience I had with central lines was one subclavian under close observation in a trauma situation. But technically, I was one for one. This month I've had two subclavian attempts. Although I got both, one gave the patient a pneumothorax (a known complication of subclavian lines, but I can't help but feel bad about it).

IJ's, the mainstay of central lines, should be routine for me by now. Instead, the only attempts I've gotten have been on patients who are awake. Now for those of you who have never attempted an IJ, imagine trying to perform a delicate procedure involving sticking long needles into people's necks in people who are combative, can't lie flat, won't stop touching the sterile drapes, keep turning their heads to see what you're doing and often don't understand enough English to follow simple instructions (Damn, I wish I spoke Italian!). In short, I am 0-for-three in IJ's, and frustrated to tears.

Femoral lines aren't often done in the ICU where I am currently working. I have seen one done, that's it. So according to the 'see one, do one, teach one' rule, I should be trying the next one. But there's not much chance of seeing another one in the two days I have left.

Chest tubes are another procedure that I've been eager to learn. In an entire month, I've done one. That's all. I was successful, but to put things in context it was a large pneumothorax in a small, thin, 40-ish woman. NOT the typical patient. I can only hope I'll be just as successful when I'm called on to do the same in people with much more tissue to cut through.

But the issue with the central lines has been really discouraging. Particularly for me, who apparently has placed far too much of my professional self-worth in my proficiency at various procedures-- after spending the first three years of medical school thinking I was going to be a plastic surgeon, I do tend to pick up things like this easily. And now I seem to have grown extra thumbs and some kind of gypsy curse, to boot.

Oh well, there's always intubations. Crap, now I've probably cursed those too.

2007-06-06T20:51:00.000-04:00

On Being a Pregnant Medical Resident...

The Good:

Limited maternity wardrobe required-- I went from yellow-string scrub pants to blue-string scrub pants around week 14 so that I could wear them over my expanding belly and not have to hike them up all day. Saves me a ton of money.
My emergency medicine program has been amazingly accommodating regarding my pregnancy and impending maternity leave. I've basically re-written my schedule for the next year so that the rotations that have to be done out-of-town will be done by the time The Bean makes an appearance.
It looks like I can take 5 months of leave and still manage to write my emergency medicine certification exams on schedule. That's 2 months more than I expected to be able to take.
PAIRO (have I mentioned that I love my union?) tops up my mat leave to 75% of my take-home salary. Not too shabby.
As a doctor, I seem to be subject to very little of the unsolicited advice that is often heaped on pregnant women. I guess people assume that my medical training makes me better prepared for managing pregnancy. With the exception of my mother-in-law, who believes, for example, that my intention to cloth diaper is something that should be met with eye-rolling and smirking.

The Bad:

I'm torn between wanting to tell everyone I work with that I'm pregnant (since I'm definitely looking wider around the middle) and not wanting them to think that I expect special treatment.
Due to some first trimester spotting, I had to stop running. I've been walking instead, but it's really not the same as far as stress reduction goes.
I need to pee about 10 times a day. This is actually pretty disruptive to a busy workday.
Eating is a challenge. I'm done with the nausea of the first trimester, but very few foods are appealing to me. And it's not like I can leave the ICU with the code pager to get myself some fresh watermelon and a McDonald's cheeseburger when the mood hits.
I miss sushi. A lot. And wine. And my beloved aspartame (I long for a Diet Coke!). I am aware that not everyone believes that forgoing sushi and aspartame is necessary during pregnancy, but it's what I've chosen. That doesn't mean I can't complain.
10 hour days with 1-in-4 call is exhausting to the most hardy of individuals. Being pregnant doesn't help. Thank God I had easy rotations during the dreaded first trimester.
My blood pressure has been problematically low. My systolic is hovering around 80. In the stuffy confines of the ICU, rounding (standing in front of a patient's bed for long periods of time) gives me pre-syncope. I think I'm going to have to tell my attending I'm pregnant, or he's going to think I'm just a lazy shit who drags a chair around the ICU with me.

The Ugly:

Uncontrollable pregnancy gas. Nuf said.

2007-06-05T19:39:00.000-04:00

Eye See You.

My last rotation of residency has begun, and it's been a hell of a rude awakening. After 7 straight months of family medicine (and before that, two months of babysitting a Level II nursery) it's been a long time since I've done any 'real' medicine. And now it's somehow become me and one staff covering a ward of a dozen people who spend much of their days actively trying to die.

It's funny, but that aspect of this rotation bothers me less than I thought it would. People die. It happens. More often than not, people die when their time has come. It's never easy to say goodbye, but it seems somehow less hard to swallow when an 86-year-old man dies after a lengthy illness surrounded by extended family. It's a good death.

Not that we let everyone have the 'good death' that (in my opinion) is the ideal way to end your time on earth. Whether it's due to the patient's wishes or the family's, many people are subject to endless lines, procedures and resuscitations before they finally pass on. Medical science is quite adept at prolonging life, even when life is not meant to be prolonged. And I'd be lying if I said that it wasn't disturbing to be doing chest compressions on an elderly man with multiple medical problems, or intubating an end-stage COPD patient for the 9th time in 2 years. Some people were just meant to die. Peacefully. Without cracked ribs and tubes down their throat.

Funny that death doesn't seem to bother me as much when I'm faced with it on a daily basis. But you can bet your ass I'm getting "NO CODE" tattooed across my sternum when I hit 75 or so. Assuming I last that long.

2007-06-03T15:45:00.000-04:00

What To Expect From Your ER Doc

People bitch about doctors a lot. Not necessarily to me, but in my presence. I don't mind, most of the time. Many times these people have legitimate beefs. But more often than not, I think that the problem lies in poor communication. Doctors often assume a level of medical knowledge in the general public that simply isn't there. And patients, for one reason or another, don't ask questions. When this is the situation, the patient will leave the encounter upset, and the doctor will have no idea that the patient wasn't satisfied with the result.

A patient's expectations should be different depending on the physician and the circumstances. This view may reflect the fact that I am currently awkwardly straddling my roles as family physician and emergency physician, have have yet to become truly comfortable with either one. But I find that whereas a certain degree of bedside matter and handholding should be expected of a family physician, to expect the same from an emergency room physician is misguided. Not to say that ER docs have free reign to be assholes, but their role is different.

So here's a quick primer on what you should expect from your friendly emergency room physician:

1. To be appropriately triaged.

The first thing that happens to you in the emergency room is that your complaint is ranked on a scale of how likely it is to be life-threatening. This system may not seem fair, but it usually works very well. So if you're grumbling because the young girl in the corner with seemingly minor stomach pain is seen before you in spite of the fact that you're puking from your horrendous migraine, remember that you don't know the whole story. If there is a chance she's pregnant, the possibility that her pain is resulting from an ectopic pregnancy definitely outranks your migraine (which, although obviously unpleasant, isn't likely to kill you). See how this works?

2. To have life-threatening conditions ruled out.

Let's say you're the one with the belly pain. If you're not pregnant, not bleeding, have no signs of an acute (aka surgical) abdomen and aren't dehydrated, you'll likely be discharged. I can understand that people want answers, but sometimes we're not going to be able to give them. It might be gastro. It might be food poisoning. It might be muscular. It might be very early appendicitis that just hasn't 'declared' itself yet. If it's the latter, that will become clear soon enough. It it's any of the former, it won't kill you. So we're sorry that we can't tell you exactly why you woke up with belly pain and had some diarrhea, but we don't have all the answers.

3. To do what is medically indicated for your condition.

Not everyone walking into the ER warrants extensive investigation. The job of the EMERGENCY room is to rule out EMERGENCIES. See how this works? So once it has been established that your presenting complaint is unlikely to cause you significant morbidity or mortality any time soon, you may find yourself punted in the general direction of your primary care provider for further care.

4. To see the doctor (although the length of time you waited is not reflected in the amount of actual time you spend with him/her).

This may come as a shock to those of you who have waited 3-4 hours in the ER only to get less than 30 seconds of face time with the physician who breezes by to tell you that your wrist is not broken (and, if you're lucky, perhaps a script for some Tylenol #3's). But if you're looking for a longer discussion about how long you can expect to be in pain, what kind of limitations you should put on your activity, how you should ice it, what kind of exercises you can start doing and when to regain strength... well, you're best to see your family doc.

This may seem unnecessarily harsh, but it's reality. Not only is the ER doc usually the ONLY doctor in the emergency room (and therefore balancing the multiple needs of many patients, most of whom are far sicker than you) but it's often hard to muster up convincing sympathy for someones infected ingrown toenail when you've got people actively trying to die in 3 different resuscitation rooms. This is not usually the place for handholding and sympathy.

5. To be waiting longer if you abuse the nurses.

Wandering back and forth to the nurses station to complain about the wait and threaten the nursing staff will prove to the nurses (and, by proxy, the doctor) that you are well enough to ambulate and complain and therefore not sick enough to warrant immediate attention. So stay where you've been put and wait your turn. Besides, wandering around the emergency department compromises patient confidentiality-- would you want people wandering around overhearing the doctor ask you personal questions? I think not.

6. To be treated respectfully.

Although you might not get stickers and hugs, you should expect to be treated as a human being. That means that your dignity will be preserved as much as possible in an environment like the ED, you will be treated fairly, and you won't feel as though you are being judged for your problem (particularly if it involves mental illness, substance abuse, physical/sexual abuse or sexually transmitted infections). If this is NOT true of your emergency room visit, this warrants an official complaint.

No doubt I'll be adding to this list as time goes on. But for now, please excuse the disjointed blogging... there has been a lot going on in my real life, which hasn't left much time for blog updates. More to come soon.

2007-05-28T19:45:00.000-04:00

And on a Lighter Note...

Guess I'm not quite as covert as I thought. After my last meme, many of you had already figured out the secret I was referring to.

In about 5-6 months, Dr. Couz is going to be someone's mother. Freaky.

Mr. Couz and I are expecting the arrival of The Bean in late November.

And no, this won't mean that this becomes a Mommy Blog. Still just me, only with added complications. :-)

2007-05-23T11:02:00.000-04:00

Que Sarah, Indeed.

Sarah is someone who I've 'known' online for several years. She is a funny, strong woman who was diagnosed with malignant melanoma. After many rounds of treatment, it looks like Sarah's fight is nearing the end. Her life is being cut far too short.

Please join me in wishing Sarah and her wonderful husband Derek all of your thoughts and prayers.

Safe travels, Sarah.

Please, wear sunscreen. Don't tan. If you notice a suspicious mole, see your doctor. If there is any suspicion, get the mole removed. It's the only way to know for certain.

2007-05-17T19:03:00.000-04:00

Medical School Applications

Although it feels like it's been decades away for me, applying to medical school is an experience that is fairly fresh in my mind. I consider myself an expert when it comes to medical school applications. Why? Not just because I went through the process three times, but because each time I further refined my application until it was exactly what the medical schools were looking for. Then, I sat on applications committees. I read applications and personal letters. I interviewed applicants. And after all that I can honestly say that if I knew then what I know now, it would have saved me time, money, and possibly a degree or two.

Since I have frequently been asked for advice on the topic, I'm giving it here. Free of charge. But my experiences are with the Canadian system and I've been around the block enough times to know that the U.S. system is a whole different ball game, so my American readers are out of luck.

Now this is just my advice based on my experiences, and if you think that following this advice guarantees you a spot then you're too stupid to be a doctor anyway. Just don't sue me.

Dr. Couz's Guide to Canadian Medical School Admissions

Step 1: Go to School

This is easier than it sounds. Go to university. Any university. Honest. Not only will the fact that you went to Nipissing instead of Queens not be held against you, it might actually make you more interesting than the typical med school candidate. Trust me-- when you see 30 medical hopefuls who are all majoring in immunology at U of T, they start to blend together. In fact, if you're the kind of person who learns better in smaller classes or when you're living at home, it's probably in your best interest to forgo the 'big name' schools, where you can be assured that you will be one of a thousand students in your first year biology class.

This doesn't mean that if you're going to U of T you're at a disadvantage in any way-- particularly if you thrive in the city, don't mind that you have no idea what your professor looks like cause you can't see her from the 102nd row, and think that going there makes you better than other people (PSA: it doesn't). It just isn't necessary if medical school is your goal.

Step 2: Study Something.

Again, it doesn't matter what. Study something you like. Now I'm sure that some of you are now doubting my sanity and wondering how you can possibly get into medical school with a degree in music performance. Well you can. And here's your strategy. Make a list of all of the medical schools you're interested in. Even the long shots. Now go to each school's web site and look up their admission requirements. You'll probably find that the total list of pre-requisites is actually pretty short. A few biology classes, a biochem, the occasional physical science... most can be completed in first year (or in CEGEP, if you're in Quebec). The rest of your time at university is your own. Love working out? Study kinesiology. Want to learn languages? Pick one and take a course in it. Want to better train your dog? Become a psych major. It's a bonus if whatever you choose to study will actually lead to an interesting career if medicine doesn't work out, but these days very few bachelors degrees actually give you employment potential anyway.

Don't feel compelled to enroll in one of the uber-competitive "pre-med" courses popping up in more and more Canadian universities these days, thinly disguised as Life Sciences or Health Sciences. They're filled with scary people who will stop at nothing to claw their way to the top of the class. Friends who have survived these programs recall stories of lab sabotage and theft of reserve materials from the library required for assignments. All of my med school classmates who came from these types of programs say that they got into med school in spite of these programs, not because of them. But that brings me to my next point:

There is a caveat.

Step 2A: Pick a Major Where Good Grades are Attainable.

This is important. Because no matter how great a doctor you have the potential to be, you won't make it past the first cut without decent grades. Some programs (philosophy, for example) have a reputation for being nearly impossible to score A's. Don't pick these programs. Although you should study something that interests you, make sure that you can do well in it. The occasional B+ won't kill you, but in order to be competitive your GPA should convert to at LEAST 3.6 on the OMSAS scale.

Which leads nicely into...

Step 3: Get Good Grades.

Sorry, there's no way around this one. Unless you can prove that French is your first language (Ottawa has different requirements for their Francophone stream-- or at least they did when I applied) or you carry a band card (proving Native status, to those of you now confused) expect to need close to an A- average to even be considered.

But here's a secret-- at most medical schools, there is a grade cutoff. How high it is depends on the medical school, and some calculate a weighted GPA whereby each subsequent year of university is worth more than then one before. But once you reach the cutoff, that's it. You don't get bonus points for having 3.8 if the cutoff was 3.65. You're all on a level playing field after that. There is one medical school that used to rank people by GPA, but according to inside sources the differences between GPA rankings at the top of the scale are so minute that it was actually other factors that ended up deciding if someone got offered an interview. And that school is weird anyway. Heh.

