Monday, 5 November 2018

On Disappointment

I don't post much anymore. In fact, my engagement with the medical community, especially online, has plummeted over the past year. That's been partially by circumstance, but in many ways by design. For my own sanity, speaking less to and about doctors - and consequently more about things other than medicine and to more non-physicians - has been extremely beneficial.

Much of the reason this has been beneficial stems from a deep and unfortunately persistant disappointment I've had in this profession. While most physicians are well-intentioned, generous, and competent individuals, many are not, and these individuals are rarely if ever held to account. It takes extremes of incompetence or selfishness for a physician to suffer consequences for their actions and, even then, the consequences are frequently below any reasonable standard that would compel changes in actions from anyone but the offending party (and even then only because of monitoring requirements). Because of this impunity, less-than-stellar physicians feel comfortable justifying their positions to learners - including residents like me - who have no real power to contradict them, and even trying to push these learners to be more like them.

On a broader scale, the good intentions of the majority of physicians don't always translate into good actions, particularly on issues outside of the area of expertise for most physicians. In recent years, physicians and physician groups have put an emphasis on political action. Yet, because most doctors have a poor understanding of economics, law, or politics, it's led to what I've seen as a number of well-meaning but poorly thought out positions being embraced by wide swaths of the profession (implementation of user fees is the most common example of well-meaning but poorly thought-out policy physicians seem quick to endorse). That these positions happen to benefit physicians or reinforce prevailing stereotypes in medicine is unsurprising, but reinforces my disappointment in the profession.

Doctors are human and therefor subject to the same biases that afflict the thinking of all groups, but due to our positions of privilege and power, the failure to confront these collective biases more easily leads to harm than it might for other groups without such influence. Despite claims to the contrary, physicians retain significant authority, particularly with regards to the healthcare system. Even when physician political preferences don't become implemented, the driving forces behind these positions remain. As individual physicians hold a significant amount of minimally checked local power over their own practices, departments, hospitals, or institutions, misguided political positions can lead to ground-level actions on the part of physicians which replicate - in part or in whole - the harms threatened by the unimplemented political beliefs of physician groups.

To be blunt, I got tired of dealing with physicians at work who weren't coming close to living up to my standards of what a physician should be, then coming home to spend what little free time I had hearing from even more of these physicians who reinforced that disappointment.

Taking time away from physicians allowed me to step back a bit and gain some perspective. It has let me acknowledge that progress has been made in this profession, even if we still have quite a ways to go. It has allowed me to notice where physicians are doing things right, and that there are many individuals who are largely living up to the promises of the profession. It has helped me realize that some of my standards were unrealistic or too narrowly defined, such that in my mind, reasonable doctors got thrown into the same bucket of bad actors without real justification.

Most importantly, it's helped me learn that disappointment shouldn't lead to despair or withdrawal. Doing so only allows the disappointing actions to propagate. Obsessing - which I was doing before - is no better, but a middle ground is possible. I've started looking for more productive ways to engage with the medical community, ones which allow me to channel any frustrations into positive actions. I can't say I've come close to fully figuring out how to do this to my satisfaction, but I feel much closer than where I was before.

Learning to tune out negative, unchangeable viewpoint and focusing on how to change my own actions (rather than trying to influence others to change theirs) have been worthwhile first steps. These were easy enough to do independently and primarily benefited me. The next steps - extending impact more broadly - are harder to do at all and even harder to do well, because they involve other people, but it's been heartening to explore options available to me. I'm still very early in my career, which leaves many paths open and means I can take the time to choose the ones that best fit my goals, my values, and my strengths. Taking a step back has led to some tentative hope, that while the medical profession falls far short of the standards it should be easily meeting, it is moving towards those goals - even if it doesn't always seem that way when immersed in the middle of the loudest voices of the profession.

Sunday, 27 August 2017

Medicine, The All-Consuming

Left unchecked, medicine can easily dominate all aspect of life. This hits people at all stages of training and experience in medicine, but now that I've dipped my toe into residency, I think it likely hits residents the hardest. Residency means being both a learner and an employed junior physician, which has the unfortunate consequence of piling on both the open-ended responsibilities of a medical student to learn as much as possible, along with many (though not all) of the day-to-day responsibilities of an independent physician. Add on a situation of minimal control over one's own schedule and the need to continue to fight for a job on graduation, whether a fellowship or full employment, and medicine can easily take up every minute of the day, and every thought running through the brain.

