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Total despair

november 25, 2016 Lämna en kommentar

I have written previously about the Swedish cardiologist Fikru Maru who is detained in Ethiopia. After awaiting trial for three and an half years, he developed a spontaneous pneumothorax that failed to heal with conservative treatment. To speed up his release, he declined the right to defend himself against the ridiculous charges and accepted a guilty verdict. A month ago he was sentenced to 4 years and 8 months, which we thought meant he would be released, since he had already served two thirds of that time. But instead the whole situation has now taken a turn for the worse.

Today we learned that Fikru will be prosecuted as a terrorist. The allegations are absurd and I hesitate to describe them in writing, not really believing this myself.

The morning after Fikru was taken from prison to hospital for treatment of his pneumothorax, protests at the prison developed into a riot. Fire broke out and 23 prisoners died under shady circumstances. According to some reports the deceased had been beaten and even shot. Now 38 prisoners are being prosecuted for involvement in the riots and Firku is one of them.

Of course Fikru wasn’t at the prison when it all started, but the that was only because he had deliberately eaten so much chocolate that his blood pressure increased to such an extent that he developed a pneumothorax, according to the allegations. He is now being accused of encouraging and even sponsoring the protests financially.

The nightmare that was supposed to end now just started all over at a higher level. There is no solution in sight. None.

 

Go on and fool me

I have a low threshold to pain. When I walk by a room and happen to see a patient squirming and crying in pain, I feel a compulsive urge to make sure that someone is dealing with the matter. As mostly, the best source of information is the patient, so I put my hand on their shoulder and say – I can see that you are in a lot of pain. Is anyone helping you out here?

If the answer is no, I offer a warm blanket and go and ask the nurses to provide some analgesia. Sometimes that means paracetamol or ibuprofen, sometimes it means opiates. For patients in severe pain it can mean all of the above and in high doses. For heroinists I order doses that the nurses refuse to administer.

The same goes for patients who need prescriptions for their pain medications. Some of them have incredulous explanations for needing one, like being robbed of all their pills. Or they have pain that I can’t find an anatomical or physiological explanation to. I don’t care. I send them home with a small prescription or with the amount of pills they need until they should be able to get hold of their regular doctor or primary care physician.

I try my best not to judge how credible or trustworthy my patients are when it comes to describing their pain or their need for medication. Because that judgement will undoubtedly be based on my prejudices. And I would rather be a fool than a bigot. I know that my suspicions of drug-seeking behavior would be directed towards men of non-Swedish origin with low education, making me a sexist, snobbish racist. That is not who I want to be. So I choose to trust my patients.

Before I send the prescription, however, I check my patient’s medical records. Our system covers most of the clinics in Stockholm, so I can count how many pills have been prescribed in total. Sometimes there is a note, or even a warning, that the patient seems to be over consuming pain medicines. I have never seen that statement followed by a treatment plan, or even a discussion with the patient about the problem, though.

So I tell the patient that he or she seems to be using more pills than ordered, and maybe even more than what they have just told me. I inform them that it says in their medical records that they might have a dependency problem. Often I’ll apologize on behalf of our health care system for putting them in this situation. I understand how living with chronic pain wears you down, both mentally and physically. How the pills, which offer some relief at first, stop working and how easy it is to increase the dose in desperation, until suddenly the pills themselves have given you another problem. Like far too many other patients they have not been given the holistic, team based care they need. Instead some doctors have prescribed large quantities of addictive drugs. And now when that suspicion of overuse and dependency has been raised, it’s going to be very difficult for them to get any medicine at all.

If the patient admits that they have a problem, I offer them a referral to a dependency clinic. When they don’t want that I strongly recommend them to make sure that they only ask for prescriptions from their primary care physician and that they limit their usage to the doses prescribed. Then I document this conversation in their records.

