Letters / Corresondance

CJRM 1998;3(4):255-7

Letters to the editor should be addressed to: Canadian Journal of Rural Medicine, Box 1086, Shawville, QC J0X 2Y0; cjrm@fox.nstn.ca; fax 819 647-2845

© 1998 Society of Rural Physicians of Canada

Why I don't and do want to be a doctor

I am going to make a list of the cons and pros.

Cons

1. Patients complain.
2. Patients come when they aren't even sick.
3. You have to sacrifice your lunch.
4. You're busy almost every day.
5. You're up late in the night.
6. You have to eat hospital lunches.
7. When people die and you know them really well.
8. You have to stay inside a great deal of the time.
9. You have to go to school for even longer times.

1. You get to see and deliver tiny, cute babies.
2. You get to meet new people.
3. You get to meet many other doctors.
4. You do mitzvahs (Jewish for "good deeds") almost every day.
5. You get to travel to conferences.

I guess I wouldn't want to be a doctor because there are many more ideas under cons than pros. The hard things about being a doctor are being on call, staying at the hospital, making people feel better, being away from your family.

I used to know this lady. She was very nice. Whenever I was at the hospital my mom and I would visit her. She died a few years ago. I was very sad; she was one of the nicest people I have known.

Lauren Robinson
[9 years old]
[First appeared in Rural Med.
Reproduced here with permission.]

The Scott Report

It was with considerable care and some degree of interest that I read the letter to the Editor by Dr. Dawes in the summer issue of the Journal (pages 178­9) pertaining to my critique of the Scott Report, which appeared in the winter issue on pages 27 to 32. To a certain extent Dr. Dawes's criticisms were predictable, but I was surprised by some of his comments, and in the interest of honest debate I would like to respond.

The legacy of the Emergency Services System that Dr. Dawes and Mr. Scott are so anxious to preserve by maintaining the status quo is one of substantially increased traumatic death rates for residents of rural Ontario. It has been estimated that a rural victim of trauma is 5 to 7 times more likely than his urban counterpart to die from similar injuries. Although this estimation may be in the realm of folklore, Rowe and colleagues¹ demonstrated that the death rate from trauma in northeastern Ontario is certainly at least twice that of areas with a greater population density.

It is estimated that one-half of this excess rural mortality is due to external crash characteristics;² unfortunately, the other half may well be due to the medical care provided in both the prehospital and emergency department phases.^3­5 Several American studies^6­9 have suggested that there is a preventable death rate of 10% to 15% in rural emergency departments. These deaths are largely a result of a failure to adequately manage the airway, failure to recognize and aggressively treat hypovolemic shock and failure to place chest tubes in situations where there are life-threatening chest injuries. Although these studies may be somewhat flawed in their methodology, having committed every one of these sins at some point in my clinical life, I believe they have the ring of truth. This, of course, relates only to the issues of trauma. God only knows how well we are faring with adult and pediatric emergencies.

Surely, the only thing that should be "sacred" to rural physicians should be our solemn commitment, indeed duty, to address this disparity and to strive for excellence in meeting the emergency health care needs of the people and communities we serve.

This task will certainly be made more difficult by the maintenance of the status quo of Ontario's Emergency Health Services System. In a 1991 survey, 50% of emergency departments, both rural and urban, failed to meet a defined minimum standard of care. The "lofty standards" that were not attained did not include the absence of capnometers and bedside ultrasonography but the more mundane issues of absence of laryngoscopes and life-saving drugs. Furthermore, the standards were not developed by "insulated academics" but by a group of emergency health care professionals with 3 practising emergency physicians, including 1 from the booming metropolis of Wawa, Ont.

This concept of emergency department standards seems to concern Dr. Dawes. I believe it should be viewed not as a mechanism to close small rural departments but rather as an important tool to force reluctant hospitals, regional health administrations and governments to "ante up" and provide the necessary resources to adequately support rural emergency departments. The Guidelines to the Practice of Anaesthesia, as recommended by the Canadian Anaesthetists' Society (CAS),¹⁰ are a case in point and provide a useful historical analogy of the benefits of such an approach. When the CAS recommended the use of pulse oximetry as a mandatory monitor for the safe practice of anesthesia, reluctant hospital administrators begrudgingly came up with the $8000 cost for such equipment rather than be found in an untenable medicolegal predicament. Similarly, this was the case for capnography. It could also be the case for necessary equipment for emergency departments.

In regard to the issue of guidelines and emergency department closures, Dr. Dawes purports to understand my position. I believe he does not. My letter published in the Canadian Medical Association Journal¹¹ clearly states my views on this subject.

I would like also to respond to the last 2 points raised in Dr. Dawes's letter. He notes that he is dismayed by my recommendation to review the $70/h stipend. I don't understand why. First, I reiterate my point that this is wonderful compensation for a low-volume emergency department of 5000 patient visits per year. However, as medical director of 2 rural emergency departments, each with patient volumes just shy of 25 000 per year, I can assure him that this has hardly proven to be an attractive component for physician recruitment and retention. Hospital administrations and boards and even the government have come to expect that the emergency physician on Scott sessional payment will provide care not only for the patients registered in the emergency department but also hospital in-patients, resuscitation calls for labour and delivery suites and serve as the after-hours primary care resource to numerous community agencies and extended care institutions. That is a lot to ask for $70/h. Indeed, a group from Hanover are attempting, through a provincial letter-writing campaign, to have this arbitrarily derived figure renegotiated.

