Wednesday, January 30, 2008

Residency Interviews

In Canada, most residencies are at least 5 years and while it is possibe to switch programs, this is by no means a given. This means that the both the specialty and the site where you do it have major implications on your life.

We have a national match in Canada. Residency programs rank their applicants, applicants rank their residencies; the computer spits out a match. To ensure that they get at least a job next year, students are advised to apply to as many programs as possible including at least 2 different specialties (one resident blurted out that he was applying to urology so anaesthesia was his fall back). Each residency however still interviews its own applicants and while some specialties have centralized the process so that students can travel to one city to interview to all their desired programs; most including anaesthesia don't. The one concession is that most programs have coordinated their interview dates so that students can make a single road trip for all the interviews at least within a single region. You can imagine the expense of travelling to 14 programs which I think is the average number applied to. This is after 6-8 years of university and medical school.

Which leads to to what I did today which was to interview 14 prospective residents. Now given my antipathy for the CoE where the residency program is based, one wonders why I would even bother to volunteer for this but the fact is they asked nicely; I actually like the program director and her secretary; they sounded desperate and I thought it would be classy thing to do.

Now I only got back into town the day before and had to spend the evening before, on the web reading over the information of my 14 interviewees which are published on the web. The first thing I realized was that I was about to interview 14 individuals whose shit not only did not stink but had never stunk.

The problem is that most residents seem to be well coached into writing a really good personal letter and with work processing it is really easy to personalize a leter to each program you are applying for. People get letters of reference from staff they have had a good experience with; staff are of course reluctant to spoil a student's career by giving them any less than a pristine letter of reference. Further because programs vary so much in Canada, looks at their marks is of no help.

Therefore the half hour the applicant spends with me becomes important.

In the interview we ask the applicant a lot of general questions (I had a lot of fun asking them what their favourite medical TV show was). We look at how they answer these questions, their body posture, general demeanor etc. We are not allowed to ask them where else they are applying, are they married or do they plan to have children.

Problem is, none of these have any bearing on the applicants ability to be trained as an anaesthesiologist or any other specialty for that matter.

At the end of the day, all 14 applicants, I interviewed I could live with as residents. Some I really liked, some I liked less. I assigned them scores between 7 and 10/10 we talked them over with the program director. She will have the huge job of ranking them based on my "objective" score and by reading their documents. Later this year the computer will spit out what they will be doing for the next five years which will have a major bearing on the rest of their lives.

And I have participated in this whole exercise and quite frankly I'm not sure what I accomplished.

Tuesday, January 15, 2008

My Jehovah's Witness Story

It seems everybody has their JW war story. Here is mine.

A couple of years ago when I still worked at the CofE I was on call for neurosurgery and was called in one Saturday morning to give an anaesthetic for an aneurysm clipping. The patient was already intubated and had lines in (I call this plug and play). We put in the head pins started the surgery and I got down to reading the Saturday paper occasionally glancing at the monitor.

A former resident called neurosurgical anaesthesia " a gall bladder with mannitol". Despite all claims to the contrary neuroanaesthesia is dead easy. Various anaesthetic drugs have some effect on ICP and CBF and I did learn all these things during my residency. If you think too much you will be anaesthetizing all your patients with lidocaine and pancuronium because those are about the only drugs that don't do something bad. However after a while you realize that the neurosurgeons could not give a shit about what drugs you use, as long as the patient doesn't move, the brain is relatively slack and the patient wakes up when the surgeons wants them to (either right away or several days later). Further the patients either do well or badly and it has nothing to do with what you did (which doesn't stop the surgoens and worse still your colleagues from pointing the finger at you)

I was well into the sports section when somebody phoned into the room to tell us that they thought that the patient might be a Jehovah's Witness. Now aneurysms rarely require blood products (except for giant aneurysm and when those rupture you may as well just turn off the ventillator and go for coffee). So I did what the surgeon should have done before the case, I read the chart. I didn't find the blood refusal form but I did find a personal directive naming her sister as her power of attorney. Around that time somebody talked to her husband who stated that he wasn't aware that his wife was JW but that they had only been married for 6 months. Soon after I was told that the sister was on the line. By this time the aneurysm had been clipped. I told the sister that it was a moot point at this time but that given that her sister obviously wasn't a practising JW anymore would she consider allowing her brother-in-law to permit his wife to accept blood products. She of course refused at which point a man (presumably the father) came on the line and asked why we wouldn't use alternatives. I explained that we actually always used alternatives unless we felt that the patients life was in danger and hung up. The cranie was closed; another JW bullet dodged.

Not quite.

Around 1800, I got a phone call stating that I needed to come in for another cranie in this patient due to bleeding. Before I drove in I suggested they might want to contact the hospital lawyer about the possibility of giving blood products but nobody took my advice. The surgeon did talk to the sister who was still insistent on no blood products.

I was never clear on why the re-bleed occured. At the time it seemed that the patient had somehow become hypothermic and had developed a hypothermic coagulopathy. Her temperature was 33 and using all the resources at my command, I just couldn't seem to raise it. A quick internet search suggested that platelets might work in this situation but of course we couldn't give them. I of course can't rule out poor surgical technique and hemostasis. Anyway the surgeon poked around, cauterized and clipped for about 2 hours before closing up and we went off to CT to see whether we had accomplished anything. The CT showed a hematoma as big as the one we started with and we shipped her off to Neuro ICU presumably to die.