It is very rare that the patient gets upset about my way of handling this. To the contrary, they often thank me for treating them with kindness and respect. It could, of course, be that they are just being manipulative and happy that they got what they came for. So maybe I’m fooled from time to time, but I know that I’ll never mistrust and mistreat that patient in severe pain who can’t speak eloquently enough for herself.

Kategorier:English

A preventable death is always unnecessary

januari 16, 2013 Lämna en kommentar

I listened to the ERCast today, the episode where Rob Orman goes through his method for making a suicide risk assessment. It was, as always, very structured and well prepared. I was surprised, however, when he said that this was one of the most downloaded episodes of his show. This was a topic, unlike most of his other EM stuff, where I felt that I already had a good understanding. Maybe that’s because we have a three month rotation in psychiatry as a compulsory part of our internship in Sweden.

It was not until now in the evening, when I started to think about a patient I met some years ago, that suddenly understood what I had to learn from this episode.

The patient was a 60 year old man, who presented to the emergency department with right-sided lower thoracic/upper abdominal pain. There was nothing acute about his pain. He had had it for weeks and had already been seen by his primary care physician, who had ordered an ultrasound of the upper abdomen, which turned out normal. Since the pain got worse with certain movements, the physician has assured him that the pain was musculoskeletal. The patient was not satisfied with this explanation and decided to seek further help in the ED.

It don’t remember the exact details, but there was something about this patient that made me worried. He had rather intensive pain and couldn’t work because of it. His right upper quadrant was tender and I believe he was a smoker. The work-up in the ED, ECG and labs, were unremarkable. So I referred him to his primary care physician with a suggestion that he undergo a CT of the thorax and abdomen, looking for an underlying malignancy.

A couple of months later, I was signing my notes. It should of course have been done much earlier, but I have a tendency to accumulate unsigned notes. Anyway, when doing so the dreaded pop-up showed up: My patient had died. I immediately started thinking that maybe this was a pulmonary embolism or something else that I had missed. Since we use the same electronic medical records system for most of the health care system in our county, I was soon assured that the patient had been well when he followed up with his PCP. I got a bit annoyed that only a CT of the thorax had been ordered and that when that also turned out normal, no other investigations had been made. The patient had been back a second time and had had his sick leave for musculoskeletal pain extended. All visits were to different doctors, unfortunately a common problem in primary care in Sweden.

And then there was a note saying that the patient was dead and that a forensic investigation had been performed. I was upset, thinking that we, his doctors, had missed some pathological process. And now this man was dead. To find out what could have been done differently, I called the forensic department to ask what had happened. Within a few days, I had the autopsy report.

There was no malignancy, nor were there any other signs of disease. The patient had killed himself. I was relieved, thinking that I had been wrong in assuming that his doctors hadn’t taken his pain seriously enough and given him a thorough work-up.

It was not after listening to this podcast today that I suddenly realized that I hadn’t been wrong. Anyone of us doctors who saw this patient could have made a suicide assessment. And if we had done it as thoroughly as Rob Orman suggests, we could have picked up that this patient actually had access to a gun, which is quite uncommon in the southern part of Sweden where hunting isn’t the everyman’s sport it is in the north.

There were things we could have done differently, which may very well have saved this man’s life. Preventing a suicide is no less important than diagnosing a pulmonary embolism. We have to look for risk factors even when it’s not an obviously suicidal patient. Thank you, Rob and Casey, I’ll do my best to remember that lesson.

My lesson learned-based CV

november 20, 2012 8 kommentarer

The first time I came in contact with CV hunters was during a four week extracurricular clinical rotation in Prague. I went there for the fun of it and to improve my Czech and was surprised to see how other medical students were asking everyone for recommendation letters. It has not until now occurred to me that a rotation like that could be used on your CV when you are a recent graduate from medical school. I’m however not the only one who thinks like this. When discussing CVs with a Swedish friend of mine, he thought his brother was embarrassing for mentioning on his CV that he used to be a football coach.