Step 4: Write the MCAT

Some people think they can beat the system by only applying to those schools in Canada that no longer require the MCAT. Bad move. For starters, this limits your applying power. Second, rest assured that you're not the only one who thought of this brilliant plan. The schools that don't require the MCAT see many more applicants than the ones who do. And the MCAT is actually a pretty painless hurdle to jump as long as you prepare properly. I don't mean by paying $1500 to some Kaplan-like organization (although if you have the money and REALLY lack the motivation, this might be worthwhile) but simply by studying. The high yield stuff is the practice tests. Do as many of them as you can get your hands on, and make sure that you can do them in the allotted time (this is particularly challenging with the Verbal Reasoning section). The Canadian schools don't seem to be quite as in love with the MCAT as the U.S. schools are-- a combined score of 30 with at least an 8 in each section should put you in good shape for your applications.

Step 5: Do Your Homework

This step will save you a lot of time and effort. And unnecessary fees.

Canadian schools reward their own. Not their own students (so don't rush to go to Western for your undergrad simply because they have a medical school) but their own region. Some go so far as to publish different GPA cutoffs for residents and non-residents of their province. Some have gone so far as to allow lower GPA's in people who grew up in the city where that medical school is located. Thankfully, these schools all publish these fun facts. They are there on the web for anyone who takes the time to look.

So don't waste your time. Apply smart. If the University of Toronto requires at least 8 in each section of the MCAT and you only got a 7 in Physical Sciences, don't waste your time or money applying there. If Dalhousie only accepts 3 non-Maritime students for their class of 125 every year, unless you're REALLY an outstanding applicant focus on schools in your own province. And be sure to check what they consider a 'resident'. Even if you did your undergrad at UBC, they don't consider you a resident of BC unless you went to high school there. At least that was the rule when I applied. Since training people from the area doesn't ensure they'll stay in the area, I think the whole residency restriction thing is stupid anyway. But I don't make the rules.

Step 6: Get Some Letters

Letters of recommendation are really a lot less important than people think. Everyone has good ones. The ones that stand out aren't the ones by people with big names-- they're the ones by people who clearly know you well and can comment on some aspect of your work/personality/life. And don't forget to ask people BEFORE they write the letter if they will be giving you a positive recommendation. This seems obvious, right? Not so much. I know more than one grad student who found out later that their primary thesis supervisor gave them a crappy letter because he thought that his favorite grad student would be 'wasted' in medicine and would better serve the world locked in a lab for the rest of his life. Nice, eh?

I also know of an applicant who managed to get a letter of recommendation from the founder of the medical school he was applying to. Apparently, the guy was his great-uncle or something. The application committee was not sufficiently impressed to invite the applicant for an interview. So really, just get good letters from people who know you. Don't stress about the number of letters after the person's name or the fact that they aren't 'medical'.

That's it for this installment. Following these simple steps should get your foot in the door-- and by that, I mean an interview invitation. The next installment in this series will be on acing the interview.

For starters, if you must throw up in the middle of your interview, there is actually a way to make it work in your favour. I am not kidding. But I'll save that story for next time.

2007-05-16T19:40:00.000-04:00

Tagged Again

Medstudentitis tagged me with another Meme, this one being "Eight Random Facts/Habits About Me". Since this is dangerously close to the last Meme in which I participated, I'll be honest about the fact that it's just a cheap way to post more to make up for the past two weeks.

My 8 Things:

1. Every now and then, I listen to country music when I'm alone in the car.

2. I have a secret crush on David Suzuki, and I take every word he says as gospel.

3. Before I wanted to be a doctor, I wanted to be a Solid Gold dancer.

4. Before I get into bed, I have to brush the 'sand' off the sheets. It's like a ritual. But if I don't do it, I swear the bed feels gritty.

5. I used to wear a silver ring engraved with the phrase "To Thine Own Self Be True" as a reminder not to rely on any guy for my happiness. Clearly, I had a bad experience somewhere along the line, but that's too much personal information for a blog.

6. I hate white underwear. I don't own any white bras. I have no idea where this intense hatred came from.

7. One of my biggest fears is being stuck somewhere with nothing to drink. I hate being thirsty. I carry a water bottle with me everywhere.

8. I've been carrying around a really big secret for a couple of months now. It's killing me. I hate secrets.

2007-05-16T10:03:00.000-04:00

The Death of a Flea

Dr. Couz is in mourning today. I recently learned, along with the rest of the medical blogosphere, that Dr. Flea's Blog is now defunct. Gone. Dead webspace. No forwarding address. No goodbye.

Flea earned my undying admiration with his series on vaccines around the time that he made the mistake of messing with some of the less rational fringe of the anti-vaccination movement. Several of his posts collected 80 to 100 comments before they tired of the game. Rather than fighting the impossible fight (you can't debate a subject like vaccination with people who believe that peer-reviewed evidence is biased and false but that alternative websites are the word of God) the Flea chose to educate. He posted a brilliant series of posts, each dealing with a different vaccine-preventable disease. He covered diptheria, polio, HiB, mumps... many diseases that people don't have a good understanding of today in a well-written series that I now wish I had saved somewhere. Flea was one of the first bloggers in my blogroll, and I don't have the heart to remove him yet.

I know that Flea was in the middle of a malpractice trial. There had been some recent debate over whether or not he was blogging in real time, or if this was a trial that has long passed. Based on the sudden disappearance of his blog, I think it was likely the former.

First Barbados Butterfly was pressured by the hospital she worked for to remove her blog. Then Vitamin K was outed, and converted her blog to invitation-only. And now the Flea.

I can only hope this is a temporary hiatus.

2007-05-04T20:57:00.000-04:00

Dollars and Cents

So I recently met with one of the financial planners at MD Management, the financial management company that works hand-in-hand with the OMA to keep residents from declaring bankruptcy before they start practice. It's a nice service. Except for the fact that they were the ones who referred us to the accountant from hell who has caused as many problems for us, tax-wise, as he's solved. But that's another post.

In breaking down my finances, I learned an interesting fact. In the past 12 months, if you add up union dues, memberships to various medical associations, malpractice insurance, educational license fees, fees to the university through which I'm doing my residency training, and the other costs 'required' for me to call myself an M.D. and train in the province of Ontario, the total was $9000.

Yup. You read that right. $9000. Nearly 20% of my GROSS income. And that doesn't include the $1500 it cost to write the LMCC-II, the $1500 it cost to write the CCFP's, and the $1500 it's costing me to apply for my license for independent practice. Altogether, the cost of being a doctor this year was about $13,500. My salary, as is available for all to see on the PAIRO website, was $53,715 before taxes. I don't like to think about how much that is when calculated hourly, because it's just depressing. But what's more depressing is the fact that a full 25% of my salary went to simply being a doctor. To be fair, I get reimbursed about $2500 of my malpractice insurance at the end of the year. But the rest is gone for good. And that's a LOT of money.

This seems somehow wrong.

2007-05-02T13:12:00.000-04:00

Why I Blog...

I've been tagged by Liana at Med Valley High in the latest Meme to circulate around the medical blogosphere. As an aside... is it pronounced MEEM or ME-ME?

5 Reasons Why I Blog

5. When I was trying to get into medical school (the third time was the charm) I would often stay motivated by reading books by medical students and residents describing their experiences. Not just House of God (which would be enough to turn anyone off medicine), but also White Coat: Becoming a Doctor at Harvard Medical School by Ellen Lerner Rothman, A Not Entirely Benign Procedure by Perri Klass, and the books by Robert Marion, The Intern Blues and Rotations. Reading these books somehow helped me "keep my eyes on the prize" when my motivation was lagging. I always imagined that one day I'd write a book describing my experiences. I am unlikely to find the time or the attention span to write a whole book, but blogging is do-able.

4. I always loved creative writing in school. As I grew older, I found that my imagination had atrophied to a shocking extent. Instead, I get the same creative outlet writing about the people I meet and experiences I have on a daily basis. No imagination required-- I couldn't make this stuff up if I tried!

3. I have a lot of strong opinions. I find that blogging is a safe outlet for me to rant about everything that rubs me the wrong way, from abuse in medical training to routine infant circumcision and everything in between. I can rant to the general blogosphere (where if you don't like what I have to say, don't read my damn blog) as opposed to alienating friends and family.

2. I want a record of the crazy shit that happens to me through residency. I'll never have these 'firsts' again, and my memory for personal events pretty much sucks. This way, as long as the internet exists and Blogger doesn't crash, I'll have my recollections of these events forever.

1. What the hell else am I going to do while my husband plays World of Warcraft?

2007-04-29T17:57:00.000-04:00

The Anti-Climax

Gah. It's done. After close to two months of doing pretty much nothing besides work and study, the CCFP exams are over. To those of you not in the know, the CCFP exams are the set of exams that family medicine residents in Canada are required to pass before hanging out a shingle. So, unlike the LMCC-II exams that I sat back in the fall, these ones actually mean something.

The first step was the written exams. They started off in the morning with some questions that were much easier that the practice exams that had been circulating around for the past month. I think it was intended to lull us into a false sense of security. As the day went on the questions got harder, and more obscure. By the end of the day we were well into "guess what I'm thinking" territory. Bah. Honestly, I'm not sure what two medical conditions preclude immigration into Canada, and I'm not entirely convinced that information should be taking up valuable brain space. But whatever. I'm just looking to pass.

The SOO's (Structured Office Orals) were kind of fun. If stress can be fun. Each situation has a patient that puts a problem on the table immediately, but you often have to uncover a second 'hidden' problem. Sometimes these problems border on the ridiculous, but generally they are pretty representative of what can walk into a family practice. You have 15 minutes to cover a staggering amount of information-- some related to the problem, some not so much. The problem with the SOO's is that the formula that you have to follow in order to pass bears no resemblance whatsoever to an actual patient encounter.

For example:

- I don't ever tell patients to 'come back for a physical exam'. In a 10-15 minute appointment in real life, we do both a history and physical.
- I would be thrilled if my patients only came in with two problems. I'm still trying to figure out an assertive way of limiting the patient who comes in for their 10 minute appointment with a list of 6 things they've been 'saving' for their appointment.
- I don't routinely ask what my patients do for a living unless it is somehow related to the reason they've come in. In the SOO's, you have to explore the impact that their complaint has had on their function. Gah.
- In the SOO's, after about 10 minutes you are expected to make an 'integrative statement'. This should sound something like "So as I understand it, this hangnail that you've been experiencing for the past month has been causing you a lot of distress, and is clearly interfering with both your relationship with your gay lover and your job as a basketweaver. Does that sound right?" I am quite safe in saying that I have never, in two years of practicing medicine, made a statement like this in the middle of a patient interview. But it is integral to the SOO.
- In the SOO's patients never wait until they are one foot out the door to tell you why they REALLY came. "Oh... I almost forgot. Thanks doc, for looking at that mole on my arm but I forgot to mention this crushing chest pain that I've had on and off for the past two days..."

But enough with the bitching. They're done, and I can get my life back. And now I have a month of geriatrics to get through. It's odd to go back to work after such a feeling of finality, but I still have two months to slog through before I move out of this town to start my PGY-3 emergency medicine year. Which is already looking to be full of interesting twists. But more on that later.

2007-04-16T12:10:00.000-04:00

The Pharmacists Aren't Perfect, Either

I've been thinking a lot about this new law allowing pharmacists limited rights to prescribe and change treatment plans in Alberta. Now generally, I think pharmacists rock. When I'm managing inpatients I often rely on the expertise of the hospital pharmacist, who thankfully is just a phone call away and is always happy to answer my questions. In the academic practice where I've been working for nearly two mind-numbing months, we have a full-time pharmacist available who also does incredibly helpful things like scan databases of patients to make suggestions on the optimization of their medical management for certain conditions. In the community, the pharmacists (for the most part) are happy to repeatedly save the ass of the new doc in town (that would be me), faxing back to politely remind me that I've neglected to include the limited use code for an elderly patient's meds, or to tell me for the third time that I can't order 5mg of Flexeril qhs because the lowest dose of Flexeril available is 10mg (regardless of what Lexi-Drugs tells me). Then again, these pharmacists who seem so patient with my rookie mistakes may be the same ones who then turn around and refer to me as an idiot who doesn't take the time to talk to my patients (as per The Angry Pharmacist).

Not long ago I had an entire family come into my community family practice-- both 30-something parents and two sons just shy of puberty. Mom was clearly unwell. She leaned on her husband for support, and complained of a sudden onset of high fever, joint and muscle aches, extreme exhaustion, headache and cough. A few more questions and a physical exam later, I diagnosed influenza. It was actually quite classic. I took a naso-pharyngeal swab to send to public health, and sat down with the family to discuss their concerns. Most of all, the parents were concerned that their two children would get this as well. None had been vaccinated, and the severity of this illness surprised both of them-- they had thought that the flu was a bad cold, and mom in particular was shocked by how debilitated she had been.

We discussed indications for treatment for mom (and decided against starting treatment based on the duration of symptoms) as well as indications for prophylaxis for the rest of the family. The parents felt strongly that they didn't want their children to suffer from the same symptoms as mom, and decided to give both children prophylaxis. We discussed the risks and benefits, weighed both boys and calculated their dosage.

I saw the father with similar flu symptoms about a week later. I asked if the children had been treated. They hadn't. Apparently, when the father had taken the script to the pharmacy, the pharmacist told him that there was no point in taking the meds before the kids got symptoms, and that he'd be better off leaving the script at the pharmacy to be filled when the kids got sick. So that's what he did.

Except that's totally not the case. The doses for prophylaxis of influenza (to avoid a full-blown case of flu in someone who has been recently exposed to a confirmed case) is not the same as the dose for treatment of a full-blown case of flu. If the father had followed the pharmacist's instructions, the flu wouldn't have been prevented and the dose prescribed wouldn't have been enough to adequately treat it if taken after the kids became symptomatic.

Now this error wasn't life threatening. And because there is a certain degree of the broken telephone game, I can't be certain what exactly was said in the exchange between the father and the pharmacist (another fact I believe The Angry Pharmacist forgets all too often). But it worries me that a pharmacist would seemingly take it into his own hands to change a treatment plan that was decided between myself and my patient with only a partial understanding of the situation.

If pharmacists were allowed to prescribe, wouldn't this scenario happen more often? And potentially with more severe consequences?

N.B. Please accept my usual disclaimer that I have absolutely nothing against pharmacists as a whole, and actually find the great majority to be an invaluable source of both clinical and practical information. And can drink me under the table.

2007-04-15T10:54:00.000-04:00

In spite of my lackluster posts of late (I'm chalking it up to a combination of stress and a genuine lack of seeing anything really interesting to blog about after 6 straight months of family medicine) someone found me worthy of nomination for a Blogger's Choice award. I don't know if these awards are usually slow to catch on, but the leader in my category only has 50 votes. So head over there and vote! Even if it's not for me.

I have taken this week off of work to give myself some uninterrupted study time-- the CCFP exam is in less than two weeks and there is tremendous pressure to pass. Not just because I can't afford another $1500 to take this exam again, but because I can't afford to have anything delay my ability to make some extra cash by moonlighting.

Expect to see some procrastination-fueled posts popping up soon.

2007-04-08T23:34:00.000-04:00

Huh. Interesting.