Now I of course felt sorry for the patient who may have died and at best would have been left brain dead. I also feel sorry for the husband whose wife of six months was now not the woman he married and hopefully was still in love with. All this because of the whim of his sister-in-law who, if he didn't know that his wife was JW, he probably had never met. Now many faiths have beliefs that are completely irrational, I am not going to give examples, you know who you are. It just seems that JWs consume a proportion of health care resources way in disproportion to their numbers. Consider everytime you have a JW coming in for major blood losing surgury, say a hip revision or liver tumour. These cases usually become a major military operation. There are usually consultations between multiple surgeons, hematology, ethics etc. Sometimes they even consult anaesthesia. The patient if he survives will have an ICU and hospital stay at least twice as long as normal.

Now you might ask, shouldn't we in a perfect health care system be prepared to do everything the patient wants to get him thru surgery. Yes, except that healthcare is a zero sum game. Service given one patient is service denied to another patient. If you spend an extra day in ICU, that is another patient whose surgery is cancelled, or who has to be looked after on the medical ward instead of the ICU or who has to transferred to another city or is on a ventillator in the recovery room.

Now somewhere in Richard Dawkins' book "The God Delusion" he pointed out that we are much more tolerant of irrational or stupid beliefs when a religion is attached to them.

Suppose I am about to undergo surgery where major blood loss is expected. Now I hate the Montreal Canadiens with a passion. I have decided that I will not accept blood from a Habs fan. Because the Canadian Blood Agency does not ask whether you like the Habs (which is in my mind WAY WORSE than paying for sex) I will not accept blood from them. Directed donation even if it were allowed would be out because I cannot be sure that my blood might be contaminated with a Habs fan's blood.

Even the biggest Bruins fan of a surgeon would flatly refuse to operate on me. There would be no meticulous planning, no ICU stay, no ethics consult. There might be a psychiatric consult.

An extreme example?. Only a question of degree. Afterall ethicists often justify the JW refusal blood by citing less extreme examples of other faiths (Catholics refusal of abortion, Jewish refusal of autopsy). It works both ways.

Saturday, January 12, 2008

Is it time to bring back hospital nursing schools?

The convergence of a number of circumstances in my life has lead me to ponder this.

1. We have a severe nursing shortage which is leading to cancellations of cases in the OR which is of course affecting my income. (This would be nice if my income was reduced by just working less; however a significant proportion of the lost time is time sitting around seeing if they will be able to do your case.) The reason is that years ago when it was decided that healthcare was too expensive and that the work of a RN could be done by cheaper workers, many nurses were laid of, retired, took up other jobs etc. Of course after reading about layoffs of nurses there was very little incentive for young people to go into nursing and secondly because we were lead to believe that RNs were unnecessary, nursing programs were reduced. Now in order to train the number of nurses necessary to run the system at it's present capacity, we are told that it will be necessary to have more academic nurses which means that we will actually have less nurses involved in patient care before we have more.

2. My wife is retraining as a nurse after being out for about 10 years. (Any nurse who reads this, no matter how bad nursing seems or how good life as a housewife looks, DO NOT let your registration lapse; work the minimum necessary to keep it; read on). This has involved over a year of home learning with periodic exams mostly covering irrellevent information, some of it incorrect (the parts dealing with anesthesia, which I know a little about, for example). Now she is in the middle of a one month unpaid practicum after which I am lead to believe if she pays her fees she will be a RN again.

3. My son is taking engineering at University. One popular option at his and other Universities is the co-op program where they get work experience and earn a little cash while pursuing their degrees.


Historically most professions learned their craft on the job by apprenticeships or other forms of servitude. This includes doctors, lawyers, accountants and nurses. Around the turn of the century (20th that is) doctors, lawyers and accountants began to go to universities although there was still some form of servitude involved.

While there were university nursing programs early in the 20th century, most nurses were trained in hospital schools. In addition to lectures, they worked on the wards and were considered an important part of the staffing of the hospitals involved. They lived in nurse's residences, got free room and board and were paid a small stipend. Gradually these hospital schools were closed and the only route to becoming a nurse was thru universities, community colleges and technical schools. (When I joined the CofE, there was still a hospital school attached which graduated its last class the year I started). Many nurses I work with now are graduates of these hospital schools and speak fondly of their experiences, both learning and social

Now many nurses would argue that nursing is a profession as dignified as medicine, law, accounting and others that now require degrees and I have no arguement with that.

However as mentioned above, many university professional schools now offer co-op programs which are surprisingly like the old apprenticeship programs that these professions evolved away from. So why not start some type of co-op program for nursing where after some basic training they can hit the wards, and help out while getting some valuable experience. They would receive some type of stipend for their time. They could be affiliated with universities of professional schools. After getting their RN, they could have the option of obtaining a BSN either by attending university full or part-time.

I think that besides being an immediate partial solution to the nursing crisis, this would enhance the practical experience of the graduate nurse.

Thursday, January 3, 2008

Happy 2008

It was just over a year ago I started my blog. Actually I started another blog, then couldn't find it, started another blog, found my first blog but continued my second. I must say Google Blogger is actually working a lot better than when I start and it is a lot easier to post my blogs.

I am still finding it very difficult to post as frequently as some other bloggers. I like to think it is because I have a life, however when I look at what some of the other bloggers do, I wonder if it is me that needs a life.

I started the blog to express my views on life both inside and outside of medicine. I am gratified that some people have actually read my blog, some replied and some even linked to it. Thanks every one. By the way I really am not as bad a speller as it appears. I am a really lousy typist however and I just can't seem to remember to use the spell checker provided.

I wish I could say that I will post more in 2008 and maybe even make my blog less lame and even add some pictures.