From my international experience I have learned that CV hunting is a common thing in many countries. People will do things, or a least volunteer for positions, that look good on their CV. I see on Twitter how American educators recommend everyone to keep detailed portfolios of everything they ever do. Even though I think that might be valuable and interesting to yourself, I don’t see how anyone else can get anything out of a long list of lectures, seminars, courses, assignments or whatever it is that you put there. Trying to assess what you know and who you are based on a list, seems to me like getting to know people in your community by reading the phone book.

So, I wrote an alternative CV, focusing on what I have learned through the years, instead of what I have done. Please leave a comment and let me know what you think.

The lesson learned based CV of Katrin Hruska

 

Lessons from education
  • If you are supposed to do a presentation and don’t prepare, you might experience nausea, dizziness and mutism to such an extent that you have to return to your seat with mission unaccomplished.
  • However embarrassing and uncomfortable this experience might be, the sun will still rise the next day.

How: Religion class in grade 8.

  • People don’t only disagree with you because they don’t understand your arguments. They might actually understand all your arguments and come to a different conclusion.

How: Local leader of the youth wing of a political party.

  • You may win the debate but still lose the issue if you are not in power.

How: Political representative in a local council for one of the opposition parties.

  • Sometimes making irrational choices will change your life for the better.

How: When I quit half way through my last year of high school to go and live in Prague with my boyfriend for half a year. I doubt we would have been married today if I hadn’t and I am far from sure that I would have gone on to study medicine.

  • If you don’t go to the lecture, you have to read the book, otherwise you won’t learn anything and you won’t pass the exam.

How: First year of medical school. Attendance wasn’t compulsory and the books were so heavy I had to read them in bed and so boring that I feel asleep.

  • If you have been to a lecture that gave you nothing because the speaker was so bad, there is no use going to his second lecture even if it is called ”All you’ll ever need to know as a doctor”.

How: Medical school. Revised at conferences by dull professors with heavy accents.

  • Socializing in a foreign language will make you seem less smart and more shy.
  • If you are used to talking a lot, this can be a good experience.
  • Studying in a system that stresses memorizing details doesn’t make you smarter, but it does make you remember more details. At least for a short while.
  • If you stay up all night playing pool, you will be tired the next day.
  • If all shops close at noon on Saturday and are closed on Sundays, you will be very hungry if you don’t do your shopping on Fridays.

How: Exchange student in Germany for my second year of medical school.

Lessons from work experience
  • Taking responsibility for a patient is different from being a medical student.
  • Even if lab results improve, it doesn’t mean that the patient is doing any better.

How: Summer job as some sort of medical assistant in a geriatric clinic. While I was looking at the creatinine that just came back and finally started to decrease after a steady increase, the nurse came to tell me the patient died.

  • To feel better patients need to eat, pee and poop. Then they need to get on their feet and regain their balance so they don’t fall and hurt themselves.
  • Doctors can’t fix this, but a team of doctors, nurses and physiotherapists can help the patients fix it for themselves.
  • Patients are not only patients, they are people. Even old patients have been young and lived exciting lives. Some have even taken part in interesting happenings such as recovering the Wasa Ship, Sweden’s most popular tourist attraction which sank on its maiden voyage in 1628.

How: Junior officer in the above mentioned geriatric clinic.

  • If you do research you need to be in a group that understands your work and can discuss it with you. You need a supervisor who can teach you how to conduct studies and how to interpret results.

How: Research assistant, trying to write a paper on a study conducted by someone else for another purpose, but where a lot of blood tubes were saved and stored.

  • Primary care is the most difficult specialty and not something inexperienced doctors should be doing without proper supervision.
  • Doing something you think is right doesn’t mean it is.
  • If you don’t ask and admit you were wrong, it is possible that no one will find out. It is also highly likely that you won’t learn anything from it.

How: Junior officer at a primary care clinic.

