Friday, February 18, 2011

When no doctor is better.

This story popped up recently. A similar story pops up a couple of times a year in Canada. Sometimes it is a radiologist, it could be a surgeon, even an anaesthesiologist. CT scans came into being while I was in medical school which is a really long time ago so if a radiologist hasn't been trained in reading what has become a pretty basic test, one has to wonder when did he train and the real question which the story doesn't answer is where did he train?

On the other hand except when a CT scan is done for trauma or a suspected intracranial bleed, interpretation is pretty much something that needs to done in days not in minutes. Urgent CTs are usually read by surgeons or ER docs anyway. Remember, a CT scan is a computer generated interpretation of multiple X-ray beams which means the image we seen on the screen or in the old days printed on a film, is really a series of 1 s and 0 s which means that it can nowadays easily be sent electronically in real time to be read by somebody who knows what he is doing. This is already being done and we of course hear of X-rays being outsourced to other countries.

Surgery and anaesthesiology of course can't yet be reduced to 1 s and 0 s which means that both of us have to be on site to do our jobs. This is causing problems in rural Canada and I suspect in the rural US.

Canada and the US are gradually becoming exclusively urbanized countries. In our province which is felt to the redneck heartland of Canada, 2/3 of the population actually live in the two largest cities. Rural populations are shrinking or not expanding; our neighbouring mostly rural province has the same population as it had in 1920. No one is denying the importance of the rural areas in producing our food, our lumber,drilling for oil and mining our minerals; clearly people need to live in there and clearly people want to live there. Increasing the rural population is devoted only to those activities with the rural population seeking services in the cites. Many people in fact involved in activities like mining and oil live temporarily in those communities while their families now live in the cities. Whereas people in rural areas used to buy their clothes at the local Saan, their hardware at the local hardware store and their groceries at the local grocery store, they now drive 1-2 hours to shop at Winners, Home Depot and Costco.

When I was in medical school, smaller hospitals still did a lot of surgery. The surgeons were usually individuals who had done a lot of surgery either in a formal residency training program or as medical missionaries. They did general practice as well and could do hernias, gall bladders, Caesarian sections and some orthopedics. A few of the these surgeons were Brits who had gotten sick of waiting for a consultant to die so they could have his position and they were very well trained. More recently we have South African surgeons fleeing their country for greener pastures who are largely good surgeons as well. (There was the embarrassment of the South African orthopedic surgeon practising in rural Saskatchewan who was wanted by the Truth and Reconciliation Commission to explain his actions while working with the army; something about death squads.)

Times are changing. Surgical training is increasing becoming pyramidal with senior residents doing a lot of surgery and junior residents doing almost none. The days when a doctor who was interested in doing a little surgery could sign up for one or two years and expect to get experience are over. I suspect the situation in other countries in the British Commonwealth where a lot of Canadians went to get surgical training is the same. At the same time job prospects for Brits are better with the government having created more consultancies. Further, graduates of Canadian training programs are reluctant to move to rural communities where they can be guaranteed to be on call all the time and may have to supplement their income by being family docs (something which under our licensing policies isn't even possible anymore).

Anaesthesia in rural areas is provided by what is a uniquely Canadian job, the GP-Anesthetist (GPA). These are family docs who have done an extra year of anaesthesia training. Our program trains these individuals, they are for the most part excellent well motivated docs. (Many of them in fact chose to do the entire residency). In the community these docs typically will do one or more morning lists with their offices in the afternoon. They also take call for anesthesia in their hospitals.

Back in the 1990s when jobs for specialists were lacking we noticed that quite a few suburban hospitals around our city were being staffed by these GPA s, some in fact were working full-time in anaesthesia. Many of us felt that these ORs should be staffed by specialists and the result was that another of the hospitals in our city refused to train GPA s. This precipitated the usual shzt storm and we were able to reinstate the program with the stipulation that the trainees had to be sponsored by a community suitably distant from our city with a "commitment" to work there. These commitments and $1.65 will get you a coffee and there still are a number of GPA s encroaching on our city (largely because specialists don't want to work and take call in those suburban hospitals).

When working with a GPA trainee I try to emphasize what should be the key point in their training. Not what they can do but rather what they can't do and more importantly what they can do but shouldn't do. For example a certain surgical procedure may be well within the skill set of both a surgeon and an anaesthesiologist but the hospital may not be able to care for the patient post-operatively. Worse the anaesthetist may be able to give a good anaesthetic but the surgeon may not be able to do the surgery competently or worst still the surgeon can do the surgery but the anaesthesiologist cannot do the patient. An interesting case took place many years ago in a rural hospital with an itinerant surgeon from the city. The surgeon wanted to do a hernia repair in a neonate. The GPA quite correctly said that he could not do the case. The surgeon who is a bit of a bully offered him a compromise. "I will start the IV and intubate the patient for you," said the gracious surgeon. You know where this is going. The surgeon could start the IV but couldn't intubate or bag the patient. There was a lot of fuss and apparently the child did okay and had an uneventful surgery weeks later in the city hospital to which he should have been referred in the first place.

