Dr. Yiwei Hu is a previous Toronto SEME graduate from 2018. She practices rural family medicine, emergency medicine, and GP-anesthesia in Grey Bruce County and the Northwest Territories. Watch her video below to learn more.
Michelle Yee: Hi everybody, I'm Dr. Michelle Yee and one of the Assistant Program Directors for SEME. Today we are doing an interview with Dr. Yiwei Hu. She’s one of our previous SEME grads. We wanted to highlight some of the places that people are now working, but also, reflect on what their SEME experience was like. So tell us about yourself, when you did SEME and where you're at now?
Yiwei Hu: My name is Dr. Yiwei Hui. I'm a rural physician. I graduated family medicine residency in 2018 and I did SEME about three months after entering practice.
I had been working a rural ER pretty much immediately out of residency for the summer and then re-entered SEME. After that I worked for about six months, mostly in Nunavut doing ER and then I entered in Anesthesia +1 program for the 2019-2020 cycle, and now I do a mix of rural anesthesia and rural ER currently. I mostly have been working in Yellowknife, Northwest Territories, which is the referral centre for the Northwest Territories as well as the Western part of Nunavut. We refer on to Edmonton, Alberta. Then I also work in rural Ontario in the Grey Bruce area, so Walkerton, Hanover, Kincardine area.
Michelle Yee: Awesome, would love to hear more about your practice in a little bit, but just to start off, what made you interested in doing the SEME program?
Yiwei Hu: I learned about it from talking with previous graduates of SEME. I had two friends who did it the year before. One of them is actually the Chief of Staff at Walkerton, Lindsay Bowman. She had had a really good experience with it and recommended it, because I was going to work ER early in my career.
I figured it was really going to formalize your approach to differential diagnoses and formalized your approach to sick patients. So I just thought for patient safety, and my own learning, it would be a useful program.
Photo: Dr. Yiwei Liu with Dr. Lindsay Bowman, another SEME grad, Chief of Staff in Walkerton, visiting Yellowknife with her husband. Note the houseboats in the background
Michelle Yee: Right. To walk us through it, when you went through the program, what was the program like and what are some of the highlights and stuff that you had?
Yiwei Hu: The most interesting thing for me for the program I think probably for most people are the simulations we had. It was very frequent, almost like every other week simulation sessions for both adults as well as pediatric critical care scenarios.
And the other parts that were very good were the procedural type workshops, so chest tube insertions, central line insertions, and a mini condensed version of CASTED. Even Arun Sayal was there and answering questions, showing us things. There was also a mini-condensed version of the AIME airway course. Those were definitely the highlights.
Otherwise, all of the academic sessions were stellar as well. We were such a small tight knit group, and a lot of it was problem based learning and discussion based. Not just academic material, but also like, what have you seen, what have you done with this in your own setting, and it was just a very interesting and informative discussion from the faculty leaders, the textbooks we were referencing, as well as other people's lived experiences.
Michelle Yee: Totally. I think with the simulations, very often we find for a lot of people, there's a lot of like bread and butter of emergency medicine that's very similar to family medicine and that's what people are comfortable with. But often with SEME, we try to focus on the things that have higher acuity or things that have really, really significant consequences, but we may not see it that often in practice.
Also it's often helpful to practice how do team dynamics work, or what are the major priorities in terms of things that you want to do, but also just reviewing content and discussing what does the management really look like.
Yiwei Hu: Definitely agree and so much of the simulations are about things in which you don't have time. So many other things you have time to look on Up to Date or call a friend, but there are certain things that you really should just be like, alright, let's roll. And that's what SEME was very good at drilling into us.
Michelle Yee: So who would you recommend the program to?
Yiwei Hu: I think the program is most ideal for people who want to practice for rural ER. And I like the fact that the cycle starts in either September or the spring, so that if you are a new grad like I was when I first started, you at least had a chance for at least three months to work and see and clarify what are the pieces that you're missing. We also had a few people who have been in practice for a few years before they join the program and definitely they came with very clear questions about: here are the things I encountered in my practice I struggle with a lot, and have a very focused approach for them.
Michelle Yee: I think you bring up a great point. Often times, we get questions around, is it better to do the program when I first graduate residency or, should I go into practice first?
I think it really depends on the learner but truth be told, there is something to be said about when you just go out and put yourself out there, and you're just forced to just do it on the spot. You get so much more from SEME and the higher level questions when you're doing SEME and able to reflect on, why are we making certain decisions around this, or why is it in this scenario, we did this, and under what circumstances, would you have changed up this.
I often find those who've been out in practice, even if it's like a year or two, they often get quite a bit more from it. Though, having said that, I think, new grads also get plenty from the SEME program, so either is reasonable.