  • Doctors from different specialties have different priorities. Anesthesiologists see a need for more fluids, where cardiologists see a need for diuretics. Chest pain in a psychiatric patient can be cardiogenic. Chest pain in a cardiology patient can be anxiety related.

How: 21 months of internship, rotating through internal medicine, surgery, anesthesia, primary care and psychiatry.

  • Anyone can start a fight. Anyone can also take the first step towards ending it.
  • Try to dislike people’s actions instead of disliking them personally.

How: Bringing up three children with strong wills.

  • If you don’t delegate well and clearly, you will either end up doing everything yourself, or frustrate people who want to help out.
  • Starting up a new business is a lot of work.
  • Even the best employees will not perform well, if the group doesn’t work well together.
  • The best result you can get as a founder, is something that will work just as well without you.

How: Starting up a cooperative daycare together with two friends but no money. The school is celebrating its tenth anniversary next year.

  • Taking care of three small kids is a hand full, even if you are two to share it. Allowing yourselves five months leave in a foreign country will make it more interesting and give you the chance to learn a new language.

How: Spending five months in Argentina with no other agenda than being with my family.

  • The emergency department is the most interesting place in the hospital. It is also where you will have to work most intensely.
  • If no one really knows what emergency physicians do, if there are no specialists and not even a recognized specialty, you cannot specialize in emergency medicine.

How: Started to work at Sodersjukhuset, one of the first hospitals in Sweden to employ doctors for full-time work in the ED, instead of doing occasional shifts.

  • Primary care can be a lonely specialty.
  • If you try to solve all you patients’ problems, your ToDo-list will continue to grow.
  • If you don’t have a supervisor who is a roll model for the kind of doctor you want to be, learning to tackle these issues is very hard.
  • If you start going into the restroom to bang your head against the wall in tears, it is time to move on to another workplace.

How: Resident in family medicine.

  • Being an expert in one field of medicine, says nothing about your ability to treat patients with diagnoses outside of that field.
  • A resident who takes a good history and does a literature search, can provide better care that a specialist who cares more about his research than about his patients.
  • Patients need care even if no specialist thinks that it should be provided in their department.
  • If the head of your department doesn’t address important issues, someone has to bring those issues up. If he fails to do what he has promised to do, someone has to hold him responsible.
  • If that person is your friend and you agree, you have to stand by her, even if it decreases your chances to get promoted.
  • If the conflicts can’t be solved constructively, one of you might have to leave.

How: Resident in Internal medicine. Specialist training concluded.

  • Replacing ”I don’t have time to…” with ”I don’t prioritize to…” makes it harder to trick yourself.
  • Introducing a new medical specialty is difficult and requires perseverance.
  • A well working group of people will come up with better solutions than any single person.
  • Even if that group decides on something after a long discussion, the work still has to be done in order for things to change.

How: Secretary of the Swedish Society for Emergency Medicine.

  • Medical evidence only applies to settings that are similar to where the data was collected.
  • Well’s score for pulmonary embolism is useless if it takes a whole day to get a d-dimer and the hospital doesn’t have a CT scanner.
  • Patient safety is a concept that needs to be taught, understood and become part of your culture.
  • For sick patients you need a team of doctors and nurses who work well together.
  • Excellent care in the emergency department, followed by inadequate care in the wards, can be life prolonging, but probably not for very long.

How: Clinical rotation in the emergency department of the university hospital in Botswana.

  • Transferring a concept like lean production will not solve the problem if the hospital hasn’t decided whether or not emergency physicians should run the emergency department.
  • You have to choose your battles and avoid unnecessary conflicts.
  • If everyone is wrong and your are the only one who is right, there is nothing to be gained by insisting.
  • Every person has a good side. If you can’t see it, you have to try harder.
  • If you want to learn well in a non-ideal environment, you have to take great responsibility for your own learning.
  • The best way to learn is to teach. It will even make you realize how much your learned in medical school but never understood.
  • When you have fully understood something, you don’t have to revise it to remember it.