For a small number of exceedingly passionate residents, this is exactly what they signed up for. Most residents, however, have parts of their life outside of medicine they would like to maintain or even prioritize, and that can become difficult in the metaphorical tempest of residency. Particularly when ambitions come into play, where a desired career path cannot be secured by simply showing up and performing well, medicine can push out those other, valued parts of life.

I'm finding myself falling into that trap early on in residency. I'm incredibly fortunate to be in a program with lower overall hours than many, and call schedules which are generally quite favourable. Yet this still means weeks far longer than a typical work week and the added time has largely gone towards maintaining a real sleep schedule and keeping up a rather bare-bones home life. My spare time now is still largely focused around medicine, either doing things for my career or, out of anxiety of having to do them all the time, unproductively procrastinating those activities.

As I was fairly ambitious in medical school, I've essentially been running on this medicine-focused treadmill for about 3 years straight now. I've learned this doesn't work well for my health, well-being, or even my achievement levels. I was able to scale-down my commitments later into my third year of medical school and into my fourth year. My choice to go into Family Medicine was influenced by this realization, a choice I'm quite happy with thus far if only for the sake of my own health.

Yet I'm still struggling with balancing my ambitions within medicine with my ambitions outside of my career. I want to do more as a physician, as I see so many opportunities to do a better job for patients. However, I've learned from experience that you can give everything you have to the medical system and end up causing more harm - especially to yourself and your loved ones - than you see in benefits for patients.

Prioritizing medicine above the rest of life didn't work and, in retrospect, many more senior physicians told me as much. So, I've tried to play a balancing act in the past year and a half, weighing any benefits to being more active in medicine with drawbacks to life outside of medicine. Again, for my health this has been a positive change, yet it comes with one major drawback - my life is still dominated by my medical career. Even if I choose not to pursue a new opportunity within residency, or put in an additional hour in a clinical setting, or do an extra bit of studying, I'm still making that decision with medicine as the focus. Unfortunately, this is leading to a fair bit of resentment towards my own medical career, without a countervailing positive in my non-medical life.

Therefore, I'm going to try to change tacks once again. Beyond trying to maintain a balancing act, I'm going to see how things work when life comes first. Before lifting an extra finger for the sake of a medical career that seems rather indifferent to my efforts, I'm going to try to make sure I have time for the non-medical things in life I care about. Getting a real amount of exercise. Spending quality time with my spouse. Watching the hockey game. Reading the newspaper. And if I'm really lucky, pursuing some hobbies I've had on the back-burner for years. Only then will I do the non-essential work in my medical career. My hope is that I can attack those activities in medicine with the vigor they deserve and which, over the course of the past 3 years, has waned from exhaustion and over-exposure.

Part of that is this, my Medical Blarg. This blog started as my way of actively de-stressing about being a medical student. As it unexpectedly gained viewership, it felt like the one activity in medicine that was leading to something productive. The encouragement to keep going from posters was immensely appreciated. Yet, it's hard for me to deny that as a result of its viewership, this blog has, in a way, also become a part of my medical career. There reached a time when posting felt more like an obligation that the enjoyable exercise it started out as. As a result, I've pulled back a bit on my posting frequency. My hope is that doing so allows me to continue to blog, but with a bit more enthusiasm and genuineness that I have been able to in the past few months.

Thursday, 10 August 2017

Residency, Block One

Well, I just finished up my first block of residency. Starting on my home rotation of Family Medicine, I got a chance to dive right into what I hope to be doing for the rest of my career. It's been a very busy transition (hence the complete lack of posting), but in a mostly good way. Here are my first impressions.

1) Increased Responsibility

This hit harder than I expected, and faster. I see my own patients. I review most of them with my preceptor, but not all of them. My preceptor sees my patients usually only when I ask them to. I can write my own prescriptions now - I even have a stamp with my name on it for those! It's a wonderful freedom in many respects, as I don't have to couch every single encounter based on what I think my preceptor wants. Instead, I can give my own impression and hedge only when I'm uncertain about the best answer.

Yet, that means when I mess up, it's all on me. And I've definitely messed up. No big screw-ups - life-or-limb cases are fortunately not that common in Family Medicine and I know enough to at least confirm my thoughts with my preceptor in these cases - but certainly less-than-optimal actions that could have been handled better. I recognize that's part of the learning process and that in my first rotation is very much expected, but it still hits a bit harder now than it did in medical school. As a student, if a patient's treatment was sub-optimal because of my mistake, outside of a clearly negligent decision, much of the fault would lie with the educational system that either failed to properly train or supervise my actions. Now those factors still matter, as I'm still a trainee, but as an employee, I share far more in that responsibility.