In the past week, I've had three random e-mails sent to the account linked to this blog. Each of them contains a link to a website, and asks me to 'evaluate their site' and consider adding them to my blogroll. I find this odd. As flattering as I find it to be included on sites that I admire (Flea and Charity Doc come to mind) and as much as I strive to someday be included on the sidebar at Mr. Hassle's Long Underpants, it would never occur to me to contact a blogger to ask to be included. Is this how people boost their hit count? Does this mean I have 'arrived' as a blogger? It would be nice to think so, but since I've never had such a request before and now have received three in short order, I have to suspect that it might simply be spam.

On the other hand, I'd like to officially introduce a couple of friends of mine to the world of blogging. Dr. H is an anaesthesia resident, her husband, Dr. J is a family physician currently doing locums in the far north. I've been enjoying their stories for awhile now, and I think that others would as well. Check them out at Adventures in Medicine.

Also, look out for yours truly in an upcoming issue of The Medical Post. I don't know exactly when it will be coming out, but I was interviewed last month for an article on physician bloggers. Hopefully, they'll make me sound somewhat intelligent.

2007-04-03T21:09:00.000-04:00

The Touch

There's a joke going around the clinic where I'm working right now. If you're looking to get knocked up, make an appointment with Dr. Couz.

I've somehow managed to run the most bizarre streak of test results. In the month I have been working at the family practice clinic in town, I have done 6 urine pregnancy tests on various women for various reasons. Some to rule it out, some to rule it in. In every single case, two lines have shown up on the dipstick. Whether it was an expected result or not. It's gotten to the point that I'm even wondering if I'd recognize a negative result if I saw one.

Complicating matters is the fact that all but one of these pregnancies was unwanted. The most recent positive test belonged to a patient that was 'undecided' about whether or not the pregnancy was wanted, in that it was a result of an extramarital affair that had ended a month ago. Her husband was already aware of the affair, and had told her to come into the doctor to get tested for STD's. That morning he told he that if she was pregnant, he'd kill the baby. Lovely. She isn't sure if she wants to terminate or not. She's coming back in a week once she's had a chance to think about things. She wasn't expecting a positive pregnancy test.

Sometimes I find it really hard not to judge my patients. Last week one of the positive pregnancy tests belonged to a 39-year-old woman. She suspected she was pregnant-- although her cycles had always been irregular, she had been feeling a lot of nausea over the past couple of weeks and hadn't had a period in nearly two months. When I informed her of the result, she said without hesitation "I want an abortion".

Now I'm pro-choice. Always have been. I think that a woman needs to have the ultimate say in what happens in her own body. But this woman knew what she was doing. She had two kids. She had terminated a pregnancy in the past. She had a regular partner with whom she was living, and they weren't using birth control. No IUD, no condoms, no pull-n-pray, nothing. What the hell was she thinking? She's an intelligent woman, with a college diploma and a respectable job. Does she not know how this works? I asked her why they weren't using protection (thinking there might have been a good reason), and got a carefree shrug. Nice.

Grr.

I don't know why these situations anger me. I'm pro-choice. She's pregnant. She doesn't want to be pregnant. It should be as simple as that. But when people start coming in and acting as though abortion were just another method of birth control, it bothers me. And it's something that's always bothered me, not just from the perspective of a woman actively trying to get pregnant. But I have to admit that also adds insult to injury. It's hard not to have a fleeting thought about all the women out there struggling with infertility when other women treat pregnancy as a disposable inconvenience.

So, of course, I bite my tongue. And I counsel accordingly, provide options, and offer the phone number to the women's clinic in town. And I try not to judge.

Sigh. Just call me the fertility goddess.

2007-03-28T18:57:00.000-04:00

Drawing the Line

One hard thing about residency is figuring out where to draw your line. And I mean this in a few different ways.

First, you have to figure out how much of "you" you're going to give to your job. In medicine, it's awfully easy to have your job become your life. Not to say that this doesn't happen with other jobs. But in medicine, where the job becomes your life for certain periods whether you want it to or not (see posts from 11/05 - 12/05 when I was an intern on general surgery for a shining example) you sometimes feel guilty for not throwing yourself in headfirst. Unfortunately, there are very few (i.e. none that I can think of) residency programs that are not harbingers of the future. What I mean by that is that if you're working your ass off for five years, you're kidding yourself if you think life will be sweet once you're done. In all of my toughest rotations, the staff were there too-- coming in on weekends to check on their patients, getting phone calls in the middle of the night informing them of significant changes in their patient's status, staying well past 'normal' working hours to get things done... and these happened when they weren't on call.

The second line that you need to learn how to draw is the one between 'personal you' and 'professional you'. I have heard enough stories of doctors who routinely have neighbours showing up on their doorstep asking them to look at their child's rash, or asking for a note for work to be wary of mixing the two. I'm hope that for me, a part of that will be avoided by the fact that I go as Mrs. Husbandslastname socially and Dr. Maidenname professionally. Currently, only two of my neighbours are aware of what I do for a living (and neither of them were told by me). That being said, I don't live in a very close-knit neighbourhood and people generally keep to themselves. If I lived in a smaller town rather than a mid-sized city, my Clark Kent persona would likely be far more difficult to maintain.

Which leads to line number three-- prescribing to self and others. By 'others', I mean people who don't fit the formal definition of patients... friends, family, co-workers, and acquaintances. We've all done it at some point. When a coworker asks for for a quick script for Cipro for a UTI-- she's had one before, and has all the symptoms, and is really uncomfortable. Most of us wouldn't think twice. But are you comfortable asking the coworker the same questions you'd ask a patient? Sexual history? Discharge? Painful intercourse? None of us would do a pelvic on a co-worker, but I've seen more than one case of genital herpes initially misdiagnosed as a UTI. What about even more benign stuff-- a script for physio to make an insurance claim? A req for bloodwork for a friend who needs her thyroid levels checked regularly but can't get in to see her family doctor for another week?

That complicates things. For those without a family doctor, something as simple as getting a prescription refill or a referral could mean hours sitting in a walk-in clinic to be seen for seconds by a physician who lets them talk for less than 30 seconds before scribbling a script and leaving the room. But that doesn't make me any less responsible for my actions if I choose to interpret the guidelines loosely.

And there ARE guidelines. The college policy states that:

Physicians should not treat either themselves or family members, except:

For a minor condition or in an emergency situation,

and

Only when another qualified health care professional is not readily available.

Unfortunately, these are very open to interpretation.

So for now, some residents will have no qualms about prescribing to friends and coworkers. Others will refuse in the spirit of erring on the side of caution. For the rest of us who fall somewhere in between, we need to figure out through trial and error where our own line will be drawn. And the sooner we figure out where our personal boundries lie, the easier life will be.

2007-03-20T19:45:00.000-04:00

Apparently I Wasn't Clear That it Was MAJOR Surgery...

So I saw a patient in my office. He was a middle-aged guy asking if he could be circumcised. I inquired as to his motivation and he explained that he had recently converted to a religion where circumcision was the norm. In addition, he and his wife had recently had their newborn son circumcised-- again, citing religious reasons. The whole exchange was pretty routine. He had clearly done his homework on the procedure and was already fairly knowledgeable about the risks, the procedure and the recovery afterwards. He wondered if he could be referred to the same physician who had circumcised his son. I explained that infant circumcision and adult circumcision were very different procedures performed with very different techniques, and that adult circumcision would be performed by a urologist in the operating room. I emphasized that this is not a minor procedure, that it is often performed under general anaesthetic. Due to my anti-circumcision bias, I admit to often emphasizing the risks and the complications associated with this elective, cosmetic procedure. I also explained that as this is no medical indication for circumcision, he would be required to pay for the procedure out-of-pocket. He nodded, picked a urologist, and I filed the consult request.

Fast forward about a week. I had taken a few professional leave days off to study for the CCFP exam (T minus 5 weeks and counting) so on my first morning back I sat down with my supervisor to catch up on any issues that had come up during my absence.

"You saw Mr. A last week, didn't you?" he asked me.

"That was the guy asking about getting circumcised, right?"

"That's the one. He got circumcised."

"What?" I was confused. There was no way he could have gotten in to see a urologist that fast for a non-emergent situation, let alone be seen, booked and had the procedure performed.

"Apparently, he decided not to wait."

My preceptor explained-- he had gotten a courtesy call from the ER while I was away. Our patient was being admitted for observation after significant blood loss. Apparently, my patient and a friend (which begs the question... what kind of 'friend' would agree to assist in something like this) decided that it would be a good idea to simply pull his foreskin out over the glans, press it down against a cutting board and 'circumcise' him with a newly-sharpened carving knife. No anaesthetic. Ouch.

He underestimated the bleeding. After attempting to stem the flow of blood with direct pressure for a considerable length of time, he became increasingly light-headed and his 'friend' called an ambulance.

Sigh. Where is Darwin when you need him?

2007-03-12T19:55:00.000-04:00

The Defectors

The Canadian health care system is hemorrhaging. We're losing doctors faster than we're gaining them. In fact, an estimated 30% of Ontario doctors are leaving within 2 years of completing their training. It is fairly safe to assume that the majority of these doctors end up in the U.S.

Why? No big mystery. Much of it comes down to money. There is more of it in the States. Docs south of the border are paid considerably more (in the private system, at least) than here in Canada. Higher income brackets also pay less in taxes in the U.S. In many specialties, the resources are easier to come by-- anecdotally, I've heard of docs being lured with the promise of less call, shorter wait times for investigations and specialist consults, labs filled with willing grad students to complete your every academic bidding, shiny new clinics with nurses (also making more than their Canadian counterparts) and physician's assistants happy to take the scut and paperwork off your hands... a virtual utopia for a new physician.

Do I begrudge them leaving? Not at all. I'm sure some of them have reasons that stretch beyond the almighty dollar. Family, geography, politics, weather... who am I to judge their choices? Good luck in your future endeavors and pay your bill at the border.

Um... bill, you say? What bill would that be?

Well, let's see. Medical school, in spite of tuition deregulation, is subsidized by the Canadian taxpayer. Your spot in medical school was intended to fill a need in Canadian society. Although clearly an imperfect science, the number of spots available to train Canadian physicians is supposed to be a prediction of the number of doctors that will be needed to serve Canadians down the road. When a young physician reaps the benefits of training in the Canadian system, it doesn't seem fair to then head to greener pastures for personal benefit. Compare the cost of medical school tuition in Canada (from $3500 yearly to $16000 CAN yearly, depending on the school) to the cost of medical school tuition in the U.S. (over $30K USD at non-state-funded universities, the only ones that will accept Canadian students)... it would be crazy to go to the U.S. for medical school when you could score the same degree for a fraction of the price here at home. But to then head down to the States to earn significantly more after benefiting from a taxpayer-subsidized education? Not cool.

I'm not saying that doctors in Canada should be shackled to the CN Tower. Hey... if you want to go, go. If you're moving solely for the financial gain you're probably not the kind of physician I'd want treating my family members anyway. But on your way through immigration, please write a cheque to the Canadian taxpayers for the balance of your education. That way it can be reinvested in the system and used to train future physicians who will stay-- or at least be put towards strengthening the system in general. Really. The way I see it, it's the least you can do.

2007-03-04T13:50:00.000-05:00

A Quick Note on Alternative Medicine

I have to admit that my recent forays into the world of alternative medicine have made me far more bitter towards the movement. Being repeatedly attacked will do that to you. But I'm not quite so bitter as, for example, Orac, who publishes a yearly compilation entitled "You Might Be an Altie" (Altie being slang for person who has a strong belief in alternative medicine). This year's edition is up to over 100 points, and is available for your amusement and/or aggravation here.

Those of you who know me know that I'm the last person to jump on any alternative-medicine-bashing bandwagon but more than a few of these hit home just based on my most recent experiences alone.

#3. If you accept without questioning vague and/or poorly documented anecdotes and testimonials as sufficient evidence for you that an "alternative" therapy can produce remarkable results "curing" cancer, heart disease, autism, Alzheimers, heart disease, etc., but routinely brutally nitpick and then dismiss well-designed randomized, double-blinded Phase III clinical studies for conventional medicine, you just might be an altie.

#7. If you make claims for a product or therapy like, "strengthens the immune system," "restores balance," "detoxifies the liver," "cleanses the colon," or "cleanses the blood," you may be an altie.

#14. If you are utterly convinced that autism is a "misdiagnosis" for mercury poisoning, despite the fact that epidemiological and basic scientific studies do not support this hypothesis, that the number of new autism cases in the U.S. has not shown a sign of falling since thimerosal was removed from vaccines three years ago (ditto Denmark, where thimerosal was removed in the early 1990's), and that autism does not share the symptomotology of mercury poisoning, you just might be an altie.

#20. If you believe that vaccines "don't work," that they "hurt the immune system," or that they are a major cause autism or other chronic diseases, you just might be an altie.

#21. If you routinely use Whale.to or Cure Zone as sources for medical information, you just might be an altie.

#24. If you underwent conventional therapy for cancer and then underwent alternative medicine treatment but attribute your survival and present cancer-free condition to the alternative medicine and not the conventional therapy, you just might be an altie.

#38. If you say your healer "is too busy people making people healthy" to conduct evidence-based trials but have never met a single person helped by them, you might be an altie.

#43. If you believe that chelation is a valid treatment for autism, Alzheimer's disease, coronary artery disease, or any medical condition other than heavy metal poisoning properly documented with appropriate symptoms and laboratory tests, you are well on the way to being an altie; that is, if you're not one already.

#51. If you talk about the pH of the "body," you're either an altie or have access to a very large blender.

#68. If you think natural is synonymous with good then you're probably an altie.

#69. If you tell me not to touch my apple because it's covered in pesticide while you're eating a Big Mac, you may be an altie.

#86. If you believe the plural of anecdote is data you are probably an altie

#87. If you believe alternative and complementary therapies cannot adequately be studied using randomized, double-blind, placebo controlled trials because they miss the essence of the therapy, as was recently suggested in an article in the BMJ, you are almost certainly an altie.

#110. If you believe polio was not wiped out by vaccination, and that FDR in fact had EPV .. you're an altie ( and probably posting on whale.to)

Now clearly I don't agree with everything on the list (Orac clearly has no faith in the training or practice of naturopaths and chiropractors) it still was good for a giggle. I think that the majority of the disagreement between my way of thinking and his, however, is based in geography. I am above the Canada-U.S. border, he is below it. In Canada, there is one English-language school of chiropractic medicine and it is fairly conservative in it's teachings. The people who graduate from it are well-educated and will work wonders with low back pain and headaches and don't necessarily believe that they can cure your gallstones through spinal manipulation. In the US, a general rule of thumb seems to be the further west the school, the more radical the school of thought. There is much more variability in the quality of US-trained chiropractors.

It's the same deal with naturopaths. In Canada, the only nationally accredited school of naturopathic medicine is the Canadian College of Naturopathic Medicine in Toronto. It's graduates aren't all anti-medicine (although some are), and are incredible when it comes to complementary care. I think quite highly of them and admire their work. Again, according to Orac "you are considered a 'doctor' with a diploma-mill ND". Not true here, where to call yourself a naturopathic doctor you'd better be a CCNM grad.