How: Resident in Emergency medicine (Still pending). Responsible for the education of junior doctors who had not yet started residency.

  • Global health is extremely complicated.
  • Political organizations develop cultures that are hard to change, but that change people who come to work there.
  • If you want big impact, you have to work through powerful channels.

How: Volunteer at WHO Headquarters in Geneva.

  • If you make your blog posts too long, people won’t read them. (Maybe not yet fully learned)

How: Tweet from the Swedish minister of health saying he started to read my blog post but put it aside when he realized how long it was.

Note to potential employer:

I am not very interested in money. Just give me the average salary for that particular position.
If you show your trust in my capability to do a good job, I will probably exceed your expectations. I won’t hesitate to tell you my opinion in the most friendly and honest way I can. NB! If your department is a mess and you don’t intend to do anything about it and won’t let me try either, please don’t offer me a job. I will make both of us miserable.

References

I assume most of my previous employers will give me excellent references. The only one who probably won’t, and hence would be the most interesting for you to contact, is the former head of the department where I did my internal medicine residency. He is also, by far, the one with the most impressive looking CV.

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Kategorier:education, English

Playing the game of emergency medicine

september 17, 2012 2 kommentarer

The best way to learn a subject is to teach it. This has become obvious to me during the last few months, when I have been responsible for the teaching of the new doctors in our emergency department. Since they are not enrolled in any residency program, it has been all up to me to decide how and what to teach.

Not only have I had to revise all the subjects we have been discussing, I have also tried to learn how to become a better teacher. Therefor we have concluded every four-hour session with an evaluation. In general no one has anything negative to say. I don’t think they like to be critical when they can see how much effort I put into this, but something that does come up frequently is the request for more interactivity. Saying interesting things is just not enough to keep people awake and receptive. So I decided to try a concept I had come up with before: Brainstorm for meducation.

Brainstorm is a quiz-style board game, that I play with my friends. The question takes the form of a topic, and the playing team has to rapidly mention as many things fitting under that topic as possible. When the time is up, the players’ answers are checked against a checklist on the question card. Every answer found on the checklist is worth one point, or two points for more difficult ones. The original game has topics like ”Things you eat at a birthday party”. My version has topics that we have covered during earlier sessions, such as ”Signs and symptoms of hypocalcemia” or ”Possible causes of lower back pain”.

So, this is how it works. A team should have three or four members and I think it is hard to handle more than four teams. To involve as many people as possible in every question I let someone from the opposite teams read the question and mark the correct answers on the card. Every card has a topic with five to ten correct answers. I choose relevant answers from Medscape, so that it is easy to go back to the source if there is any controversy. To avoid unnecessary frustration and endless debates, I thoroughly inform the participants that if an answer is correct, but not on the card, they won’t get any points. Another person writes all the answers on the white board. I have tried both two and three minutes per question and I think two minutes are usually enough.
So for two minutes the whole team is brainstorming around the subject, creating an atmosphere where saying the right thing is less important than coming up with many suggestions. Often wrong answers are corrected by other team members, but it is somehow less intimidating and embarrassing to say stupid things when you are playing a game. And misconceptions are always important to bring out, so they can be replaced by a deeper and more correct understanding.

When time is up, the answers on the board are compared to the ones on the card. Now the group’s collective knowledge has been brought out, and this is when the actual teaching takes place. I highlight and elaborate on some of the answers and also address the wrong ones. It is brief and intense, and nobody dozes off.

The first time we tried this everyone was extremely positive and when it wasn’t included in the next session, they were disappointed. So now I have decided to make it a part of every session. With three teams they can do two questions each in one hour. Normally, a board game gets boring when you use old questions, because you already know the answers, but here that is exactly the point. The old cards can be used over and over, and new ones can be included. My plan is to add at least two new cards after every session, to repeat what has been taught that day. I am also considering adding bonus cards with more specific questions like ”How to calculate the osmolar gap” or ”Branches of the celiac trunk”, for teams that score a certain point.