2) Rush, Rush, Rush

When I started my rotation, I got a slow introduction. Lots of time for patient appointments. Arguably too much time. I was getting bored going into my second week, and started asking to see more patients. Then I got ramped up to a full schedule in my third week. It. Was. Crazy. I managed to keep up with my schedule, yet only at the expense of my note-writing. On the busier days, I was at the clinic hours afterwards finishing my notes and completing other paperwork.

Nevertheless, I mostly kept my head above water and I'm fairly proud of that fact. At the end of my block, I was handling a workload roughly what I can expect as an early PGY-2 and while I wasn't nearly as consistent or efficient as the PGY-2's in the office (who were nothing short of amazing), I at least did the job. As I gain some more experience and familiarity, I'm hoping the late nights of note-writing well decrease.

That said, even my current "full schedule" pace is about half what it will be in full practice. Even with the advantages of a shorter lunch (currently I get over an hour, which I don't really need), lighter note requirements (my notes are detailed now, especially compared to the 2-3 lines most of my preceptors write), an extra exam room (I get a single room now), and no delays caused by checking with a preceptor, I'm nowhere near being able to operate at full speed. Yet, I've got 25 more blocks, including many family medicine blocks, to get up to that pace, so there's still plenty of time.

3) Home Call is Not Like In-House Call

One of the interesting quirks to my residency program is that we do a full home call on our Family Medicine blocks. It's not particularly frequent (about one weeknight every 2 weeks and one weekend every 2 months) and in many Family Medicine centres, it wouldn't be too busy. Except at my centre. Our weekend call is Friday night through until Monday morning. I got at least two dozen calls during that time, some of which were simple and straight-forward, others which took a fair bit of time to sort out. Ended up having to do a fair bit of driving, either to see patients in clinic over the weekend or to visit patients in the nursing home we cover.

The main advantage of home call is that you can still do life-stuff when you're not actively working. That's pretty great, since you can get a lot done if you don't get called often. It's way better than in-house call in that respect, where you're basically working a 24-hr shift that may involve some long breaks if you're lucky, but which doesn't allow you to do anything outside of the hospital. Yet, since my home call was over 60 hours long and was reasonably busy - during the day, I rarely got more than an hour off - I didn't get much opportunity to get anything done and developed some rather intense pager anxiety. It's surprisingly hard to "switch off" on the third day of being page-able at any time!

4) Conclusions

Overall, I'm enjoying residency more than I did medical school. There's a bit more independence and some clear ways to progress forward over time. Getting paid rather than paying insane amounts of tuition is a significant benefit, as finances are now slowly moving in the right direction. Month-long blocks rather than two week rotations provides a bit of stability, and the ability to take vacations provides some much-needed flexibility, though the schedule remains fairly hectic.

Life still isn't yet where I'd like it to be - I spend too much time at work or on work and don't have enough consistency or control over my own schedule to prioritize other aspects of living. I'll be glad to finally finish up in two years' time and to experience the supposed wonder of full, independent practice. Nevertheless, residency feels closer to my ultimate lifestyle goals than medical school did and what sacrifices are necessary feel more like they're in the service of meaningful progress than they did as a medical student.

Tuesday, 27 June 2017

Practicing Medicine with an MD Only

The tragic story of Dr Robert Chu is making the rounds on social media after a profile in the Toronto Star and an accompanying piece about the troublesome nature of the CaRMS match that did not provide him a residency position despite two application cycles. His is a horrific end that highlights the high-stress, low-support nature of medicine in general, but particularly for those who hit speed bumps on their path to becoming a physician.

Many words have been written or spoken about how to remedy situations like this and prevent outcomes like Dr Chu's. These are important topics to discuss which for far too long have been left unaddressed in actions if not in words. I wish these conversations were happening independent of this story, however, as there is so much unknown about Dr Chu's situation that it prevents his particular circumstances from being meaningfully addressed and throws his death into the middle of a discussion that is much, much bigger than his individual story, significant as it is.