Guess we do things differently up here.

2007-03-01T21:08:00.000-05:00

What Happened to Childhood?

It's nothing like I remember. I remember walking to school-- just a few blocks to elementary school and less than 2 kilometres to high school. I remember playing outside all day, making up games with other neighbourhood kids until mom called us in as it got dark. I remember finding pop in the fridge and knowing that meant that mom and dad were having people over.

At the risk of sounding incredibly old, being a kid is entirely different now. Parents drive kids to school even just a few blocks away. Unstructured, unsupervised play time seems to have gone the way of Crystal Pepsi and cassette tapes. It's just... different. And those differences are just the tip of the iceburg.

Child obesity has been in the news a lot lately. Along with the disturbing statistics are the discouraging findings-- dieting and food restriction in childhood and adolescence not only fails to result in weight loss, but actually results in a long term increase in BMI. So what can we do that will make a difference?

There are 5 very specific factors which have been shown to accurately predict a child's risk of obesity. The problem is figuring out how and when to identify these factors. Should we be asking about them at the 18 month well baby visit? Should they be added to our Rourke sheets? If we wait until 3 years, is that still too early? Will it be too late?

Here are the 5 factors:

Consumption of more than one 6-8oz sweetened beverage per day (coke, Gatorade, fruit juices... anything sweet)
Media time (including TV, computers, video games... even cell phones qualify)
Parental presence at dinnertime (one or both parents sitting down with kids to eat)
Unscheduled active time (time spent being active that does not include formal team sports)
Fast food consumption more than once a week (regardless of type-- Subway sandwiches vs. chicken fingers vs. Big Macs)

Some of these (such as the fast food) are pretty predictable. Others, such as parental presence at the evening meal, are a little surprising. And no doubt just reading these made a lot of parents out there feel pretty darned defensive. But before I get a flurry of comments defending their fast food eating/juice drinking/absence at mealtimes, I need to remind people that these are not rules-- there is no God of obesity looking down on us with a checklist and cursing children who don't follow them with poor health and excess fat. These are guidelines for how to reduce your child's risk, and a place to start examining old habits if your child is starting to fall into the 'overweight' category.

I don't claim to have all the answers. And maybe I'll be more sympathetic when I have my own children to feed. But right now, I cringe whenever I hear a mom complain that her picky toddler won't eat anything but McDonald's french fries. Why does a 2 year old know what McDonald's french fries taste like? I can't help but feel slightly judgmental (and then immediately guilty for feeling judgemental) when parents bring an obviously overweight child into my office. Unless this child is independently wealthy and buying their own food, the responsibility falls squarely in the parents laps. They control what is available to eat in their house. And, for better or for worse, the parents activity level is the biggest predictor of how active their kids will be.

I don't claim to have all the answers. I'm certainly not immune to concerns over body weight-- it's been at the forefront of my mind for as long as I can remember. I remember being 8 or 9 years old and refusing to wear a purple striped top because I believed it made me look fat. I don't want that for my kids, and I wish I knew how I could ensure that weight won't be a problem for them. I know I can't guarantee it, but I'll do the best I can by not having unhealthy foods in the house, being active as a family, limiting computer/TV/video game time and making sure that Mr. Couz or myself is there to sit down to dinner. And when my patients come in asking me to put their chubby kids on a diet, I'll give them the same advice. I just hope that will be enough.

2007-02-27T17:01:00.000-05:00

Blowing my Own Horn

Behind the scenes in Dr. Couz's head-- here is the interview that I did for Dr. Nick Genes at Blogborygmi in honour of hosting Grand Rounds a couple of weeks ago. It's on Medscape, so you may need to register to view it.

Is a "Well-Rounded Physician" an Oxymoron?

2007-02-23T21:48:00.000-05:00

Not Quite The News

I have a love-hate relationship with the media. I love it in the sense that I have an addiction to information. I want to know what's going on. I read newspapers, watch the news on TV and listen to it on my car radio during my endless commute. I hate it when it comes to medical news. It is usually sensationalist and can pretty much be counted on to distort whatever new study has been deemed 'newsworthy' by some guy in an editing booth. It's frustrating.

And today is no exception. This news article describes the story of a woman who died after spending 3 days under observation in the hospital. The article goes on to describe the concept of the 'orphaned patient', and goes on to blame the fact that the doctors who take responsibility for orphaned patients have a maximum quota of 5 patients per day. Then Kevin, MD jumps on the bandwagon by posting the link to the article with his parting shot... "no wonder there's an access shortage up there".

Please. The issue of orphaned patients in GP-run hospitals is a little more complex than that. A bit of background for the lay-folk-- in many community hospitals, when patients are admitted it's their family doctor who assumes responsibility for their day-to-day care. If a patient is admitted who doesn't have a family doctor (or whose family doctor doesn't have privileges at the hospital admitting the patient) the patient is assigned a family doctor-- either a family doctor who takes on the care of these 'orphaned' patients, or a hospitalist, whose sole job is to manage the care of a large number of orphaned inpatients.

Family doctors have it tough when it comes to the care of inpatients in the hospital. It doesn't pay terribly well, and it's a difficult responsibility to balance with a full day of office. At my practice, a typical day has me coming in at 8am to begin rounding in the hospital. If I know we have more than 3-4 patients in at any time I'll come in earlier. If we had the misfortune of getting hit with an orphaned patient overnight, I was often faced with rounding on our inpatients as well as sorting out an often complex medical history and medication list for a patient I've never laid eyes on before. No easy task. One orphaned patient admission could easily take 45 minutes. Add that to the usual rota of patients in the hospital at any given time and rounding in the morning could stretch to 2 hours, starting the day's clinic 45-60 minutes late.

Last year our call group made the decision to stop accepting the assignment of orphaned patients. The workload had become unreasonable, and was only getting bigger as more physicians removed themselves from orphaned patient coverage. The hospital kept promising to hire hospitalists to help shoulder the load but none were forthcoming. So our group bailed.

Caring for inpatients means more than just stopping by to say hello on the way to clinic every morning. The five patient quota would still be a full house when you consider the time to round, write orders, put out fires, liaise with specialists and field phone calls throughout the day relating to the usual odds and ends that come up. And this is on top of the full day's office, minor procedures, house calls and paperwork that fill the typical family doctor's day.

Who is the Ottawa Sun (or Kevin MD, for that matter) to suggest that family doctors who limit their 'quota' to five patients are somehow slacking and shirking their responsibility to the health care system? Would it somehow be better for family doctors to double their inpatient quotas and cut their office hours in half? Family doctors are already putting in 12 hour days on any given workday-- something has to give.

2007-02-23T21:38:00.000-05:00

All By Myself...

HowManyOfMe.com

There is:
1
person with my name
in the U.S.A.

How many have your name?

How fun is this?

Funny that I'm so unique in the U.S. In Canada, not so much. In fact, there was another girl with the exact same name as me who shared my childhood pediatrician. They always mixed up our files-- she had asthma.

People in Ontario frequently comment on the 'uniqueness' of my maiden name. I tell them that in Quebec, my name is the equivalent of 'Smith'.

And that end's this evening's deep thoughts.

2007-02-21T11:36:00.000-05:00

Evidence 1, Fear 1... It's a Tie!

So way back when, I discussed elective cesarean section as a reasonable birthing alternative. In women who are adequately informed regarding the risks and benefits of both vaginal and cesarean, elective c-section should be perceived as no less valid a choice than home birth, drug-free birth, unassisted home birth, birthing centre birth, or any other option currently available to pregnant women. Then, in a seeming 180, I posted a few months later regarding my interest in being delivered by a midwife in a hospital setting. Again, all of this remains hypothetical since as far as I know, I remain fetus-free. But it never hurts to be prepared.

My personal views on the subject are pretty predictable to anyone who has been reading my blog for awhile-- as long as women are informed regarding the risks and benefits to both mother and baby, they should be allowed to make the decision that is best for them. As I mentioned before, my only problem with this situation are the increased costs to the health care system if one opts for an elective c-section. But for simplicity, I'm going to overlook that little detail for the purposes of this particular discussion.

I am no stranger to obstetrics. I completed one rotation as a medical student in a relatively small academic centre. My next two month block was also spent in an academic centre, although in a much larger city. During my time in family medicine over the past two years, uncomplicated obstetrics has been a big part of my practice-- I have followed many women through from their initial positive pregnancy tests through to their deliveries and beyond. Now that I'm nearing the end of my 8 months of full-time family practice, I'm seeing several women whose babies I delivered coming back with positive pregnancy tests once again. Sharing such an incredible moment in a family's life still feels like such an honour. And as much as I complain about the effect it has on my free time, I still love the fact that my family practice has such a significant obstetrics component.

From my end, though, I'm still torn. I have seen so many of the worst-case-scenarios it seems like a normal vaginal delivery with good outcomes for both mom and baby are the exception to the rule. I am very aware that my perceptions are heavily influenced by my experiences in high risk obstetrics. I had hoped that my experiences in uncomplicated obstetrics through my family practice would help to give me a more balanced viewpoint when it came time to make birthing choices for myself.

I am uncomfortable with uncertainty. Aside from the odd sports injury, I have never experienced pain. And as one of my friends at work put it, I have an 'internal locus of control'-- I think that's a nice way of saying that I'm a control freak. What scares me about giving birth is the unpredictability of it all. I can plan and prepare for a vaginal birth all I want but may still end up with an emergency c-section. Vaginal births are sometimes uncomplicated and beautiful, but other times-- forceps, tearing, incontinence, sexual dysfunction, uterine prolapse... and that's just the maternal outcomes. The number of things that could potentially go wrong with baby is staggering.

I'm not sure when I started to think this way, but I began to view elective c-sections as a way of maintaining some degree of control and predictability over the whole birthing process. Although the concept of entirely elective c-sections hasn't been completely accepted by the medical community (let alone society in general) it's not something I've talked about very much. But there is plenty of evidence to support the idea. Although none of the data is completely undisputed, studies have suggested that elective c-section may reduce the risk of post-partum urinary incontinence, fecal incontinence, uterine prolapse and sexual dysfunction.* And that's just on mom's end. From the baby's side, studies suggest a reduced risk of unexplained stillbirth, chorioamnionitis and cord prolapse. These possible benefits must be weighed with the increased risks, particularly those associated with post-operative complications for mom and increased incidence of breathing difficulties in newborns.

Unfortunately, the decision to opt for primary elective c-section over vaginal delivery isn't so straightforward as just weighing the risks and benefits of each option. If it were so simple, I'd be first in line for for my uncomplicated, low intervention vaginal delivery. But no one can guarantee anybody that their planned vaginal delivery won't evolve into more-- operative vaginal deliveries (meaning a vaginal delivery that is vacuum or forceps-assisted) increase the risk of complications to mom and baby considerably. If an emergency c-section is required, the risks are increased even more. Each of these scenarios carries a greater risk than if an elective c-section had been undertaken initially.

And that's where I'm stuck. I want one of two scenarios-- a low intervention vaginal birth attended by a midwife in the secure environment of the hospital, or a planned, controlled, elective c-section. Ideally, the former plan would be the ideal one. But again, there is no guarantee that plan won't evolve into something more risky. And that's what scares me, because that's the part I have very little control over.

I am a primip, so by definition I have an 'untested' pelvis. I don't know if I'll be able to give birth vaginally, and I won't know until I try. I am healthy, which is in my favour. I am older than ideal, although still a couple of years away from being considered 'advanced maternal age'. My mother gave birth to three children vaginally with no major complications. But it's still that uncertainty that makes me unwilling to completely discount the elective section option.

A month ago I would have said that my plan would have been to have a midwife-assisted delivery in a hospital. And then the Canadian Medical Association Journal published Maternal Mortality and Severe Morbidity Associated with Low Risk Planned Caesarean Delivery Versus Planned Vaginal Delivery at Term. It wasn't a perfect study, but added more information to the information already out there. And now I'm undecided yet again. And around here, midwives book up fast. So if I want to have a midwife-assisted delivery as an option, I'd better make the decision before I even pee on a stick.

Bah. With my luck, mini-Couz will end up breech and the decision will be made for me.

*Interestingly, more recent studies have actually found no difference in urinary incontinence between c-sections and vaginal births. And they've found that method of delivery is not a significant predictor of sexual dysfunction one year after delivery. So even the 'evidence' isn't set in stone.

2007-02-18T21:00:00.000-05:00

Another Week Down

It's been a long week.

Big dog managed to impale himself on a stick while we were playing fetch in the off-leash park last weekend. One sleepless night and an early morning trip to the vet later he was diagnosed with a wound infection. Since the vet had to sedate him to explore the wound, I actually called in sick to spend the day looking after him. I blame Mr. Couz, who was still visiting his family, for not coming home early to be with our poor injured dog. When I suggested this to him, he called me a crazy dog lady.

The next day the snow started to fall. I got in the car to make the 1 hour commute to my family practice, and made it all of 8 blocks before turning around and coming home. Good call, since by the time the snow stopped falling about 60cm had fallen on my town. More had fallen on the town where I practice. It was not a good day for commuting. I stayed home and studied for my board exams.

The day after that I didn't even make it out of the house. It was a Snow Day-- capital "S", capital "D". People were being told to stay off the streets, and even the malls were closed down. I stayed home another day, leaving the comfort of my couch only to join my husband in shoveling out our front path, our sidewalk and our cars. Considering that I live in a part of Canada where this kind of weather is really not the norm, this was an event. The fact that the snowbanks are as tall as I am brings me back to my childhood faster than a Raffi song.

The next morning I woke up, ready and willing to go to work. Well, maybe not entirely willing... my throat was scratchy, I was coughing, and my head hurt. I am *not* impressed. A month after getting over URTI #1, URTI #2 hits. Ugh. I guess I should be happy it's not a gastro. But how I managed to get sick the one week I wasn't in contact with patients (unless I caught it from a dog) is beyond me. But I couldn't very well take another day off when I had already missed more than half the week, so I dragged my germ-y butt into work and saw a steady stream of patients with the same symptoms as I had. Seriously... if there was a cure for the cold, don't you think I would have used it on myself?

And in spite of the copious amounts of time I've had to sit around with my laptop and a cup of green tea, readers may have noticed a lack of blog postings recently. I've been hit with... The Block. It must be a midwinter blah thing. I can't come up with anything worth talking about, and when I try to force it I manage to create posts that ramble on for pages without actually making a point. So I stopped trying.

So that's it for my random thoughts from this week. At least I made it until the weekend. Hopefully this week will be better-- my last week in my community family practice. Sigh.

2007-02-08T11:57:00.000-05:00

What Bugs Me Today II

I couldn't believe it when I stumbled across this British medical student's shameless plea for donations. I'll give you the recap so that you don't need to click on it and drive up this loser's hit count-- he's a 4th year medical student in Manchester, U.K. (over there it's a 5 year program) and he's nearly 30,000 British pounds in debt. He's begging randomly to the internet community to send him donations because he doesn't want to 'graduate in debt'.