Yiwei Hu: I think, almost the most ideal would be like, for me, I was a new grad benefiting from the fact that there were people who were experienced from practice. Because then you could see it and they could tell you well, I tried to do this before and I got burned by X, Y, Z. So you were like, okay well, I don't have to make that same mistake now that somebody else has made that mistake for me. And you can learn from other people graciously sharing the things that they wish they had known.
Michelle Yee: Yeah, I mean truth be told, I always say that so much of emergency medicine is trial by fire. Everybody jokes we're the cowboys and such of medicine. And it kind of is, because no matter if you did two years of family, or with the SEME program, or one year with the EM program or five years of the FRCP, it doesn’t matter. It's when you get into practice and you're making those independent decisions that you really, really end up learning.
The reality is, no matter who you are, you will make mistakes in those first couple years but it's what you've learned from them and it's how you adapt. So having that clinical experience, really, really helps.
So for those who are entering the SEME fellowship, what advice would you have for those fellows and those who are about to approach doing more training? How can they get the most out of the program?
Yiwei Hu: I would say, most importantly, is to focus in on being present for simulations and really getting into them. I think, the more you invest your emotional energy into the situation and the more you tell yourself, it is real, the more you can get out of it. Certainly I think people who were not as emotionally invested did not appreciate the acuity of the scenarios. And I feel learning is very much linked to your emotional intensity when you learn something.
Secondly, I would say, take a lot of notes. I wish I had taken more notes during SEME, there were so many pearls being thrown out all the time by different presenters and people we were were working with, and the teaching sessions themselves.
What I really liked was my faculty mentor because we all got paired with a faculty mentor and every day I would write down three new things, whether they would be something practical or something academic but three new things I learned every day. And we would just make a list, and those are just some great pearls.
Michelle Yee: Mentorship has been such a big part of being able to reflect upon people's experiences and such, and yeah I think the faculty pairing works really well for people for them to have check ins.
What I think sometimes people don't fully appreciate is that SEME is very much as a full time program. The Toronto one, it's three months, and it’s intensive. Not only are you doing all your clinical rotations, but weekly there’s didactic sessions, as well as the procedural skills sessions that’s a full day on Wednesday. So, sometimes I think if people try to bite off more than they can chew, you can see it if they’re trying to balance their clinic work or whatever else. Then they're not getting the most that they can out of the program, just because there’s so much to learn in such a short period of time. I think, exactly as you said, like if you're able to invest and really, really commit to the program itself, we find that those are people who get the most out of it.
Yiwei Hu: And the other piece, too, is the time you spend in clinical settings, in addition to academic days. Like if you are on ICU one of the three blocks, if you're available to just hang out until whatever time in the evening every single day, you will get more procedures, you will see sicker patients. Like sick patients don't stop coming in at 4pm, that's just not how things work in an ICU. If you just clear your availability, to the extent that your family, and your other commitments permits you to do that, I think, at least for those months, that was incredible.
Michelle Yee: Yeah, same goes for when people who do the trauma rotations right? Like the hours are crazy, they're intensive, it's very much like a surgical residency program if you're like talking about rotation burden, but the more that you see, the more that you do, the more that you'll learn from it. And doing clinical shifts where people aren't watching you, you're kind of just doing your regular job and that's what you will do for the rest of your life.
But I think the great thing that happens with SEME is that you actually get clear feedback about what you're doing right and wrong. Like I'm a few years out in practice, and now I actually wish if I had people watching me or, if I could actually watch some of my colleagues in terms of what they’re doing, I think you'd actually get a lot from it. Being able to go back and be a learner, you really have that opportunity to narrow in on some of the gaps.
Yiwei Hu: The other interesting thing is most rural ER doctors are single coverage and often they work in settings where there are no specialist on site. They're only phoning the specialist and there's no one to chat to or no one who's practices they were observing directly.
And what's interesting with SEME is even taking aside the direct feedback part, you're there to see 5, 6, 7, 8, 10 other docs we're working with, seeing what they're doing with their patients, and even that is very good at highlighting maybe there are many different ways to skin a cat. There are several creative approaches that are all equivalently safe and effective for the patient. And the collegial environment, discussing everyone's approaches is very valuable for rural doctors who often practice alone in the on hospital.
Michelle Yee: Totally. I think you're you hit the nail on the head in terms of like, everyone practices emergency medicine differently, and I think that's one of the greatest parts in terms of going being able to go back into being a learner, seeing how people do it and realizing like there's no right or wrong answer sometimes. All of this is grey, and everyone has their own rational decisions about how they choose to make things work, but they all can certainly work.