There are numerous responses being discussed, but I wanted to focus on one of them. Namely, that having an MD, even without any residency training, should permit someone to work in healthcare in some capacity. Indeed, an MD is rather unique among degrees in that, on its own, means very little. Even in fields where additional training is often necessary, the introductory degree still holds value and can be used to pursue various career paths. The MD is, in effect, a useless degree.

This idea has been circulating among American physicians for some time, even if it hasn't gained much traction in Canada, in no small part due to the increasing presence of Physician Assistants (PAs) and Nurse Practitioners (NPs) in the US. Particularly when it comes to PAs, American physicians see people who have spent less time training than a freshly-graduated MD who cannot work independently, but are able to essentially practice medicine under a qualified physician. This begs the question as to why MDs who were unable to match couldn't do the same. It may not even be overly difficult to set up such a system, as PAs don't have much legal authority themselves, but work under the framework of delegation legislated for physicians. The legal and regulatory framework is largely in place already to allow supervised MD practice without residency, under the direction of a fully-trained physician.

Yet, as things currently stand, I would not being in favour of letting MDs practice in a manner similar to PAs. While MD training is longer, and thus both deeper and broader than that for PAs, it's not particularly functional. MDs are trained more to know rather than to do. PAs are trained to work as they were intended as soon as they graduate. A fresh PA is essentially an extra arm to a physician, allowing them to do more using their already-established knowledge. A fresh MD is more like an extra brain, which isn't particularly helpful to a fully-trained physician who already has that knowledge in spades.

Updating training within MD programs to emphasize practical skills above knowledge could solve this problem and set physicians up to have some sort of back-up option if they fail to land a residency. I'd far prefer a set-up like this with continual supervised practice as opposed to something like the old rotating internship leading to the ability to work as a GP after only a year of post-graduate training. This would require a fairly massive shift in medical education from the current approach, all at a time when getting even small adjustments is an uphill battle. Still, I believe that making medical student education more practical and focused on what we do rather than what we know is worthwhile on its own merits, independent of its implications for the job market.

So, it's an option I think should be considered in these sorts of discussions. It's not the simplest solution (that would be simply making moves to improve the student-to-residency spot ratio) and it's not without its flaws. However, I think it could fit into a broader approach to improving medical education that moves the profession forward.

Tuesday, 13 June 2017

Ontario Binding Arbitration Framework

The OMA and the Ontario Government, against all odds, have come to an agreement. A preliminary one. On how to approach a real agreement. This isn't a physician services agreement, which is what would be needed to provide for a real update of physician funding schemes, but it's a start. Effectively, this sets the stage for negotiations and provides a framework to come to an agreement through a binding arbitration system.

In rejecting the previous tentative physician services agreement, I had two main concerns. First, that the presence of a defined, limited physician services budget with clawbacks on physicians as a whole put too much responsibility on individuals physicians for results beyond their power to affect. Worse, it set up an economic situation that would further encourage physicians to bill and practice in ways that advantaged them at the expense of patients, taxpayers, and their own colleagues. Second, it did not provide any protections for physicians against decision-making of the Ontario government, which is vitally important as physicians have minimal protections from current labour laws and no practical ability to strike in the event of a protracted labour dispute.

This agreement, the Binding Arbitration Framework, effectively has the Ontario government yielding the second point entirely. If this framework is agreed to, we have binding arbitration now and, by the looks of it, moving forward to future negotiations. It appears to be a reasonable solid arrangement, without much in the way of loopholes. The worst criticism I've read is that the government maintains policy-making rights, including which services should be funded which... of course they do. I doubt we could remove that in an agreement regardless of how it was written, thanks to the current Canadian constitution and the Canada Health Act. This was always going to be a loophole, but it'd be extremely inconvenient - politically and legally - for the government to take advantage of this under the proposed framework.

More interestingly, the framework touches on the first point of concern I had as well. It doesn't remove a set physician services budget, which I still find worrisome, but neuters its effectiveness considerably. First, it makes the budget subject to binding arbitration. Second, it explicitly dictates factors that an arbiter should consider, most importantly demographic changes. It does include consideration for the economic situation in Ontario, which is troublesome from an administration that has used any hint of economic weakness to justify public service cuts, but could end up being beneficial as well, as economic strength should work in our favour. Third, and most importantly, breaches in the cap on the physician services budget do not automatically result in punitive action against physicians. Rather, breaches will be subject to arbitration, where it can be determined to what extent, if any, physicians are responsible. Additionally, any punitive actions are subject to negotiation and arbitration, meaning more targeted cuts are possible, in contrast to the current approach of across-the-board cuts. I'd rather see the physician services budget cap removed entirely, but this is a reasonably well-tailored way to maintain its existence while blunting the more objectionable aspects to such a cap.