Please. Call the whaaaaa-mbulance. In Canada, since deregulation of medical school tuition in the mid-1990's a student would be unbelievably lucky to finish medical school with only 60K in debt (assuming the very rough conversion of 1:2 for British pounds to Canadian dollars). Not to mention the fact that we then have to make payments on this debt as we complete anywhere from 2-6 years of residency at which time our pay starts at $45K yearly. In fact, if you divide the weekly salary by the average number of hours a medical resident works in a week, we almost make minimum wage.

I admit, my debt is on the high end of normal. I didn't have a family to support, so I don't have that excuse, but I did put myself through a master's degree and a second undergraduate degree before medical school without outside assistance. And until the government student loan program wakes up and realizes that the max allowance of 10K a year is ridiculous for a medical student (whose yearly tuition and fees nearly doubles that and it's not like we have the flexibility in our schedules to work-part time through school), the bulk of my debt is with the bank. I could sell my first, second and third born to the bank and I'd still end up owing them in the end.

I don't usually feel sorry for myself when it comes to my financial situation. I don't begrudge the loan system-- without it, medical school wouldn't have been an option for me. I don't even resent the amount of tuition that we're expected to pay-- even my $16K yearly tuition is heavily subsidized by the Canadian taxpayers. But it's difficult to keep your head above water for the first few years making payments that eat up 50% of your take-home salary.

On one hand, I think it deters people from primary care (family medicine, pediatrics) where salaries are traditionally lower and overhead traditionally higher. But on the other hand, I wonder how my specialist colleagues in 5 and 6 year residencies can manage with the high debt and low salary for even longer than I have to.

I don't love being my age (i.e. not a spring chicken) still having to rent. There is so much travelling I want to do but unless it involves camping and is accessible by car it's unlikely to happen any time soon. Even having a baby may strain the finances more than I care to think about. But as long as I manage to make ends meet until I'm making real money, I know the debt will be manageable. It just means our first house will be small, we'll make due with our car until it dies a natural death, we won't be taking any vacations and we won't be contributing to RRSP's until we're in our late 30's. But that's not so bad, right? Um... right?

I guess that's why people like this guy irk me so much. What makes HIM so special that he deserves to graduate debt-free? Why shouldn't he have the same concerns as the rest of us who chose a life in medicine regardless of a distinct lack of rich relatives? I don't begrudge the people who had a hand in getting through school-- but I don't think I would have asked it of my parents even if they COULD afford it.

I just wish people would stop assuming that Mr. Couz and I are on easy street because of my title. Trust me... right now, it's no financial windfall.

(Thanks to Kevin, M.D. whose post brought this wing-nut to my attention)

2007-02-06T06:00:00.000-05:00

Grand Rounds 3.20

The People Behind the Medicine

More than most other professions, medicine has the ability to devour all it touches. Those who enter the world of medicine as patients soon find it difficult to identify themselves beyond the confines of their label-- at least within the walls of the hospital. Those who enter into it as a career soon discover just how far-reaching a life in medicine is. Interests and relationships that once defined us as people too often take a backseat to the demands of medicine. Too easily we find that we lose sight of ourselves. We advise patients to rest, exercise, eat right, deal with stress, develop good coping mechanisms... and then we go home, order out, catch up on paperwork and try to fit in a few moments with our loved ones before catching a few hours of sleep.

Although I appreciate that not everyone enjoys 'themed' Grand Rounds, I thought it was about time that we acknowledged the people behind medicine for more than just their clinical expertise. Here are 30 submission that I thought conveyed that message in some way, regardless of how they chose to accomplish it.

The Medical Professional as a Professional

It is often a judgment call whether or not it can be therapeutic to let the line between professional and person blur in front of patients and their families. Joy, from My Own Private Soapbox examines the pros and cons of letting patients see past the professional veneer. It's not always pretty under there, and sometimes even the patients prefer to stay distant from the realities of medicine. Not so in the case of Susan Palwick, a volunteer hospital chaplain at 'Rickety Contrivances of Doing Good'. She blogs about the fact that she freely shares pieces of her own medical history to make a connection with the patients she counsels. Vitamin K also reminds us that when we take our work home with us, sometimes it's for the greater good.

Sandra Miller from 'A Shot in the Dark' recounts the tale of a particularly difficult experience with the health care system and how she believes that a little less 'professionalism' from the people involved might have made it a little more bearable. One woman (and frequent patient) from 'Tales of my Thirties' finds herself wondering how the doctors in her life end up in the specialties they choose.

Dr. Scott at Just Practicing reflects on why he chose to keep his blogging persona anonymous, and maintain that imaginary line between the person and the physician he plays at work.

Rita at MSSPNexus Blog talks about her favorite boss and what qualities made her special.

The Medical Professional as Patient

The quickest way to see our world from the other side of the fence is to be forced to experience it firsthand. Over at Protect The Airway, an RN wonders what is bringing on his runs of symptomatic PVC's. Dr. Dork tells a tale of some unseemly side effects experienced when the doctor becomes the patient. More on the subject of the professional as patient comes from Diabetes Mine in the form of an interview with Gary Scheiner, an accomplished diabetes educator and long-time diabetic. Kim at Emergiblog takes it one step further with memories of a time when she straddled the line between nurse and patient (or rather, patient's mom) until someone gave her permission NOT to be a nurse this time.

The Medical Professional as Parent

Role strain is almost inevitable when the health professional becomes a parent. Caring for others as a profession often takes on a whole new dimension when you're trying to balance it with caring for a child. Geena at 'Code Blog: Tales of a Nurse' lets us in on her inner struggle to find balance between her identity as a nurse and her new role as a mom. In a similar post by MSG at 'Creating the Godcomplex', he attends a c-section that brings back powerful memories of his own daughter's birth. Moreena at 'The Wait and Wonder' shares a moving story about caring for her daughter under the watch of the untouchable PICU nurse-- until the strain pushes them both to emotional breakdown.

The Medical Professional as an Emotional Being

Yup-- they have feelings too. Nick Jacobs from 'Hospital Impact' waxes philosophic on the subject of emotional attachment-- something that we, as medical professionals, occasionally take too lightly. Wyatt at 'Foggy Bottom Lantern' explores playing favorites among the patients have touched him throughout his career. Nurse Ratched recalls a patient who touched her life almost as much as she touched his-- and reminded her in many ways why she became a nurse in the first place.

The Medical Professional With Outside Interests

The quest to find balance in a life dominated by medicine lead me to unearth some interesting hobbies and interests in my fellow medical bloggers. At 'Universal Health', N=1 talks about one of his (her?) non-medical obsessions-- along with a nice reminder that we shouldn't take ourselves too seriously. This is GirlVet's strategy too-- at 'Madness: Takes of an Emergency Nurse' she claims that it's her warped sense of humor that keeps her coming back to the ER. And she's not the only one-- it seems that finding humor in bizarre situations is a common thread among those of us drawn to the ER (GruntDoc being a good example).

For those of us without the warped funny bone, George finds solace outside of the OR with his travels and for those of us living vicariously through the travels of others, provides many photos. Liana from Med Valley High discovers that not only does climbing make her well-rounded, the skills she learns while climbing aren't that different from the ones she learns in medicine. Don't worry, Liana-- I haven't started my CCFP review yet either!

The Medical Professional as a Spiritual Being

Big Mama Doc reminds us over at 'Fat Doctor' that a few moments in patient-lead prayer might be more therapeutic than any other intervention we have to offer. While many of us might be uncomfortable with the idea, it only takes minimal effort on our part to ask about our patient's spiritual needs-- particularly in the face of serious illness or major surgery. Dr. Wes has also had a recent lesson in link between medicine and divine intervention that might have made him just a little more of a believer. Even if you don't consider yourself religious, these posts are food for thought.

The Soon-to-be-Medical-Professionals

The next generation of medical professionals are still trying to figure out if they can avoid allowing medicine to overtake them. Topher at 'The Rumors Were True' acknowledges that while he's striving to find balance as a medical student, at times he fails miserably. Over at 'FIFE-me', A Girl looks with wonder at her accomplished medical school classmates and wonders how long she'll be able to juggle all of the balls she has in the air. On a lighter note, Clerk at 'A Cure for Hiccups' explains why the desire to settle down and find a wife isn't just on the minds of the men in her class. Finally one of my new favorite bloggers, Vitum Medicinus, reminds us all that tact and empathy really can't be taught-- particularly to medical students.

This week's Editor's Pick goes to TC at Donorcycle-- she gives a heartbreaking minute-by-minute account of what transpires when a child dies. She managed to tell a terrible story in an incredibly sensitive manner and reminded me that no matter how 'professional' I become, I don't ever want to lose the ability to cry.

Thank you to everyone who took the time to submit. Have a great week!

2007-02-04T20:27:00.000-05:00

Why Can't We All Just Get Along?

As far as doctors go, I consider myself fairly knowledgeable when it comes to alternative therapies. Other doctors consider me somewhat left-wing in my practices and policies although in a generally right-wing profession such as medicine I guess that really doesn't say much. I regularly recommend that my patients try chiropractic, massage therapy, acupuncture, or naturopathic medicine. I am a huge breastfeeding advocate, and support mothers who can breastfeed their babies beyond infancy. I am very anti-circumcision. I appreciate the benefits of such 'crunchy' parenting beliefs as co-sleeping, baby-wearing, and attachment parenting in general.

So because I know few people in real life who think the way I do (not to mention the very real problem of not really having the time to make any friends in the city I've been living in since starting residency), I often rely on the internet for information and to find people with common interests. In particular, I am a fan of message boards. One such message board that I won't mention (it's not my intent to start a war) seemed to be exactly what I was looking for-- there were reviews of cloth diapers, vegetarian and vegan recipes, information on natural health and healing and all kind of great information probably considered 'off the beaten path'. Just one problem.

They hated me.

Well, maybe it wasn't 'me' they hated. After all, I hadn't contributed anything at that point. It was more a matter of hating what I (voluntarily or not) represent. I first realized this when I ventured into a forum on vaccination. Vaccines weren't something I had spent much time thinking about through my medical training-- in emergency medicine, the only vaccine that had a role in the emergency room was the Td booster, which we offered to everyone who came in requiring sutures who hadn't received the vaccine in the past 10 years. I didn't really concern myself with people who refused it-- just explained the indication and documented that it was offered and declined.

In family medicine, however, they became more routine. But still, I hadn't thought much about them. They were routinely given at 2, 4, 6, 12 and 18 months. Only once did a patient take me up on my quick "do you have any questions or concerns about the vaccinations scheduled for today?". He was concerned about the mercury in vaccines. I assured him that vaccines in Canada no longer contained thimerosal with the exception of the flu shot, and he was happy with that. At his next visit, the same father asked about the use of formaldehyde in vaccines. I told him that I didn't know, but that I'd be happy to look into it for him. We delayed his son's vaccinations that day.

The 'Vaccination' forum would have been much more appropriately named the 'Anti-Vaccination' forum. A few clicks was all it took to realize that the nature of the forum went far beyond having evaluated the literature and deciding that the risks of vaccination outweighed the risks of contracting vaccine-preventable diseases. That, I can respect. But instead these people have decided that the entire medical profession is, at best, a bunch of ignorant and obedient pharma shills. At worst, we are voluntary conspirators pushing dangerous interventions on people to benefit our own pockets.

I have to admit that when it comes to something as seemingly benign and beneficial as vaccination, we're probably not as critical as we should be. We know what we've been taught-- and that is that vaccines have been proven safe and effective, that adverse effects are rare, and that the benefits of vaccines far outweigh the risks. It's not 'dogma', it's not a belief system, it's simply presented in the same way as every other one of a million other pieces of medical information that we, as physicians, are expected to know. And as with anything else, we should be prepared to discuss it intelligently with our patients rather than simply shutting down at the suggestion that there may be more to it.

But the anti-medical sentiment runs far deeper than the vaccination forum. Among the opinions presented as fact are:

Well baby visits are simply an opportunity to push vaccinations and berate parents who choose not to vaccinate.
Well baby visits exist solely for the financial benefit of physicians
Physicians receive kickbacks from pharmaceutical companies for prescribing their products
Physicians make up statistics to coerce patients to agree to certain interventions
Physicians are "unethical liars telling women rubbish to suit their own purposes" in regards to childbirth
Obstetricians are "knife-wielding surgeons who are bound and determined to slice you open no matter what your wishes"

It actually makes my stomach hurt. Poll a thousand medical school applicants and I can bet you that not one of them mention the desire to have people accept their word without question or perceive them as superhuman among their reasons for pursuing a career in medicine. But many of them will talk of a desire to feel like they're helping people, and working to better patient's lives. During medical school we are never taught trade names for drugs-- we refer to all medications by their generic names and discuss only broad categories rather than specific therapies (i.e. "use a beta blocker for this condition" rather than "use metoprolol" and certainly never "use Lopresor") and have no contact with the influence of drug companies. Again, unless things are dramatically different in the U.S. the ideas expressed on this board are ridiculous.

But it's a sentiment that goes both ways. Allopathic medicine is slow to accept, let alone endorse, many branches of 'alternative' or 'complementary' medicine. It took years for acupuncture to finally be endorsed by the medical community in spite of years of evidence in support of its benefits. Recently, when my family medicine group discussed a case where a woman came into my colleagues office asking about her opinion on the naturopathic remedies that had cured her condition, my colleague had to admit that she had no idea what to say or how to handle the situation. I suggested having a naturopath come in to speak to our group about some of the principles of naturopathic medicine and alternative healing-- it's something I've always wanted to learn more about and clearly it was an area of weakness for my colleagues as well. Instead my suggestion was met with uncomfortable silence. Instead it was decided by the group that we'll be having an MD give us a talk on alternative medicine. Um... right. Talk about defeating the purpose.

The attitude that practitioners of alternative medicine have against physicians and the attitude that physicians have towards much of alternative medicine is only hurting the patient in the long run. A recent study showed that 63% of patients over the age of 50 were using some form of complementary or alternative medicine, and nearly 70% of these had not discussed it with their doctor. Many of these women on the anti-vaccination board were advising each other to lie when asked if their child was up to date on their vaccinations to avoid questioning and condemnation. That can't be good for anyone.

Traditional allopathic medicine has much to learn from the world of naturopathic and alternative therapies-- we should be keeping an open mind and ensuring that we have (at minimum) a basic knowledge of the therapies and techniques available. Alternative medicine would gain more acceptance by traditional medicine by shelving the adversarial attitude and through more rigorous scientific testing of their therapies.

It's too bad that each side has to feel so darned threatened by the other.

2007-01-28T09:37:00.000-05:00

All By Myself...

Whoa. Silence.

Mr. Couz has loaded up big dog and velcro dog and headed out to the boonies to spend a few days with his family. Dr. Couz, of course, is stuck working. But now I have four whole days with an empty house and I'm at a bit of a loss as to what to do with it.

