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Specialty Spotlight – Emergency Medicine – With Dr Andrew Bezzina (Part 1)

Dr Andrew Bezzina (Part 1)

Dr Andrew Bezzina (MB BS, FACEM) is a senior staff specialist in Emergency Medicine in the Illawarra region of NSW. He is widely respected in the emergency medicine community, and as the Chairman of the not-for-profit organisation Emergency Life Support, contributes to medical education in Australia, and internationally.

In this two-part article, Andrew will discuss his reasons for getting into emergency medicine, lessons learnt for trainees, and crucial tips for CVs and interviews in emergency medicine.

 

Thanks Andrew for joining us to talk about your career as an Emergency Physician. Can you tell us how it all started for you?

I drifted into Emergency Medicine as a career. I had originally intended orthopaedics but after an internship in “the big teaching hospitals” I decided that such a restrictive pathway in ivory towers wasn’t for me. I then did the common thing in those days of heading for General Practice by picking up a broad range of terms including Psychiatry and paediatrics. Part of that was to spend 12 months as an Intensive Care and Anaesthetics Registrar. When I had completed what I considered to be a “full hand” of terms a stint overseas just bumming around followed. On my return the thing that struck me was that I had acquired a whole skill set in critical care terms that I was unlikely to use as a GP. I was at a decision point – do I relinquish those and take on general practice or do I look at an alternative career.

While mulling this over I was working in an Emergency Department on the Central Coast of NSW and the Director suggested I should take up a career in Emergency Medicine. I suggested I wasn’t interested in signing my life up for 5 more years of training. He advised me that given my experience to that point I was unlikely to need to do 5 years. I contacted the College for Emergency Medicine and was informed that whilst I would have to pass primary and Fellowship exams I would only have to completed a further 2 years and 3 months of experience.

The rest as they say is history. 2 and a half years later I had my Fellowship.

 

What was it about emergency medicine that attracted you?

Apart from the sequence of events just described Emergency Medicine attracted me because of the immediacy of it and because it involved working in a team. The immediacy meant that people present with acute problems and we can rapidly relieve their problem in the majority of situations. It may not be a cure often but it does mean a rapid relief of suffering or anxiety.

I was also inspired by watching some of the people senior to me and amazed at the breadth of their clinical and procedural skills. Just being part of the team whether as a “foot soldier” or as team leader meant the same in terms of the sense of achievement when solving a problem.

 

How has the job changed since you became an emergency physician?

The job is incredibly different to the early days. It is much more complex as a working environment with attention and politics brought to bear on Emergency Departments due to problems like access block. It is now a fully recognised specialty in comparison to those days when we were seen as a lesser class of doctor working in “casualty” or “A and E”. It still surprises me that some 30 years since the official name change to Emergency Department folk still use the old terms.

The patient spectrum is another major change. We see many more elderly patients and patients from residential care facilities and the expectations of the level of intervention in that group have also changed.

The training program is now much more structured and much better focused on how you perform the role rather than whether you can pass the exam.

Work practice has altered significantly especially in larger departments with more of the minor procedural work and initial care steps being performed or initiated   by nurses at one level of seniority or other.

There is a big focus on education beyond the Emergency Department. Emergency Physicians are involved in local community education and in reaching out to junior clinicians and clinicians in the community to guide acute care in less resourced settings. This has also extended into international outreach to less well off countries in Asia and Oceania.

This is exemplified by the Emergency Life Support Course which started life in 1997 as a course to help medical practitioners in the rural and regional areas of Australia manage critically ill patients with the confidence provided by a simplified step by step approach. It was developed by a small group of Emergency Physicians and continues to be provided as a course by volunteer instructors who are all Emergency Physicians or experienced GPs/generalists who have significant emergency medicine experience. (This sort of role didn’t even exist in the early days). Now it has developed to include other functionally isolated medical practitioners e.g. locums in small regional hospitals without specialist support; intern groups and international courses in developing countries. Again this was not even an idea in the early days of Emergency Medicine.

Finally there is now a much greater reliance on technology than in the early days. Tools such as ultrasound have become a part of the everyday armamentarium of the doctor in Emergency Medicine.

Where do you see emergency medicine heading?

Emergency Medicine is currently at a cross roads which reflects the situation in the Health System generally. There are major issues where change is being driven.

The first is the ubiquitous “Access Block” issue and the pressures that has placed on health systems generally but the Emergency Departments especially. This will continue to lead to work practice changes. It will also promote Emergency Physicians spreading out of the larger centres and providing more input into smaller Emergency Departments.

It continues to lead to the system relying in doctors in the emergency department minimising use of inpatient beds as much as is safely possible by creating or supporting strategies such as hospital in the home or short stay units.

The second issue is balancing the use of high tech diagnostic and interventional technologies in the search of diagnostic certainty against risks of “overdiagnosis”. What that means is that we are starting to recognise that technology is not infallible. We are never going to be in a position where we can provide patients with guarantees regarding their diagnoses. We are now at a point where the testing may lead to more harm than not testing and just using good old fashioned clinical acumen and Gestalt. This creative tension is just bubbling to the surface locally and internationally.

Finally there is the community awareness that we cannot supply all things to all people irrespective of their baseline status. Is it really appropriate or indeed even humane to practice invasive high tech medicine on elderly dependent patients from nursing homes? Should we “do because we can”? We are realising again that no intervention is inherently appropriate to a given condition. The key is the patient in front of us.

 

In Part 2 of this article, Dr Bezzina will discuss tips for new trainees, must-have inclusions for emergency medicine CVs, and how to put your best foot forward at your next interview.

 

 

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