Some other objections to this agreement have been raised, however. First is that it generally precludes negotiation on the unilateral changes enacted since 2014. Yet, I haven't seen any indication this would be on the table - even the most favourable labour decisions wouldn't include significant back-payments and the OMA has little bargaining power for this time (due in no small part to its own actions). There's what's ideal and there's what's realistic; getting any meaningful compensation for the last 3 years during (failed) negotiations seems like a pipe dream more than anything. Second, the agreement limits ability to engage in strikes or job actions that directly affect patient care... which we couldn't (and shouldn't) do anyway. Job actions that negatively affect patient care in a meaningful way, including strikes, contravene recommended ethical guidelines, including those listed by the CPSO, our regulatory body. Furthermore, physician strikes don't work. The history of them in Canada is full of physicians losing badly. While recognizing a significant desire among Ontario physicians to engage in job actions, if this agreement prevents that, it'll only be saving us from ourselves.

I think I've painted a fairly clear picture of where I stand on this framework. It's not perfect, far from it. Yet, it gives Ontario physicians clear, long-term wins that looked unlikely even a few months ago. The compromises for those wins, while not insignificant, are tolerable. Critically, these benefits come before money is even on the table - I honestly figured that to gain some of these concessions moving forward, physicians would have to endure more financial pain in the short-term. To have them arranged in advance of the negotiations for the current physician services agreement would be a welcome surprise. I rejected the previous tPSA, loudly and proudly. I just voted in favour of this framework.

Saturday, 3 June 2017

The Worst Part of Medical Training

While working on another post, I found the following paragraphs saved as a draft post. I'm not sure if I'm the author of these words and suspect that I'm not, yet can't find who wrote them originally. I have a feeling this was a forum post that ended up getting deleted, that I copied because I felt the words were worth saving.

I present them here as I found them in my draft folder - if the original author comes across this and wants them removed, I will happily do so. However, I think these paragraphs provide an important context to medical training which should be shared.

"I have to highlight this for those considering or early in their medical training, because it's a part of medical training no one appreciates until they're in it.

As a trainee, there will be times where a patient's treatment is below what you consider acceptable. The worst is when there's a preceptor acting completely inappropriately. All you can do is sit back and watch the carnage unfold. If you're lucky, you'll be able to debrief the patient and provide some more appropriate guidance, as well as a bit of simple human empathy.

More often you're simply a cog in a system failing patients that, because you're new to that system, you don't understand and are ill-equipped to navigate. You act the way you think you're supposed to act, even the way others expect you to act, and it causes harm to patients in one way or another. Everyone goes along like it's normal or, worse, thanks you for your part in it. Yet, you have to continue with your role as that cog, because as a trainee, you have no alternative short of quitting. As you gain experience, becoming more knowledgeable about medicine as well as the healthcare system you're now a part of, you start to see opportunities to work around the system to avoid causing harm, to lessen it, or at least to warn patients of what's coming so they aren't blindsided.

This is the worst part of medical training - not the long hours, not the pressure to perform, not the vast amount of knowledge you need to acquire, not even the (fortunately uncommon in my experience) instances where you're personally treated poorly by preceptors - but the time where you're made to be complicit in bad care or outright mistreatment of patients. You don't have the power to change it, and so ultimately you aren't responsible for it, but it sure doesn't feel like it at the time."

I am now about a month away from starting my residency. This is definitely the part of my medical education thus far that I hated the most. It's the part of my upcoming residency I most fear. This is the dark side of medicine, the part that doesn't just challenge your ability, but compels you towards the corruption of your own ideals - ideals which the profession purports to share and uphold, yet frequently betrays.

Saturday, 27 May 2017

Working Hard and Being Successful

I've been reading about and discussing socioeconomic barriers to success lately, particularly as it relates to medicine. I also had an opportunity to be a very small part of an outreach program aimed at increasing interest in medicine in youth from disadvantaged backgrounds. One aspect to socioeconomic disadvantage I've found myself increasingly reflecting on is how multifaceted and variable this disadvantage can be. Thinking back, I've found most conversations on socioeconomic disadvantage tend to treat it as more uniform or monolithic than it is, and I've fallen into that trap of thinking too often as well. Perhaps others have come to this realization and I'm just behind in the thought-process, but I'd like to take a post to spell things out a little bit for my own sake.