For those who are interested in applying to SEME, where they’re doing primarily family but are interested in doing rural ER but they're like not quite there yet, and not quite sure how to even approach it if they've done mostly family, do you have any kind of suggestions on how those kind of individuals can improve their knowledge or their experience as they might ramp up and start getting interested in applying to something like SEME?
Yiwei Hu: Usually in a rural town, the colleague group is quite tight knit and people always appreciate having a second set of hands in a solo coverage rural ER when things are busy. And people are usually extremely open to other people saying hey, I would like to learn more about X, can I come and shadow this with you?
I almost decided to do obstetrics at some point, after I like finished training and then I just asked a bunch of like really experienced GP-OB’s, including those who do c-sections, like hey, maybe I can just like come and deliver some babies with you for a while, is that okay? And they are perfectly happy to do that, and I would think it would be very similar. Certainly if somebody asked me to come and work in the ER, I would be extremely happy to do so. So I would approach your colleague group or other ER’s around you and ask if you could work in the ER alongside somebody, so that way, if you have something that you're concerned about you have someone more experienced to ask about just get your feet wet to not feel overwhelmed or not to feel unsafe.
And then, other than that, obviously podcasting is a big part of ER culture and how a lot of people learn about new things, so I definitely recommend listening to the usual. EM cases is very excellent, all of their topics are great and very in depth, with a nice mix of expert opinion, and up to date, evidence review with practical tips about how to approach the situation.
EM Playbook is very good about pediatric ER as well just to get yourself in the mind set of how do other people think about emerge, what are some things to work out.
Michelle Yee: Yeah I think you highlighted something that works really well for lots of people, which is that in lots of the small towns, there so, so, so happy to have people come and accommodate, and that even the specialists are very on board. So like letting the general surgeon in town know that you'd like to get more experience with chest tubes or whatever. Or, like if they have reductions that they ought to do, or sedations and stuff, they are more than happy to have an extra pair of hands. Even anesthetists or GP-A’s, I often find they’re receptive towards feedback and are like, yeah do you want to come to the OR and do some airways and stuff. Even though it's a little different than what your airways are in ER, it still gets you that practice, and I think it's such a valuable thing. In small communities, it's just way more tight knit.
Yiwei Hu: Yes, I definitely have a lot of people come to the OR and intubate as well. And, in general, most of anesthesia, we are very happy if you are going to intubate somebody in the ER and you're not feeling good about this or for whatever reason you just want us to be there. Or if haven't done an LP in 10 years, can you just come and stand here, while I do this LP for moral support? We're always happy to do things like that so just seek out your local resources as Michelle mentioned.
Michelle Yee: And just highlighting some of the sites that you work at, you mentioned you work in Grey Bruce, which you know I always say, I locum there too sometimes as well and I actually really, really love it as an institution. I find that their network is really good at having good resources and algorithms and support within the network. But for those of you for those who aren't as familiar with Grey Bruce and the area, can you let us know about kind of what your experiences are like in that department? What is the size and supports are like? And what are kind of volumes and patient populations do you see?
Yiwei Hu: Michelle described it very well. The referral network is highly organized, there are two main referral centres for the Grey Bruce area. The closest one would be Owen Sound, which has most specialties like paediatrics, internal medicine, ICU and CCU. They do have stroke neurology on-call, surgery, including thoracic and ENT, orthopaedics. They obviously don't have cardiac surgery or neurosurgery, or dialysis or infectious disease. Those patients are often sent to London, where it's a quick tertiary care centre and you can get pretty much everything you want.
Everything has can go through these coordinated phone lines where everything's recorded, so you just tell the person on the phone, I would like to speak to so and so on call for this patient. And the fact that it’s recorded with all the times, I think it gives us a lot of medico-legal protection, with here's a clear record of how I tried to reach for help and what was the outcome of the consultation. But usually the specialists are extremely nice extremely accommodating and very good at providing phone advice. Either they feel it's something very benign or there’s prompt follow up or acceptance of your patient to their hospital.
Otherwise, the Grey Bruce area usually as we mentioned are single coverage ER’s. The shifts range anywhere from 8 to 12, to 24 hours at of time, depending on how busy the ER is. A lot of these small places will also have an on-site CT scanner and on-site ultrasound on most days, with X-Ray and lab work. Some of the smaller sites like Kincardine don't actually currently have a CT, although they are fundraising to build a CT scanner as we speak.
The transport for a CT can be a bit of an interesting judgment call, because often you get into a situation of head trauma but you're not that concerned that you want to directly consult neurosurgery and you know neurosurgery won't take them unless there's something on a CT scan. So you're trying to make that decision of how best to care for your patient but, overall, I would say the network specialists are very supportive.
Michelle Yee: The other thing that I always found was that the nurses were so, so incredibly helpful. You know, as a locum sometimes you're like, I'm not familiar with what the referral patterns are like. Or they’ll know what to do if I’m trying to get a CT or an ultrasound. The nurses and clerks have just been so good at being able to provide you that direction and they make it really, really easy.
