Saturday, November 21, 2009

Bright Lights, Big Residency

This week the program director for the family medicine residency program in Newfoundland came to speak to the Canadians in our group about working and/or doing a residency in the Maritimes.

I am not going to make a secret about the fact that if I HAD to choose a residency at this exact moment in time it would likely be a 2+1 program in emergency med or anesthesiology. In Canada we have these residencies where you do 2 years of family medicine and then a year training in a specialty like emergency, anesthetics, surgery, oncology, womens health, etc.

This allows one to practice in only a slightly limited scope in that specialty. For example, you can work as an ED doc in any non-tertiary emergency department, you are not an ERP...but you can perform the same procedures as an ERP in a clinical setting. To be honest, I'd love to do a 2+1+1 in emergency and anesthetics.

This is why.

Last summer I worked with several South African anesthetists who also worked in the ED as emergency docs. When things got hectic, they had just that little additional skill edge of being uber comfortable with paralytics and hypnotics--and were also very proficient with procedures like lumbar punctures, intubations, nerve blocks, central lines, etc.

I thought--schizzammm! This is the perfect combination of backgrounds to be a very badass and on-top-of-things ED doc. (I know that this may have also been partly because they were Saffas and just used to doing 100 intubations a day and sewing people's arms back on in the ED when they worked in SA.) Regardless, it really got me thinking. It is so useful to have the two skill sets plus a great way to be prepared to work in rural emergency and international medicine situations.

Back to the Newfoundland presentation.

The program director was talked a lot about how they specifically orient the program toward eventual rural practice, they in fact have a 2+1 program for emergency medicine, and they choose their large hospital attendings very carefully--i.e they choose surgeons, internal med, obs specialists who actually believe in the importance of a very well trained family medicine physician. They don't want you to be the lowest rung on the ladder when it comes to procedures or input. Apparently the school feels so strongly about this they will actually put you in a different rotation if that starts occurring. Pretty amazing if you ask me.

So I asked him what his thoughts were on training in a large urban setting, like Toronto or Vancouver in ED's where you are going to see a lot more trauma, many MI's, septics, etc. and perform dozens of procedures a day...vs...doing a program that is rural focused and set in rural hospitals where you may have a lower volume of the high acuity presentations. Which is better for someone who wishes to set up practice in the Back 40?

He told me as a 2+1 resident in a major center I'd be the bottom rung and even though the high acuity presentations are more plentiful there will be 4 specialist residents and a fellow ahead of me in line to even peek at these presentations. Many specialists will feel I am a waste of their time because I 'only' want to do family medicine (which is kinda funny because I don't actually...I want to work in an ED but I don't feel like doing a 5 year ERP specialty is really necessary for my career aspirations). I know that in the hospital the ED docs are crapped on by the specialists anyway so I am used to that...but I digress. He also said since in the rural hospitals I'd be 'it' in terms of residents I'd get to do as much work and as many procedures as I wanted. Be on call as often as I wanted. This definitely appeals to me. And I can certainly relate to working with the docs who trained in an urban setting and then were clinically very useless when they first got to rural settings where there was no neonatal team, no stroke team, no respiratory therapist, no 24h lab...madly tapping into their Blackberry's 'does NOT compute!!!'

Anyway, the presentation certainly gave me food for thought regarding residencies. I am still unsure of the best way forward. A part of me also is intrigued by the 3 year emergency medicine residencies in the US. So we shall see. I know that as an international applicant I need to blow the USMLE out of the Time will tell what my options will be. It is a long way off but these days I need to see that there is an exciting light at the end of this tunnel.


Beach Bum said...

Definite food for thought. I'm now falling in love with obstetrics, and considering a 2+1 in FM/Obs. Ugh. So many choices, so little time. (And such a big loan to pay off)

Albinoblackbear said...

That is amazing--what a surprise, no? Well good on ya..the world certainly needs more FM docs willing to do obs!

And um...yeah I HEAR ya loud and clear about the loans. I've toyed with the idea of going back after a couple of years for the +1 part of things as well.

Liana said...

The +1 in emergency medicine is pretty competitive. I don't have any solid stats on this, but it's probably harder to get in if you go off and work for a few years then try to come back and do the +1.

You can actually challenge the exam in emergency medicine without doing the formal R3. I know many rural doctors who have done this successfully.

Albinoblackbear said...

Yessss...there is some definite competition for the +1, but I have worked with rural ED docs who were actually invited to the residencies to increase services in the remote locations they worked in. (This may be only a UBC thing my anecdotal evidence with this has been with BC docs...)

Yeah, challenging the exam is also an option. But I have to say when I look at the rotations for the emerg +1 they look pretty fun (plastics, ortho, etc.).

I am sure by the time I am done medical school and a couple years of res I'll be so haggard that only sleeping will seem like fun though... :)

Keet said...

Definitely try and do a lot of plastics rotations. The microvascular and suturing skills will pay off. Besides, I'm going to need some work in a few years. Mates rates right? Right? *wink* I can be your practice nurse.

Albinoblackbear said...

Keet--yeah if you keep burning your tuchas off in Spain I'm going to be turning your solar-elastosed skin into a leather handbag!! :)

Mates rates? But of course.

Anonymous said...

Just a bit of a clarification for you - the 2+1 docs can absolutely work in tertiary care hospitals. Lots of CCFP(EM) docs working at St Paul's in Vancouver, Foothills in Calgary, and St. Michael's in Toronto (all major trauma centres). You'd be MORE likely to get a job with the FRCPC, but it's achievable.

Albinoblackbear said...

Thanks Anon--yesssss...I do in fact know of a couple of docs working at St.P's that are CCFP(EM)...good to know they are elsewhere though too!