Unfortunately, I won’t be able to develop this any further, since I am leaving my position. I will keep the cards, though, and maybe challenge some of the other EM nerds over a beer sometime.

If no one is teaching you, you have to learn yourself

When I decided to go to Botswana, there was never a question of whether I would bring my family or not. First of all I wouldn’t go anywhere without them for more than a week or two for selfish reasons, but I also thought it would be a great experience for them. In Sweden kids from other cultures are different, and my kids are part of the norm. I wanted them to learn what its like to be the odd ones out. I didn’t even occur to me to worry about their missing important parts of the Swedish curriculum.

I knew the Swedish educational system was different from many others, that we stress other qualities than theoretical knowledge and are reluctant to encourage good academic results. The teacher will never tell the class who got the highest test scores. There are no grades in public schools before grade 6, and until recently they were actually only given from grade 8. The private schools were earlier not allowed to give the younger students “grade-like assessments“, but I think they can from grade 4 nowadays. It is a controversial issue, since grades and competition are believed to discourage the students with weaker performances. I also knew that we favor understanding concepts over memorizing facts (which we call “sausage stuffing“). As long as the children are reaching that year’s academic and social goals, while enjoying coming to school, the teachers are pleased. No need for anyone to excel.

This view on education applies to higher education as well. In medical school we didn’t have any grades. You passed your exam or you didn’t. Clinical rotations were never evaluated in any formal way. The course coordinator would discuss the students with the other doctors and if there was a problem address it, but as students we never got any feedback from those discussions. In fact, medical students are always complaining about the lack of feedback, not knowing how well they are performing. But Swedes are reluctant to criticize each other, especially downwards in the hierarchy. We like to assume that everyone is doing their best.

I did my second preclinical year in Germany as an exchange student. The structure was different since they studied multiple subjects in parallel, while we were doing every subject separately, so I had to combine courses from two different years to cover everything. Since I wouldn’t have to sit their major exam at the end of the second year, I didn’t have to study too much. The questions for the minor exam at the end of the course were always taken from a selection of questions that you could buy at the copy shop. I guess I was lucky there because it would have been hard for me to study for such an exam. The questions were so different to what I was used to. In Sweden, we were rarely expected to learn details, but more to understand general principles. There wouldn’t be questions about formulas, and if there were seven things listed in the book, they would only ask for five on the exam. In Germany they wanted an exact answer and I passed only because I had memorized the correct answers. (My memory didn’t serve me all that well, though, and the teacher marked one of my answers ”intressanter Satzbau”, indicating that my German offered a new approach to constructing sentences.)

When I got back I had to have my courses recognized by the Karolinska Institute. I went to the director of pathology to discuss what I had done during my time in Germany. It turned out I had only taken the first out of two pathology courses, but should have taken both. He asked me a question about different kinds of lung tumors that I actually knew the answer to and we agreed, on my request, that I should take part in a few postmortems. He didn’t find it necessary for me to do anything else, since “you always learn a lot from living and studying abroad“, as he put it.

Our internships and residency programs follow the same pattern of minimal assessment and feedback. There are occasional compulsory sit-ins, but there is no daily feedback and definitely no ranking among the interns and residents. Who is to say that one is a better doctor than the other?
Any hospital in Sweden can train residents. If it’s a smaller hospital, part of the training has to take place at a university hospital. But there is no accreditation of the residency programs. In fact, I wouldn’t really call them programs. There is continuous teaching, but there is no study plan for the full five years. Instead you are supposed to write your own study plan together with your supervisor, deciding what courses to take and what rotations to do. All the residents go to the same sessions, if you are off on parental leave for a year, you just join the group again when you get back. You don’t actuallly even apply for a program, but for a job at the department where you want to work. For most specialties it is not that hard to get a six month contract. If you do a good job you will probably be employed as a resident after finishing that probation period, which will count as part of your residency. Nobody keeps track of what year a resident is in. You are not expected to work more than the regular 40 hour week. On calls and shift work are considered overtime and compensated with free time and extra pay.
There is no ranking of the different hospitals and it doesn’t really matter where you did your training. Your place of training won’t haunt or help you in your future career the way it seems to do in the US.