To be perhaps a bit over-simplistic, I see a few distinct ways in which low socioeconomic status can manifest itself into real barriers to achievement. First is a simple lack of resources, which tends to be the focus of many interventions to assist those from lower socioeconomic backgrounds. It's undoubtedly a major problem - if some people can pay for things that others can't, and those things either directly or indirectly lead to personal achievement, then wealthier individuals will naturally benefit over their less-wealthy counterparts. In medicine these lead to some obvious and not-so-obvious barriers. To get into medicine, a student needs to pay for their undergraduate education, the MCAT, application fees, travel to interviews, and interview attire. These are not small expenses, especially when added together. However, that's just the bare minimum. Things money can buy that aren't necessary, but very helpful for getting into medical school include taking extra courses or second degrees (or even doing medical school outside of Canada), taking various prep courses or receiving extra tutoring, spending more time on unpaid extra-curriculars, or even paying for certain extra-curriculars.

Yet these examples hit only the "economic" portion of socioeconomic status. To get into medical school, there is also a significant social component that I don't believe gets recognized as often as it perhaps should. One is the development of baseline skills that many people take for granted. To use an extreme example, if a person was never taught how to read, they won't get into medical school, no matter how intelligent, responsible, and personable they might be. They can, of course, learn how to read and then start to move towards medicine, but it's a difficult skill to learn in adulthood and fundamental to all the steps that come after it. It's also a skill that typically requires significant support from others. We're lucky that in Canada most people get that support as children, but there are other skills which are not provided as reliably by our primary or secondary education system. One that springs to mind is professional communication skills, which are sorely lacking in formal education. The ability to write a concise, polite, effective e-mail has enormous benefits in securing various opportunities on a path to medicine, yet this may not be a skill some individuals even see from their elders or peers if they grow up in a setting without business people or other professionals in their lives. It's a skill that can be developed, but this takes time, support, and a certain degree of trial-and-error that more initiated individuals will not have to go through.

Likewise, access to opportunities is far from equitable across individuals of different social status. One example that comes to mind is students who happen to have physicians as parents. These parents hear about or inquire about opportunities with their colleagues and provide a point of introduction for their children. These students must still show they are worthy of those opportunities and perform well once they secure them to advance further, but that first step is often a critical one. More importantly, opportunities create a snowball effect, where prior experience justifies acceptance to future opportunities, up to and including medical school. That is, individuals with higher social status and more connections can turn into seemingly more capable applicants - and may actually be more capable applicants - due to these connections, completely unrelated to ability or effort.

I'd like to emphasize that higher socioeconomic status does not remove the need for hard work or eliminate the role of a certain degree of natural ability in the process. Medicine, like many fields, is full of well-off individuals, but these people have nevertheless put in significant effort to get to where they are. However, what my recent experiences have reminded me of is that while hard work is necessary for success, it is not sufficient on its own, hence the title of this piece. Without trying to set up too much of a strawman, I think some well-off individuals give too much credit to their own hard work in achieving success, because they started to see success when they started putting in the effort. Yet these individuals started seeing success after they started to work harder towards success because everything else was already set up for them. I've met plenty of people who haven't had the same experience, where hard work perhaps improved their situations, but that improvement was limited due to factors beyond their control.

Bringing this back to the original point about the multifaceted nature of socioeconomic disadvantage for a minute, I now worry more that many interventions to improve such disadvantage are perhaps too simplistic to be effective. We can throw money at a problem but it can end up being a waste if the more social aspects to disadvantage are left unaddressed. On the flip side, we could try to improve these social elements, yet see minimal results if resources are still lacking. However, on a more positive note, this also means that there are many different ways we can make marginal improvements in peoples' lives. If we don't have money to help, we can volunteer time to teach new skills, or provide connections that might otherwise being lacking. If we're busy and running off our feet, financial supports can nevertheless be valuable. When people move up the socioeconomic ladder, patchwork systems of support like this can be an important reason why, allowing them to fully utilize their own natural talents and work ethic.

From a personal perspective, as I move forward within my own career in medicine, I'm hoping there will be more opportunities to level the playing field a little bit - and I hope I'll have the good sense to recognize when those opportunities arise.