aka American ER Doc Gone Walkabout 009
Arriving in Tassie, I had only the vaguest sense of how the intern-resident-registrar system compared to our US system. (OK, so planning ahead has never been my strong point. Works out amazingly well. Sometimes.)
By the time I finished, I had concluded:
On to some details. In the US resident physicians are doing their specialty training. In Australia, residents are doing general training – the Americans might think of it as an extended rotating internship, while the registrar has moved on from residency to specialty training.
For you Aussies: the US system is a post-graduate medical school system: high school, then (usually) 4 years of college, 4 years of medical school, and then for ER Docs, straight into specialty training – called residency in the US. 3 or 4 years of specialty residency training right out of medical school. Many, especially if interested in academics, do another 1 or 2 years of fellowship training in a subspecialty – wilderness medicine (I think that means that you go skiing or bushwalking on your days off), ultrasound, education, etc.
During that first year of residency, you’re called an intern even though you’re already in the training program, and spend part of the year in the ER, and part of the year rotating through a variety of inpatient services. From there on out it’s all ER, all the time – a few electives thrown in.
Remember, Aussies, the Americans residents are in the EM training program and there is no such thing as a registrar in the US system (except the guy that does the paperwork at the front desk). And I’ll use the terms “attending” and “consultant” interchangeably for the fully trained, independently working, board-certified guys.
For the Yanks: some Australian medical schools are directly after high school, (though some are similar to ours with undergraduate college first) – therefore, the interns may seem pretty young. But, here’s where it gets really interesting: rotating internships for everybody, 1 year. Then, “residency” – which is still not a specialty track, and during which you continue to rotate through a variety of specialties. During your residency, you choose and apply for specialty training. Your residency can last for a few years, or for lots of years: 3-5 seems common.
(I won’t mention the brutality and lack of pertinence, except for a small number going into bench research, of the primary exams.)
Then, on to specialty training – as a registrar. Here’s where the registrars begin to function as what the Yanks consider residents. But, a few differences: the Reg already has spent time in the ER as part of his rotations during internship and residency. The Reg has several years of broad background in clinical medicine, surgery, peds, OB/Gyn that our residents don’t have. The Reg has also had several years of exposure to a variety of clinical services to assist him in making his choice for specialty training, rather than the intense pressure in the US to make your choice during 3rd year of medical school so that you can do sub-internships in that specialty during your 4th year and have your residency applications done half-way through your 4th year.
The years as registrar are a bit different from the US residency:
More years. Usually 4-5. Less defined curriculum – after the minumum required of 4 years of ‘advanced training’, you remain a registrar as long as you need until you can pass the specialty exam (Australasian College of Emergency Medicine – ACEM) – it would take me approximately 12 years, I think, to get smart enough. You don’t enter a single registrar program and stay there – you go through a variety of independent positions that are typically 6 or 12 months long. Some time on other services, like Critical Care. Some time at rural hospitals. Maybe even some time as a Retrieval Registrar – flights to bring patients from outlying hospitals in to the larger centers. Take the ACEM exam when you feel ready, and keep on with training until …….well, until you can pass the exams. And the pass rate for the ACEM is lower than for the ABEM exams – about 50-60%, if I hear correctly. Why so low? Take a look at the LITFL exam resources and try some of the ACEM questions. You’ll understand. They are insanely difficult – no way that I could pass the ACEM exam. ABEM looks simple.
That program has a great advantage: not everyone can grasp the required knowledge, nor acquire the required skills at the same pace. In the US, you’ve got 3 or 4 years depending on the program. Learn it or fail. Or fail to learn it, and get eased through. In the less defined Aussie system, take 3-4-5 (?more) years and get it done at a pace appropriate to your skills and speed of learning.
As a Registrar, you’re pretty independent – you see patients, supervise the interns and residents as in the US, but unlike the US, often present a case to a consultant/attending only if you wish to. Particularly with the senior registrars, we would often go through several shifts without discussing a patient. Not at all sure that I liked that, how else do we learn except by sharing & discussing – even when we already know the answer. Sometimes I felt that I was asking for opinions on my patients, more than the reverse. (And there were some skills that I had long ago abandoned to our nurses and paramedics, but had to request help from the registrars – or relearn the skills for 3 months. I chose the easier route.)
The junior registrars in their first and second training year, are clearly further along than our PGY 1 and 2 – no surprise, since they’ve had 3-5 years of general clinical experience. And, by the time they’ve been registrars for a few years, they function more as we would expect of a fellow or junior faculty. Even though the junior registrars are less seasoned in emergency medicine – especially some of the procedural stuff – they commonly knew more than I did about medicine outside of emergency medicine. That broad background does indeed show up, and is useful. The knowledge required for the primary exams, however, did not ever rear its ugly head.
But, in the end, if you blindfolded me, and disguised the accents, I’d have a hard time sorting out the differences in capabilities between the trainees in Tassie, and those at home.
But, you may ask, wouldn’t 8-10 years of training, even if the hours worked are less crushing, constitute a severe personal and financial load? Well, a little context:
The Australians have contracts that call for 37 hours a week, plus 5 hours of educational sessions whereas the US it’s typically 48 hours of clinical time plus educational time – and in the realm of electronic medical records and the pressure to “move the meat”, at least at my hospital, many of the house staff are spending hours after each shift finishing up their charting. Never happened at LGH – done and gone as soon as handover rounds were done. So, the weekly work load in the US is about 25% – at least – greater than in Australia.
Americans finish medical school with a debt load perhaps 4-5 times that of Aussies finishing med school (perhaps a bit higher debt load for those finishing a graduate, rather than undergraduate medical school). An Australian intern earns 30-50% more per year – plus 5 weeks of paid vacation, plus state holidays, and some of that income can be tax-free – than American interns. And, as the Australian moves through the system, the year-to-year increase in salary is substantially greater than in the US. So, as a registrar, the Australian physician has a much more reasonable debt load, work hours compatible with a career – rather than a right of passage, and earns a comfortable living. He appears to be passing through stages of a career. Whereas the American resident is passing through an unsustainable, though prolonged and brutal right of passage – at the end of which he has a sudden transition, seemingly overnight from an underpaid, overworked trainee to a fully formed, newly omniscient, and generously compensated attending. I exaggerate, but only a little.
Think about it: if you’re an engineer or businessman, you don’t finish training, then join a firm or start your own business and become the senior partner. You gradually work your way up as you gain experience and establish the tentacles of power. But US medicine assumes that as soon as you have that certificate, you’re ready for full do-it-all medicine. Perhaps a slower and lower-angled ramp up to full certification has some advantages.
Another observation about the residents and registrars with whom I worked: diversity. In the US, we consider diversity in skin color. But, not much in backgrounds. The Australian registrars were from the big island, the little island, India, Africa, Burma, and Singapore. What’s up, can’t Oz grow their own? Consider this: in the US, about 11% of our population was born abroad. In Australia, that number is over 30%. With that kind of a rate of growth through immigration, it’s not surprising that immigrant doctors need to be part of the equation. The diversity of background was sometimes challenging – not all of our residents and registrars were starting from the same knowledge and experience base, and often enriching – both culturally and medically (“Oh, yeah, boss, we saw lots of typhoid in India – here’s how we did it……”).
If I was doing training now, I think I might like the longer but less brutal program that really felt to me, as an observer, much more as a progression through current career stages, rather than the US training that seemed more an independent step to a future career. [Salaries in the US (pdf)]
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