The National Board of Health has set the requirements for specialist certification. There is a chapter for every specialty, but they are all quite similar and vague, stating that you have to know how to manage the “common and important“ diseases within that field of medicine. The professional organizations of respective field are responsible for putting together a curriculum. When I was finishing my internal medicine residency that curriculum was being revised, a process that took several years. In the meantime there was no curriculum. They decided to revise the specialist exam, too, so I never got the chance to take it. It doesn’t really matter, since the specialist exams are not mandatory. Actually, the National Board of Health won’t allow the professional organizations to make them mandatory. I don’t know that employers ever ask if you have passed the exam, but I guess doctors who have will at least put it on their CV.

SWESEM, the Swedish Society of Emergency Medicine, has created the most extensive and detailed curriculum of all medical specialties in Sweden. As a young specialty that not many have heard of and even fewer understand the concept of, it was given a top priority to define the area of competence. Our curriculum is similar to the European curriculum and those of other European countries.

But that curriculum is constantly questioned, not only by other specialists, but among the residents and the directors of EM residencies as well. Many directors argue that it is difficult to teach EM resident airway management since patients are rarely intubated in the ED and it is hard to arrange rotations in the anesthesiology department (and we all know that airway management in the OR differs from the ED), besides “why learn something you won’t use and will forget how to do after a while?”
The same argument is used about gynecology, ophthalmology and ENT, at least in the large hospitals. I don’t think doctors working in smaller hospitals in remote areas object in the same way, since they have to be prepared to treat whomever hits the door. But in a small-volume ED, chances are they won’t see the whole spectrum of presentations.
Either way we will all be specialists in the end. Your personal supervisor (one of the consultants) and the head of the department decide when you qualify to apply for a specialist certificate and then the National Board of Health goes through your paperwork to make sure you took the right courses and did adequate rotations. That’s it. That is our specialist training.

A resident in family medicine was doing a terrible job during a rotiation at our department of internal medicine. He lacked fundamental knowledge in medicine and 11the director of our program wanted to fail him, but the director of his program said it wasn’t up to us to do so. He finished his rotation and moved on with his training. This is the downside of our system. As forgiving as it might seem, underachivers are never given a chance to better themselves. No one will tell them that they aren’t good enough and need to try harder, instead they will be regarded as lost causes and other doctors will try to avoid getting involved with them.

I do believe our system needs more structure. Residents need to know what is expected of them and feedback is essential for learning from your mistakes. Reading books and journals should definitely be part of a specialist training program. Knowing your basic sciences helps you understand the principles of clinical disease and I have tried to make up for that year in Germany. But when I hear educators on medical podcasts stress that ”this is something you need to know for your board exam”, I feel pretty good about not having to bother my strained memory with facts that I will easily look up if I ever need them. I just wasn’t taught that way. What is striking, however, is that even without grades, evaluations, promotions and other kinds of encouragment, most of our doctors do well. We provide good care for our patients, following evidence based protocolls, when we find them reasonable, and make adjustments when we don’t. Doctors are never sued for malpractice and since the abolition of the disciplinary committee a few years ago, we don’t really face any consequences when our patients don’t fare well. The only incentive for us to provide excellent care is that we care about our patients. But in the end, I think that is what makes great doctors all over the world. In my experience, the lack of interest in the patient is a much bigger problem than the lack of theoretical knowledge. Still, good doctors always want to learn more.