But I'd like to state proudly for the record that within 20 minutes of my husband leaving the house, I had managed to blow a fuse in the kitchen for having the audacity to run the kettle and the toaster at the same time. Ah, the glory of living in a 100-year-old house. That's not what I'm proud of, though. I ventured down into the dungeon-like basement, located the fuse box, and solved the problem. Considering that it was something I had never done before and that I am usually irrationally afraid of our basement (don't ask), this was a pretty proud moment. Hey, I appreciate the small victories.

So now I'm headed to the gym to do my long run for the week-- 10k (or a little over 6 miles for you Americans out there). It will be mind-numbingly boring to do it on the treadmill, but there is a lot of very slippery snow on the sidewalks and it would be a really bad time for me to be on crutches. Plus, it's not the same without a furry companion.

Then, the plan is to shower at the gym and head out to pick up a few groceries for the week. Due to my schedule this job is usually done by Mr. Couz, so I'm actually kind of excited about doing it today. There hasn't been enough money lately for fun shopping, so I'll take whatever kind of shopping I can get to get my fix.

Post-groceries I'm headed out to Starbucks to continue my studying (okay-- start my studying) for my CCFP exams. They're fast approaching. And I'm not doing much of anything about it.

My day might be shot to hell, though, as it seems that my LAST prenatal patient (the last patient we have scheduled to deliver while I'm still on service in family medicine) has ruptured her membranes. She's term (39 weeks), GBS negative, and the baby looked fine on the fetal monitor so there's really no cause for concern, but for some reason they admitted her last night anyway. So now I'm waiting to find out my preceptor is going to induce her or what. And if he does, I'll probably have to make the hour trek out to the community where I practice to deliver her. She's a primip, so she might not be pushing until tomorrow morning. I don't understand why they don't just wait at least 24 hours and see if she goes on her own. But either way, I'll be tethered to my cell phone waiting to hear if I'm expected to drive two hours just to catch a baby. I'm not quite as enthusiastic about the deliveries as I was before as I've recently learned that I've exceeded my obstetrical requirements for family medicine threefold easily, and have decided not to include uncomplicated obstetrics as part of my practice in the future. A pretty easy decision to make now that I have a spot waiting for me in the emergency medicine fellowship.

Lots of blogging on the burner, though. I have posts in progress on the subject of the us vs. them mentality that so many practitioners of alternative medicine seem to possess, the answer to a commenter who wondered if I'd come to terms with my childbirth preference or if I was still torn between the extremes of elective c-section and midwife-assisted birth, and some thoughts on the anti-vaccination movement. Now that I've committed to these topics, I hope I'll feel forced to see them through to completion.

And don't forget that Grand Rounds version 3.20 will be hosted by yours truly on February 6th. I can't wait to start reading the submissions. If you have a recent blog entry that you feel might interest readers, send it in. I'm not going to be terribly strict in enforcing the theme this week. The deadline for submission with be 10pm EST on Sunday, February 4th.

2007-01-27T22:10:00.000-05:00

On the Road Again

At about this time last year, I took up running. Some of you who have been reading my blog since the start might remember the trials and tribulations of my plantar faciitis at that time. The funny thing is, I hate running. I always have. But at some point in my athletic career, running became the holy grail of athleticism. If you could run, you were fit. If you could run, you were an athlete. It didn't matter how good I was at jiu-jitsu, kickboxing, rowing, softball or any of the other more competitive pursuits I've been involved with in my life, I always looked at runners with envy.

It wasn't that I hadn't tried to run. I had completed the Couch to 5K program no less than three times. After my second year of medical school I completed the Learn To Run program through The Running Room with two of my friends. At the end of the 10 week program I could get through 5k, but still hated every painful minute of it. Regardless of how long I spent on the elliptical trainer at the gym or how much I was able to squat I never got any good at running. I just figured that my body wasn't built for it.

Last spring I decided to give running yet another kick at the can. I wasn't finding the time to make it to the gym regularly, and running had the added bonus of walking the dog at the same time. I'm all about the multitasking.

So I started slow. Big dog loved it. He got so used to our 5:45am wake up times that if I dared hit the snooze button he'd plop his big head up on the bed so that his nose was nearly touching mine. He was not a training partner that would take no for an answer. So I'd get up and run. And walk. And run. And walk some more. And pretty soon, I was doing more running than walking. And pretty soon after that, I was running 30 minutes straight. I still didn't love it, though.

There were obstacles. A heat wave in the summer kept me from running anywhere but the treadmill at the air conditioned gym for three weeks. I never felt acclimatized to the severe humidity, and even my little 30 minute runs became a struggle. In September I ran a 5k race and missed my 30-minute goal by 30 seconds. I got discouraged. But running gave me more energy and I knew if I stopped, I'd lose the gains that I'd worked so hard to achieve. So I kept running.

Soon I began to notice strange urges-- when I was at home in the evening, I'd think about going for a run. If I hadn't run the day before, I'd be thinking about running throughout the day. It's wasn't a guilt... it was a craving. I ran in the rain. I ran in the snow. I ran in the cold. And at some point along the way I realized that I enjoyed running.

I'll never win any races. I'm not breaking any land-speed barriers. But I've recently committed to running a half marathon in May. I'll be happy if I run it in less than 2.5 hours. My closet is filled with running shoes in various states of destruction and I use words like Fartlek and Body Glide without giggling.

I guess I'm a runner.

2007-01-24T19:08:00.000-05:00

Meme-y Goodness

Steph from Ice Cream and Puppy Dog Tales has tagged me with the latest Meme to be traveling at warp speed through cyberspace. The theme of the meme (hey... that rhymed!) is to come up with five things about myself that are somewhat interesting. A challenge for me, however, as I'm still trying to keep this blog somewhat anonymous.

So here is my attempt at coming up with five things about me that are relatively interesting without being too revealing.

1. I am fluent in French and English, and at one time I spoke pretty passable Spanish.

2. I have a secret fetish for celebrity gossip magazines. I don't buy them, but I manage to read them in hiding at the office, at the gym or at Starbucks.

3. My favorite colour is orange. My husband finds that odd.

4. I used to be a member of the Church of Jesus Christ of Latter Day Saints (the Mormons). I left the church when I was 21 years old.

5. I am a huge fan of Buffy the Vampire Slayer. I still mourn its cancellation.

I don't usually like to tag, but this time I'm making an exception:

Vitamin K, just cause I miss her. And I'm curious if there are 5 things I don't know about her!

Nikki, cause I just found her new blog and I'm excited that she's writing again.

A Girl, from FIFE-me. Just because I like her stuff and I think that more people should be reading her blog.

And that's all.

2007-01-21T18:15:00.000-05:00

Who Knew?

The longer it's been since medical school, the more I realize how little I actually learned in medical school. Particularly in terms of practical knowledge.

Take pregnancy, for example. Getting pregnant seems to be something that should be pretty straightforward. Insert Tab A into Slot B, so to speak. But since Mr. Couz and I started contemplating kidlets of our own (aside from our fur-kids, I mean), I've learned a lot of things about procreation that make me wonder what the hell I was DOING for four years.

Things that were complete news to me:

It takes an AVERAGE of 8 months for a woman in her early 30's to get pregnant (in the absence of any fertility issues)
If your (non-hormonal) cycles are longer than 36 days, they are likely to be anovulatory
Pretty much all lubricants are spermicidal
Saliva is also spermicidal
Having sex daily will decrease your chances of conceiving when compared to doing it every second day or so-- apparently, doing it daily results in lesser quality sperm

I'm sure there are more, but these are the ones that come to mind immediately. But the most important message here is this-- when a type A personality and her husband decide to pull the goalie and let the fates decide from there, it is only a matter of days before she succumbs to the innate drive to read many books on the subject, starts charting her basal body temperature on fertility websites and obsessively analyzing charts and coverlines and prematurely puts down a deposit on a Bugaboo Frog.

Sigh. I can't be laid-back about anything anymore.

2007-01-20T10:50:00.000-05:00

What Bugs Me Today

As some of you may remember from previous posts, I still haven't really decided on my stance when it comes to pharm reps. Right now I'm leaning in the direction of banning them from my future practice entirely, in the spirit of No Free Lunch. As an emerg doc I won't really be a target of drug reps anyway... although if I continue to keep a foot in family practice by moonlighting in a walk-in clinic or student health centre (which is my intention right now), it will likely become an issue.

But what annoys the crap out of me is the doctors that act all sanctimonious about the fact that they don't meet with drug reps but have no problem accepting drug rep money to fund a golf tournament, a hockey tournament, a CME dinner or other doctor-centered activity. They don't see their stance as hypocritical as they don't see it as 'direct' influence.

Grr.

2007-01-14T19:34:00.000-05:00

Mmmm... Books.

I love books. I've always loved books. I admit it. My obsession started early, with Archie comics and Peanuts paperbacks. I was the kid who would be up at night with a flashlight under the covers trying to read one more page before being discovered by my mom. I eagerly anticipated the days my mom would bring us to the library, my sisters and I leaving with armfuls of hardcover books with crinkly covers. There was no feeling like cracking the spine of a brand new book. I've always loved bookstores-- from the tiniest hole-in-the-wall to the enormous Chapters/Indigo/Borders type-places, I can browse for hours.

I don't have much time to read for pleasure anymore, but I still get the same excitement out of books. Even the kind I 'have' to read. This has not always been a good thing. I don't know what on earth possessed me to buy our medical schools recommended pharmacology textbook-- I think I used it once in second year to look up some pharmacodynamics for a PBL session. I also have a nearly untouched Robbins Pathological Basis of Disease... I know that the American medical schools tend to regard this as a bible, but I managed to get through medicine with much more user-friendly texts. Other buys that made more sense at the time were a very good (and very large) textbook on rheumatology (on which my experience beyond the classroom has been non-existant) and a lovely (but somewhat heavy) textbook on infectious disease. That one I should probably crack open again-- I could use a refresher on bugs and drugs. But even now, I find browsing through a medical bookstore one of my favorite ways to spend a free hour.

These days, I'm a lot more careful about buying books. I don't buy books randomly at the start of every new rotation. In fact, since buying a subscription to up-to-date and installing the Lexi series on my PDA, I don't really use textbooks much at all anymore. And the ones I do buy I make sure will be a good investment-- a book that I'm likely to use and refer back to in the future. So most of those are relating to emergency medicine in some way.

Sometimes this works better in theory than in practice. My last major book purchase was one of the bibles of emergency medicine, Tintinalli. (When you're this well known in the world of emergency medicine, you're referred to by name) It was an exciting purchase to make... this text, together with Rosen, form the basis of resident preparation for the emergency medicine board exams. I eagerly dug in-- with each new rotation in my internship year, I'd read the corresponding section of Tintinalli. Great idea, right? Problem was, this textbook is about 5 inches thick. Not terribly portable, particularly for someone who does her best studying over non-fat vanilla lattes at Starbucks. On top of that, the weight of the book causes self-imposed time limits on studying. More than 45 minutes at a time causes painful ridges to form across the tops of my thighs where the book rests when I read. I think that Rosen had the right idea when they split their bible into three volumes.

So it's been a while since I've purchased any new medical books. Which is why I've been anxiously stalking the mailman for my package from Amazon. New medical books... yay!

First I got a family medicine text. It was less than $100 (a bargain for medical textbooks) and it much more complete than the Mosby text I'm using now. I wanted something beyond the review materials being passed around the internet when I'm studying for the CCFP licensing exam which is coming up in a little more than three months. This exam is freaking me out-- coming into family medicine from emerg and therefore knowing nothing about family medicine-oriented subjects like psychiatry, screening for disease and guidelines for management of primary health care issues, I still feel like I'm at a bit of a disadvantage. So over the next few months, I have some catching up to do. A friend brought this text to one of our academic days not too long ago and I really liked it-- complete, readable and relatively cheap. Add that to the shiny cover and pretty pictures and it's pretty much the perfect textbook. I was sold.

As long as I was ordering a book for exam prep, I decided to throw in another text that I've been eyeing for the better part of a year. The ICU book has been recommended by everyone I know who has read it. Seeing as how I'll be spending the month of June in the ICU here, another month of ICU next year during my emerg year, and will be using many of the procedures and protocols described in the emergency room. I had been waiting for the new edition to come out, so it's the perfect opportunity.

And speaking of perfect opportunities, Amazon.ca was offering The ICU Book in combination with another book I had my eye on, the Manual of Emergency Airway Management. This is another topic I'm a little insecure about, in spite of the month of anaesthesia that was intended to teach me these skills. All I've done in an emergency situation is fairly straightforward endotracheal intubation. The fancier stuff I've seen done in controlled situations, but I'd like to have more in my arsenal when some apneic 300lb guy with a Mallampati IV oropharynx rolls in the door. I'm hoping I get a lot more out of my next month of anaesthesia than I did in my first. I am perfectly aware that the techniques that will save my ass in a tight situation aren't the kind that can be taught in books, but I'm hoping it will be a good start.

Mmmm. Books. Love em. I can't wait. Now if only I could find the time to READ them, I'd be laughing.

2007-01-10T19:24:00.000-05:00

Just When You Thought It Was Safe to Go Back in the Water...

Okay, surgery isn't Jaws II. But what I mean to say is that it's often shocking how complacent you can get around things when everything goes well for a while.

It's been a long time since I've been away from the academic centre... or to borrow a phrase from The Flea, TBFTHITW.* Things in the community are... well, nice. Patients come into hospital with usual things, like urosepsis and COPD exacerbations. Some are palliative, and pass away quietly with adequate pain control. Surgery happens, people recuperate and rehab. Births happen, very rarely by c-section, and require nothing more in the way of intervention than a few absorbable sutures for mom and some blow-by oxygen for the baby. It's easy to fall into the complacency trap.

Last weekend I was on call for my preceptor's call group. Now that his call group no longer accepts the care of orphaned patients, rounding on the group's patients in the hospital rarely takes longer than 3-4 hours. Mercifully short, and I can often salvage at least enough of the weekend to go for a long run while there is still daylight left.

On Saturday, one patient on our list stood out like a sore thumb among the usual band of CVAs, ACSs and 'gastro+dehyrations'-- a kid in the ICU. Hmm. Don't see that everyday, particularly not in our sleepy community hospital.

So the story is this-- healthy kid sustains a fracture. Not a serious fracture, but it is slightly displaced and may not heal correctly without intervention. Enter surgeon who arranged for an ORIF of said relatively minor fracture (Open Reduction and Internal Fixation-- basically, we cut you open and put your bones back together, then make sure they stay that way).

It should be routine. Instead, as the kid was emerging from anaesthetic he bit down on the tube. The details are sketchy-- I wasn't there, just read the notes from anaesthesia in the chart. The patient was intubated with an LMA (as an aside, does anyone else think that those things resemble female genitalia?) and when he bit down, it obstructed the flow of oxygen through the tube. When someone is in this state-- emergence-- you can yell in their ear to stop biting down all you want and it won't make a difference. They have little to no control over their actions, but are no longer under the effects of the muscle paralytic. So as this guy's oxygen went down-- and it went WAY down, to about 50% O2 sat as evidenced by the OR record-- he continued to bite down reflexively. And then, likely secondary to hypoxia... his heart stopped.

