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Posts Tagged ‘Emergency medicine’

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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Emergency Medicine in the Evidence-Free World

november 21, 2011 Lämna en kommentar

Cape Town in November. Sunshine and the fresh air of spring make the third biennial conference on Emergency Medicine in the Developing World a tempting event. I have been looking forward to meeting other Emergency Physicians who face the same kind of dilemmas as I do in Botswana. Knowing what the right thing to do does not help you much when the right equipment and medicines are not available. There are so many things I have to relearn. As far as I understand this conference is a South African initiative. Most delegates are from Africa. A few Asians are to be seen, probably because they are there to present a poster. The speakers are almost exclusively from South Africa, the UK or North America. Without exception they are well prepared and excellent speakers. Maybe it is their fluency in English, maybe it is that they are clinically active and try to make it relevant for anyone who is. Regardless of which they make most of the professors I have listened to at the EuSEM conferences seem rather dull. Emergency Medicine in Southern Africa is a lot of trauma and a lot of infectious diseases, mainly HIV/AIDS and tuberculosis. We do not have a significant amount of either in Sweden. Even though I might have sufficient theoretical knowledge, I definitely lack the necessary experience to function as any kind of specialist or expert in this setting. South African doctors unfortunately have a lot of experience of both trauma and AIDS and the ones who work in tertiary hospitals have access to fairly modern equipment and treatments. They are fully aware, however, that that is the exception rather than the rule. Somehow they manage to make their talks relevant for my practice in Sweden as well as in Botswana, which I find impressive.

Most of the speakers from overseas have no experience of working in a resource limited setting. They proudly present the evidence for how to treat hemorrhagic stroke and seem taken aback by questions about how to make that diagnosis without a CT scanner, or rather, they can present the evidence for why a scan is necessary, but not offer much guidance on how to manage the patient with sudden hemiparesis when a CT scan is not an option. Some speakers realize the problem and admit it during their talk. Others promise to teach us things that we can take back to our next shift. We are then presented a patient who is bleeding on Dabigatran, a drug which, at least as of Aug 1 2011, has only been approved in one African country, namely Namibia. The drugs that are suggested for reversal of the coagulopathy and could be of benefit (nothing really seems to work) cost hundreds of dollars and are definitely not avalaible in most hospitals. Where I work it is often hard to get even 0 negative blood. I wonder if there is even evidence to suggest that anticoagulation is beneficial for patients with AF in this setting where trauma is common and helicobacter pylori infection is highly prevalent. The mortality of acute gastrointestinal bleeding for patients admitted to the ICU in Togo was 45%, even without anticoagulation (Med Trop (Mars), 2010 Jun). If there is no evidence available you cannot practice evidenced based medicine. You can only do what seems reasonable, based on what you do know. Using evidence from a totally different population is likely to do more harm than good since it makes you think that you are actually practicing evidenced based medicine and reduces your critical thinking.

To lighten up the talks some show a few slides of their hospital and home town. During a talk on intensive care we are shown a hospital with more than 200 ICU beds, with another 100 beds on the way. We cannot believe our ears. No wonder that intubating a patient does not seem to be a big deal! After the talk a Sudanese Emergency Physician has a question: – In Khartoum, with a population of four million, we only have six ICU beds and two ventilators. How can we intubate a patient and maintain eucarbia. Should we just bag them? The fancy EtCO2 curves just faded away. -Yes, just bag them at a rate of 8-10 breaths per minute, the speaker replies. He has nothing else to offer. – For how long? For 24 or 48 hours? She is trying to use his expertise to improve her practise, but probably also to make a point. – 24 hours, 48 hours, as long as you have to. In this case it is obvious to me that the expert cannot provide better care than the medical officer in the local hospital. Everything we do requires a risk-benefit analysis and the results of those analyses in the US are just not applicable to a resource limited setting. Doing the right, evidenced-based thing here, might kill your patient. An intensivist from Angola told me how he and one nurse were responsible for fifteen patients. When there was a power cut the ventilators stopped working. Two sets of hands cannot possibly ventilate fifteen people and they had to prioritize, sometimes letting the patients with multiorgan failure die. Disturbingly familiar with equipment failure, they knew not to keep the patients too sedated, which in a first-world setting might not be good practice, but in this case saved lives, since the patients could breath for themselves. It is important to emphasize that good practice might not be so good if the patient ends up dying as a direct cause of it.

Somethings are barely mentioned during the conference. Things like how basic barrier care and good hygiene reduce nosocomial infections and save lives, just like team work and good communication do. The South African speakers like to refer to some treatments as ”sexy”. They generally refer to intensive insulin therapy or advanced airway equipment when they say that, not team training or alcogel. I cannot say that we are good role models in the rich world, either. Reducing complications by washing your hands does not give you the same status as using more advanced and expensive measures. The means are sometimes more important than the end itself. To practice medicine in a resource limited setting is of course much more difficult, but it is also in some ways easier. The patients present late with findings on their physical exams and x-rays that are easy to appreciate. In the rich world we are searching vigorously for indications of disease, feeling a need to provide evidence for absence rather than presence of disease. Many of us realize that we might have taken it a step too far, but it is very hard to stop investigating and treating diffuse chest pain or pleuritic chest pain in healthy young women who are found to have a minor pulmonary embolus.

We can use our experience and knowledge to help the development of emergency medicine in Africa, but if we do not learn from the experience and knowledge that the doctors here have, it is probably not going to benefit our own patients. Following the development here, we can learn which of the interventions we consider standard care, actually carries the highest benefit. What is the minimum acceptable care, and how big is the difference in outcomes between the two? In a tax financed health care system, as we have in Sweden, the resources are definitely not unlimited and it would be great to know what the natural course of small pulmonary emboli is. I know that we do not see a lot of young women who are brought in dead after an episode of pleuritic chest pain here in Botswana. Working together with the local doctors and universities we can improve the evidence for patients everywhere. Or, we can pretend to have all the answers and just give them a lecture on the Wells criteria…