The justification for keeping operating rooms open in these small centres is often so that locals can get their surgery close to home. Frequently now much of their surgical volume comes from itinerant surgeons from the city who are looking for OR time and compliant anaesthesiologists who won't trouble them with concerns about the patient's medical problems, ICU beds or regional blocks. The patients are as likely to have come from the city as they are to be locals. Full-time surgeons have as I mentioned above largely fled these smaller hospitals. A few specialists have actually been allowed by smaller hospitals to develop boutique practices where they practice their specialty in the hospital but do not do trauma or take call.

The problem is as has become very clear is that as surgical volume drops complications go up. In fact the administrator of our hospital at a meeting was quite clear about this when she said at a meeting I was at that if you have surgery at a hospital with fewer than 50 beds, you are putting yourself in harm's way. She said this in a closed meeting. No public official would ever say that in public.

People in small towns while happy to drive to the city to do their shopping are attached to their little hospitals. Reducing any service, let alone close them is political suicide. In many small communities the hospital is the town's largest employer. Closing these hospitals is not the answer, they need their emergency rooms, they need to be able to stabilize patients for transport,they need to be able to take patients for short admission and be able to act as convalescent care areas where people can recover from surgery or serious medical problems close to home. It is hard to think of an surgical problem that is not amenable to stabilization and transfer to a more advanced surgery centre.

Obstetrics is of course the justification for most small hospitals keeping their surgery units. This would be a good justification except that currently many of them are transferring in their patients to deliver in the city as family docs flee obstetrics or refuse to be on call 24/7 meaning that our hospital gets a significant number of transfers because nobody in town is doing obstetrics that (usually) weekend. Further it is getting harder to find someone trained in general surgery who is capable of doing a caesarian section. The days of surgery (or obstetrics) residents doing off-service rotations are over.

But getting back to the problem of the less than competent radiologist; we also have the problem of the less than competent surgeon who is hired to staff a rural hospital. I have actually spent whole evenings on call where every case we did was a complication of surgery done at rural hospitals by surgeons with questionable training.

We also have the problem of the less than competent anaesthesiologist. A few years ago we had an apparently specialty trained anaesthesiologist from another country who married a Canadian teacher who lived in our city. She asked to do a self-funded (meaning unpaid) residency which our chairman approved. I soon noticed she was showing up in my room to work with me quite a bit. She was very pleasant to talk with but in my mind was functioning at a very junior resident level and had some very bad habits. After a while she asked me if I would do a letter of reference for her. I assumed that she was applying for a Canadian residency which we had discussed. It was with some shock that about a month later I received a letter from a hospital an hour away asking for a letter of reference for a staff position. As I said, I like her but I felt I could not recommend her; I talked with the residency program director, who disavowed any responsibility for her saying it was the chairman who had arranged her "residency". I therefore wrote a letter stating that I felt that she was not capable of independent practice to Canadian community standards. She still got the job.

The point of all of this is that sometimes it is better not to have a doctor at all and deal with that problem than to have a doctor who is incompetent. This is not limited to specialists, an incompetent family doctor can hurt rather than help a community. The resources needed to keep these small operating rooms operating could be more efficiently used opening more rooms in larger centres. Residents of rural areas want access to health care which is understandable; what they fail to realize is that by keeping access to less than competent care they are preventing themselves and unfortunately others from accessing competent care.


Anonymous said...

I am just starting out in an anaesthesiology resident program. I am keen to work hard, becoming a good anaesthesiologist when I finish my training. Having just read your article, I was just wondering about the bad habbits you have noticed in trainees, that I may be able to avoid by learning about them if possible?

Also very interesting post, and so true in all rural communities unfortunately.

Bleeding Heart said...

There were a lot. Clearly she had worked a lot and did things that we wouldn't consider acceptable practice. The only episode that stands out was when she moved a patient from supine to prone without disconnecting him from the circuit. That is in my mind a no-no.

burnttoast said...

I have avoided rural anesthesia practice because I know that a rural hospital will ignore surgical incompetence unless forced, anything to keep their one or two bed OR open. (Urban big hospitals protect incompetence as well, but they have a larger base of good surgeons to dilute out the bad apples, so you aren't doing anesthesia with a doofus every case.) I do not know how to resolve this. I would love to live in a rural place, but only if the work situation was good, which I doubt it would be. The call schedule alone is ridiculous. I do believe standards of care should be the same, urban, rural, suburban.