Holy crap. At this point I was sitting at the ICU nursing station, reading the kids chart like a bestselling novel. A full 10 seconds of asystole. Basically, the kid was dead. Compressions were started, and eventually the anesthesiologist got another dose of sux into him which re-paralyzed him. The situation improved from here.

The result of all this was non-cardiogenic pulmonary edema-- basically, a heckuvalotta fluid in the lungs. Not so good for the breathing. And more fluid third-spacing... going to places it shouldn't. The poor kid looked like the Stay-Puft marshmellow man on a CPAP. After 18 hours or so on CPAP, the intensivist managed to wean him down to O2 by nasal prongs, but attempts to wean him beyond that resulting in rapid desats.

The poor kid and his parents were stunned. Thankfully, the story had a happy ending... he hung out in the ICU for a couple of days until he was able to be successfully weaned from supplemental O2 and went home, none the worse for wear.

Still... scary story. Serves me right for starting to think of surgery on healthy people as 'routine'.

* The Best Fucking Teaching Hospital In The World, a phrase intended to illustrate the view of the staff/clinicians/trainees at said hospital that everything done there must be the right way to do things, because we're TBFTHITW.

2007-01-09T21:44:00.000-05:00

Knock, knock... who's there?

Who is staffing our emergency rooms these days? Around these parts, it's a hot topic. When I first moved to this town to start my residency training in emergency medicine, one of the teaching hospitals affiliated with the university had undergone a pretty dramatic upheaval. For some reason not fully understood, the hospital emergency room was being staffed by Med-Emerg, a medical staffing agency. Basically, they take over responsibility for staffing the emergency room. This was significant as it required pulling all residents out of this hospital, as Med-Emerg staff were not affiliated with the university and therefore not able to teach residents. Word around the Valium fountain in the Emergency Department was that they staffed ED's with fresh grads, most of whom didn't have any emerg training. Family doctors who got paid handsomely to drop in and staff a shift with no commitment to the hospital or the community. I'm not entirely sure why docs affiliated with this agency are instantly deemed inferior, but it definitely had an impact on the residency training in our academic centre. After the Med-Emerg one year contract with the hospital expired, the hospital was again staffed by university-affiliated staff docs. And now, residents are back in the ED there.

The Med-Emerg solution is costly, but probably better than the other alternative to EDs facing severe staffing shortages. Another ED in the region facing closure due to staff shortages managed to stay open by recruiting a CCFP-EM resident (a resident who has finished training in family medicine and is currently doing an additional year of training to specialize in emergency medicine) to cover its weekend shifts. This was widely reported in the news at the time, trumpeted as a 'partnership' between medical academia and the government to meed the regions needs.

Crazy. This wasn't a success! This was a clear failure of the system. The ED had to reach into the pool of medical trainees for staff-- while I'm impressed that the resident in question had the cojones to work without backup in a busy emergency department just two months after finishing her family medicine residency, I wouldn't have felt comfortable in that situation. Why would I be doing a third year in emergency medicine if I could just walk into an ED with nothing but my family medicine certification and an 'interest' in emergency medicine and work without concern?

This is likely to happen more and more often in a system where supply is clearly falling short of meeting demand. In Canada, there are 27 spots in FRCP Emergency Medicine each year. Twenty-seven. For ALL of CANADA. The year I matched there were about 75 applicants for these positions. Granted, these are the spots intended for academic positions in emergency medicine, but it still seems like a ridiculously small number. In the stream that I'm in, the CCFP-EM program, there are about 6 spots for each academic centre. In spite of that, there is still considerable competition for these training spots. So my point is that the lack of qualified staff to man emergency departments is certainly not from lack of interest on behalf of residents.

Now things seem to be going one step further. Out east, one politician believes that the solution lies in staffing emergency departments with nurse practitioners and paramedics. I'm not sure how, in the words of Kevin, M.D., NP + paramedic = ER doc. Paramedics are not trained in any way to diagnose disease. The paramedics scope of practice pretty much ends at assessment. Treatment is only given insofar as it fits into one of numerous protocols set forth by the BLS Manual. Advanced Care Paramedics do have an extended scope of practice, but again are not trained to diagnose disease. I do not understand the role that they are intended to play in replacing physicians at the helm of the emergency department.

I'm not putting doctors on a pedestal here. In fact, I've never really understood the difference between a primary care nurse practitioner and a primary care physician. Both may assess and examine the patient, both may order diagnostic tests, both may diagnose disease, both may prescribe and/or administer treatment. So if nurses can do all this, why have primary care physicians at all? What can they do that NP's can't?

My exposure to NP's has been restricted to academic centres. I've worked with them in the dialysis unit, in the NICU and in the PICU. Their role in those places seems to be similar to that of the Physician Assistant in the U.S. (we don't have PA's in Canada)-- but they work as members of a team, not independently from the physician. So you can understand my confusion when it comes to the role of NP's practicing independently in the community. I know this happens in remote places, but I've never had first-hand experience.

When I think about it, though, it's kind of frustrating for the primary care physician. NP's are trained in just 12 months (if they hold a university B.Sc.N) or 24 months (if they held a college nursing RN) according to this journal article. It's no wonder doctors are worried. Compare that to the university degree (4 years), medical school (4 years) and residency (2 years minimum) completed by a primary care physician and it's easy to understand why there might be resistance to declaring the two equivalent. If a NP can do a family doctor's job, why would a wanna-be family doctor bother doing medical school at all? Not when the same end may be accomplished with half the years of training and a fraction of the debt load.

Seems like a shortsighted solution to the physician staffing problem.

2007-01-05T19:27:00.000-05:00

Why the Nurses Love Me

Yesterday morning I was rounding on a patient who is on the surgical floor, awaiting an ERCP. I was discussing some issues with the charge nurse when a middle-aged man in scrubs approached the desk.

"Who is Sue?" He boomed, clearly expecting immediate attention.

The charge nurse turned to him. "We've both been working here over 20 years and you still don't know my name?"

The man in scrubs shrugged, clearly unmoved. "Nurses are generic."

And with that, he grabbed a chart, spun on one heel and left. Nurses rolled their eyes in the general direction of his back.

"Who the hell was that?" I had to know, if for no other reason than to avoid him carefully in the future.

"Dr. Pompous,"* she replied. "He's the oral surgeon. He doesn't come in much, which is probably why you haven't met him yet."

Thank God. So Sue and I go back to our discussion of how to best reverse my patient's anticoagulation until Dr. Pompous blows back into the nursing station.

"I want her NPO today before I touch her." He announced. I had been in mid-sentence, a fact which clearly did not faze Dr. Pompous. He stepped in front of me to address Sue as though I wasn't even there.

I saw red. This kind of bullsh*t might be shrugged off my the nurses, but I didn't have to play the academic hierarchy game anymore.

"Oh, I'm sorry," I said loudly, "I thought I was speaking here."

Dr. Pompous stopped in mid-sentence. He turned to face me with an eyebrow raised, clearly trying to size me up.

"I'm sorry," he said, clearly not sorry in the least. "I'm Dr. Pompous. And you are?"

"Dr. Couz," I replied, putting the emphasis on the title. I didn't explain further.

That changed the game a bit. He sputtered a bit, then backed down and let me continue my conversation with the charge nurse.

If I were a little gutsier, I would have replied: "I'll try to remember your name, but surgeons are generic."

Freaking surgeons.

* Names have been changed to protect the innocent... and the pompous.

2007-01-03T20:38:00.000-05:00

The Scutmonkey Rules

Okay, I rarely do this-- post passages directly from another blogger. But rarely does another blog actually make me laugh out loud. Which isn't so great if I'm working on my laptop, say, in the middle of Starbucks. People think I'm crazy. But this recent exchange, ever-so-wonderfully captured by Michelle over at The Underwear Drawer, was worth risking a Form 1.

(That 'Form 1' comment was a medical joke. And jokes like that are why I will never be cool.)

So for context, Michelle is an anesthesiology resident in NYC. And this recent OR exchange illustrates what is wrong with the traditional medical mentality:

So of course Joe and I had to work this last week, but thankfully the OR schedule has been somewhat light, with the exception of the orthopedic rooms, because those orthopods just don't know when to stop. Yes, they love doing surgery, and I respect that, but at some point, don't you think that stopping the smell the roses or having outside pursuits is a sign of a fully realized life? Or am I just a lazy turd?

Apparently the latter, according to the neurosurgeons. I was in a neuro case just the other day when the following conversation transpired between the surgical team and myself. They were discussing interdepartmental rivalries between our institution and [Upper East Side Affiliate Hospital]. You know, the surgeons down there talking smack about the surgeons up here and vice versa. The attending surgeons then posed this question.

NEUROSURG ATTENDING
How about Anesthesia? Did the anesthesiologists down there have some sort of big rivalry with the group up here?

SCRUB NURSE
[Who has worked at both hospitals]
No, the anesthesiologists were pretty laid-back.

NEUROSURG RESIDENT
Anesthesia doesn't have rivalries because anesthesiologists have no ego.

MICHELLE
I'm trying to figure out if you said that as a compliment or an insult.

NEUROSURG RESIDENT
(Bitterly)
All Anesthesia wants to do is go home! You know they leave at 4pm some days? 4pm!

MICHELLE
Um, it's 7pm now, and I'm right here.

NEUROSURG RESIDENT
(Starting to froth)
I get into work at 4am and leave at 10pm! They get six extra hours in their day! Six hours! That's a whole life!

MICHELLE
That's exactly right. That is a whole life. My whole life outside of the hospital.

NEUROSURG ATTENDING
If all you want to do is go home, why be a doctor at all?

MICHELLE
I don't think that wanting regular hours means that you shouldn't be a doctor. I think that having regular hours enables me to be a doctor and something else too.

MICHELLE'S INNER MONOLOGUE
Like a human being.

NEUROSURG ATTENDING
Ignore us, we're just jealous.

NEUROSURG RESIDENT
(Mumbling angrily to self)

It's this strange attitude in medicine, this macho thing, that in order to be the best, most committed, most self-sacrificing, most punk rock doctor, you have to basically sell your soul to the hospital. LOOK AT ME IN AWE AND WONDER, FOR I HAVE NO OTHER LIFE. I just don't really get that attitude. I mean, I'm glad there are people like that out there, I suppose. I mean, when it comes down to it, most of us will do what we need to do to take care of a patient in trouble, regardless of what time of day it is. But on the other hand, doesn't it make you a better doctor to, I don't know, take a break once in a while? Or think of it another way--do you want to be operated on at 8pm, the fourth elective CABG of the day, after your surgeon has been awake for the past 30 hours?

("No" and "Hells, no" are both acceptable answers.)

Thank God I'm not the only one that thinks that medicine and having a life are not incompatible life goals.

If you want to read more of Michelle's wicked and warped sense of humour, check out her blog at The Underwear Drawer. I only recently discovered that she is also the force behind Scutmonkey, who was the originator of the Twelve Types of Med Students that circulated around my med school class way back when. Check her out. Seriously.

2006-12-29T20:38:00.000-05:00

Lullabies and Lawsuits: How Sleep Deprived are Medical Residents?

Maybe the question is moot. Of course medical residents are sleep deprived. It's practically in the job description. We know it's not healthy. We know it's not a sustainable lifestyle. But it's the way it's always been done.

Stories of sleep deprivation are legendary among residents, who often share them as though they were badges of honour. One obstetrics resident spoke of falling asleep while driving home on a particularly straight stretch of highway. One of my medical school classmates confessed to driving off the road on the way home from a 36-hour shift. 'Post-call' wasn't just a description our work schedules, but a state of mind and an excuse of all sorts of mental dysfunction. It was part of the rite of passage.

In the States, this has been a much more heated topic of discussion. Since the Libby Zion case in 1984, where the death of a young woman in New York City was found to be at least in part related to extreme fatigue on the part of the residents responsible for her care. The woman's father has attacked the system responsible for the training of residents and has contended that the hospital was grossly negligent in allowing residents to practice medicine in a state of extreme fatigue. Between the Zion case and the subsequent Bell commission, the face of medical training in the US has changed dramatically in the past 20 years.

Medical residents have all worked with old-school physicians who are quick to recall the days of 'internship', where the interns were literally living in the hospital. Marriage was prohibited (at least unofficially) and the interns were paid peanuts-- occasionally out of the pockets of their supervisors. These doctors went on to become old-school doctors who never really left the hospital, and were always accessible to their patients. Admirable to some, but these are the same guys who had three wives by the age of 50 and often a brood of children to whom they were a virtual stranger. In my experience, these doctors (many of whom are now at or well past retirement age yet still hang on to hospital appointments, unable to imagine life without medicine) do not look fondly on the current crop of trainees. We're soft, our training was watered-down, and we have the audacity to feel entitled to a life outside of medicine. As I've said before, most of today's young doctors aren't willing to subject themselves to a life of 14-hour days and being on call 24 hours a day at the exclusion of family, friends and mental and physical health.

Now, residents in the US follow the 80-hour work week, as legislated by law. The rules limit residents to an 80-hour workweek; prohibit any single stretch on duty of more than 24 hours, which must be followed by a full 24 hours off; and require at least 10 hours between shifts and at least one full day off a week. To most other professions, this is still a hellish schedule. To a Canadian resident, this is a cakewalk. In Canada, the rules are less complicated-- 'in-house' call (meaning when you work overnight in the hospital, usually with little to no sleep) is limited to one every four days. So on this 'on-call' day, you start with your team (start time could be anywhere from 6am to 8am, depending on the rotation) and you work through the day and night. On your 'post-call' day you must be excused from your duties by noon. Ideally.

These rules are haphazardly enforced. Particularly in surgical specialties, where the old-boys-club rules, leaving the hospital when you are post-call is often viewed as a sign of weakness. Many of the surgical residents don't feel that they should leave, for fear of missing an interesting case. So they work a usual 12-14 hour day after putting in a full 24-hour shift. Or, in the case of orthopedic surgery (the ultimate 'old-boys-club') they consider their call 'home call' (meaning they sleep at home and come in when needed) even though they end up spending the entire night in the OR more often than not. This allows them to be on call every three days, rather than every four days. In the province of Ontario, the Workplace and Contract Compliance Committee that is run by the resident's union is impotent in cracking down on abuses unless someone comes forward with concrete proof. And no one wants to be 'that guy'.

Ironically, the new laws aren't being implemented in the US without resistance from the very people the law is intended to protect. Residents resent being forced to restrict their work week to 80 hours, saying that their 5-year residency becomes a 3-year residency if they're forced to work 25% fewer hours. They worry that continuity of care is compromised, and that their learning is affected if they are unable to see anything through.

True, in theory. But in my experience, the stuff that residents stay post-call for has nothing to do with continuity of care. They stay to scrub in on that day's OR, or to attend clinic. Once rounds have been done and the day's plans set in motion, attention turns to the new cases. And a resident staying to scrub in isn't the one who will be called when a patient on the floor crashes anyway. That's why we have handover, so the new team will be fully informed regarding the active issues and unstable patients. Sure-- ideally, residents will always be available for 'their' patients. But that's not a realistic scenario. Maybe we should look at improving handover rather than extending resident shifts.