Emergency medicine in the slow lane

februari 15, 2012 4 kommentarer

Emergency medicine is a new specialty in Sweden, only recognized in 2006 as a supra specialty. Basically that means you need around nine years of postgraduate training to qualify as a specialist, but still get very little emergency medicine training and exposure. The emergency departments are run by the respective departments, which can add up to eight separate sections under one roof. And I think it’s safe to say that none of the doctors working there follow the EM literature. It’s like evidenced based medicine is reserved for their patients upstairs. To get them to accept that emergency physicians take over their on call work is not a problem, but to make them realize that that will mean a change in practice is much more difficult. They are all willing to teach us their part of emergency medicine, but there are no role models to convey the integrated knowledge. Instead we have looked to international bloggers and podcasters. It has been hard to see how this could be translated to our setting, so I wanted to go somewhere where emergency medicine was an established specialty and my first choice was Australia. Unfortunately that turned out to be too complicated and expensive and I ended up in Botswana instead.

It is fair to say that my experience in Botswana fundamentally changed my perspective on emergency medicine. Talk about culture clash! I knew that Sweden was a developing country when it comes to emergency medicine, but I didn’t expect the gap to be so wide. Of couse it was tough to get used to the heavy burden of disease in this relatively wealthy country, but it was being caught in the interface between advanced, anglosaxian emergency medicine and the more improvised, basic emergency care that made me realize that I didn’t know what I was aiming for in Sweden.

I had tried to describe to the EM specialists in Botswana beforehand, how I lacked training and experience in certain areas. Like Gyn/OB, for instance. We don’t see these patients in Sweden since there is a separate ED for them. As a resident you will do a rotation there, which I hadn’t done yet, but you will be taught by gynecologists who don’t really see the point in your learning something that you won’t be dealing with once you leave their department. Another thing is trauma. I work in the largest ED in Sweden and we don’t see severe trauma cases. Of course the occasional patient wanders in after being stabbed or stomped by a mousse (actually that only happened once, to my knowledge), but it is definitely not part of our daily life. And in fact, hardly a part of our training. Of course we take ATLS and other courses, but in terms of exposure we get two weeks at the trauma center, where they see around 300 severely injured patients per year.

But it is not only the trauma cases that seem to be a lot less frequent here. I have only seen one crashing asthmatic patient. We mostly get old COPD patients with exacerbations. DKA is rare, too, in adult patients. It is hard to find another explanation than that these patients are being adequately treated in primary health care.
We have a high suicide rate in sweden, but I have never seen a serious intoxication on TCA, beta blockers or calcium channel blockers. When I was talking to the second year residents the other day, most of them had never seen a blood transfusion given in the resuscitation room.

I tried to tell this to my EM specialist colleagues in Botswana, but I don’t think they believed me. Admitting everything you don’t know is never pleasant, especially not when people are surprised that you don’t know the basic things. Like placing a chest tube. I have never seen a chest tube placed in the ED. The same goes for central lines, but maybe we just missed that train, since CVP is going out of fashion and IO is gaining ground for the really acute cases. But if one was to be placed, someone from anesthesiology would come and do it, in no time. Just like they come and intubate the patient if necessary, which is rarely done in the ED. Cardiac arrests are often intubated in the field by a nurse anesthetist. (I won’t go into whether that is optimal practice or not.) If the critically ill patient needs to be intubated, they will mostly be taken to the ICU and have the procedure performed there. An emergency medicine program director even questioned that intubation skills were necessary for emergency physicians!

My hospital only has around twenty ICU beds and it is hard to get a patient admitted there. The STEMIs go there of course, but they bypass the ED and go straight to cath lab, so we only see the not so obvious ones.

What it all comes down to is that as much as we need to increase our resuscitation skills for the really sick patients, these cases are not common enough for us to train a large number of emergency physicians. Our work is more of preventive emergency medicine and driving in the slow lane. And even though I would love to bring upstairs care downstairs, I have to ask myself if the outcomes won’t be better if we keep bringing downstair patients upstairs.

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