Yiwei Hu: Yes, definitely I think the fact that they are used to working with new doctors all the time, they are the main safety mechanism.
Michelle Yee: So tell me about your experiences in Yellowknife and the Northwest territories. I think a lot of people have always been interested in hearing more and considering doing it. But for some, they haven't taken that kind of leap, so talk us through a little bit about your experiences.
Yiwei Hu: As a rural ER, I would say it's a very well resourced site in terms of specialists at the hospital. You always have general surgery, internal medicine, paediatrics, ENT, ophthalmology, and orthopaedics. If required, you can access CT and labs 24/7, although overnight, the CT/lab tech will have to drive in from home, so there may be a bit of a delay with that. In terms of the medications you pretty much have access to all the medications that you would want. Blood products are kind of a limiting factor. In terms of packed red cells and fresh frozen plasma that's not usually the limiting factor. It's more platelets so because of their short duration. No platelets are actually kept in the hospital, so we unfortunately cannot transfuse platelets as part of the massive transfusion protocol or if patients have low platelets, which does change your practice somewhat. For example, I had a guy with a subdural hematoma with midline shift, but because platelets were under 50 I did speak with neurosurgery immediately and they accepted the patient. Because if he gets worse, there is nothing I can do for him so that's something to learn about.
And it's a very well resourced centre in terms of airway equipment as well, so we do have a fiber optic scopes that has very nice excellent video and level one transfuser.
Photo: The Aurora Borealis / Northern Lights when coming out of the hospital at 2am.
Michelle Yee: Yeah and for people who might be interested in doing it, I know they actually offer quite short locums, so it doesn't have to be a huge commitment. Very often they'll do around one week and they pay for your traveling time there and back. They often also include things like your flights and accommodations government reimbursements.
Yiwei Hu: Yeah a lot of locums come up for just seven days, and so you do day, day, evening, evening, night, night, and then you're done your shift cycle. For the permanent positions, here they do a six on, six off, and kind of cycle. It is mostly single coverage until probably the last year, where they've developed a double coverage period between like 11-7PM, you'll have a second doctor on who will just see lower acuity patients so that's been really helpful in terms of reducing your waiting room backup.
In terms of the logistics of coming up, Michelle's absolutely right, you are paid a travel day for coming here and a travel day for exiting. You are obviously paid for your flights and your accommodations are arranged for you. You will typically get a car rental if you are not sent somewhere to live close to the hospital and that is covered as well. Then if you want to do some tourism before or after your trip, you can always say hey, can you make my coming here flight or leaving here flight with some gap between.
Michelle Yee: Oftentimes people ask about the experience of getting licensed in a new territory. What was it like for you?
Yiwei Hu: It's so easy. The thing is, there is no college in the territory, so they really depend on you, having an existing license and one of the provinces with existing colleges so.
Anybody with like an Ontario license for example can easily get a license through physician apply that website and it's quite quick turnaround and very straightforward paperwork.
Michelle Yee: Yeah and there's such a huge need that very often, even if you're not sure about the exact dates, the suggestion is to get licensed so you can go up on a whim whenever it fits with your schedule. But there are such high, high needs and these rural communities would be very, very happy to have people help do locums and such.
Yiwei Hu: Yes, I think a lot of places like Yellowknife are covered primarily by locums. And because of that, the nurses and everyone at the hospital are very used to working with new doctors so you don't need to worry about, hey I don't know what paperwork needs to be done to admit or consult someone, or what do you typically do in this situation. The nurses, are extremely helpful with things like this.
Michelle Yee: So thank you so much for taking the time to chat with us. Any final thoughts or words of wisdom that you want to share with people?
Yiwei Hu: I just want to tell people who are thinking about doing the SEME that even though you work in academic centres, and even though the faculty leads who teach on academic days are from tertiary care centres, most of the faculty like Michelle have worked extensively in rural areas, they understand also lack of resources, lack of equipment, lack of particular medications or blood products. So I don't think you should worry about being treated as a country bumpkin or people not understanding the fact that you come from a place that has low resources. The program is tailored to help you make decisions in a resource poor side and to help you truly prioritize what's important.
Michelle Yee: Awesome so thank you again so much for taking the time today we really appreciate hearing from you and we hope that, for those who have listened that this is helpful for you guys to get a sense of what this program is like but also you know what some of the practice kind of rural locations may look like as well. Alright, take care.
Yiwei Hu: Take care thanks so much Michelle.
Photo: Another rural emergency physician at the ruins of the Ice castle on top of Great Slave Lake in Northwest Territories, in stages of melt in April.