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Knowing Our Limits So I am now t...

Posted Sep 12 2008 9:29am

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.
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