Getting started in the ER

Finally - only one more required signature and I can work officially tomorrow. Yesterday spent most of the day getting organized, and today couldn't officially manage any patients, but since the residents don't have to have a consultant sign off on every patient as we're used to at UCH, I could organize a "teaching session" and the resident could then manage the patient. Managed to help out the registrar's on some cases, also.

So here's the players in Australian medicine. After high school, most of the Australian medical students take high school graduates straight into a 6 year medical school program without any college. A couple of the "big island" schools are considered "post graduate" medical schools on the American style of 4 years of college, then 4 years of med school.

After medical school, the internship years is a year of rotating through various services without any specialization, and that non-specialized pattern continues for 2 or 3 more years as a resident. So, the interns and residents get broad exposure and are not orienting to a specialty yet.

Then the 3rd or 4th year, they begin specialty training which continues for 3 or 4 more years. Unlike our residencies, there is more flexibility in the registrar's program: he continues the program until he passes the specialty board examinations and until he chooses to leave the registrar program (apparently the pay is good enough that some choose to continue longer than might otherwise be thought necessary).

So, the interns are chronologically quite young. The residents have not begun specialty training, but have more extensive experience as inpatient house officers than our residents. And, the registrars are considered fully ready to function on their own with minimal supervision, they have lots of experience as house officers, but in their first years as registrars, may not have as much direct ER experience.

Stay tuned for more on how that seems to work in practice. Thus far, even when just doing a "curbside" consult for the registrars, the presentations have tended to be a bit longer and more structured than I'm used to (we don't often hear a full recital of the review of systems in the UCH ER). On the other hand, that may be a function of more reliance on the history and physical than on technology. More on that little issue later.

A couple really cool things: lots of patients arrive with their "Medical Information Book" that they carry with them - an organized booklet with a listing of their medical and surgical histories, active problem list, and current medications all filled out by hand and carried about with them.

Even cooler: although the Electronic Health Record system is currently limited to not much more than a computerized control board, it does have on it a "Discharge Letter". The doctor discharging the patient has a couple computer clicks to pull up a blank space to type in a brief note: free text and as detailed, or basic as desired that will then automatically be formatted with hospital letterhead, date, MR #, and signature line, and then be printed out in multiple copies - one for the paper chart, and the rest for the patient to carry with him to his follow-up exams with GP's, or specialists, or to keep personally in case of a "bounceback" to a different ER. It's quick, flexible, easy and brainless. The patient carries it so there's no looking around and getting consents to get stuff faxed over from hospital X, it's there for the f/u MD when he needs it - without extra steps. It is sweet! Love it.

More later.