The other argument against the shorter work week is that patient care suffers from having less staff on. I'm not really going to argue with the fact that patients suffer when hospitals are understaffed. What I am going to disagree with is the fact that this is the responsibility of the residents to correct. Having been in the position of being responsible for two floors of very sick (and occasionally unstable) surgical patients, one half floor of pediatric surgical patients, overnight OR's and surgical consults for both adults and pediatrics through the ER during my general surgery rotation just a few months after graduating from medical school, I know all too well the feeling of panic as I put out fires and prayed that everyone would just stay alive until morning when the people who knew what they were doing would be back in the hospital. I still feel that it is totally inappropriate for such a junior resident to be faced with so much responsibility with nothing but 2-3 buddy calls with a senior resident to prepare them. If one of my parents had been a surgical patient in that hospital and had crashed with only a very junior resident to manage their care, you can bet I'd be pushing to change the system. Very loudly, and with a team of lawyers behind me. Sad that tragedy has to occur before the system is re-examined.

As for the staffing shortfall, maybe the Canadian government should look into expanding the roll of nurse practitioners, opening up more residency spots and hiring hospitalists to help shift the load from the shoulders of trainees. It can't be an impossible task-- in Europe, the average work week for residents and physicians hovers around 60 hours per week. In Scandinavia, an unheard-of 40 hours of work per week.

Just because something has 'always been done' a certain way, doesn't mean that changing it won't make it better. I don't think the American system is necessarily the solution. And I don't actually mind the way things are done here. But as recent studies have shown that sleepy residents are more likely to make medical errors than residents who aren't sleep deprived, it's clear that the system is in need of a tune-up.

2006-12-25T15:52:00.000-05:00

A Laugh for the Holiday Season

Brought to you by Doc Around the Clock.

How to Tell if you Might be a Drug Seeker

Hope you laugh as much as I did. Happy Holidays to all.

2006-12-18T12:42:00.000-05:00

'Tis the Season

Because I've been looking to blog and haven't had much to talk about over the weekend, I'm joining in the fun after being tagged by Dr. Wes. I still don't know what the heck 'meme' means, but apparently this is one. In honour of the season...

1. Hot Chocolate or Egg Nog?
Given a choice, probably the hot chocolate. I'll drink Egg Nog if it's diluted 50/50 with milk, but I don't crave it or anything.

2. Does Santa wrap presents or just sit them under the tree?
He wraps them. Unwrapping is half the fun of receiving!

3. Colored lights on tree/house or white?
White is my preference, but lights are lights... I love all of them!

4. Do you hang mistletoe?
Nope-- my lips are spoken for, and I haven't been married for so long that I need a reason to kiss my husband!

5. When do you put your decorations up?
My family tradition is to do the deed the first weekend of December, but now that I end up spending holidays traveling to see my mom and my inlaws it doesn't seem worth the effort. A little Scroogey, I know.

6. What is your favorite holiday dish?
Turkey. Save me a drumstick. And my sister's patented marinated mushrooms.

7. Favorite Holiday memory?
When we were kids my mom made a massive advent calender and under each day of the month there would be a small felt bag that contained three identical little gifts for my sisters and I. It made the whole month feel like Christmas!

8. When and how did you learn the truth about Santa?
The truth is highly overrated in this case.

9. Do you open a gift on Christmas Eve?
I have in the past, but don't right now... and Mr. Couz and I haven't really decided what traditions we'll be passing on to our own future kidlets.

10. How do you decorate your Christmas Tree?
With a collection of ornaments that mix old and new, tasteful and tacky, meaningful and not. Again, we're still working on establishing our own traditions.

11. Snow! Love it or Dread it?
Love it! It would be un-Canadian to say otherwise.

12. Can you ice skate?
What Canadian hasn't skated the length of the Rideau Canal at Winterlude? Of course I can skate. Can I skate WELL, however, is another question altogether.

13. Do you remember your favorite gift?
Would it be unromantic to say that it was the deep freeze that my mom gave me last year?

14. What’s the most important thing?
Remembering the reason for the season and spending time with loved ones.

15. What is your favorite Holiday Dessert?
It's all about the Buche de Noel.

16. What is your favorite holiday tradition?
Christmas morning-- opening stockings first (my family makes a fuss over stockings), then sitting down to a Christmas Brunch which always features my sister's rocking marinated mushrooms, a huge fruit salad, Montreal bagels and smoked salmon. Damn. Now I'm hungry.

17. What tops your tree?
It used to be an angel with black wings that I made in pre-school. Now it's a much nicer angel that doesn't have nearly as many memories attached to it.

18. Which do you prefer giving or receiving?
Giving, although with so little time to shop it becomes stressful. I'd rather do away with presents altogether and just make it about family.

19. What is your favorite Christmas Song?
Angels We Have Heard on High

20. Candy canes, Yuck or Yum?
Love 'em. We're lucky if there are any left for the tree.

I won't be tagging anyone-- most of the blogs I frequent have meme-d already (is that a verb?) and I don't want to be responsible for putting pressure on a relative stranger.

More real blogging to come later.

2006-12-13T20:41:00.000-05:00

The Clothes Make the Clinician

While stopping at a nearby Tim Horton's on the way to work, I saw a resident that I recognized. I smiled politely and waved while I struggled to remember her name-- or, at least, where I'd encountered her before. I studied her from my spot in line. It was 7:45am, so I knew she wasn't in surgery-- she would have been at the hospital long before now. She was nicely dressed, so she wasn't likely to be in anaesthesia. Anesthesiologists would either be wearing scrubs to work or dressed casually, intended to change once they got there. Couldn't be emergency medicine, or I'd know her. Family medicine and pediatrics were unlikely, as she was wearing a slim skirt and stylish sweater. Family and peds residents tend to dress more casually, as a general rule. Must be internal medicine. But wait... as she stepped away from the counter, I noticed her feet. Black heels that must have been 3 inches high. No way would an internist, or anyone in ward medicine for that matter, suffer through a 12-hour day in impractical shoes. Not to mention that running for codes would be next to impossible. By the time she greeted me I had it-- psychiatry. Stylish outfit, impractical shoes, lack of white coat (not that she'd be wearing it outside of the hospital, I'd hope)... it all added up.

It's amazing how much you can tell about someone by the way they dress. It's probably something that's true everywhere, and not just within the confines of the hospital. What we wear to work has been a topic of conversation since we started medical school. My medical school, as I've mentioned before, is a little on the traditional side. A little stuffy, a little old school. Initially, the only guidance we were given pertaining to dress code was: Men should be attired in dress pants, a dress shirt and tie. Women should aim to match this level of dress. Whatever the hell that means. Soon after trading in our classroom uniforms of jeans and t-shirts for the 'business casual attire' appropriate for patient encounters, it became clear that we needed more guidance than that. One of my classmates was reprimanded in third year for dyeing her hair pink. Another for wearing a midriff-bearing top (seriously... who thinks that is appropriate?). I can only imagine what other transgressions were unearthed as the year went on, since we seemed to get regular 'warnings' regarding our attire throughout clerkship.

There will always be those who just don't give a shit. One of my classmates, upon deciding that he wasn't going to go through the match but would rather travel the world and save it from a grassroots level, stopped 'playing the game'. He started coming to clinics and rounds unshaven, dressed in jeans (if it was a 'dressier' day) or some variation of workout clothing. He was reprimanded on more than one occasion and couldn't care less. When they have nothing to hold over your head, there's not much the 'powers that be' can do to make you dress better. Now he is a community medicine resident working on his Master's of Public Health and I have no doubt he WILL save the world someday... and he'll probably still be dressed like a bum.

This has become an issue discussed in the media as well... a recent American Journal of Medicine article actually tested the effect of a doctor's attire on the doctor-patient relationship. Not too surprisingly, when doctors were dressed casually their patients had less confidence in their clinical abilities and were less likely to share important medical information with them. What did surprise me a bit was the fact that the white coat won out over regular professional dress. The results are discussed in this article: When Young Doctors Strut Too Much of Their Stuff

This has been on my mind recently as well. When I switched into family medicine I soon adopted the uniform of khakis/cords on the bottom, sweater on the top. Comfortable, not TOO casual, and fairly effortless. Soon, however, I found myself reverting back to the slightly more formal dress pants, shirts with collars (although sometimes under sweaters), blazers and jackets... just generally more professional. I don't necessarily feel like I'm conforming to the mold, I just feel that professionalism comes more naturally when I'm dressed the part. It's like my 'uniform'. Part of it might be because I have so much working against me-- I'm female, and I look much younger than my age. Being female doesn't seem to matter much to anyone but the odd elderly male patient, but many of my patients have remarked that I 'don't look old enough to be a doctor'. I usually reply with a polite smile that I'm older than I look and leave it at that. But when I'm dressed more professionally, I don't seem to get the comments nearly as often. I know the piercing in my nose (a small, tasteful stud) doesn't help. So I do what I can.

Hey, in an ideal world we'd be judged based on only our clinical skills and ability to relate to our patients. But if my patients have more confidence in me when I'm wearing pants that are Dry Clean Only, it's a small price to pay.

Besides, in the emerg it's all scrubs, all the time. Heh.

2006-12-11T20:04:00.000-05:00

Can I be Friends with my Patients?

I am putting this out there. Not only to fellow residents, physicians and medical students, but to the public at large. Is it possible to be friends with your patients?

It has happened a few times in the year I've been working in this community that I've just really hit it off with a patient. They're always my prenatal patients-- they're female, close to my age, and in many cases just damn cool people. I meet with them monthly during their early pregnancy, then every two weeks, then every week... you get to know a person pretty well when you spend that much time with them. Then, at the end of it all, I get to play a key role in one of the most important events in their lives. They like me. I like them. Often, I like their husbands too. And I'll find myself thinking of how much fun it would be for my husband and I to hang out with them. Last week, one of my prenatal patients who is nearing the end of her pregnancy joked that she'd buy me a beer when all this was over if I could get her through the birth without tearing. Meant as a joke, I know. But when you think about it, would it really be wrong? On one hand, I know things about my patients that I don't know about my friends (for example, I've never seen Vitamin K's va-jay-jay, even through she's been my best friend for years... and we like it that way). On the other, it's not like I'm thinking about people's embarrassing medical issues when I bump into them on the street.

My preceptor has some overlap between his friends and his patients. They were all friends first, though, if that makes a difference. Which I don't entirely understand. There is no way in hell I'd go to a friend to have my paps done, no matter how professional he or she was about it. In fact, Dr. Boss has even delivered the babies of his friends and coworkers. Again, too much information. But they have no problem with it.

Sigh. Can't wait to do emergency medicine full-time. This isn't an issue when you don't get to know your patients.

2006-12-10T21:58:00.000-05:00

So Much More Than a Driver's License

I've recently been on both sides of a very sticky subject.

First of all, I'm convinced that the city in which I live is home to all of Canada's very worst drivers. People sit in the left hand lane driving 110 kph, oblivious to people trying to pass. No one thinks to actually indicate turns before they make them. Half of the drivers in town seem to be endlessly looking for an address. The worst, I'm sorry to say, seems to be the elderly. They crawl along city streets, braking for no apparent reason at random intervals. They come to a complete stop while merging into faster traffic. They seem to forget that you can turn right on red lights. They'll pull halfway into a lane from a parking lot and then stop when they see oncoming cars-- this subsequently blocks the lane as they don't seem to understand that the fact that half their car is already in the lane means that traffic can't proceed. It's aggravating, sure. And I admit that I am not the world's most patient driver. I've often voiced the opinion that it seems that many of the people on the road probably shouldn't be. Particularly those over 80 years old. In fact, I think that after the age of 75 drivers should have to pass a road test at least every two years to renew their licenses.

Now I know that age doesn't determine driving ability. There are shitty drivers of all ages. There are dangerous drivers of all ages. But when I see a car that appears to be driven by someone who can't see over the steering wheel, has an altered level of consciousness or some combination of the two-- well, more often than not the driver is of very advanced years. Although experience does improve driving ability, age does not. As a person gets older, reflexes slow, perception is decreased and judgment is gradually impaired. Sometimes these alterations are obvious, and sometimes not. Many elderly people have fairly good insight into their declining abilities-- they will stop driving at night, on the highway, in poor weather-- eventually, they give up their license entirely. For others, it's not a voluntary situation.

Last week one of my patients came in with his wife... he is in his early 70's, and although our communication has been a little hit-or-miss in the past I've never really doubted his judgment. The reason for his visit was difficult to tease out from his broken English, but it seemed that a few weeks after a routine visit to his ophthalmologist he had received a letter from the Ministry of Transport (DMV for my American readers) asking him to come in for a 'review'. The patient was, understandably, confused. He attended the 'review' as requested and was required to attend a seminar. After the seminar, he was provided with numerous forms and papers, some of which had to be completed by his family doctor. That's where I came in. As I figured it, the ophthalmologist probably notified the MOT that my patient shouldn't be driving. I think it was awfully unprofessional of him not to have given the patient himself a head's up as to his intentions to contact the Ministry, but knowing the problems I've had communicating with this guy in the past I wouldn't be surprised if he had explained everything and it just hadn't been understood.

It didn't take long for us to determine that there was no WAY this guy should be on the road. When the nurse tested his vision using the Snellen Eye Chart (at left), he was unable to see the chart from 3 meters away with his left eye. Or his right eye. Using both eyes, he was able only to correctly identify the "E" on the top line. And this was his corrected vision-- with his glasses. Scary.

I went into the room to meet a very indignant Mr. E. He had no idea why the Ministry had contacted him in the first place, and didn't think there was any problem with his vision. He read the eye chart fine, he believed. Unfortunately, as in my last appointment with Mr. E., there was no reasoning with him. I explained that it wasn't my job (or the eye doctor's, for that matter) to determine his fitness to drive. All we did was evaluate his health, and report our findings to the MOT-- they did the rest. Which is exactly what I did. I filled out his forms-- I outlined his diabetic control (not good, but no hypoglycemic episodes that we were aware of), his cardiac status (afib, cardiomyopathy and CHF, all controlled with medication) and the results of his eye exam. I noted that although he did not show any overt signs of dementia, we were not able to complete formal testing due to language barriers and he did occasionally show signs of impaired judgment. I carefully documented that the patient has been advised not to drive. Which I did. Mr. E. was crushed.

"What am I gonna do?" he asked, looking at me imploringly, "how am I gonna get around?"

I turned to his wife, who seemed to be taking in the situation with resignation. This was not a surprise to her.

"Do you drive?" I asked her.

"Yes."

I looked back at Mr. E. In one visit, he had lost a good chunk of his independence and his freedom. Suddenly, he looked very old. Although I knew that he was honestly not safe to be on the roads, I felt awful for having to change his life so abruptly. He shuffled out the door, and his wife stayed behind to thank me. She had suspected as much for the past year or so, she said. But he didn't listen. She would take his car keys until the MOT officially revoked his license, she said.

I did what I had to do. But I still feel lousy.