Second, I think it is reasonable to expect, in these times of fiscal restraint and evidence-based medicine, that any new health care initiative should be monitored for its effect on health care delivery and patient outcomes. I am unaware of any published data that supports Dr. Dawes's statement that the Scott Report has "functioned well as a successful recruitment and retention initiative." If he has such information I would urge him to share it with us. I would be much more impressed, however, if the measurement parameter was an improvement in the level and not mere quantity of care.

I am also surprised by Dr. Dawes's statement that I "bemoan the lack of input from representatives of organized emergency medicine." I do indeed believe that those involved in the discipline of emergency medicine must provide a leadership role in meeting the challenge of providing emergency care in rural environments and should be formally consulted in any attempts at reforming the system. Emergency services, after all, represent a continuum of care, and initiatives aimed at one locus ultimately will have an impact on the others. By restricting the solution to rural family physicians in isolation, I believe we risk not developing a workable, comprehensive solution; better that as a team of equals we strive to improve and strengthen the various links of this chain of care for the acutely ill and injured.

Last, I would like to commend Dr. Dawes for his many, well-recognized efforts in improving the lot of rural physicians. I would also like to thank him for encouraging debate on the difficult issue of emergency service provision in rural environments. I would be more than happy to join him in any initiative aimed at improving the standard of emergency care for rural Ontarians.

References

1. Rowe BH, Therrien S, Johnson C, Sahai VS, Bota GW. Regional variations of northern health: the epidemic of fatal trauma in northeastern Ontario. Can J Public Health 1995;86(4):249-54.
2. ;Maio RF, Green PE, Becker MP, Burney RE, Compton C. Rural motor vehicle crash mortality: the role of crash severity and medical resources. Accid Anal Prev 1992:24(6):631-42.
3. Kearney PA, Stallones L, Swartz C, Barker DE, Johnson SB. Unintentional injury death rates in rural Appalachia. J Trauma 1990:30(12):1524-32.
4. Krob MJ, Cram AE, Bargish T, Kassell NF, Davis JW, Airola S. Rural trauma care: a study of trauma care in a rural emergency medical services region. Ann Emerg Med 1984:13(10):891-5.
5. Svenson JE, Spurlock C, Nypaver M. Factors associated with the higher traumatic death rate among rural children. Ann Emerg Med 1996:27(5):625-32.
6. Certo TF, Rogers FB, Pilcher DB. Review of care of fatally injured patients in a rural state: 5-year followup. J Trauma 1983:23(7):559-65.
7. Maio RF, Burney RE, Gregor MA, Baranski MG. A study of preventable trauma mortality in rural Michigan. J Trauma 1996:41(1):83-90.
8. Esposito TJ, Sanddal ND, Hansen JD, Reynolds S. Analysis of preventable trauma deaths and inappropriate trauma care in a rural state. J Trauma 1995:39(5):955-62.
9. Veenema KR, Rodewald LE. Stabilization of rural multiple-trauma patients at level III emergency departments before transfer to a level I regional trauma center. Ann Emerg Med 1995;25(2):175-81.
10. Canadian Anaesthetists' Society. Guidelines to the practice of anaesthesia. Toronto: The Society; 1987.
11. Drummond A. Is it time to close your hospital's ER? [letter]. CMAJ 1992:146(10):1696-7.

Ontario region of the Society of Rural Physicians of Canada

You are invited to the Annual Meeting of the Ontario Region of the Society of Rural Physicians of Canada to be held in conjunction with the meeting of the Ontario College of Family Physicians

Where: Eaton Marriott Hotel, Bay St., Toronto, Ont.
When: Nov. 19, 1998.
What: Agenda.

1. Review of priorities
2. Hosting the annual policy and scientific conference of the SRPC in 2000
3. Election of officers
4. Other business.

Dear Friends:

Despite relatively quiet politics this last year, the Ontario section has been quite active in promoting rural medicine. Our efforts to support rural physicians can be characterized as direct support with research and advice, general media relations and policy development.

We have also been approached by rural doctors for advice on issues ranging from rural midwifery, to rural primary care reform pilots. Rural doctors can no longer be singled out and isolated.

Many media have been informed about rural health care needs. We helped organize a "day in the life" piece on ON-TV. There have been several spots on radio including CBC. We even got a word in in MacLean's. We released a joint press release with the OMA decrying the raise in medical school tuition, which will make it even harder for poor country kids to get trained as physicians. This had extensive coverage in many regional newspapers.

The new media also have heard our message. We have an Ontario regional page on the SRPC Web site (home.nstn.ca/~cjrm).

Our collaboration with the residents union PAIRO continues. We are hammering out yet another draft of the upcoming "Rural Blueprint" that will form an integrated template to deal with rural recruitment and retention that has been lacking to date.

Is that enough to get you intrigued?

Peter Hutten-Czapski, MD
Rural physician
Ontario Regional Chair
Haileybury, Ont.

Come and find out what's going on

Join us in Newfoundland in 1999 for the 7th annual Society of Rural Physicians of Canada's Policy Meeting and Rural and Remote Area Conference to be held once again at the Delta Hotel in St. John's, Nfld., from Tuesday, Apr. 13 to Saturday, Apr. 17, 1999. The ALARM Course will once again be offered for those interested, as well as a full slate of other specialized programs and Rural Critical Care workshops. We are taking all the great feedback received from previous conference attendees and plan to make the 1999 program better than ever. We look forward to entertaining you in true Newfoundland style and hope to see you here in 1999. More information in the next issue of CJRM. Meanwhile, MARK YOUR CALENDARS!!

Contact:
Fran Kirby, MEd,
Professional Development,
Faculty of Medicine,
Memorial University of Newfoundland,
St. John's;
tel 709 737-6653;
pdmed@morgan.ucs.mun.ca