Transition to practice

Residents' Corner

CJEM 2009;11(4):397-398

This article has not been peer reviewed.

As residents we’re often told that we’ll learn the most during our first 6 months in practice. I never imagined that adage would prove true in my own transition to practice. I knew that it would take years for me to become a confident clinician, like many of the preceptors I admired. Frequently humbled by how much material was covered in my 2 years of family medicine residency and in my emergency medicine fellowship, I found it unfathomable that I would learn even more in the first months of practice.

Since finishing my residency program, I have been lucky enough to have had an exceptionally diverse practice experience. I have worked in the academic centre in which I trained, in a busy rural family practice and emergency department, in a community health centre, in an urban community emergency department and in the most remote regions of the Himalayas of India. Each experience has brought me defining moments and has contributed to the steepest learning curve I’ve ever experienced.

The encounter that stands out most from these early months in practice came on a Friday afternoon in a small rural hospital. I drove the hour down the 400series highways of Ontario and winding country roads at noon on that clear November day. This was the end of a long week that had started with 4 clinically taxing shifts at the community hospital in the city; I was ready to have a few days off.

The paramedic patch radio crackled to life shortly after 4 o’clock that afternoon. A baby had been born at home in our little town and had had a period of apnea and bradycardia. The 3 midwives on hand had called paramedics after initial resuscitative efforts had not been entirely successful. This hours-old infant was coming to our emergency department with resuscitation in process.

As the lone emergency physician in a rural hospital on a Friday afternoon, I did what any new grad would do in that situation. I panicked. I only panicked for a second and only in the privacy of my own mind, but still, I panicked. Outwardly, I tried to project an illusion of calm. I set about getting our department ready for our young patient. With a terrific team of nurses, I got all of the necessary equipment out of its various hiding places. I found my neonatal resuscitation program card in the stack of cards I carry with me wherever I go. I had the temperature of the department turned up, way up. You see, in our community obstetrics had been centralized to the other site of our hospital, about 20 minutes down the road. As a result, we didn’t have a baby warmer on hand. In fact, the very experienced team of nurses present could not remember when the last time a neonatal resuscitation had been performed in our hospital. I called the anesthesiologist who was next door in surgery and gave him a heads up that I might shortly need his help. Then I waited.

I did not need to wait very long. A few minutes later, the paramedics arrived through the back door providing supplemental oxygen to the smallest patient I have had since starting practice. Hours old, the as-of-yet nameless infant was dusky and making very little sound. So we set to work. The ABCDs of emergency medicine: airway, breathing, circulation and disability (neurologic); monitors; oxygen, then back to the ABCDs. Shortly after the baby’s arrival, the anesthesiologist popped out of the operating room and stayed with me until I felt comfortable, even though we’d decided together not to intubate the infant. Somehow a colleague who practises general practice obstetrics at our hospital’s other site arrived, from home, and helped secure an umbilical line. The neonatologist from the regional referral centre offered practical advice over the phone and called back to make sure I was comfortable with his suggestions while I waited for his team to arrive by ground ambulance. At one point I looked up and saw that a colleague had come down from his hospital rounds and started seeing the backlog of patients who had accumulated in the department while I tended to the infant. Another colleague walked through to make sure I didn’t need any help from him and then just stayed in the background to be sure I wasn’t in over my head. For those keeping score, that means there were 5 local physicians in the emergency department at a time when I was used to being the lone physician in the building.

The transport team arrived nearly 2 hours after the tiny patient came through our door. Although this rural hospital is close enough for me to enjoy living in the downtown of a major city while still working rurally, sometimes the logistics of transfer makes the referral centre seem a million miles away. I gave the team the story, her course in hospital, what had been done and what drugs we’d administered, and then we turned over care to their experienced hands. It wasn’t until close to 10 pm that I’d finished documentation, signed over to the overnight physician and his resident, tied up other loose ends and finally headed home.

I have been lucky in the past 7 months to learn a tremendous amount about clinical medicine. Many codes, intubations and rare and wild presentations have kept me so permanently on my toes that I have developed calves of steel. That Friday afternoon I learned a lot about neonatology, but the most important lesson that was solidified for me that day had little to do with clinical medicine, but more to do with the community that makes up medicine. In those potentially terrifying 2 hours, I was never alone. Four colleagues from the town arrived to help in whatever way they could, even if it was just to stand by in case they were needed. Even if the local physician cast hadn’t arrived (and I’m sure glad they did!), I had help from the neonatologist from the referral centre at the other end of the phone, and I had tremendous help from the seasoned emergency medicine nurses. Colleagues came together to help me care for a very sick infant and when the acute encounter was over, they debriefed with me.

The learning curve in the first months of practice is steep and seems to be flattening only slightly as the months roll by. The transition to practice is far from easy. Maybe I didn’t believe it was possible to learn this much in such a short time, but I’m not sure I realized that the challenges of that steep learning curve would be so rewarding.